Escolar Documentos
Profissional Documentos
Cultura Documentos
Referred for:
FoodandNutritionRelatedHistory:Ptcurrentlytoleratingcardiacdietandreportshavingeggsandcereal forbreakfast. Ptstatesappetitehas remainedthesameandhashadconsistentintakesperRNreport. Pthas+3bilateral legandftedemariflpurpletoes. Athomepttypicallyeats cereal w/ milk and juice for B, turkey sandwich for L, meat/starch/veggie for D. Since becoming sick, husband has been doing shopping and does not read food labels well. Pt admits to having canned foods and frozen dinners regularly, as well as deli meats daily. Pt was provided w/ DASH diet/lowNadieteducationandsubstitutesforfavoritehighNaproductswerediscussed. CHFfluidrestrictionwasalsocovered.
Anthropometric Measurements
Age: 82 years
Gender: Female
Ht: 64"
Wt:200#
Wt Hx: % Wt chanpe:
Biomedical Data, MedicalTests & Procedures Glucose HbAIC Labs/Date I Albumin 2/5174
BUN
Crat
Na+
K+
Heb
Hct
MCV
Other
NT-PRO BNP
31f
7087+
Medical Diagnosis/PMH/Relevant Conditions: CHF, A-Fib, hyperlipidemia, anemia, breast cancer, bladder problems, arthritis Fam Hx: mother died @ 37 from unknown causes {possiblv malignancy), father died @ 80 from Ml Pertinent Medications: Coumadin 5ms/dav
Skin
Phvsical Assessment:
Estimated Nutritional Needs Based on Comparative Standards: Protei n : 1..O-1..2g/ ke Calories: Mifflin St. Jeor x 1.3 activity factor 91-109s/dav 1768-2068kcal/dav Diet Order: Feeding Ability Regular; Cardiac Diet X lndependent
Fluid: 20ml/kg
1.8l/dav
Oral Problems lntake
n tr n tr
P
tr tr n X
Mouth Pain
None
ofthe Above
tr X n n
N
Minimal
NPO
(<25%)
time
Proceed
E (Etiology) Iack of prior exposure to nutritionrelated information for CHF as evidenced by:
S (Signs & Symptoms): Pt intervlew of high Na foods and NT-PRO BNP of 7087
{Etiolosy)
as evidenced by:
S (Signs
& Symptoms)
Nutrition Prescription: Modified Diet: cardiac diet to provide 1768-2168kcal/daV,91-lo9gpro/day, fluid restriction of 1.81/day
Food or Nutrient Delivery: Meals and Snacks: DASH diet/low sodium
diet
Nutrition education: verbal/written DASH diet, sodium restriction, and fluid restriction education
Coordination of Care (refer to): n/a
lt
,!l
{A ,t-l\
5
Qlfttlt*
A/
tr
/,t,
2013
SGS DI