I.

GENERAL INFORMATION

The patient’s name is Mr. George Fernandez Baniel, 53 years old. He was
admitted at FEU- NRMF on March 29, 2009 and stayed at room 506 B. He was
discharged on April, 28,2009.

II. MEDICAL HISTORY

A. Present Illness and chief complaints

The present illness started prior 1 week before the admission when the
patient had swollen feet with associated scrotal swelling, occasional difficulty
of breathing and easy fatigability. No other accompanying symptoms like
fever, coughs and cols. No medications were taken and no consultation was
done.

1 day prior to the admission, still with the same condition stated above,
patient’s urine output had decreased. Still no consultation was done.

Then, few hours prior to admission, the condition stated above persisted
and accompanied by cough, productive whitish sputum, low grade fever and
chills.

Chief Complaints: fever and chills

B. Past Illness and surgery, allergies, hospitalization

o Patient had usual childhood diseases such as measles, mumps and

chickenpox.
o Patient is non- hypertensive, non- diabetic and non- asthmatic
o No allergies in food but allergic to medicines such as Ibuprofen and
mefanamic acid
o Undergone appendectomy last 1972 at Perpetual Hospital in Cebu
City.
o He was admitted to FEU-NRMF last February 9- March 7, 2009 and was
diagnosed with CHF II, CAD and Acalculous cholecystitis.

C. Physical State of Health:

o No appetite, digestion and elimination problems.

D. Family Medical History

o (+) hypertension – maternal side

 o (+) DM – maternal side
o (+) Heart disease – maternal side
o Mother died at age 55 due to heart disease
o Father died at age 84 due to old age
o He denies other heredofamilial diseases such as bronchial asthma,
malignancy, lung and liver diseases.

THEORETICAL CONSIDERATIONS

Disease Conditions

Congestive Heart Failure

Coronary Artery Disease

Definition

• Congestive heart failure (CHF) is a condition in which the

heart's function as a pump to deliver oxygen rich blood to the
body is inadequate to meet the body's needs.
• Coronary artery disease (CAD), also called coronary heart
disease, is a condition in which plaque (plak) builds up inside
the coronary arteries. These arteries supply your heart muscle
with oxygen-rich blood.

A. Etiology

CHF: Many disease processes can impair the pumping efficiency of the
heart to cause congestive heart failure. The most common causes of congestive
heart failure are:

• coronary artery disease,

• high blood pressure (hypertension)

• longstanding alcohol abuse, and

• disorders of the heart valves.

Less common causes include viral infections of the stiffening of the heart
muscle, thyroid disorders, disorders of the heart rhythm, and many others.

It should also be noted that in patients with underlying heart disease, taking
certain medications can lead to the development or worsening of congestive heart
failure. This is especially true for those drugs that can cause sodium retention or
affect the power of the heart muscle. Examples of such medications are the
commonly used nonsteroidal antiinflammatory drugs (NSAIDs), which include
ibuprofen (Motrin and others) and naproxen (Aleve and others) as well as certain
steroids, some diabetic medication, and some calcium channel blockers.

CAD: Research suggests that coronary artery disease (CAD) starts when certain
factors damage the inner layers of the coronary arteries. These factors include:

• Smoking
• High amounts of certain fats and cholesterol in the blood
• High blood pressure
• High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues
release compounds that promote this process. This healing causes plaque to build
up where the arteries are damaged.

The buildup of plaque in the coronary arteries may start in childhood. Over time,
plaque can narrow or completely block some of your coronary arteries. This reduces
the flow of oxygen-rich blood to your heart muscle.

Plaque also can crack, which causes blood cells called platelets (PLATE-lets) to
clump together and form blood clots at the site of the cracks. This narrows the
arteries more and worsens angina or causes a heart attack.

B. Incidence

CHF: Each year, there are an estimated 400,000 new cases. (Source:
excerpt from NHLBI, Congestive Heart Failure Data Fact Sheet: NHLBI)

CAD: Incidence: 13,199,999 (USA prevalence calculated from this data:

estimated 13,200,000 in the USA 2001 (American Heart Association, 2004)

C. Pathology

Congestive heart failure can affect many organs of the body. For example,
the weakened heart muscles may not be able to supply enough blood to the
kidneys, which then begin to lose their normal ability to excrete salt (sodium)
and water. This diminished kidney function can cause to body to retain more
fluid. The lungs may become congested with fluid (pulmonary edema) and the
person's ability to exercise is decreased. Fluid may likewise accumulate in the
liver, thereby impairing its ability to rid the body of toxins and produce essential
proteins. The intestines may become less efficient in absorbing nutrients and
medicines. Over time, untreated, worsening congestive heart failure will affect
virtually every organ in the body.
 Coronary Artery Disease is characterized by an inadequate supply of
oxygen-rich blood to the heart muscle (myocardium) because of narrowing or
blocking of a coronary artery by fatty plaques. If the oxygen depletion is
extreme, the effect may be a myocardial infarction (heart attack); if the
deprivation is insufficient to cause infarction (death of a section of heart muscle),
the effect may be angina pectoris, or spasms of pain in the chest. Both
conditions can be fatal because they can cause heart failure or ventricular
fibrillation—an uncontrolled and uncoordinated contraction of the ventricles (the
lower chambers of the heart) that induces sudden death. Middle-aged men,
especially those with a family history of the disease, are particulary vulnerable
to developing coronary heart disease, as are individuals with hereditary
conditions such as familial hypercholesterolemia (a disorder in which the body’s
tissues are incapable of removing cholesterol from the bloodstream). Coronary
artery bypass surgery or balloon angioplasty may be necessary if medications
and diet and lifestyle changes such as frequent exercise and cessation of
smoking are not effective.

D. Clinical Manifestations

The symptoms of congestive heart failure vary among individuals

according to the particular organ systems involved and depending on the degree
to which the rest of the body has "compensated" for the heart muscle weakness.

• An early symptom of congestive heart failure is fatigue. While fatigue is a

sensitive indicator of possible underlying congestive heart failure, it is
obviously a nonspecific symptom that may be caused by many other
conditions. The person's ability to exercise may also diminish. Patients may
not even sense this decrease and they may subconsciously reduce their
activities to accommodate this limitation.

• As the body becomes overloaded with fluid from congestive heart failure,
swelling (edema) of the ankles and legs or abdomen may be noticed.

• In addition, fluid may accumulate in the lungs, thereby causing shortness of

breath, particularly during exercise and when lying flat. In some instances,
patients are awakened at night, gasping for air.

• Some may be unable to sleep unless sitting upright.

• The extra fluid in the body may cause increased urination, particularly at
night.

• Accumulation of fluid in the liver and intestines may cause nausea,

abdominal pain, and decreased appetite.
 A common symptom of coronary artery disease (CAD) is angina. Angina is
chest pain or discomfort that occurs when your heart muscle doesn't get
enough oxygen-rich blood.

Angina may feel like pressure or a squeezing pain in your chest. You also
may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get
worse with activity and go away when you rest. Emotional stress also can
trigger the pain.

Another common symptom of CAD is shortness of breath. This symptom

happens if CAD causes heart failure. When you have heart failure, your heart
can't pump enough blood throughout your body. Fluid builds up in your lungs,
making it hard to breathe.

The severity of these symptoms varies. The symptoms may get more
severe as the buildup of plaque continues to narrow the coronary arteries.

Prognosis

Congestive heart failure is generally a progressive disease with periods of

stability punctuated by episodic clinical exacerbations. The course of the disease
in any given patient, however, is extremely variable. Factors involved in
determining the long term outlook (prognosis) for a given patient include:

• the nature of the underlying heart disease,

• the response to medications,

• the degree to which other organ systems are involved and the severity of
other accompanying conditions,

• the patient's symptoms and degree of impairment, and

• other factors that remain poorly understood.

With the availability of newer drugs to potentially favorably affect the

progression of disease, the prognosis in congestive heart failure is generally
more favorable than that observed just 10 years ago. In some cases, especially
when the heart muscle dysfunction has recently developed, a significant
spontaneous improvement is not uncommonly observed, even to the point
where heart function becomes normal.

An important issue in congestive heart failure is the risk of heart rhythm

disturbances (arrhythmias). Of those deaths that occur in patients with
congestive heart failure, approximately 50% are related to progressive heart
failure. Importantly, the other half are thought to be related to serious
arrhythmias. A major advance has been the finding that nonsurgical placement
 of automatic implantable cardioverter/defibrillators (AICD) in patients with
severe congestive heart failure (defined by an ejection fraction below 30%-35%)
can significantly improve survival, and has become the standard of care in most
such patients.

In the U.S., coronary artery disease is the leading killer of both men and
women. In 2003, nearly 500,000 people died because of CAD. On the positive
side, heart attack mortality rates have been declining. Half of men and 63% of
women who die of heart disease do not have angina or other warning symptoms
prior to their fatal attacks. Although at this time no tests can reliably predict
whether a heart attack will occur, experts estimate that up to 30% of fatal
attacks and many follow-up surgeries could be avoided with healthy lifestyle
changes and by sticking to medical treatments. Two-thirds of patients who have
suffered a first heart attack, however, do not take the necessary steps to
prevent another.

III. SOCIO-ECONOMIC HISTORY

A. Composition of the family

The head of the family is George Baniel and his wife is Celia Baniel.
They have three children, one female and two males. Their family is
nuclear.

B. Educational background

George Baniel, the patient, did make it to college but unfortunately,

turned down his studies because of lack of financial resources. He stopped
at 2nd yr college (undergrad).

C. Type of residence

They reside in a semi-concrete house that was turned over by the

mother of his spouse after her death.

D. Occupation

The head of the family, George Baniel, drives a bunch of car for his
boss. He works as a family driver.
 E. Religion

George was baptized as a born-again Christian and the same as his

wife and children.

F. Income bracket

The client, being a driver, receives up to 12,000 - 15,000 a month.

G. Recreation, hobbies & exercise

During free time or day offs, George enjoys playing basketball with
neighbors or co-workers or sometimes with the family.

H. Cultural influences

They originally came from Cebu. Obviously, they are much oriented
and influenced by the Visayan culture and traits.

IV. ASSESSMENT OF NUTRITIONAL STATUS

A. Anthropometry

Height – 5’7” 170.18 cm 2.89

Weight- 65 kg

BMI = = = 22.49 (WNL)

DBW = 170.18 – 100 = 70.18 kg

= 70.18 – 7.018 (10% of 70.18)

= 63.16 63 kg

B. Biochemical Assessment
 Patient’s Normal Variance Rationale
Laborator Values (High/Lo For
y w) Variance
Values
BUN 3.0-9.2 High Indicates increased protein in the diet
(14.30) mmoL/L and as a result of congestive heart
failure
( which decreases blood flow in the
kidneys )
Creatinine 62-115 High Indicates increased protein in the diet
(130.0) mmoL/L and as a result of congestive heart
failure
( which decreases blood flow in the
kidneys )
SGOT/AST 5-34 U/L Normal Liver is normal
(26.0)
RBS/CBG < Normal Blood Sugar Levels are normal
(201) 300mg/day
Total 64-83 g/L Normal No indication of liver disease
Protein
(74)
Albumin 35-50 g/L Low Indicates the presence of a disease
(33) which enables kidneys to control
albumin leakage from the blood to the
urine
Globulin 29-33 g/L High Presence of infection/inflammation (UTI)
(41)
SGPT/ALT 0-48 U/L High Caused by congestive heart failure
(83)
ALP 40-150 U/L Normal Liver function normal
(67)
Sodium 135-148 High Indicates increased blood pressure
(150.30) mmoL/L
Potassium 3.50-5.30 Normal Potassium levels are regulated (to
(5.26) mmoL/L monitor condition and effect of
treatment)
Magnesium 0.65-1.25 Normal Status of digestive
(0.94) mmoL/L system/gastrointestinal tract is WNL
Ionized 3.0-9.2 Low Relatively caused by low
Calcium mmoL/L Albumin levels
(1.30)

C. Clinical assessment

Observed signs of nutritional deficiencies by clinical changes:

 Part of the body Clinical sign Possible nutritional
deficiency

Eyes Yellowish, droopy Vitamin A and riboflavin

Face Facial grimace every Thiamine and calcium

once in a while

Skin (sole of the foot) Large amount of skin that Vitamin A, Water, Vitamin
is peeling off C, Protein and Vitamin E
Skin (total body)
Dry

Muscles of the Weakness manifested by Potassium, protein

extremities slow muscle response
and action

Legs and feet Edematous Excessive sodium

D. Dietary assessment

The patient usual food intake for a day is mostly kimchi- a Korean food
composed of vegetables seasoned with great amount of salt, spices and additional “
bagoong” that is fried in large or the fat of animals with or without rice (mostly
without) – from lunch up to dinner. His breakfast is consisted of fried fish or
vegetables and rice. In eating kimchi, the ingredients are no longer measured. The
amount of each ingredient varies with every serving.

• What are the nutrients present in the patient’s diet?

The nutrients that dominates in the patients diet is sodium and chloride
or simply salt as well as fat.

• Why are these important?

The primary function of sodium is the control of fluid balance in the body
and participates in the transmission of nerve impulse essential for normal
muscle function. And as for chloride, it is essential for the maintenance of fluid,
electrolyte and acid-base balance. Fats play a vital role in maintaining healthy
skin and hair, insulating body organs against shock, maintaining body
temperature, and promoting healthy cell function.

• What are the nutrients missing in the patient’s diet?

Mostly protein is missing. Next to protein are the carbohydrates, the
essential vitamins and minerals such as vitamin A, B1, B2, C, E, calcium,
potassium and water.

• Why are these important?

 Protein is important for the regulation of the body processes.
Carbohydrates provide energy. Vitamins and minerals aid in providing for the
body by enhancing other nutrients or acts as a catalysts for carbohydrates,
protein, and fat metabolism.

Dietary history of the patient:

1. Food preferences
Likes: fish and kimchi

Dislikes: none (eats any kind food served)

2. Food pattern- regular

Breakfast: vegetables or fish with rice

Lunch: Kimchi (without rice) or kimchi pop (with rice)

Snacks: nothing in specific

Dinner: dishes with some kimchi ingredients

3. Usual cooking method- stir frying, re-heating, frying in animal grease

4. Frequency of eating out- when he started working for the Korean
nationals, it was lessened up until he can no longer eat out.
5. Allergy to certain foods- none
6. Other sources of nutrients in addition to usual food and drink- none but
takes eskellan a food supplement for arthritis.
7. Nutrition and knowledge were obtained- from his instincts and beliefs of
being a “cebuano”
8. Appetite- normal, not picky on foods

Dietary requirement given by the nutritionist of FEU-NRMF for everyday to

Mr. George Baniel is a low sodium / low fat diet meal composed of fish or low fat
meat, fruits (especially bananas) and rice. The subjective data: “madalas walang
lasa ung mga pagkain. Tinitiis ko nalang kahit hindi masarap.”
V. NUTRITION CARE PLAN

A. Identification of nutrition and non-nutrition related problems

PARAMETERS NUTRITION RELATED NON-NUTRITION RELATED

PROBLEMS PROBLEMS
Anthropometry N/A N/A
Biochemical  Protein breakdown  Impaired kidney
 Malnutrition function
 Edema  Liver disease
 Hypocalcemia

Clinical • Deficiencies of N/A

Vitamins
• Deficiencies of
Minerals
Dietary  Deficiencies of N/A
Vitamins
 Deficiencies of
Minerals

B. Analysis of Diet Prescription

The diets prescribed by the doctor are low salt and low fat diets. The low salt
diet is used for the client having diseases that affect fluid balance or where a
decrease in his body fluid volume will relieve symptoms of the disease/s. His health
conditions where control may be indicated are severe heart failure and high blood
pressure. On the other hand, low-fat diet is a diet that consists of little fat,
especially saturated fat and cholesterol, which can lead to increased blood
cholesterol levels and heart disease risk. In the case of the client, to reduce the risk
of incidence of heart problems and complications of the problem being experienced,
this diet can be of great help in minimizing the client’s diseased state. We do agree
with the diets given by the doctor behind the fact that the diets really fit the client
e.g. in terms of prevention of the development of health threats, pursuing the diets
will actually prevent potential health problems that may arise from the actual
problems and another, in terms of curative when it comes to taking the right
nutrients in order to diminish some manifestations of the client’s health problems.

Food Items to Choose More Often

Breads and Cereals

6 Servings per day, adjusted to caloric needs

Breads, cereals, especially whole grains; pasta; rice; potatoes; dry beans and peas;
low-fat crackers and cookies

Vegetables

3-5 servings per day fresh, frozen, or canned without added fat, sauce, or salt

Fruits

2-4 servings per day fresh, frozen, canned, dried

Dairy Products

2-3 servings per day Fat-free, 1/2%, 1% milk, buttermilk, yogurt, cortage, cheese,
fat-free and low-fat cheese

Eggs

2 egg yolks per week

Egg whites or egg substitute

Meat, Poultry, Fish

<5 oz. per day

Lean cuts loin, leg, round, extra lean hamburger; cold cuts made with lean meat or
soy protein; skinless poultry; fish

Fats and Oils

Amount adjusted to caloric level: unsaturated oils; soft or liquid margarines and
vegetable oil spreads; salad dressings, seeds, and nuts

Food Items to choose less often

Breads and Cereals

Many baked products, including doughnuts, biscuits, butter rolls, muffins,
croissants, sweet rolls, cakes, pies, coffee, cakes, cookies

Many grain-based snacks, including chips, cheese puffs, snack mix, regular
crackers, buttered popcorn

Vegetables

Vegetables fired or prepared with butter, cheese, or cream sauce

Fruits

Fruits fried or served with butter or cream

Dairy Products

Whole milk, 2% milk, whole-milk yogurt, ice cream, cream, cheese

Eggs

Egg yolk, whole eggs

Meat, Poultry, Fish

Higher fat meat cuts: ribs, t-bone steak, regular hamburger, bacon, sausage; cold
cuts: salami, bologna, hot dogs; organ meats: liver, brains, sweetbreads; poultry
with skin-fried meat; fried poultry; fried fish

Fats and Oils

Butter, shortening, stick margarine, chocolate, coconut

C. Computation of Calorie, CHO, CHON, and Fat Requirement

Given:
DBW = 64 kg

Kcal/kg DBW/day = 27.5 (bed rest but mobile)

TER = ?

CHO = ?

CHON = ?

FAT = ?

TER = 64 x 27.5 = 1,760 kcal 1,750 kcal

Energy Contributions:

CHO = 1,750 x 0.65 = 1,137.5 kcal

CHON = 1,750 x 0.15 = 262.5 kcal

FAT = 1,750 x 0.20 = 350 kcal

Required Intake for each nutrient:

CHO = 1,137.5 / 4 = 284.375 285 g

CHON = 262.5 / 4 = 65.625 65 g

FAT = 350 / 9 = 38.88 40 g

Diet : 1,750 kcal; CHO 285 g; CHON 65 g; FAT 40 g

D. Sample One-Day Menu duly signed by a Registered Nutritionist-Dietitian

Breakfast

2/3 c bran cereal

1 slice whole wheat bread

1 medium banana

1 c fruit yogurt, fat free, no sugar added

1 c fat-free milk
2 tsp jelly

Lunch

1/4 c chicken salad

2 slices whole wheat bread

1 T mustard

1/2 c fruit cocktail, juice pack

Salad:

1/2 c fresh cucumber slices

1/2 c tomato wedges

2 T ranch dressing, fat free

Dinner

3 oz spicy baked fish

1 c green beans, cooked from frozen, without salt

1 small baked potato

2 T fat-free sour cream

1 T chopped scallions

2 T grated cheddar cheese, natural, reduced fat

1 small whole wheat roll

1 tsp soft margarine

1 medium peach

1 c fat-free milk
Snack

1 c orange juice

1/3 c almonds, unsalted

1/4 raisins

1 c fruit yogurt, fat free with sugar

References:

• Client’s records

• http://www.labtestsonline.org

• http://www.weight-loss-professional.com

• Grodner, Long, et. al. Foundations and Clinical Applications of Nutrition: A

Nursing Approach. Winsland House I, Singapore. Mosby, Inc. 2004

LEARNING INSIGHTS

The study had given us the opportunity to be exposed to a client –

considered as the core of nursing care. It allows us to practice nursing as
part of a broad field of profession behind the fact that as nurses in the near
future, diverse duties and responsibilities are to be performed as such in
terms of nutrition of a certain client/patient. In addition, beyond the technical
benefit of the study, it also enhanced the collaboration and harmonious
rapport among us which is actually vital to the efficiency and effectiveness of
a healthcare team.

“Nursing is a holistic care.” This adage is often become a basis for

nurses in carrying out their nursing care. As a holistic care, nursing focuses
not only in managing disease/illness state but also in deciphering the
etiology contributory to the disease/illness which can be derived in some
cases due to poor nutrition. With this guideline, we can formulate the
correlation between nursing and nutrition. In nursing assessment,
particularly during interview with patients, nutritional assessment is made.
The said assessment is essential for the making of a plan of nursing care
which can dictate nursing interventions that could eventually help patient/s
in attaining optimal nutrition.

One intervention a nurse can perform is diet education for the patient.
This study can be a reference for nurses in conducting health teaching to the
client involved herein and the like. Diet education for the hospitalized patient
is often overlooked because no referral is made for education or the diet is
related to an old diagnosis. It is sometimes difficult for the nurse to discern
how much information to provide. Often patients are dealing with more
urgent medical issues and cannot give full attention to learning a new diet. It
is essential to let the amount of education be patient-guided to avoid
overwhelming him or her. Using valuable time to teach an uninterested
patient could result in missing an educational opportunity with a motivated
patient. The best course of action is to: inform the patient of the diet; be
available for questions; provide basic written information; verbally
emphasize a few memorable key points; and provide contact information or
refer the motivated patient to the dietitian.

Emphasizing a few key points is the crux of diet teaching. For the
purpose of this experience, we are referring to these points as “nursing
skills.”

Nursing skills are immediately useful, small pieces of knowledge

patients can use at home. Then when he/she is medically and mentally
ready, diet knowledge can be developed using the written material a nurse
has provided, and the patient can decide whether further education is
desired. Complete nutritional education should be done on an outpatient
basis where it is the main focus, without other urgent medical issues to
hinder the learning process.

We hope you will find these nursing skills useful. It is important to feel
comfortable with the nutrition education you provide to your patients. 