Nutrition Care Plan

Brianna Bessette
NTR 417

SOCIAL HISTORY: Mrs. B is a 75-year-old female who lives with her husband in North
Greenbush, NY. They own a one-story home. Mrs. B is a retired Troy School District
secretary and Mr. B is a retired Troy School District carpenter. According to the patient,
they have ample funds to buy food and pay bills. Mrs. B states that she has never had a
drivers license and relies on her husband for transportation. She has no history of
tobacco or alcohol use.
Nutritional Implications: Mrs. B has a very supportive husband. Since she does
not have a drivers license, which limits her ability to make meals. If she does not have
the ingredients at home she cannot go out and get what is needed.
MEDICAL HISTORY: Mrs. B had polio when she was a child, however, no lasting
effects have continued. She has a history of type II diabetes mellitus,
hypercholesterolemia, and hypertension (HTN) for the past twenty years. In 2014, Mrs. B
had a heart attack and was diagnosed with stage three, congestive heart failure. A pace
maker was placed s/p heart attack. Edema is present. She is unable to walk for long
periods of time due to shortness of breath and weakness.
Nutritional Implications: Mrs. Bs diabetes has been managed with medication
since she does not follow a diabetic diet. Her current medical condition directly
affects her nutritional status. Her history of HTN and hypercholesterolemia will
limit the amount of sodium and fat that she can have in her diet. Her diagnosis of
stage three, congestive heart failure also limits the amount of sodium she can have
in her diet. With the presence of edema, there is the potential for a fluid
restriction.
DIET HISTORY: Mrs. B currently consumes a non-restricted oral diet. She has a good
appetite and her diet provides approximately 1491 calories, 121 grams of carbohydrates,
89 grams of protein, 3118 mg of sodium and about 44% of total calories come from fat.
Specifically, 19% of calories come from saturated fat. Aside from bread, Mrs. B tries to
stay away from carbohydrates and fruits because she believes it is better to control her
diabetes. Her doctor prescribed a daily multivitamin, fish oil supplement, and vitamin D
supplement.
Nutritional Implications: Mrs. Bs current diet does not provide all the necessary
nutrients. Her caffeine levels need to be limited since caffeine increases heart rate.
She is deficient in carbohydrates, dietary fiber, calcium, potassium, vitamin D,
vitamin E and magnesium. Mrs. B might consider taking a magnesium
supplement due to her use of diuretics. Her diet is high in fat, specifically
saturated fat. Since her diet is high in saturated fat, this increases her risk of
atherosclerosis and cardiovascular disease. Her excessive sodium intake puts her
at risk for hypertension.
She is also at risk of osteoporosis since she is deficient in calcium and doesnt do
weight bearing exercise.

MEDICATIONS:
Aspirin- it is used to prevent potential blood clots from forming due to Mrs. Bs history
of atrial fibrillation.
Nutritional Implications: Aspirin should be taken with milk or water after meals
in order to avoid irritation of the GI tract. Food decreases absorption of aspirin, so
adequate fluid levels must be present. Avoid foods like garlic or ginger, which
can affect coagulation. Caffeine should also be limited to prevent GI effects.
Aspirin can potentially cause anorexia.
Imdur (isosorbide mononitrate)- it is used to prevent Mrs. Bs chest pain by dilating
blood vessels, before it occurs.
Nutritional Implications: Imdur should be taken on an empty stomach with water
in order to increase rate of absorption. Side effects include: dry mouth, GI
distress, and decreased potassium levels.
Klor-Con 10 (potassium chloride)- it is a supplement used to regulate Mrs. Bs potassium
levels, thus regulating her heart rate.
Nutritional Implcaitons: Klor-Con 10 should be taken with meals and liquids.
Side effects include: GI irritation, abdominal pain, diarrhea, and flatulence.
Lasix (furosemide)- it is a diuretic used to prevent fluid accumulation in order to control
Mrs. Bs blood pressure.
Nutritional Implications: Lasix should be taken on an empty stomach because
food decreases bioavailability. It can cause anorexia and increase thirst.
Lipitor (atorvastatin)- it is used to lower Mrs. Bs LDL cholesterol and raise HDL
cholesterol.
Nutritional Implications: Lipitor should be taken with food or at a specific time of
day. Grapefruit should be avoided as this could lead to increased atorvastatin
concentration levels resulting in rhabdomyolysis (muscle breakdown). Fat and
cholesterol should be reduced in the diet. Side effects include: nausea, dyspepsia,
abdominal pain, constipation, diarrhea, and flatulence.
Norvasc (amlodipine)- it is an antihypertensive, calcium channel blocker, which is used
to lower Mrs. Bs blood pressure.
Nutritional Implications: Norvasc should be taken with food to reduce GI distress.
Natural licorice should be avoided since it can increase sodium reabsorption,
water retention, potassium excretion and increases blood pressure. This ultimately

counteracts the action of diuretics and antihypertensives. Side effects include:

dysphagia, nausea, and cramps.
Toprol-XL (metopropol)- it is an antihypertensive beta-blocker used to control Mrs. Bs
blood pressure and regulate her heart rate.
Nutritional Implications: This drug should be taken with food in order to increase
bioavailability. A diet with decreased sodium and calories is recommended and
natural licorices should be avoided. Side effects include: dry mouth, dyspepsia,
flatulence, diarrhea, and constipation.
Actos (pioglitazone)- it is an antidiabetic agent used to lower Mrs. Bs blood sugar.
Nutritional Implications: Actos should be taken with food or once in the morning.
Side effects include: tooth deficiencies and pharyngitis. It is recommended to be
on a prescribed diabetic diet and if weight loss is needed, decreasing calories is
recommended. Actos can increase weight and insulin sensitivity in muscle and
fat, but decreases gluconeogenesis.
Metformin- it is an antihyperglycemic agent used to lower Mrs. Bs blood sugar.
Nutritional Implications: Metformin should be taken with meals to decrease GI
distress. A diabetic diet is recommended with decreased calories if weight loss is
necessary. It can cause anorexia, decrease or stabilize weight, and can decrease
absorption of folate and vitamin B12. Other side effects include: nausea, vomiting,
bloating, diarrhea, and flatulence.
Glipzide- it is an oral hypoglycemic used to lower Mrs. Bs blood sugar.
Nutritional Implications: This drug should be taken thirty minutes before the first
meal of the day because food delays absorption. It can increase and decrease
appetite and increases weight. A prescribed diabetic diet and exercise is
recommended. Other side effects include: dyspepsia, nausea, diarrhea, and
constipation.
Quinapril- it is an antihypertensive ace inhibitor used to lower Mrs. Bs blood pressure.
Nutritional Implications: Quinapril should be taken one hour before meals on an
empty stomach because food decreases absorption. High fat meals can also
decrease absorption and it is important to ensure adequate fluid intake. It is
recommended to decrease sodium and calories. Monitor potassium and
magnesium supplementation since ace inhibitors increase levels. Side effects
include: anorexia, possible weight loss, dry mouth, abdominal pain, constipation,
and diarrhea.

PATHOPHYSIOLOGY:
Mrs. Bs health status consists of three major health disparities: hypercholesterolemia,
hypertension, and congestive heart failure.
Hypercholesterolemia is the diagnosis of ones LDL levels ranking above the 90th
percentile with a presence of xanthomas (cholesterol deposits in the arteries). About 85%
of men and 50% of women will have a coronary event before the age of 65 unless
hypercholesterolemia can be treated. A defect in the LDL gene receptor causes
hypercholesterolemia, and there is a possibility of 800 different mutations that have been
discovered. One major cause of this is excessive saturated fat intake in the diet. Other risk
factors include: physical inactivity, diabetes, hypertension, and obesity.
Hypercholesterolemia is generally controlled with the use of statin drugs. Limiting fat
intake in the diet can also control hypercholesterolemia. The primary prevention for
hypercholesterolemia is physical activity. A combination of diet and physical activity can
control and reduce hypercholesterolemia (Mahan, Escott-Stump, Raymond, 2012, 746752).
Hypertension is defined as having continuously high arterial blood pressure. In order to
be diagnosed with hypertension, blood pressure must exceed a systolic pressure of 120
and must exceed a diastolic pressure of 80. A general diagnosis of hypertension is when a
person has a blood pressure of 140/ 90. Hypertension is a very common health problem.
It is prevalent in about 74 million Americans from ages 20 to older. More than half the
adult population (65 years or older) has hypertension and it affects about 16% of boys
and 9% of girls. Blood pressure is measured by, the resistance in the blood vessels in
regards to blood flow. When the diameter of a blood vessel narrows, resistance and blood
pressure increases. The kidney regulates blood pressure by controlling extracellular fluid
output and secreting renin, which ultimately activates the renin-angiotension system.
When this system is activated, blood pressure increases because the kidney is trying to
maintain perfusion. It is common in most cases of hypertension that peripheral resistance
increases forcing the left ventricle of the heart to increase the force of contraction to push
blood out of the heart. Genetic mutations in the RAS gene with ACE and
angiotensinogen have caused hypertension as well. Diet modification, weight loss, and
physical activity have shown to reduce hypertension. It can also be controlled with the
use of diuretics and antihypertensive drugs (Mahan, Escott-Stump, Raymond, 2012, 758767).
Congestive heart failure occurs when the heart cannot provide an adequate amount of
blood flow to the rest of the body. This causes fatigue, dyspnea, and edema. Heart failure
affects more than five million people in the United States and about 10 per every 1,000
people over the age of 65. Heart failure begins with damage to the heart with the
incidence of a MI or insidious onset. Symtoms generally do not arise for many months or
years after cardiac remodeling begins. Overuse of compensatory systems leads to further
damage of the heart. Heart failure patients have increased levels of norepinephrine,
angiotension II, vasopressin, aldosterone, and endothelin. These hormones increase
hemodynamic stress on the ventricles of the heart, which causes more sodium retention

and peripheral vasoconstriction. Some risk factors for heart failure include: hypertension,
diabetes, and left ventricle hypertrophy. If left ventricle hypertrophy is left untreated, this
can lead to thickening of the ventricle walls, ultimately leading to congestive heart failure
In women, the presence of both diabetes and hypertension increases the incidence of
heart failure. There are four stages in which heart failure is classified. For stages A and B,
more aggressive treatments to cure underlying causes like diabetes and hypertension are
used. In stages C and D, the secondary prevention strategies are used. This includes the
use of drugs like: ACE inhibitors, angiotension receptor blockers, aldosterone blockers,
beta blockers, and digoxin. Diet assessment plays a major role in managing heart failure
patients as well. The first medical nutrition therapy goal for heart failure patients is to
restrict sodium. The sodium restriction varies depending on the health condition of the
patient. It is also recommended that heart failure patients consume smaller, more frequent
meals because they can be tolerated better. A fluid restriction may also be placed
depending on the lab values of the patient (Mahan, Escott-Stump, Raymond, 2012, 769777).
ASSESSEMENT:
Mrs. B has multiple health problems that affect her nutritional status. Her weight poses
more problems regarding her health. Mrs. Bs current weight is 210 pounds or 95.5
kilograms. Based on her height and weight, Mrs. Bs BMI is 39. Since edema is present,
this could skew her weight. Mrs. Bs weight needs to be recorded daily and she should
weigh herself before eating and in the morning (at the same time each day). If there is
more than a two-pound weight gain in one day, Mrs. B should notify her doctor
immediately. Since weight loss is also necessary monitoring her weight carefully is vital
in order to avoid excessive and rapid protein catabolism. Mrs. Bs current diet provides
about 1491 calories, 89 grams of protein and 44% of total calories come from fat.
Mrs. Bs estimated energy needs should be between 1,000 to 1,200 calories per day and
her estimated protein needs (based on 1.12 gm/ kg of body weight) are 106.96 grams.
Generally, heart failure patients are not put on weight loss programs unless their BMI is
above 30. Since Mrs. Bs BMI is 39, it is wise to restrict her calories since there is no
sign of malnourishment. Her current diet also provides too much salt and saturated fat.
Her diet should be restricting sodium to about 1,200 to 2,400 milligrams per day and
saturated fat to less than 10% of total calories per day. For healthy individuals, it is a
sodium restriction of 1,200 mg is recommended. Since Mrs. B is taking Lasix, it is
recommended to restrict sodium to less than 2,000 mg per day. Depending on Mrs. Bs
serum sodium levels, it would be appropriate to place a fluid restriction on her diet to
reduce edema that cannot be controlled despite the use of diuretics. If her serum sodium
levels are less than 130 milligrams, her fluid levels should be restricted to less than two
liters per day. Mrs. B should also be consuming smaller meals more frequently
throughout the day. PES statements:
Excessive sodium intake (NI-5.10.2) related to lack of knowledge about
management of a disease state requiring mineral restriction as evidenced by HTN
and stage three CHF.

Excessive fat intake (NI-5.5.2) related to food- and nutrition-related knowledge

deficit concerning appropriate amount of dietary fat evidenced by
hypercholesterolemia.
INTERVENTION:
Provide ~1,200 kcals/ day to initiate weight loss plan.
Initiate exercise slowly. Walk ten to fifteen minutes every three days.
Restrict sodium to 2,000 mg/ day (ND-1.2.11.7.2) and restrict saturated fat to 10% of
total calories (ND-1.2.5.5.1).
Nutrition Education: priority modifications (E-1.2) and recommend modifications (E1.5).
Nutrition Counseling: goal setting (C-2.2) and self-monitoring (C-2.3). Suggest that she
keep a food diary and weigh herself regularly.
MONITORING & EVALUATION:
Short Term Goals
1. Reduce dietary sodium intake to 2800 mg in two weeks.
2. Reduce saturated fat to 15% of total calories after two weeks.
Long Term Goals
1. Lose five pounds in one month.
2. Walk 20 minutes every day after two months.

References

Mahan, L. Kathleen, Sylvia Escott-Stump, and Janice L. Raymond. Krause's Food and
the Nutrition Care Process. 13th ed. St. Louis: Elsevier, 2012. 746-777. Print.
Pronsky, Z. M., Elbe, D., & Ayoob, K. (2015). Food Medication Interactions (18th ed.).
Birchrunville, PA: Food-Medication Interactions. Print.