I.

INTRODUCTION
A. Clinical Impression

B. Nutrition Drug Interaction

II. NUTRITION CARE PROCESS/PLAN
A. Nutrition Screening & Assessment
 Patient Ed weighs 75 kilograms and stands 5’6 he has a body mass index of 26.9.kg/m 2
which is classified as Overweight by the World Health Organization (WHO). His
Corrected Body Weight is 80 kilograms. While her Ideal Body Weight range is 61-71
kilograms. Upon his admission his BP is 180/120 which is classified as Hypertensive
Crisis by the American Heart Association (AHA). Also he has a fever with body
temperature of 37.5 °C.

See Attachment of NRS 2012 & SGA

A. Biochemical
Table 1 shows the pertinent laboratory finding of patient Ed and the possible indications with the
variability of each parameter from the normal references.
Biochemical Findings Normal/Standard Indications
Parameters References
Hemoglobin 69 136-172 g/L Below Normal; Can develop
Anemia.
Hematocrit 0.25 0.39-0.49 Below Normal; Can develop
Anemia
WBC 3.90 4.6-11 K/uL Below Normal; Higher risk
of getting sick from a
bacterium or virus
RBC 3.1 4.5-5.9 K/uL Below Normal; Can damage
the bone or kidney can cause
Anemia
Lymphocyte 0.22 150-200 mg/dL Below Normal; Low level
can also be a sign of a
condition known as
lymphocytopenia or
lymphopenia.
Monocyte 0.13 0.2-1.0 Below Normal ; Can lead to
Neutropenia and
Lymphocytopenia
Neurotrophils 0.36 1.5-8.0 Above Normal; A high
percentage of neutrophils in
the blood is called
neutrophilia. This is a sign
that the body has an
infection.
Serum 3.1 3.5-5.5 g/dL Below Normal ; May have
malnutrition. It may have
Albumin
liver disease or an
inflammatory disease.
Serum Choles 6.5 7-150 % Below Normal ; Can lead to
stroke
Triglyceride 375 150-200 md/dL Above Normal; High risk of
stroke, heart attack and heart
disease. Can also develop
acute inflammation of
pancreas.
HDL 37 40-60 mg/dL Below Normal; Higher risk
of death from cardiovascular
LDL 109 <150 mg/dL Below Normal; High risk of
Cancer and Hemorrhagic
stroke
Platelet Count 185 150-450 Normal
 B. Clinical
The Chief complaint that Patient Ed has an Angina, Difficulty in breathing, Sever
Dizziness, Right-sided weakness and numbness.

C. Dietary
Patient Ed has a Dysphagia which means he has a problem swallowing certain foods or
liquids.

D. Lifestyle
Patient Ed was diagnosed as a hypertensive a year ago and he didn’t take his
maintenance medication. He is also a heavy smoker and heavy drinker which is 6-8
bottles of beer/week

B. Diagnosis
1) Overweight related to decrease energy expenditure associated with sedentary lifestyle,
limited physical activity, heavy drinker as evidence by BMI of 26.9.kg/m2
2) Inadequate oral intake related to Dysphagia as evidenced by Mandibular Fracture.

C. Intervention

Short Term Goal

Diet Rx:
Kcal- 1,800 Rationale

CHO-

CHON-

FAT-

Long Term Goal

Diet Rx:
Rationale

D. MONITORING & EVALUATION

 Evalutaion

Monitoring Findings Goal Recommendation

1. Blood 180/120 120/80 Normal - Eat healthy food such

Pressure BP as vegetables, fruits,
fish rich in omega 3
- Quit Smoking
- Limit the amount of
Alcohol you drink or
as much as possible
quit drinking alcohols
- Cut back the caffeine
- Reduce stress
- Monitor your blood
pressure at home and
see your doctor
regularly
2. Body 37.5°C 37°C - Keep hydrated.
Temperature Drinking water, iced
tea, or very diluted
juice to replenish
fluids lost through
sweating.
- Take over-the-counter
medications like
Biogesic, Bioflu and
ibuprofen to reduce
fever.
- Take tepid baths or
using cold compresses
to make you more
comfortable.
- But no matter what
the number on the
thermometer reads, if
you have any
concerns consult your
doctor.