Alicia Walker Nutrition Assessment 3/20/14

Care Plan Narrative

SOCIAL HISTORY: Mr. L is an 80 yo white male who resides alone in Petersburgh, NY. His wife died 14 years ago, from leukemia. He lives in a mobile home, only a few hundred feet from his only child. She is 44 yo and has three daughters of her own. Mr. L is a retired draftsman. He currently works in the town at his church and Town Hall. He possesses adequate funds for food and shelter. He owns a car and is able to drive, so he has access to food as well. Mr. L quit smoking almost 30 years ago. He reports alcohol consumption socially, equaling about 3 drinks/week. NUTRITIONAL IMPLICATIONS: Mr. L lives in Petersburgh, so access to food is difficult. Petersburgh is rural, and it takes about 20 minutes to get to the nearest grocery store. Since he has a vehicle, he is able to combat his environment. Mr. L lives alone, but his daughter is close by. If he is in need, he could always call her. MEDICAL HISTORY: Mr. L was diagnosed with HTN in 1999, and GERD in 2008. Mr. L was diagnosed with prostate cancer and received seed implants in June 2002. Yearly, he undergoes a PSA blood test and his counts have been great. Mr. L experienced a mild myocardial infarction in August 2003 and went to the hospital. He had an angioplasty and stent placement (2 stents). In April 2004, Mr. L underwent a cholecystectomy. In October 2004, Mr. L underwent a herniorrhaphy, located in his abdomen. In February 2012, Mr. L experienced repeated cardiac arrests, approximately 5 separate times due to a severe myocardial infarction. He again had an angioplasty and stent placement, with 2 more stents placed (he now has 4 altogether). Following this surgery, Mr. L also had an ICD unit placed. This unit acts as a pacemaker, as well as a defibrillator. This unit was placed in March 2012. He visits his cardiologists every 6 months and receives a blood test, along with an EKG. NUTRITIONAL IMPLICATIONS: Mr. L has had a wide variety of problems, with multiple surgeries and visits to the hospital. He experiences symptoms of GERD, and this in turn leads him to follow a bland diet. Controlling blood pressure and sodium intake are a big focus, due to his problems concerning his heart. Nutrition practices can help to decrease his symptoms from

GERD and lower his blood pressure. Helping these problems could improve his QOL and potentially decrease his hospital visits. DIET HISTORY: Mr. L prepares his own meals and only eats out at a restaurant occasionally (once a month). His daughter sometimes brings him things that she has prepared. He is able to feed himself and follows a routine diet to avoid symptoms from GERD. He has been preparing his own food for 14 years, so he is well versed and able. Mr. L has a good appetite and eats a variety of food choices. He is intelligent and tries to follow healthy guidelines put forth by his doctor. NUTRITIONAL IMPLICATIONS: His diet recall is slightly high in sodium, and low in calories and cholesterol. His fiber is also low, but he does ingest a decent amount. He diet is also low in iron, calcium, potassium, and Vitamin D & E. His diet is low in fat, but adequate in carbohydrates and protein. His dairy intake is almost non-existent. He includes whole wheat, and low fat milk in his diet. MEDICATIONS: Omeprazole (20mg)- treats heart burn and GERD by preventing the stomach making acid. Proton-pump inhibitor. NUTRITIONAL IMPLACATION: for best results, take before meals. Side effects may include headache, nausea, diarrhea, stomach pain, or constipation (MedlinePlus). Mr. L is not now experiencing any of these symptoms. Aspirin (81 mg)- reduces the risk of myocardial infarction. Analgesic NUTRITIONAL IMPLICATION: Side effects may include upset stomach and heartburn. Other side effects include severe stomach pain, bloody vomit or vomit that looks like coffee grounds, and blood in the stool or urine (MedlinePlus). Mr. L is not experiencing any of these symptoms as of now. Carvedilol (37 mg)- treats high blood pressure and reduces the risk of myocardial infarction. Avoid alcohol intake and avoid taking a multivitamin, may decrease the action of the drug. Beta-blocker. NUTRITIONAL IMPLICATIONS: symptoms may include diarrhea, unusual tiredness and weakness (MedlinePlus). Mr. L is not experiencing any of these symptoms at this time. Benicar (20mg)- treats high blood pressure and reduces the risk of myocardial infarction. Avoid over the counter potassium supplements. Angiotension receptor blocker.

NUTRITIONAL IMPLICATIONS: symptoms may include dizziness, headache, and severe diarrhea (MedlinePlus). Mr. L is not experiencing any of these symptoms as of now. Ticlopidine (250mg)- prevents blood clots from forming in veins and arteries. Take with or right after ingesting food to reduce stomach upset. Platelet Aggregation Inhibitor. NUTRITIONAL IMPLICATIONS: symptoms may include bloating, gas, stomach pain, dizziness, and mild diarrhea (MedlinePlus). Mr. L is not now experiencing any of these symptoms. Amlodipine (10mg)- treats high blood pressure and prevents event of myocardial infarction. Multivitamins/minerals may decrease the action of the drug. Calcium Channel Blocker. NUTRITIONAL IMPLICATIONS: symptoms may include chest pain, dizziness, or unusual tiredness (MedlinePlus). Mr. L is not now experiencing the symptoms. Simvastatin (40mg)- treat high cholesterol and prevents event of myocardial infarction. Avoid grapefruit/grapefruit juice because it can increase the level of drug in the blood. HMG CoA reductase inhibitor. NUTRITIONAL IMPLICATIONS: symptoms may include nausea, vomiting, stomach and muscle pain, and weakness (MedlinePlus). Mr. L is not experiencing any of these symptoms as of now. Metocolpramide (5mg)- treats GERD. Avoid alcohol intake. Dopamine-2 receptor antagonist. NUTRITIONAL IMPLICATIONS: symptoms may include constipation, diarrhea, headache, restlessness, and trouble sleeping (MedlinePlus). Mr. L is not now experiencing any of these symptoms.

PATHOPHYSIOLOGY: Mr. Ls present problem is HTN. This problem could be due to genetic disposition or excessive sodium intake over a period of time. The pathophysiology of this disease will be discussed below. HTN is defined as persistently high arterial blood pressure (the force exerted on the walls of the arteries). Systolic blood pressure (contraction phase of the cardiac cycle) must be 120 mm Hg or more, and diastolic blood pressure (relaxation phase of the cardiac cycle) must be 80 mm Hg or more to be considered HTN. HTN is classified in stages related to the risk of developing CVD. HTN is a common public health problem, affecting around 74 million Americans (Mahan, Escott-

Stump, & Raymono, 2012, 758). One in three adults has HTN. If left untreated, HTN can lead to HF, end-stage renal disease, along with other degenerative diseases. It is often referred to as the silent killer because individuals can be asymptomatic for years, and suffer a fatal myocardial infarction or stroke. There is no cure, however, it is controllable (Mahan, EscottStump, & Raymono, 2012, 760). Mr. L reports high intake of sodium and cholesterol in his diet, prior to being diagnosed. He claims that he followed a poor diet along with physical inactivity and smoking. There is also family history of HTN, his mother and sister were both diagnosed with HTN. The development of his HTN is multi-factorial. Prevention of HTN is key and can be achieved by lifestyle modifications, awareness, treatment, and control of blood pressure. Primary prevention can improve quality of life and expenses. Prevention and treatment can both be achieved through medical nutrition therapy. For patients experiencing HTN or pre-hypertension, the DASH diet is often recommended. The DASH diet has a focus on fruits, vegetables, whole grains, low fat or nonfat dairy and lean proteins, and avoids processed, high sodium, and high fat food choices. It is high in fiber, calcium, potassium, and magnesium, and low is saturated fat, cholesterol, and added sugar. Calcium, potassium and magnesium, when taken together, may help reduce blood pressure (Mahan, Escott-Stump, & Raymono, 2012, 1108). The DASH diet can be high in protein, phosphorus and potassium, depending on how it is implemented. This makes it not advisable for patients with end-stage renal disease (Mahan, Escott-Stump, & Raymono, 2012, 762). Weight loss is another way to treat, or possibly cure hypertension. The risk of developing elevated blood pressure is two to six times more likely in individuals who are overweight compared to those of a normal weight, based on BMI (Mahan, Escott-Stump, & Raymono, 2012, 763). Physical activity can help decrease blood pressure, due to weight loss and increased blood flow. Avoidance of sodium is also important due to the correlation found between high intake of sodium and high risk of heart attack or stroke. Finally, alcohol consumption of three drinks/day is found to increase an individuals risk for hypertension. No more than two drinks should be consumed each day. Life-style modifications should be attempted before drug therapy is initiated (Mahan, Escott-Stump, & Raymono, 2012, 764). For Mr. Ls needs, the DASH diet would recommend 6 servings of grains (whole grain), 3 -4 servings of vegetables, 4 servings of fruit or 100% fruit juice, 2-3 servings of dairy (nonfat or low fat), 1-2 servings of meat, poultry or fish, and 2 servings of fats and oils (low fat, light). Nut and seeds are included, 3 servings per week are recommended. Sweets are not recommended for everyday consumption, and when consumed, should be low in fat (Mahan, Escott-Stump, & Raymono, 2012, 1108).

Mr. Ls current diet is low in calcium, high in sodium, low in fiber, and low in calories. He attempts to follow a heart healthy diet, however he is not entirely knowledgeable about how to achieve this. The changes he has made to his diet were a great start, and show that he can achieve behavior modifications. ASESSMENT: Mr. L has a number of health problems that can be treated using nutritional tactics. His has attempted to change his diet already, and added what he thought would be beneficial and adequate. The changes were a great start, but his diet could use some help. It is high in sodium (almost double what he should have), low in fiber, and low in calcium. He takes medications that may cause constipation or diarrhea, so fiber plays an important role in that aspect as well. It is also low in calories, however he could be under-reporting. Mr. Ls intake of fluids was low as well, and consisted of caffeinated and sugary choices. Mr. L shows good signs that he will be dedicated to make the changes I recommend, due to the changes he has made already. Mr. L is willing and well educated, just not in nutritional approaches to treatment. His current BMI is 27.7 kg/m2 which is classified as overweight, but is close to normal weight. Mr. Ls estimated energy needs (based on Mifflin St. Jeor with activity factor) is 1577 kcal, 52 gm protein (based on 0.8 gm/kg BW), and 2000 ml fluid (due to the need of at least 2000 ml). Right now, his diet consists of ~1300 kcal and 80 gm protein with inadequate fluid intake, not to the point of dehydration. His diet is high in protein, low in calories, low in calcium, low in potassium, low in fiber, and low in Vitamins D, E, & K. Currently, based on calories, he eats about 80% of his estimated energy needs. Nutrition education is needed in order to educate Mr. L on food choices that could help him to reach his recommendations easier (calcium, potassium, fiber, and Vitamins D, E, & K rich foods). He is already active, so he does not need education. PLAN: SHORT-TERM GOALS1.) Implementation of DASH diet within one week LONG-TERM GOALS1.) Decrease sodium intake to 2000 mg/day within one month 2.) Increase calcium intake to 900 mg/day within one month 3.) Weight maintenance of +/- 2 lbs of current weight

IMPLIMENTATION: 1.) Obtain Mr. Ls food preferences, and recommend appropriate snacks that also fit with the DASH diet guidelines. 2.) Recommend healthy ways to obtain calcium from oral intake (low or nonfat dairy choices, dark leafy greens, fortified cereal, etc.). 3.) Request the Mr. L keep a food diary for one week. Assess intake. 4.) Complete a f/u assessment within one month.

Reference List

Mahan, Kathleen L., Escott-Stump, Sylvia, & Raymond, Janice L. (2012). Krauses Food and the Nutrition Care Process, Edition 13. Elsevier. MedlinePlus; Trusted Health Information for You. (2014). National Institutes of Health. Retrieved from http://www.nlm.nih.gov/medlineplus/