Cs Field Essay, Research Paper
CASE STUDY FIELDWORK Soap Note:1. S: Pt c c/o SOB and heart failure that comes and goes. Pt c/o poor appetite for the last few months and states she has lost 25 pounds since her surgery in December. Pt states she follows a low salt, low sugar diet and that her husband prepares the meals at home under her direction. Pt denies any CP, N/V.O: 65 y.o. white female, 67 in (170cm), CBW 147h (67kg) IBW 135 #(61kg), % IBW 108, BMI 23, BP 155/100PMH: Hx of IDDM, HTN, s/p CABG, s/p Gallbladder removalLABS: Glucose 264MEDS: IV, 1000cc + N saline @ 50cc an hour Lasix 40mg IV Q12 Kdur 20mg PO daily Bacitracin Regular Insulin Capoten 12.5 mg POTIDIMPRESSION: ?CHF, Decubiti Sacry & Lower Extremities, EdemaDr. s DIETS ORDER: 1800 cal ADA 2g NaA: Pt is at nutritional risk due to decubitis and 17% wt loss in the last 3 months which seems to be related to compromised appetite as a result of recent open heart surgery. 1800 cal diet ordered for glucose control and wt maintenance. Dietary Na restriction warranted for CHF and HTN. Protein need is increased in view of decubitus healing. Pt does not seem to be meeting needs due to compliant of poor appetite. Pt may benefit from dietary supplement. A cholesterol and saturated fat restriction may be indicated due to history of CABG. Pt does not seem attentive to counseling due to lack of attention. Kadur ordered for Lasix RX.P: Suggest 1800 kcal ADA 2g Na, ¯chol ¯sat fat diet. Will attempt to educate significant other. Suggest resource Diabetic 250 cc QD. Assist with meal planning and attempt to improve PO intake. Discuss incorporation of food preferences into daily meal plan. Check pertinent labs as available..3a) Pt is placed on a sodium restriction of 2g NA as well as low fat, sat. fat & Protein was increased to 22% due for wound healing of decubitus. Patient was placed on kdur in the hospital for potassium loss due to her diuretic. I would also try to educate her on foods with high potassium to incorporate into her diet. Patient was placed on a supplement to help meet energy needs due to poor appetite. Diet Plan: Kcal = 1800 CHO = 256g, 57% PRO = 99g, 22% FAT = 42g, 21% Meal Plan: Exchanges CHO PRO FAT KCAL 2 milk (1%) 24 16 6 180 4 vegt 20 8 0 100 5 fruit 75 0 0 300 9 starch 135 27 0 720 7 meat 3VLM 0 21 0 105 3LM 0 21 9 165 1MFM 0 7 5 754 fat 0 0 20 180 254 100 40 1825 Meal Pattern: Breakfast: 1 fruit, 2 starch, 1 fat, 1 milk Lunch: 2 fruit, 3 starch, 3 meat, 1 fat, 2 vegt Dinner: 1 fruit, 3 starch, 3 meat, 2 fat, 2 vegt Snack: 1 fruit, 1 starch, 1 meat, 1 milk Menu: Breakfast: Lunch: 1 orange + cup grapefruit juice 1 slice toast + cup sliced peaches + cup oatmeal 1 slice whole wheat bread 1 tsp. margarine (LS) 1 medium baked potato 1 cup skim milk + cup broccoli & + cup cauliflower coffee/tea 1 tsp. Margarine (LS) 3 oz broiled chicken Dinner: Snack: 1 fresh fruit (in season) + banana 1 + cup pasta 6 unsalted saltines 1 cup tossed salad 1 oz cheese 2 tbs reduced fat calorie dressing 1 cup skim milk 1 tsp. margarine b) According to the literature, uncontrolled hypertension is a precursor to CHF. Mrs. V has both HTN and DM, which are risk factors. (1) HTN is defined as blood pressure, which is 140/90 or greater. Because there is a large percentage of people whose blood pressure is higher than normal there is a major emphasis on preventing and decreasing elevated blood pressure by lifestyle changes. This diet is called the DASH diet. It is high in fruit and vegetables and low fat foods reduced saturated, total fat and low in cholesterol. (2) In a study, 459 adults were placed for 8 weeks on either one of three types of diets: a control diet, a fruit & vegetable diet and a combination diet. The combination diet, which was rich in fruits and vegetables, low fat dietary products succeeded in lowering the patient s blood pressure. The DASH diet consists of 27% fat, 55% CHO, 18% PRO, 150 mg chol. And 3000 mg Na. (3) According to another article pertaining to the coexisting conditions of DM and hypertension, while there is a large focus on pharmacological management, it is important to educate patients on non-pharmacological management as well. These recommendations include Na restriction of c) There are not many controversies surrounding this plan. It is widely accepted. One thing that I gleamed from the reading is how many physicians feel it is necessary to place the patient on an anti-hypertensive medication, but it is recommended with diet changes as well. (2) Diuretics are deemed to be an effective way to relieve sodium retention and edema and are a choice many time with hypertension. (5)d) Due to her condition of CHF, which occurs when the quantity of the blood pumped by the heart each minute is sufficient to meet the body s normal requirements for oxygen and nutrients which is often characterized by breathlessness, abnormal sodium and water retention. (6) A diet, such as the one provided, is restricted in sodium to control the fluid imbalance. I also placed her on a restricted fat and cholesterol diet, since she is s/p CABG. Too much cholesterol tends to clog the blood vessels by sticking to their walls. Reduction of cholesterol and saturated fat will lessen the aggravation of her already existing disease. Another option was placing the patient on a Step-1-Diet, but I elected to recommend that diet for home use.e) We want to monitor the patients bld values, in particular her glucose level for management of her diabetes, her cardiac enzyme to make sure she does not suffer a MI, as well as watching her electrolyte balance. Blood pressure should be taken regularly. Weight should be monitored against sudden drops. PO intake should be observed. When patient is released, refer for nutritional counseling for low fat, low-cholesterol, and sodium restriction. When patient symptoms are alleviated, light exercise may be recommended under a Dr. s supervision.f) We want to see improvement in lab values, blood pressure, and patient s adherence to dietary recommendations in order to prevent re-hospitlizaiton due to aggravated symptoms. The patients CHF will never go away but we want to make sure that the reoccurrence are limited and mild.g) 1. We want the patient to maintain weight since she is undergoing abnormal weight loss. Make sure she gets enough protein so she won t have to use her own stores to heal the decubiti. As well as carbs and fat for energy.2. We want patient to lower blood pressure which is a complication to her CHF by reducing Na, fat and cholesterol. (Instructing her on the principles of the DASH diet)3. Providing her with the knowledge and tools to maintain proper dietary habits once she is released from the hospital. h) Patient maintains 1800 calorie diet at home using Step-1-Diet, 2g Na. The Step-1-Diet emphasizes grains, cereals, legumes, vegetables, fruits, lean meats, poultry, fish, and not-fat dairy products. (7)Diet:1800 KcalCHO = 247g, 55%PRO = 90g, 20%FAT = 50g, 25%2g Na diet Meal Plan:Exchange CHO PRO FAT KCAL3 milk (1%) 36 24 9 2704 vegt 20 8 0 1003 fruit 45 0 0 18010 starch 150 30 0 8004 meats 2LM 0 14 6 110 2VLM 0 14 2 706 fat 0 0 30 270 251 90 47 1800 Meal Pattern:Breakfast: 1 milk, 1 fruit, 2 starch, 1 fatSnack: 1 fruit, 2 starch, 1 fatLunch: 2 vegt, 2 starch, 2 meat, 2 fatSnack: 1 milk, 1 fruit, 2 starchI would provide the patient with a list of items she can eat in this meal plan and what foods to avoid. I would give her some flexibility if she wants a little more meat to cut out a fat. (Dietary manual was given at the hospital for patient home use.)i) Since the patient was admitted the night before I saw her. I was in charge of the care plan under the supervision of Karen Bosco, Head Dietician. When I reviewed what we had done in the hospital I adjusted some of the percentages and grams. I agree with the 2g Na, low-fat, low cholesterol 1800 kcal diet for this patient. For the home plan I chose to give the patients a little more fat to make it more manageable for home use. I also decreased her protein due to the wound that healed and discontinued her supplement since her appetite was restored. BIBLIOGRAPHY 1. Levy, Daniel, The Progression from Hypertension to Congestive Heart Failure. JAMA, v275n20, p.1557 1563, 19962. Rose, Verna, Hypertension Care and Treatment. American Family Physician, v57n2, p.362 366, 19983. Zemel, Michael, Dietary Patterns and Hypertension: The DASH Study. Nutrition Reviews, v55n8, p.303 306, 19974. Wood, Mary, Current Considerations in Patients with Co-Existent Diabetes and Hypertension. The Nurse Practitioner, v21n4, p.19 25, 19965. Sadovsky, Richard, Congestive Heart Failure in Elderly Patents. American Family Physician, v56n5, p.118 120, 19976. Pointdexter, S., Nutrition in Congestive Heart Failure. NUTR CLIN PRACT, v1, p.83 88, 19867. Liebman, Bonnie, Dietary Intervention Trial for Nutritional Management Of Cardiovascular Risk Factors. Nutrition Reviews, v55n2, p.54 56, 1997
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