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Kylie Leeper assessed a 36-year-old African American male patient with pre-hypertension and occasional heartburn. The patient has a family history of obesity, heart disease, and hypertension. He has gradually gained weight over 15 years and is currently sedentary. His daily diet consists of 2 fast food meals, one beer, a home cooked meal, and snacks, totaling around 3000 calories. The nutrition assessment found the patient to have a high BMI of 35.7 and lab results indicating pre-hypertension, high cholesterol, and triglycerides. The nutrition diagnosis identified excessive calorie, sodium, and fat intake from his regular fast food consumption as problematic. The nutrition prescription recommends decreasing calorie and

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409 views

Adime 1

Kylie Leeper assessed a 36-year-old African American male patient with pre-hypertension and occasional heartburn. The patient has a family history of obesity, heart disease, and hypertension. He has gradually gained weight over 15 years and is currently sedentary. His daily diet consists of 2 fast food meals, one beer, a home cooked meal, and snacks, totaling around 3000 calories. The nutrition assessment found the patient to have a high BMI of 35.7 and lab results indicating pre-hypertension, high cholesterol, and triglycerides. The nutrition diagnosis identified excessive calorie, sodium, and fat intake from his regular fast food consumption as problematic. The nutrition prescription recommends decreasing calorie and

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api-308400395
Copyright
© © All Rights Reserved
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Kylie Leeper

NTRS 415A
1/29/16

Assessment

ADIME #1
Date/Time
Pertinent
information
provided by patient

1-27-16/3:15pm
Patient RF is African American with pre-hypertension. He has occasional heart burn
after meals and has gradually gained weight over the past 15 years. There is a family
history of obesity, heart disease, and HTN. He is currently sedentary. According to 24
hour recall his day includes eating 2 meals from fast food restaurants, one beer a day,
and a home cooked meals followed by snacks. HE eats approximately 3000 kcal a day.

Age; Gender; Dx;


PMH
Ht; Wt; UBW;
IBW; %IBW; BMI
Labs
Meds
EER; EPR;
Fluid requirements

36Y, Male, Dx: pre-hypertension; heartburn

Current Diet

Ht:510 Wt: 248lb(113kg) UBW: 248 IBW: 166lbs %IBW:149 BMI: 35.7
Bp: 140/92 FBS: 99 Cholesterol: 210 HDL:41 LDL: 134 Triglycerides: 175
Prilosec
EER: 2500kcal
EPR:90g protein (113kg x 0.8g/kg)
Fluid: 2.1L/day (1mL/kcal)
3000 kcal/day including 2 fast food meals, a beer, and one home cooked meal followed
by snacks

PES #1

Diagnosis

Excessive
energy intake

Intervention

AEB

R/T

Eating fast food


for breakfast and
lunch daily

AEB

R/T

Making poor
food choices

AEB

PES #2
Excessive
sodium intake
PES #3

/Monitoring

R/T

Eating 3000
kcal/day

Food and
nutrition related
knowledge
deficit

Weight gain
over the last 15
years and poor
food choices
Prehypertension
and BP lab
values
24 hour recall
and normal
eating habits

Nutrition
Prescription

Decrease calorie intake of patient from 3000kcal to 2500kcal per day. Also reduce
sodium and fat intake specifically by reducing fast food consumption.

Treatment plan:
nutrition therapy,
education,
acquisition of
additional
information
Plan(s) for
evaluating
outcomes of
interventions listed
above; plan for
Signature

1. Educate patient on proper eating habits and DI of fat and sodium intake.
2. Encourage and educate RF on eating more home cooked meals by meal planning.
3. Prescribe patient to begin exercise. (walking 30min/day)
4. Educate patient on other food options from fast food restaurants when on the go that
contain less fat and sodium.
5. Begin a food journal so patient is aware and can see the foods he is consuming.
1. Patient will lose approximately one pound a week by decreasing current caloric intake
from 3000kcal to 2500kcal per day.
2. Test BP regularly to keep BP lower by investing in a at home BP monitor. (Test Daily)
3. Redo lab tests and compare values of initial tests at follow up appointment in one
month.
Kylie Leeper

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