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ADIME Note: Hypertension: Assessment

This African American male patient presented with elevated blood pressure and a family history of hypertension, obesity, and heart disease. He consumes fast food for most meals and does not exercise regularly. His current daily calorie intake is 3000 kcal. Laboratory results show pre-hypertension, elevated cholesterol and triglycerides, and a BMI of 35.6. The diagnosis is excessive calorie, sodium, and fat intake from fast food. The intervention plan recommends a reduced calorie diet of 2185 kcal per day, less than 1500 mg sodium per day, nutrition education, exercise 3 times per week, and follow up in 2 weeks.

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Jasperl Niña Malabuyoc
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1K views

ADIME Note: Hypertension: Assessment

This African American male patient presented with elevated blood pressure and a family history of hypertension, obesity, and heart disease. He consumes fast food for most meals and does not exercise regularly. His current daily calorie intake is 3000 kcal. Laboratory results show pre-hypertension, elevated cholesterol and triglycerides, and a BMI of 35.6. The diagnosis is excessive calorie, sodium, and fat intake from fast food. The intervention plan recommends a reduced calorie diet of 2185 kcal per day, less than 1500 mg sodium per day, nutrition education, exercise 3 times per week, and follow up in 2 weeks.

Uploaded by

Jasperl Niña Malabuyoc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ADIME Note: Hypertension

Assessment:
The patient is an African-American male. He presented to his family physician with elevated
blood pressure and heartburn. He has a family history of hypertension, obesity, and heart
disease. He has steadily gained weight over the past 15 years and does not exercise regularly,
despite being an athlete when he was younger. The 24-hour recall reveals that the patient
consumes fast food for breakfast and lunch. His wife prepares his dinner, and he occasionally
consumes snacks after dinner. He consumes one beer per day. Based on the 24-hour recall, his
energy intake was 3000 kcal.

36 y.o. male
Dx: Pre-hypertension
Ht. 5’10” (70 in. or 178 cm), Wt. 248 lbs. (112.7 kg)

Labs:
BP: 140/92 mmHg (High)
FBS: 99 (Normal)
Chol: 210 mg/dL (Borderline high)
HDL: 41 mg/dL (Normal)
LDL: 134 mg/dL (Borderline high)
Triglycerides: 175 mg/dL (Borderline high)

EER: 2,685 kcal


EPR: 90 g
Fluid needs: 2,685 mL/day = 2.7 L/day
BMI: 35.6
IBW: 166 lbs.

Diagnosis:
1. Excessive energy intake R/T consumption of fast food for breakfast and lunch AEB
intake of 3,000 kcal on 24-hour recall.
2. Excessive sodium intake R/T consumption of fast food for breakfast and lunch AEB
blood pressure of 140/92.
3. Excessive fat intake R/T consumption of fast food for breakfast and lunch AEB blood
LDL levels of 134 mg/dL and blood triglyceride levels of 175 mg/dL.
4. Obese, class I R/T nutrition-related knowledge deficit and physical inactivity AEB BMI of
35.6.
5. Food and nutrition-related knowledge deficit R/T calorie-dense, but nutrient-poor food
choices AEB 24-hour recall.

Intervention:
1. Recommend that the patient consume 2,185 kcal per day to lose up to 1 lb. per week.
2. Recommend that the patient consume no more than 1,500 mg of sodium per day.
3. Educate the patient and his wife on identifying high-sodium and high-fat food items by
understanding food labels. Explain how excessive intake of sodium and fat can worsen
hypertension and increase the risk of heart disease and obesity. Also, explain how
consumption of meals that are high in fat can worsen heartburn.
4. Provide handouts and online resources that the patient and his wife can use to identify
spice substitutions for salt and to get ideas for low-calorie, portable meals and snacks.
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5. Refer the patient and his wife to a community class on healthy food preparation to
increase food preparation skills and healthy meal ideas.
6. Recommend that the patient exercise by playing basketball with his son or going for a
walk with his wife for 30 minutes three times per week.

Monitoring/Evaluation:
1. The patient will lose 1 lb. per week.
2. The 24-hour recall or food diary will show that the patient is following the low-sodium,
reduced-calorie diet plan.
3. The patient will state an understanding on which foods are high in sodium and fat, as
well as how to read food labels.
4. The patient will state an understanding of low-sodium, low-fat food preparation,
particularly in meals that can be packed and consumed at work.
5. The patient’s blood pressure will decrease, nearing normal range (less than 120/80
mmHg).
6. The patient will exercise for 30 minutes three times per week.

Follow up in 2 weeks.

Alyssa Snow Callahan


Student dietitian

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