Mr. B, a 47-year-old man, 6 ft 2 in tall and weighing 200 lb, is admitted to the hospital with chest pain. Three days after admission, at patient care rounds, it is discovered that Mr. B has gained 30 pounds over the last 2 years. Review of the medical record reveals the following laboratory data: LDL: 240 (desirable 130), HDL 30 (desirable .50), triglyceride 350 (desirable ,200). Blood pressure is 120/85. Current medications: multivitamin/mineral daily. Cardiac catheterization is scheduled for tomorrow. Diet history reveals frequent consumption of high fat foods.
Nutrition Diagnostic Statements
Altered nutrition-related laboratory values related to undesirable food choices as evidenced by elevated LDL and low HDL. Excessive fat and energy intake related to consumption of high fat foods at all meals as evidenced by patient report.
Nutrition Care Questions
1. What other information do you need to develop a nutrition care plan?
2. Was nutrition screening completed in a timely manner? Discuss the implications of timing of screening versus implementing care.
3. Develop a chart note, using ADIME format, based on this information and the interview you conduct with the patient.
4. What nutrition care goals would you develop for this patient during his hospital stay?
5. What goals would you develop for this patient after discharge? Discuss how the type of health care insurance coverage the patient has might influence this plan.