Patient Assessment Summary

1.4 Describe how and when to seek additional guidance about and individual’s choice of food and

In this assignment I will be choosing and describing a service user for my case study and I’m going to explain how some factors such as medical disorders, life style and many more may have influenced their dietary intake. Due to the data protection I will not be using their real name.

To further explain Joe’s rapid heart rate, the student may request an electrocardiogram to investigate any presenting heart arrhythmia's.

Looking back at the nutritional food plan for the week for my individual which I previously done in my P3, I will be looking back at the kind of food and exercise the individual was doing in that week. This will then link into my D2- as in my previous P5 for this unit I had to create my own healthier diet plan for my individual and I will be evaluating how my plan may help the individual’s health.

Based upon the 48-hour intake journal, patient eats between 1500 to 2000 calories a day. Patient has been trying to minimize foods high in sodium and fat to help regulate recommended caloric, fat, and sodium intake. Patient wants to reduce the risks of hypertension and diabetes. Patient states that she runs on the treadmill 2 times a week for 1 hour. She walks around the mall 3 times a week for approximately an hour and walks to school 4 times a week for 30 minutes. Patient sleeps approximately 7 hours per night (falls asleep around 10:00 pm and wakes up at 5:30 am). Patient falls asleep due to fatigue. Patient wakes up in the middle of the night due to difficulty sleeping, from thinking about school and stressed. Patient’s quality of sleep

The client will need a consultation with a dietician. A dietician will teach the client the appropriate foods

Patient’s diets have changed over the last 100 years and have created a large increase in chronic illnesses and higher needs for medical care. This demand has created the need for a much greater system of healthcare that includes hospitals, providers, and insurance companies.

Low Fiber, Low Residue Diet: Many of the patients that are admitted into the VA hospital are admitted for gastrointestinal issues (GI), some may require surgery. While inpatient those individuals may be placed on a low reside, low fiber diet to allow their GI to rest while in recovery. A patient may be required to continue a low fiber, low residue diet while at home. This handout explains why this therapeutic diet is important to follow as well as specific symptoms like diarrhea and abdominal cramping this diet can help reduce. This handout also, provides tips to patients on how they can continue their diet at home such as how to read nutrition labels and certain foods that to restrict such as milk and prune juice. Included in the handout is a chart with each food group, from those foods groups there are list of foods a patient can choose from and a list of foods that should be

Drinking more than that is harmful to your heart. Tell your health care provider if you drink alcohol several times a

The last visit I had with the patient on June 7th, I elected to start him on antihypertensive therapy. He was given a prescription for Zestoretic 10/12.5 mg one p.o. to take daily. He says that he did take one as recommended. That same day in the afternoon, he noted that he was short of breath in the afternoon. He says that he attributed it to the work that he was doing out in the yard and later that day, it seemed to resolve. A few days later, he had the same thing happen again. He eventually went on to see Dr. Lilly on June 25th. Please see that note for complete details. She did have him go through a series of testing, including laboratory studies, which were normal

Mary Martinez is a 72 year-old female that is here in Prep and Holding for a scheduled elective right knee replacement surgery. I am performing a final pre-op exam at 6am. The patient is awake, alert, and oriented to name, place, and date. Patient has no known allergies. Patient stated her past medical history included: atrial fibrillation, hypertension, coronary artery disease, Type II diabetes mellitus, hyperlipidemia, and osteoporosis. Medications were reviewed with patient. Patient stated taking Coumadin, aspirin, metformin, metoprolol, calcium, and simvastatin. The last time, she has taken her medications were last night at 2000, including her warfarin and aspirin. She has been NPO since midnight. Physical assessment was performed. Patient complains of chronic pain in the right knee. Pupils are equal and reactive. Lung sounds are clear with auscultation on all lobes without any respiratory distress noted. Respiratory rate is 18 breaths per minute. Patient is on room air with oxygen saturation of 97%. Heart sounds are irregular with no murmur noted. Heart rate ranges from 92 to 120 beats per minute (bpm). Blood pressure is 140/67. Labs were reviewed. Abnormal values were International normalized ratio (INR)

Food: The father has a reported condition of high blood pressure and when taken at the assessment it was 190/102. He is on medications but will receive education regarding nutritional importance. He will consume fresh foods and remove as many pre-packaged foods as possible from his daily regime.

The food that was agreed upon to use was Walnuts, Celery, Carrots, Ginger, and Mushrooms.

Annual testing for abnormalities in fasting serum cholesterol, triglyceride, HDL cholesterol, and calculated LDL cholesterol levels (ADA, 2008)

Justin's dietary habits affect his daily routine because while at work he drinks and eats things that are convenient and quick. When it comes to the weekend, he usually follows the same eating pattern because of his long hours of work during the week. He usually consumes most of his meals during the evening and during the weekend but not much great choices to reduce caries. My goals and objectives for my patient after reviewing his two five-day food diaries, I suggested to the patient to drink water with fluoride in it such as tap water which is accessible at home and at work. I also suggested that he can eat green leafy vegetables, cheese, almonds and so forth because these foods are high in calcium and low in sugar which is always important.