Aurelio, Lyca Mae M.

BSN II-D

NUTRITION AND DIET THERAPY LABORATORY ACTIVITY NO.4

Nutritional Assessment

I. Patient’s Profile

Name NEHEMIAS MEDRANO

Age/ Sex Cooperative Manager
Occupation 54/ M
Educational Status College Graduate

Chief Complaint: Fluctuating physical activity level, excessive stress, slight loss of appetite and
lack of adherence to diabetes management as per verbalization of “Sagpaminsan ko lang al-alan
blood glucose level ko. “

II. Health History

A. Family Health History

Causes of Mortality Causes of Morbidity Common Illnesses

Leukemia Hypertension Colds and Flu
 Sister died at the age  Mother, d/x since 47,  s/sx include runny
of 49 due to acute s/sx include nose, fever, cough;
myeloid leukemia; headaches, fatigue, managed with OTC
triggered by and chest pain; drugs, Neozep or
unresponsiveness to managed with Bioflu TID and
curative treatment. Amlodipine 5 mg OD, Paracetamol 500mg
Benazepril 10 mg OD QID.
and DASH Diet

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 (Dietary Approaches Urinary Tract Infection (UTI)
to Stop Hypertension)  s/sx include painful
 Sister, d/x since 43, urination, fever, and
s/sx include headache lower abdominal
and dizziness; pain; managed with
managed with Amoxicillin 500mg TID
Amlodipine 10 mg , Paracetamol 500 mg
OD, Metoprolol 50 QID, and increased
mg BID and DASH Diet fluid intake.
(Dietary Approaches
to Stop Hypertension) Diarrhea
 s/sx include a
Chronic obstructive frequent urge to
pulmonary disease (COPD) evacuate bowels,
 Father, d/x since 61, watery and bloody
s/sx include shortness stools, abdominal
of breath, wheezing, cramps, nausea and
chest tightness, fever; managed with
chronic cough and Pocari Sweat, OTC
lack of energy; Loperamide and
managed with oxygen increased fluid intake.
therapy, Salmeterol
and Fluticasone
inhaler BID,
Theophylline 250mg
OD, and quitting
smoking.

Diabetes Mellitus Type II

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  Sister, d/x since 46,
s/sx include fatigue,
increased thirst and
hunger and blurred
vision; managed with
Metformin 500mg
BID, low carbohydrate
diet, 30 minutes
exercise (zumba)
daily.

B. Personal Health History

Past Health History Social History Health Maintenance

Activities
Diabetes Mellitus Type II  Drinks alcohol  Sleeps 7-9 hours a day
 d/x at the age of 48, occasionally in  Exercise Regularly
s/sx include fatigue, minimal amount(1-2  Adheres to Adheres
increased thirst and bottles) to quarterly check up
hunger, dizziness and  Adheres to prescribed
areas of darkened  No travel history medications and diet.
skin ; managed with
Metformin-
Glibenclamide
(Glucovance) 500mg
BID, low carbohydrate
diet, reduced alcohol
intake, 30 minutes
exercise (biking) daily.

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 Hypertension
 d/x at the age of 44,
s/sx include headache
and dizziness;
managed with
Captopril 25mg TID,
Amlodipine 5 mg OD,
DASH Diet (Dietary
Approaches to Stop
Hypertension ),
reduced alcohol
intake and 30 minutes
exercise (biking) three
times a week.

 No surgical history
and allergies

III. Diet History

A. General Diet Information

First, Nehemias follows a particular diet called DASH diet (Dietary Approaches to Stop
Hypertension). It is a lifelong approach to healthy eating that is designed to help treat or prevent
hypertension and also shown to improve insulin production, prevent hyperlipidemia and obesity.
The DASH diet encourages him to reduce his sodium intake and eat variety of foods rich in

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nutrients such as potassium, calcium and magnesium. Second, he is not picky with foods, he likes
everything as long as it is not exotic. Third, he has strong craving on raw meat (goat meat and
beef) or kilawen, since he can only eat it during special occasions. Fourth, he rarely eats fast
foods, only if he goes to the city. Fifth, his family has adequate financial resources to purchase
foods but not the expensive ones, only the budget-friendly foods. Sixth, his family obtain food
through the local market in their community and small vegetable garden and chicken poultry in
their backyard. Nhemias’ wife regularly prepares and cooks food for the family using LPG and
dalikan. Lastly, in the last 12 months, he slightly loss weight which is from 68kg to 65kg, moderate
level of appetite is stable, did not changed his diet and no undesirable effects experienced
towards his food intake.

B. Food Intake History

3-Day Diet Recall

Day Breakfast Lunch Dinner Snack

1  3 pcs pan  1 cup rice  1 cup rice  1 slice
de sal  1 pc  2 cups suman
 1 boiled steamed cooked  2 pc lumpia
egg tilapia monggo  1 can
 1 pack  1 cup stir  1 longganisa pineapple
wholegrain fried squash  1 banana juice
crackers and string  1 cup boiled
beans peanuts
 1 banana
2  2 slice  1 pancit  1 cup rice  3 pcs puto
wheat serving  1 cup beef  2 banana
bread adobo

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  1 cup rice  1 bowl beef  2 cups  1 pack
coffee paksiw steamed whole grain
 4 pcs banana crackers
rambutan blossom  1 pack
fortified
milk

3  3 pcs pan  1 cup rice  1 cup rice  2 pcs

de sal  1 bowl pork  1 pc avocado
 1 rice lauya with steamed  1 pc tupig
coffee cabbage and galunggong  2 cups miki
 1 hard- papaya  2 cups
boiled egg  1 pc orange steamed
ampalaya
leaf

24-hour diet recall

Breakfast Lunch Dinner Snack

 3 pcs pan de  1 cup rice  1 cup rice  2 pcs avocado
sal  1 bowl pork  1 pc steamed  1 pc tupig
 1 rice coffee lauya with galunggong  2 cups miki
 1 hard-boiled cabbage and  2 cups
egg papaya steamed
 1 pc orange ampalaya leaf

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IV. Physical Assessment

General Inspection

 Coordinated gait
 Medium body build
 Conscious and alert
 Blank facial expression

Vital signs

 Temperature: 36.4 oC
 Pulse rate: 78 bpm
 Respiratory rate: 18 bpm
 Blood Pressure: 130/80 mmHg

General Body Examination

 Pallor, jaundice and cyanosis absent

 Diabetic dermopathy (DD), appears as dull red papules in lower extremities
 Edema not present
 Dehydration absent

Head, Face and Neck Examination

 Hair color and texture is normal, clean scalp

 No discharge and redness on the eye; blurred vision
 No discharge on the ear but has difficulty in hearing
 No discharge, bleeding and smelling problems on the nose
 Some missing teeth and dental carries
 No enlarged lymph nodes and thyroid gland; normal neck mobility is present

Respiratory Examination

 Normal breath sounds

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  Non-tender

Cardiovascular Examination

 Normal pulses strength

 No murmur in all areas
 Non-tender

Abdominal Examination

 No distension; moving symmetrically with respiration

 Non-tender
 Normal sounds present

Neuromuscular Examination

 Oriented in person, place, and time.

 Sensory loss in the lower extremities

V. Laboratory Data (if any)

No data available

VI. Nutrition Care Plan

Nursing Diagnosis

Risk for unstable blood glucose related to fluctuating physical activity level, excessive
stress, slight loss of appetite and lack of adherence to diabetes management as evidenced by
blood glucose levels below or above normal levels.

Nursing Goal

After 6 hours of rendering nursing intervention, the patient will be able to identify factors
that may lead to unstable blood glucose levels, verbalizes understanding of balancing body and

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energy needs, plan in modifying identified risk factors to prevent shifts in glucose level and
maintains blood glucose levels within the normal range

Nursing Intervention

Nursing Interventions Rationale

1. Assess risks and contributing factors to unstable blood glucose levels

Determine the client’s factors that may Certain risk factors like a family history of
contribute to unstable blood glucose levels. diabetes, history of poor glucose control, poor
exercise habits, eating disorders, and failure
to recognize changes in glucose needs can
result in blood glucose stability problems.

Determine the influence of client’s cultural These factors may need to be addressed in
and religious factors affecting dietary creating a client’s healthcare plan.
practices, taking responsibility for own care
and expectations of healthcare outcome.

Determine the client’s awareness or ability Age, developmental stage, maturity level, and
to be responsible for own healthcare plans. current health status affect the client’s ability
to adhere to treatment plans.

2. Assist client in creating preventive strategies for unstable blood glucose levels

Ensure client is knowledgeable about using The blood glucose monitoring device is a
his own blood glucose monitoring device. handy and accurate way of assessing blood
glucose levels. Proper usage of this device is
essential in detecting unstable blood glucose
levels.

Educate about balancing food intake with Vital in preventing a sudden increase or
physical activities. decrease in blood glucose levels.

Educate about adjusting home glucose To quickly identify fluctuating blood glucose
monitoring frequency depending on the levels for immediate correction.
client’s risk factors like stress and poor diet.

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 Review and discuss the client’s carbohydrate Blood glucose levels greatly depend on
intake. carbohydrate intake. It should be monitored
and controlled closely when stabilizing high
blood glucose levels.

Discuss how the client’s anti-diabetic Essential in ensuring the client’s

medications work. understanding of his treatment regimen to
ensure his compliance and adherence.

3. Promote wellness

Review client’s risk factors and provide Ensures prevention of unstable blood glucose
information on how to avoid complications. levels in the future.

Refer the client to a dietitian to plan specific To balance dietary intake with complicated
dietary needs based on complicated body needs.
situations.

Provide information about community For client’s access to additional resources for
resources, support groups and diabetic diabetes management.
educators.

Nursing Evaluation

After 6 hours of rendering nursing intervention, the patient was able to identify factors
that may lead to unstable blood glucose levels, verbalizes understanding of balancing body and
energy needs, plan in modifying identified risk factors to prevent shifts in glucose level and
maintains blood glucose levels within the normal range.

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