I. GENERAL INFORMATION The patient’s name is Mr. George Fernandez Baniel, 53 years old. He was admitted at FEU- NRMF on March 29, 2009 and stayed at room 506 B. He was discharged on April, 28,2009.
II. MEDICAL HISTORY A. Present Present Illnes Illness s and chief chief complain complaints ts The present illness started prior 1 week before the admission when the patient had swollen feet with associated scrotal swelling, occasional difficulty of breathing and easy e asy fatigability. No other accompanying accompanying symptoms like fever, coughs and cols. No medications were taken and no consultation was done. 1 day prior to the admission, still with the same condition stated above, patient’s urine output had decreased. Still no consultation was done. Then, few hours prior to admission, the condition stated above persisted and accompanied by cough, productive whitish sputum, low grade fever and chills. Chief Complaints: fever and chills B. Past Illness Illness and surgery, surgery, allerg allergies, ies, hospita hospitalizat lization ion
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Patient had usual childhood diseases such as measles, mumps and chickenpox. Patient is non- hypertensive, non- diabetic and non- asthmatic No allergies in food but allergic to medicines such as Ibuprofen and mefanamic acid Undergone appendectomy appendectomy last 1972 at Perpetual Hospital in Cebu City. He was admitted to FEU-NRMF last February 9- March 7, 2009 and was diagnosed with CHF II, CAD and Acalculous cholecystitis.
C. Physic Physical al State State of Heal Health: th: o
No appetite, digestion and elimination problems. problems.
D. Family Family Medic Medical al Histor History y o
(+) hypertension – maternal side
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(+) DM – maternal side (+) Heart disease – maternal side Mother died at age 55 due to heart disease Father died at age 84 due to old age He denies other heredofamilial diseases such as bronchial asthma, malignancy, lung and liver diseases.
THEORETICAL CONSIDERATIONS Disease Conditions Congestive Heart Failure Coronary Artery Disease
Definition Conges Congestiv tive e heart heart failur failure e (CHF) (CHF) is a condit condition ion in which which the heart's function as a pump to deliver oxygen rich blood to the body is inadequate to meet the body's needs. Corona Coronary ry artery artery dis diseas ease e (CAD) (CAD),, also also calle called d coron coronary ary heart heart disease, is a condition in which plaque (plak) builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood.
A. Et Etio iolo logy gy CHF: Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure. The most common causes of congestive heart failure are: •
coronary artery disease,
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high blood pressure (hypertension)
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longstanding alcohol abuse , and
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disorders of the heart valves. valves .
Less common causes include viral infections of the stiffening of the heart muscle, thyroid disorders, disorders of the heart rhythm, rhythm , and many others. It should also be noted that in patients with underlying heart disease, disease , taking certain medications can lead to the development or worsening of congestive heart failure. This is especially true for those drugs that can cause sodium retention or affect the power of the heart muscle. Examples of such medications are the commonly used nonsteroidal antiinflammatory antiinflammatory drugs (NSAIDs), which include
ibuprofen (Motrin and others) and naproxen (Aleve and others) as well as certain steroids, some diabetic medication, and some calcium channel blockers. blockers . CAD: Research suggests that coronary artery disease (CAD) starts when certain factors damage the inner layers of the coronary arteries. These factors include: •
Smoking
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High amounts of certain fats and cholesterol in the blood
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High blood pressure
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High amounts of sugar in the blood due to insulin resistance or diabetes
When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. The buildup of plaque in the coronary arteries may start in childhood. Over time, plaque can narrow or completely block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle. Plaque also can crack, which causes blood cells called platelets (PLATE-lets) to clump together and form blood clots at the site of the cracks. This narrows the arteries more and worsens angina or causes a heart attack. attack.
B. Inci Incide denc nce e CHF: Each year, there are an estimated 400,000 new cases. (Source: excerpt from NHLBI, Congestive Heart Failure Data Fact Sheet: NHLBI ) CAD: Incidence: 13,199,999 (USA prevalence calculated from this data: estimated 13,200,000 in the USA 2001 (American Heart Association, 2004)
C. Path Pathol olog ogy y Congestive heart failure can affect many organs of the body. For example, the weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their normal ability to excrete salt (sodium) and water. This diminished kidney function can cause to body to retain more fluid. The lungs may become congested with fluid (pulmonary edema) and the person's ability to exercise is decreased. Fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins. The intestines may become less efficient in absorbing nutrients and medicines. Over time, untreated, worsening congestive heart failure will affect virtually every organ in the body.
Corona Coronary ry Arter Artery y Diseas Disease e is charac character terize ized d by an inadeq inadequat uate e suppl supply y of oxygen-rich blood to the heart muscle (myocardium) because of narrowing or bloc blocki king ng of a coronar coronary y artery artery by fatt fatty y plaq plaque ues. s. If the the oxyg oxygen en depl deplet etio ion n is extr extrem eme, e, the the effe effect ct may may be a myoc myocar ardi dial al infa infarc rcti tion on ( heart heart attack attack)); if the deprivation is insufficient to cause infarction (death of a section of heart of heart muscle), muscle ), the the effe effect ct may may be angina angina pectoris pectoris,, or sp spas asms ms of pain pain in the the ches chest. t. Both Both condit condition ions s can be fatal fatal becau because se they they can can cause cause heart heart failure failure or ventricular fibrillation—an fibrillation—an uncontrolled and uncoordinated contraction of the ventricles (the lower chamb chambers ers of the heart heart)) that induces sudden death. Middle-aged Middle-aged men, especially those with a family history of the disease, are particulary vulnerable to deve develo lopi ping ng coro corona nary ry hear heartt dise diseas ase, e, as are are indi indivi vidu dual als s with with here heredi dita tary ry conditions such as familial hypercholesterolemia hypercholesterolemia (a disorder in which the body’s tissues are incapable of removing cholesterol from the bloodstream). Coronary artery bypass surgery or balloon angioplasty may be necessary if medications and diet diet and lifest lifestyle yle change changes s such such as frequ frequent ent exerc exercise ise and cessat cessation ion of smoking are not effective.
D. Clinical Clinical Manifes Manifestatio tations ns The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensa " compensated" ted" for the heart muscle weakness. •
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An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. The person's ability to exercise may also diminish. Patients may not even sense this decrease and they may subconsciously reduce their activities to accommodate accommodate this limitation. As the body becomes overloaded with fluid from congestive heart failure, swelling (edema ( edema)) of the ankles and legs or abdomen may be noticed. In addition, fluid may accumulate in the lungs, thereby causing shortness of breath,, particularly during exercise and when lying flat. In some instances, breath patients are awakened at night, gasping for air. Some may be unable to sleep unless sitting upright. The extra fluid in the body may cause increased urination, particularly at night. Accumulation Accumulation of fluid in the liver and intestines may cause nausea nausea,, abdominal pain, pain , and decreased appetite.
A common symptom of coronary artery disease (CAD) is angina. angina. Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get worse with activity and go away when you rest. Emotional stress also can trigger the pain. Another common symptom of CAD is shortness of breath. This symptom happens if CAD causes heart failure. failure. When you have heart failure, your heart can't pump enough blood throughout your body. Fluid builds up in your lungs, making it hard to breathe. The severity of these symptoms varies. The symptoms may get more severe as the buildup of plaque continues to narrow the coronary arteries.
Prognosis Congestive heart failure is generally a progressive disease with periods of stability punctuated by episodic clinical exacerbations. The course of the disease in any given patient, however, is extremely variable. Factors involved in determining the long term outlook (prognosis) for a given patient include: •
the nature of the underlying heart disease,
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the response to medications, medications,
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the degree to which other organ systems are involved and the severity of other accompanying conditions,
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the patient's symptoms and degree of impairment, and
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other factors that remain poorly understood.
With the availability of newer drugs to potentially favorably affect the progression of disease, the prognosis in congestive heart failure is generally more favorable than that observed just 10 years ago. In some cases, especially when the heart muscle dysfunction has recently developed, a significant spontaneous improvement improvement is not uncommonly observed, even to the point where heart function becomes normal. An important issue in congestive heart failure is the risk of heart rhythm disturbances (arrhythmias). (arrhythmias). Of those deaths that occur in patients with congestive heart failure, approximately 50% are related to progressive heart failure. Importantly, the other half are thought to be related to serious arrhythmias. arrhythmias. A major advance has been the finding that nonsurgical placement
of automatic implantable implantable cardioverter/defibrillators (AICD) in patients with severe congestive heart failure (defined by an ejection fraction below 30%-35%) can significantly improve survival, and has become the standard of care in most such patients. In the U.S., coronary artery disease is the leading killer of both men and women. In 2003, nearly 500,000 people died because of CAD. On the positive side, heart attack mortality rates have been declining. Half of men and 63% of women who die of heart disease do not have angina or other warning symptoms prior to their fatal attacks. Although at this time no tests can reliably predict whether a heart attack will occur, experts estimate that up to 30% of fatal attacks and many follow-up surgeries could be avoided with healthy lifestyle changes and by sticking to medical treatments. Two-thirds of patients who have suffered a first heart attack, however, do not take the necessary steps to prevent another.
III. SOCIO-ECONOMIC HISTORY A. Compos Compositi ition on of the fam family ily The head of the family is George Baniel and his wife is Celia Baniel. They have three children, one female and two males. Their family is nuclear.
B. Educa Educatio tional nal back backgr groun ound d George Baniel, the patient, did make it to college but unfortunately, turned down his studies because of lack of financial resources. resources. He stopped nd at 2 yr college (undergrad).
C. Type Type of of resi reside denc nce e They reside in a semi-concrete semi-concrete house that was turned over by the mother of his spouse after her death.
D. Occu Occupa pati tion on The head of the family, George Baniel, drives a bunch of car for his boss. He works as a family driver.
E. Religion George was baptized as a born-again Christian and the same as his wife and children.
F. Inco Income me brac bracke kett The client, being a driver, receives up to 12,000 - 15,000 a month.
G. Recreatio Recreation, n, hobbies hobbies & exercise exercise During free time or day offs, George enjoys playing basketball with neighbors or co-workers or sometimes with the family.
H. Cultu Cultural ral influe influence nces s They originally came from Cebu. Obviously, they are much oriented and influenced by the Visayan culture and traits.
IV. ASSESSMENT OF NUTRITIONAL STATUS A. Anthropometry Height – 5’7”
170.18 cm
2.89
Weight- 65 kg BMI =
=
= 22.49
(WNL)
DBW = 170.18 – 100 = 70.18 kg = 70.18 – 7.018 (10% of 70.18) = 63.16
63 kg
B. Biochemical Assessment
Patient’s Laborator y Values BUN (14.30)
Normal Values
Variance (High/Lo w)
Rationale For Variance
3.0-9.2 mmoL/L
High
Creatinine (130.0)
62-115 mmoL/L
High
SGOT/AST (26.0) RBS/CBG (201) Total Protein (74) Albumin (33)
5-34 U/L
Normal
Indicates increased protein in the diet and as a result of congestive heart failure ( which decreases blood flow in the kidneys ) Indicates increased protein in the diet and as a result of congestive heart failure ( which decreases blood flow in the kidneys ) Liver is normal
< 300mg/day 64-83 g/L
Normal
Blood Sugar Levels are normal
Normal
No indication of liver disease
35-50 g/L
Low
29-33 g/L
High
Indicates the presence of a disease which enables kidneys to control albumin leakage from the blood to the urine Presence of infection/inflammation (UTI)
0-48 U/L
High
Caused by congestive heart failure
40-150 U/L
Normal
Liver function normal
135-148 mmoL/L 3.50-5.30 mmoL/L
High
Indicates in increased bl blood pr pressure
Normal
Potassium levels are regulated (to monitor condition and effect of treatment) Status of digestive system/gastrointestinal system/gastrointestinal tract is WNL Relatively caused by low Albumin levels
Globulin (41) SGPT/ALT (83) ALP (67) Sodium (150.30) Potassium (5.26) Magnesium (0.94) Ionized Calcium (1.30)
0.65-1.25 mmoL/L 3.0-9.2 mmoL/L
Normal Low
C. Clinical assessment Observed signs of nutritional deficiencies by clinical changes:
Part of the body
Clinical sign
Possible nutritional deficiency
Eyes
Yellowish, droopy
Vitamin A and riboflavin
Face
Facial grimace every once in a while
Thiamine and calcium
Skin (sole of the foot)
Large amount of skin that is peeling off
Skin (total body)
Vitamin A, Water, Vitamin C, Protein and Vitamin E
Dry Muscles of the extremities
Weakness manifested by slow muscle response and action
Potassium, protein
Legs and feet
Edematous
Excessive sodium
D. Dietary assessment assessment The patient usual food intake for a day is mostly kimchi- a Korean food composed of vegetables seasoned with great amount of salt, spices and additional “ bagoong” that is fried in large or the fat of animals with or without rice (mostly without) – from lunch up to dinner. His breakfast is consisted of fried fish or vegetables and rice. In eating kimchi, the ingredients are no longer measured. The amount of each ingredient varies with every serving. What are the nutrients present in the patient’s diet? The nutrients that dominates in the patients diet is sodium and chloride or simply salt as well as fat.
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Why are these important? The primary function of sodium is the control of fluid balance in the body and participates in the transmission of nerve impulse essential for normal muscle function. And as for chloride, it is essential e ssential for the maintenance of fluid, electrolyte and acid-base balance. Fats play a vital role in maintaining healthy skin and hair, hair, insulating body organs against shock, maintaining body temperature, and promoting healthy cell function. •
What are the nutrients missing in the patient’s diet? Mostly protein is missing. Next to protein are the carbohydrates, the essential vitamins and minerals such as vitamin A, B1, B2, C, E, calcium, potassium and water.
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Why are these important?
Protein is important for the regulation of the body processes. Carbohydrates provide energy. Vitamins and minerals aid in providing for the body by enhancing other nutrients or acts as a catalysts for carbohydrates, protein, and fat metabolism. Dietary history of the patient: 1. Food Food pref prefer eren ence ces s Likes: fish and kimchi Dislikes: none (eats any kind food served) 2. Food Food patt pattern ern-- reg regula ularr Breakfast: vegetables or fish with rice Lunch: Kimchi (without rice) or kimchi pop (with rice) Snacks: nothing in specific Dinner: dishes with some kimchi ingredients 3. Usual cooking cooking methodmethod- stir frying, re-heating, frying frying in animal grease grease 4. Frequenc Frequency y of eating outout- when he starte started d working working for the Korean Korean nationals, it was lessened up until he can no longer eat out. 5. All Allerg ergy y to certa certain in foods foods-- none none 6. Other sources sources of nutrients in addition addition to usual usual food food and drink- none none but takes eskellan a food supplement for arthritis. 7. Nutrition and knowledge knowledge were were obtained- from his his instincts instincts and beliefs of of being a “cebuano” 8. AppetiteAppetite- normal, normal, not not picky picky on foods foods Dietary requirement given by the nutritionist of FEU-NRMF for everyday to Mr. George Baniel is a low sodium / low fat diet meal composed of fish or low fat meat, fruits (especially bananas) and rice. The subjective data: “madalas walang lasa ung mga pagkain. Tinitiis ko nalang kahit hindi masarap.”
V. NUTRITION CARE PLAN A. Identification of nutrition and non-nutrition related problems PARAMETERS Anthropometry Biochemical
Clinical
NUTRITION RELATED PROBLEMS N/ A Protein breakdown Malnutrition Edema Hypocalcemia
NON-NUTRITION RELATED PROBLEMS N/A Impaired kidney function Liver disease
Deficiencies of Vitamins Deficiencies of Minerals Deficiencies of Vitamins Deficiencies of Minerals
N/A
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Dietary
N/A
B. Analysis of Diet Prescription The diets prescribed by the doctor are low salt and low fat diets. The low salt diet is used for the client having diseases that affect fluid balance or where a decrease in his body fluid volume will relieve symptoms of the disease/s. His health conditions where control may be indicated are severe heart failure and high blood pressure. On the other hand, low-fat diet is a diet that consists of little fat, especially saturated fat and cholesterol, cholesterol, which can lead to increased blood cholesterol levels and heart disease risk. In the case of the client, to reduce the risk of incidence of heart problems and complications of the problem being experienced, this diet can be of great help in minimizing the client’s diseased state. We do agree with the diets given by the doctor behind the fact that the diets really fit the client e.g. in terms of prevention of the development of health threats, pursuing the diets will actually prevent potential health problems that may arise from the actual problems and another, in terms of curative when it comes to taking the right nutrients in order to diminish some manifestations manifestations of the client’s health problems.
Food Items to Choose More Often
Breads and Cereals 6 Servings per day, adjusted to caloric needs
Breads, cereals, especially whole grains; pasta; rice; potatoes; dry beans and peas; low-fat crackers and cookies
Vegetables 3-5 servings per day fresh, frozen, or canned without added fat, sauce, or salt
Fruits 2-4 servings per day fresh, frozen, canned, dried
Dairy Products 2-3 servings per day Fat-free, 1/2%, 1% milk, buttermilk, yogurt, cortage, cheese, fat-free and low-fat cheese
Eggs 2 egg yolks per week Egg whites or egg substitute Meat, Poultry, Fish <5 oz. per day Lean cuts loin, leg, round, round, extra lean hamburger; hamburger; cold cuts made with lean meat meat or soy protein; skinless poultry; fish
Fats and Oils Amount adjusted to caloric level: unsaturated oils; soft or liquid margarines and vegetable oil spreads; salad dressings, seeds, and nuts
Food Items to choose less often Breads and Cereals
Many baked products, including doughnuts, biscuits, butter rolls, muffins, croissants, croissants, sweet rolls, cakes, pies, coffee, cakes, cookies Many grain-based snacks, including chips, cheese puffs, snack mix, regular crackers, buttered popcorn
Vegetables Vegetables fired or prepared with butter, cheese, or cream sauce
Fruits Fruits fried or served with butter or cream
Dairy Products Whole milk, 2% milk, whole-milk yogurt, ice cream, cream, cheese
Eggs Egg yolk, whole eggs
Meat, Poultry, Fish Higher fat meat cuts: ribs, t-bone steak, regular hamburger, bacon, bacon, sausage; cold cuts: salami, bologna, hot dogs; organ meats: liver, brains, sweetbreads; poultry with skin-fried meat; fried poultry; fried fish
Fats and Oils Butter, shortening, stick margarine, chocolate, coconut
C. Computation of Calorie, CHO, CHON, and Fat Requirement Given:
DBW = 64 kg Kcal/kg DBW/day = 27.5 (bed rest but mobile) TER = ? CHO = ? CHON = ? FAT = ?
TER = 64 x 27.5 = 1,760 kcal
1,750 kcal
Energy Contributions: Contributions: CHO = 1,750 x 0.65 = 1,137.5 kcal CHON = 1,750 x 0.15 = 262.5 kcal FAT = 1,750 x 0.20 = 350 kcal Required Intake for each nutrient: CHO = 1,137.5 / 4 = 284.375 CHON = 262.5 / 4 = 65.625 FAT = 350 / 9 = 38.88
Diet
285 g 65 g
40 g
: 1,750 kcal; CHO 285 g; CHON 65 g; FAT 40 g
D. Sample One-Day Menu duly signed by a Registered Nutritionist-Dietitian Nutritionist-Dietitian
Breakfast 2/3 c bran cereal 1 slice whole wheat bread 1 medium banana 1 c fruit yogurt, fat free, no sugar added 1 c fat-free milk
2 tsp jelly
Lunch 1/4 c chicken salad 2 slices whole wheat bread 1 T mustard 1/2 c fruit cocktail, juice pack
Salad: 1/2 c fresh cucumber slices 1/2 c tomato wedges 2 T ranch dressing, fat free
Dinner 3 oz spicy baked fish 1 c green beans, cooked from frozen, without salt 1 small baked potato 2 T fat-free sour cream 1 T chopped scallions 2 T grated cheddar cheese, natural, reduced fat 1 small whole wheat roll 1 tsp soft margarine 1 medium peach 1 c fat-free milk
Snack 1 c orange juice 1/3 c almonds, unsalted 1/4 raisins 1 c fruit yogurt, fat free with sugar
References: •
Client’s records
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http://www.labtestsonline.org
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http://www.weight-loss-professional.com
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Grodner, Long, et. al. Foundations and Clinical Applications of Nutrition: A Nursing Approach. Winsland House I, Singapore. Mosby, Inc. 2004
LEARNING INSIGHTS
The study had given us the opportunity to be exposed to a client – considered as the core of nursing care. It allows us to practice nursing as part of a broad field of profession behind the fact that as nurses in the near future, diverse duties and responsibilities are to be performed as such in terms of nutrition of a certain client/patient. In addition, beyond the technical benefit of the study, it also enhanced the collaboration and harmonious rapport among us which is actually vital to the efficiency and effectiveness of a healthcare team. “Nursing is a holistic care.” This adage is often become a basis for nurses in carrying out their nursing care. As a holistic care, nursing focuses not only in managing disease/illness state but also in deciphering the etiology contributory to the disease/illness which can be derived in some cases due to poor nutrition. With this guideline, we can formulate the correlation between nursing and nutrition. In nursing assessment, particularly during interview with patients, nutritional assessment is made. The said assessment is essential for the making of a plan of nursing care
which can dictate nursing interventions that could eventually help patient/s in attaining optimal nutrition. One intervention a nurse can perform is diet education for the patient. This study can be a reference for nurses in conducting health teaching to the client involved herein and the like. Diet education for the hospitalized patient is often overlooked because no referral is made for education or the diet is related to an old diagnosis. It is sometimes difficult for the nurse to discern how much information to provide. Often patients are dealing with more urgent medical issues and cannot give full attention to learning a new diet. It is essential to let the amount of education be patient-guided to avoid overwhelming overwhelming him or her. Using valuable time to teach an uninterested patient could result in missing an educational opportunity with a motivated patient. The best course of action is to: inform the patient of the diet; be available for questions; provide basic written information; verbally emphasize a few memorable key points; and provide contact information or refer the motivated patient to the dietitian. Emphasizing a few key points is the crux of diet teaching. For the purpose of this experience, we are referring to these points as “nursing skills.” Nursing skills are immediately useful, small pieces of knowledge patients can use at home. Then when he/she is medically and mentally ready, diet knowledge can be developed using the written material a nurse has provided, and the patient can decide whether further education is desired. Complete nutritional education should be done on an outpatient basis where it is the main focus, without other urgent medical issues to hinder the learning process. We hope you will find these nursing skills useful. It is important to feel comfortable with the nutrition education you provide to your patients.
