Carolyn Booth

NUTR 431 January 16th 2015

Nutrition Documentation Form
Assessment, Diagnosis, Intervention, Monitor & Evaluate (ADIME)

Case Study __5__

This assignment was from Medical Nutrition Therapy, a class that applies nutrition science
considering clinical settings. Case studies address a variety of diseases and medicalnutrition situations (ex. cardiovascular disease, pediatric care, obesity). Each case study
gives patient health history, diet patterns, and lab-work results.
A: Nutrition Assessment (Assessment info related to Nutrition Dx)
Client Hx
61 yo male admitted after MI.
Full-time Lutheran minister with
sedentary lifestyle (15-min dog
walks as daily exercise)
Smokes 1 ppd / 40 y
FH of CAD; father had MI at 59 yo

Nutrition-Focused
Physical Findings

Anthropometrics

OW
Diaphoretic
Pale

Ht 510 (177.8 cm)

Wt 185 lb (84.09 kg)
BMI 26.6
IBW: 166lb (75.5kg)

Food/Nutrition-Related Hx & Comparative Standards

(Usual Intake, Recent Intake, Diet Order, PA)

Biochemical, Medical Tests &

Procedures: As of 12/2:

Clear liquids diet with no caffeine after surgery.

Elevated lipid profile:

HDL:33mg/dL, LDL:141mg/dL,
Cholesterol: 214mg/dL, LDL/HDL
ratio: 4.3, ApoA: 98mg/dL

24-hour recall:
High intake of saturated fats, starches, 11 lean meats
and large portion sizes
Wife reports she has been using corn oil instead of
butter, fewer fried foods

-ALT, AST, CPK, and CPK-MB.

Cardiac tissue damage shown by
elevated Troponin I (2.8ng/dL) and
Troponin T (2.7ng/dL) indicators.

D: Nutrition Diagnosis (Problem-Evidence-Symptom [PES] statement)

1. Inappropriate food choices R/T (related to) food- and nutrition-related knowledge deficit
AEB (as evidence by) high intake of saturated fat and large portion sizes
2. Physical inactivity R/T short duration of low-intensity exercise AEB only 15-minute dog
walks daily
_____________________________________________________________________________
I: Nutrition Intervention (Prescription, Goal and Intervention)

Carolyn Booth
NUTR 431 January 16th 2015
Prescription:
Post-MI: NPO to alleviate digestive stresses
During hospitalization: Progression from clear liquid diet to soft foods, followed by TLC
(Therapeutic Lifestyle Change) diet at 2380 kcal (accounting for injury factor of 1.2) provided in
up to six small meals throughout the day to prevent additional stress on his GI system and heart.
Post-Discharge: TLC diet at 1682-2103 kcal (1182-1603 for 1 lb weight loss/wk).
TLC diet: Saturated fat <7% of calories; cholesterol <200 mg/d; 10 pound weight-loss; add 5-10
g/d soluble fiber; add 2 g/d plant sterols/stanols.
Goal: Lose lb to 1 lb/wk to achieve 15 lb weight loss.
Improve blood lipid profile as revealed by biochemical tests.
Indicator
Goal Range
kcal
<1600
Weight
150-170 lbs
Cholesterol
120-199 mg/dL
HDL-C
>45 mg/dL
LDL
<130 mg/dL
LDL/HDL ratio
<3.55
Intervention: Improve knowledge deficit through nutrition counseling and education, with an
emphasis on the TLC diet, portion sizes, and types of cooking fat.
Increase physical activity to 30 minutes of moderate-intensity exercise per day.
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M & E: Monitoring and Evaluation
M: Keep a food diary in order to observe adherence to nutrition recommendations and
understanding of nutrition concepts. Keep an exercise log to determine adherence to physical
activity recommendations. Continue to monitor blood lipid profile to move towards goals by
testing blood once a month.
E: Meet 1x-2x a month to assess progress and evaluate adherence to nutrition recommendations.
Make changes as necessary to improve adherence to the plan.