Question

Course Project: Nutrition Care Process: Assessment

Assignment Overview

After reading the case study below, you will create a nutrition care plan for the client. This week you will complete section A, the nutritional assessment. This portion of your nutrition care plan is worth 40 points. Please refer to the Grading section of this document for the distribution of these points. You will also find Writing Guidelines at the end of this document that will assist you in meeting the expectations for writing your care plan.

This assignment is intended to explore basic nutritional principles such as energy requirements, sources, and uses. Additionally, you will formulate nutritional assessments and describe nutritional requirements corresponding to stages in the life span. You will also examine how effective nutritional counseling is contingent upon collaboration, organization, and concurrence among the members of the health care team.

Assignment Details:

Perform the following tasks:

Complete the reading assignment and the interactive lesson before attempting this assignment.

Please review the following case study:

Case Study: Mr. Leonard Anderson is a 38-year-old male, 5 feet 8 inches tall and weighs 215 lbs. This has been his stable weight for most of his adult life. He has been diagnosed with GERD. Testing revealed he has a narrowing of his esophagus from the GERD. His symptoms consisted of food (even though chewed thoroughly) getting caught in his throat, and frequent and severe heartburn about 1 hour after eating. Mr. Anderson continues to eat his diet which is high in carbohydrates and fat. He also complained of some pain in and around his jaw and neck. Mr. Anderson meets with his physician and is started on a proton pump inhibitor. Mr. Anderson is concerned because he has never taken anything besides over-the-counter medicines before. He is also scheduled for a colonoscopy. It was noted that he has diverticulosis.

Complete the following:

Review Nutrition Care Process at the eatrightPRO® website (you can locate this article by going to www.eatrightpro.org, clicking on Practice in the top navigation, and in the Dietetics Resources section, click on “Nutrition Care Process”) and Chapter 17 of your text. Use the digital library resources for research.

Complete a nutrition care plan for Mr. Anderson using the Nutrition Care Process worksheet located in your course. Note: You will need to open this document and save it to your computer. Use the same template for weeks 8, 9 and 10.

Focusing on the assessment portion of the plan, complete the portions of Section A.

Submit the Week 7 Assignment via Blackboard by clicking on the “Week 7 Assignment” link.

Include the proper file naming convention: SCI115_wk7_assn_jsmith_mmddyyyy.

Grading:

Gradable items in assignment	Points
Complete Section A physical assessment.	15
Complete Section A nutrition evaluation.	15
Complete Section A nutritional needs.	5
Adhere to Writing Guidelines (see below).	5
Total Points	40

Writing Guidelines:

	Exemplary	Accomplished	Developing	Beginning
Content	High quality information focuses on the task/topic in engaging ways Intriguing and/or compelling examples, evidence	All information is accurate and focused on task/topic Examples and evidence support topic	Information sometimes repeated and/or wanders from prompt/task; may contain inaccuracies Examples and evidence are incomplete; lacks detail	Information inaccurate, inadequate or omitted Examples and evidence are unclear or missing
Writing Conventions	Accurate spelling, grammar, and punctuation (0 errors).	Grammatical, spelling & punctuation errors are rare (2 errors per page avg).	Grammatical, spelling & punctuation errors are common (3 errors per page avg).	Grammatical, spelling & punctuation errors significantly detract from meaning of paper (4+ errors per page avg).

NUTRITION CARE PROCESS Male_X_Female___                Age:         38                      Initials:       LA          Date:
A	Diagnosis: ____________________________________________________________________________ Relevant Medical/Surgical History: _______________________________________________________ Pertinent Medications:_________________________________________________________ PHYSICAL ASSESSMENT Age________     Ht________      BMI_____     Weight ________ Describe any recent weight changes:_________________________________________________________ Chewing/Swallowing issues: __           Nausea/Vomiting: __          Elimination:   _ Describe the problem and possible causes____________________________________________________________________ Pertinent Diagnostic Studies_______ ________________________________________________________________ NUTRITION EVALUATION Present Diet:_________________________________ Dietary Supplements: _____________________ Diet history as appropriate: _____________________________________________________________________ ___________________________________________________________________________________________ ESTIMATED NUTRITIONAL NEEDS Calories:   __________________        Protein: _______________________ Fluid needs:      _________________________ Increased requirements for: ______________________________________________________________________ Method and rationale: __________________________________________________________________________ Based on the Assessment what are the main concerns and potential problems for this client _____________________________________________________________________________________________________
D	NUTRITION DIAGNOSIS: List 2 actual diagnosis and 2 potential diagnosis and the rational for each based on the specific information about your client.
I	INTERVENTION: Based on all of the information gathered to this point what would be 3 interventions that would improve the wellness of this client? List them in order of priority and explain why you chose and ordered each intervention
M – E	MONITORING AND EVALUATION: Come up with a plan for ongoing monitoring. What should be included? Then determine how you will evaluate your plan (how will you know it is working) what would you look for in the short term? Long term?

Answer 1

NUTRITION CARE PLAN:
?A, Diagnosis:- Gastro esophageal reflux disease
?    Relevant medical/surgical history:- Medical history includes food getting caught in his throat,and frequent and severe heart burn about 1 hour after eating..Some pain in and around his jaw and neck.
    Pertinent medication:- Proton pump inhibitor
? PHYSICAL ASSESSMENT:-
   Age: 38yrs    HT: 5feet and 8inches BMI: 32.7    wt: 215
?    Describe any recent weight changes:    Nil
? Chewing/swallowing issues:    Food getting caught in his throat(even though chewed thoroughly)
   Nausea/vomiting-    No
   Elimination: Normal
?Describe the problem and possible causes:- Anderson main problem he is having narrow esophagus..he is having GERD symptoms like food geeting caught in his throat and frequent and severe heart nurn and pain in and around his jaw and neck..
?    When we swallow lower esophageal sphinter relaxes to allow food and liquid in to your stomach then the sphinder closes again..
? When there is abnormality or weakness,stomach acid flow back upto the esophagus..due to acid irritates the lining of your esophagus causes inflamed esophagus..
    Damage to the lower esophagus from stomach acid causes scar tissue to form..The scar tissue narrows the food pathway,leading to problems with swallowing..
Persistent Diagnostic Studies: Colonoscopy..
NUTRITIONAL EVALUATION:
?Present diet: He eats high carbohydrates and fat diet..
?Dietary supplements:    low-fat,high-fiber diet,heavy whole grains,fruits and vegetables and lean meats..
?Diet history as appropriate: he eats high carbohydrated and fat diet
?Estimated nutritional needs:
Calorie: 4.1868 Protein: 98-176 grams/day    Fluid needs: 1960ml(20ml/day)
?Increased requirements for: High-fiber,low-fat diet and increased vegetables and fruits..
?Method and rationale: Eating small,frequent meals instead of three large meals,smaller meals are easier on your stomach they give less pressure on the esophagus and stomach..avoid caffeinated and spicy food it worsen the heart burn..
Based on the assessment what are the main concern and potential problems for this client:
?    Patient already having a present history of difficulty in swallowing as a complication of GERD that narrow esophagus can cause esophageal cancer(Barrett's esophagus)
D,NUTRITION DIAGNOSIS:
?    Actual diagnosis: esophagitis, esophageal stricture
?    Potential diagnosis: Esophageal cancer, and tooth decay
? Rationale:
? Peolple with GERD can develop with this condition patient eating high fat diet can cause in stomach acid it can lead to precancerous changes in cells..But doctors can remove the abnormal cells when it diagnosed earlier.
?    Tooth decay: stomach acid can also accumulate in down to your enamel it can weaken the tooth and lead cavities..so that the patient already having pain in jaw..