Nutrition Care Process - Case Study 4

Name: Michaela Patrisse Roldan Yr & Sec: BSND201 Instructor: Ms. Criselda Joy Dela Cruz

Case Study:

EC is a 71 year old Filipino born woman who is 4 feet 11 inches tall and weighed 47 kg. She is referred to
nutrition counseling with the following medical conditions: (1) Hypertension, (2) Dyslipidemia.

EC has always been a stay at home mother who has 3 children who are all now working, and now
shoulders the expenses of their household. For EC it is such a relief that she no longer needs to cook a
meal for her family since she always stays alone at home. She is not fond of cooking but cooks anyways
for her kids, when she is alone almost everyday she opts for instant and ready to cook meals for herself
and on weekends she cooks meals like Kare-kare, Lechon Kawali anything fried and high in sodium
because it is the only time she and her kids are complete.

Every Morning she would always have a cup of coffee, a pastry or anything available in her pantry and
would have it for breakfast. After breakfast she would tend to her garden and do some household chores
like washing dishes, sweeping the floor which makes it her physical activity. She doesn’t like having a
morning snack and afternoon snack, instead she likes to have a big lunch and dinner. Often she becomes
lazy in cooking her food she orders through food delivery service, her order consists of anything fried,
with rice and a side of fries or soup. For her dinner she opens anything that is easy to eat and canned food
just so she doesn’t have to prepare too much.

She always has trouble sleeping, always in need to urinate, swelling of feet and ankles, tired and weak.
She decided to have her checked when she observed that her urine is bubbly and foamy.

EC had done her test twice and showed no improvement from her results which led her to be referred to
nutrition counseling . Her test results show that her Cholesterol, LDL, VLDL, HDL Ratio, and Creatinine
are all elevated. She does not have medication prescription and is hoping by changing her diet and
lifestyle can decrease her hypertension, dyslipidemia and chronic kidney disease.
ASSESSMENT DIAGNOSIS INTERVENTION MONITORING AND
EVALUATION

Objective Data: ● Elevated ● Implement a ● Continuously

cholesterol levels heart-healthy monitor the
Age: 71 predisposing to diet patient's progress
Sex: Female dyslipidemia and emphasizing and adjust the
Ht: 4”11 cardiovascular fruits, nutrition plan as
Wt: 47kg risk. vegetables, needed.
BMI: 21.17 ● Impaired kidney whole grains, ● Maintaining a
function lean proteins, healthy balanced
Subjective Data: indicated by and healthy fats diet.
elevated (e.g., olive oil, ● Regularly assess
● trouble sleeping creatinine levels. fatty fish). blood pressure,
● always in need to ● Potential ● Limit intake of lipid levels, and
urinate electrolyte saturated fats, renal function to
imbalances due trans fats, and track improvements
● swelling of feet
to chronic kidney cholesterol to and make necessary
and ankles disease. manage modifications to the
● tired and weak. ● Increased risk of dyslipidemia. nutrition
● urine is bubbly and Chronic Kidney ● Monitor intervention.
foamy. Disease due to sodium intake ● Overall patient has
hypertension and to control blood improved health
dyslipidemia. pressure. condition
● Consider a
phosphorus-
restricted diet
to manage
chronic kidney
disease,
limiting dairy,
processed
meats, and
high-
phosphorus
additives.
● Monitor
potassium
intake, focusing
on moderation
and choosing
low-potassium
options to
prevent
hyperkalemia.
● Encourage
adequate
hydration
unless
 contraindicated
by kidney
function.
● Adjust protein
intake based on
individual
needs and
kidney
function,
aiming for
moderate
protein intake
to minimize
strain on the
kidneys.
● Educate on
portion control,
mindful eating,
and label
reading to
empower the
patient in
making
healthier food
choices.