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    CHF Case Study

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    Jesse Terris is a 38-year-old woman who was recently diagnosed with heart failure. She is 6 weeks postpartum and has a history of hypertension and anemia. She has lost her appetite and reports foods tasting bad. Her weight is 120 lbs with a BMI of 20.62. The nutrition assessment found she has inadequate intake due to loss of appetite and lacks knowledge of her cardiac diet. The intervention includes education on her cardiac diet of 1362-1635 kcals and 54-65g protein daily to improve her intake and understanding of her condition.

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    CHF Case Study

    Uploaded by

    api-622273373
    181 views3 pages
    Jesse Terris is a 38-year-old woman who was recently diagnosed with heart failure. She is 6 weeks postpartum and has a history of hypertension and anemia. She has lost her appetite and reports foods tasting bad. Her weight is 120 lbs with a BMI of 20.62. The nutrition assessment found she has inadequate intake due to loss of appetite and lacks knowledge of her cardiac diet. The intervention includes education on her cardiac diet of 1362-1635 kcals and 54-65g protein daily to improve her intake and understanding of her condition.

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    Jesse Terris is a 38-year-old woman who was recently diagnosed with heart failure. She is 6 weeks postpartum and has a history of hypertension and anemia. She has lost her appetite and reports foods tasting bad. Her weight is 120 lbs with a BMI of 20.62. The nutrition assessment found she has inadequate intake due to loss of appetite and lacks knowledge of her cardiac diet. The intervention includes education on her cardiac diet of 1362-1635 kcals and 54-65g protein daily to improve her intake and understanding of her condition.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    181 views3 pages

    CHF Case Study

    Uploaded by

    api-622273373
    Jesse Terris is a 38-year-old woman who was recently diagnosed with heart failure. She is 6 weeks postpartum and has a history of hypertension and anemia. She has lost her appetite and reports foods tasting bad. Her weight is 120 lbs with a BMI of 20.62. The nutrition assessment found she has inadequate intake due to loss of appetite and lacks knowledge of her cardiac diet. The intervention includes education on her cardiac diet of 1362-1635 kcals and 54-65g protein daily to improve her intake and understanding of her condition.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3
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    The patient is newly diagnosed with heart failure and has a history of anemia and hypertension. She has decreased appetite and poor intake since giving birth 6 weeks ago.

    The patient has a history of hypertension, anemia, and just gave birth 6 weeks ago. She reports her appetite has been poor due to foods tasting bad.

    The patient's nutrition diagnoses are inadequate oral intake related to decreased appetite and knowledge deficit regarding her new cardiac diet needs.

    ADIME Progress Note- Template Only

    Name: Jesse Terris

    Disease State: Cardiovascular – Heart Failure

    Name/Date/Time:

    Follow-up Consultation For:


    (Reason for Referral/Presenting RN admission screen: for decreased appetite
    Complaint/Diagnosis)
    NUTRITION MONITORING AND EVALUATION

    Weight: 120 lb (54.5 kg) BMI: 20.62

    Height: 5’4”

    Estimated Energy Needs: 1362-1635 kcals

    Estimated Protein Needs: 54-65 gm protein

    Other (specify)

    Food/Nutrition-Related History Anthropometric Measures


    Patient is newly diagnosed with CHF. Patient She is 5’4” and weighs 120 lb. Her BMI is 20.62. She is 6 weeks
    reports food tastes bad due to taste but changes. postpartum.

    Biochemical Data, Medical Tests and Procedures Nutrition-Focused Physical Findings


    Pt has a history of anemia. Pt has excessive fluid and swelling.

    Nutrition Assessment, Monitoring


    Client History Comparative Standards
    and Evaluation Tools
    Patient is 6 weeks postpartum Nutrition Focused Physical Exam 25-30 kcal/kg
    and has a history of iron not conducted.
    deficiency anemia and Protein for those with CHF 1-1.2
    hypertension.

    CURRENT NUTRITION DIAGNOSIS

    January 2022 Page 1 of 3


    PES Statement(s) Inadequate oral intake related to decreased ability to consume
    sufficient energy as evidenced by decreased appetite and poor
    Problem, Etiology, Signs po.
    and Symptoms
    Food and nutrition-related knowledge deficit related to lack of
    prior exposure as evidenced by newly diagnosed heart failure.
    NUTRITION INTERVENTION
    Nutrition Prescription Energy needs: 1362-1635 kcals

    Protein needs: 54-65 grams.


    Aims/Goals (SMART) Follow a sodium diet of 2 gm Na; low fat; 2000 ml fluid by week
    4 understand how to read food labels and understand the
    cardiac diet to see a decreased in fluid retention.
    Detail of Intervention/Plan Provided education to patient on the cardiac diet and how to
    read food labels. Patient expressed that she was ready to make
    necessary changes to make sure she was there for her baby.
    While still in the hospital patient will receive strawberry mighty
    shake BID, to help with nutritional intake.
    NUTRITION MONITORING AND EVALUATION
    Tick all that apply Food/Nutrient/Energy Nutrition Assessment/Monitoring and Evaluation
    Tools
    Anthropometrics
    Labs (specify)
    Behavior or
    Knowledge/Beliefs/Attitudes
    Specific Indicators, While in the hospital I will follow up with the patient in 3 to 5 days, to answer any questions
    Criteria and Time she may have on the cardiac diet and how to follow it once she leaves the hospital. I will also
    frame check to see if her po has improved.

    What will you assess


    during follow-up
    consultations?

    January 2022 Page 2 of 3


    Also Complete a Narrative ADIME Note for the same patient with the following Format:

    Nutrition Assessment:

    The patient is a 38- year-old woman who lives with her significant other. She is 6 weeks postpartum with her third child.

    She has a history of hypertension and anemia. The RN admission screen was positive for decreased appetite and RD

    screened for heart failure. The patient reports that her appetite has been “bad” due to foods tasting bad and having no

    appetite. She says the food in the hospital has no flavor and is not appetizing. The patient had no knowledge on the

    cardiac diet. Information regarding the cardiac diet and how to read a food label was provided to her. She states that

    she is confident that she can make the necessary changes.

    Nutrition Diagnosis:

    Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by decreased appetite and
    poor po.

    Food and nutrition related knowledge deficit related to lack of prior knowledge as evidenced by newly diagnosed heart
    failure.

    Nutrition Intervention:

    Aim toward understanding and complying with the cardiac diet.

    Nutrition Monitoring/Evaluation:

    Reducing her sodium intake to meet the guidelines of the cardiac diet, monitor her intake, hoping to see improvements.
    While in the hospital continue to watch labs to see if things need to be adjusted.

    Modified from Nutrition Care Professionals; Updated 1/1/2022

    January 2022 Page 3 of 3

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