Assignment 4 - Case Study: Interpreting Labs

Description

Case Study - Interpreting Labs

Objectives

• Write an NCP including PES statement.
• Correctly interpret lab values.

Assignment: Nutrition Care Process (ADIME Note) for a Patient with Cardiovascular Disease

Scenario:
Pete, a 45-year-old police officer, has been recently diagnosed with cardiovascular disease (CVD). He is 6’2” tall and weighs 230 lbs. (BMI = 30). His labs are as follows:

• Prealbumin: 30 mg/dL
• Total Cholesterol: 242 mg/dL
• HDL: 30 mg/dL
• LDL: 212 mg/dL
• Blood Glucose: 220 mg/dL
• Blood Pressure: 130/90 mmHg

Pete’s doctor recently prescribed Simvastatin (Zocor) for managing his lipid levels.

Lifestyle Factors:

• Pete works as a police officer, which he describes as a very stressful job.
• He is currently going through a divorce but prefers not to discuss it.
• His dietary habits include eating out frequently, consuming processed meats and high-fat meals, drinking 2-3 sodas daily, and having 2-3 beers most nights. He typically eats a breakfast biscuit with ham/sausage and egg, a sub sandwich, burrito, or burger for lunch, and a large salad for dinner.

Instructions:

Using the Nutrition Care Process (NCP) framework, write an ADIME (Assessment, Diagnosis, Intervention, Monitoring, and Evaluation) note for Pete. Your ADIME note should include:

1. Assessment (A): **please interpret the values**

   • Anthropometric Data (Height, Weight, BMI)
   • Biochemical Data (Lab Values) 
   • Clinical Data (Medical and Medication History, Blood Pressure)
   • Dietary History and Lifestyle Factors

2. Diagnosis (D):

   • Write a PES (Problem, Etiology, Signs/Symptoms) statement that identifies Pete’s primary nutrition-related issue(s).
   • Use the standardized nutrition diagnosis terminology (e.g., “Excessive saturated fat intake related to frequent consumption of processed meats and fast food as evidenced by high total cholesterol and LDL levels”).

3. Intervention (I):

   • Outline a realistic and individualized nutrition intervention plan to improve Pete’s CVD risk factors.
   • Address dietary changes, lifestyle modifications, and behavioral strategies that Pete can incorporate.
   • Consider SMART goals (Specific, Measurable, Achievable, Relevant, and Time-bound).

4. Monitoring & Evaluation (ME):

   • Identify at least three measurable outcomes that will be used to assess Pete’s progress.
   • Include follow-up recommendations and criteria for success (e.g., target cholesterol levels, dietary adherence).

Additional Requirements:

• Provide protein and calorie requirements based on Pete’s weight and activity level.
• Support your recommendations with evidence-based guidelines, such as the American Heart Association (AHA) dietary recommendations.
• Ensure that your ADIME note is clear, concise, and well-structured using professional nutrition documentation practices.

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