Assessment

Chat review and patient

interview reveals the
following data:
Symptoms: Epigastric
pain- suffering from on
& off pain at the upper
right quadrant and to
the back for a year,
pain is most severe
after a meal
Nutrition Interview
Findings:
Preferred meals: salty
and fried foods
Food habits: chocolates
and chicharon
Fluid intake: low
Laboratory data:
WBC:
Indirect bilirubin:
Cholesterol:
Medical Exam:
X-ray: irregular density
at the RUQ
Ultrasonography:
stones, thickened
gallbladder wall
Anthropometric Data:
Height: 52
Weight: 77 kgs
DBW: 52 kg
BMI: 31 ~ Obese I
Personal Information:
Gender: Female
Age: 50 y/o

Diagnosis
1. Epigastric pain
related to
cholecystolithiasi
s diet as
evidenced by
diet history and
Increased
bilirubin and
cholesterol levels

Intervention
Nutrition Diagnosis 1:
Epigastric Pain
Objectives:
1. During the
hospitalization
Lorna will reduce
her
current weight from
77kg to 52 kg for 28
weeks; following a lowfat diet with a diet rx of
________________
2. During acute
attack, no food is
given to rest the
system.
Gradually the
patient is given
clear
fluids followed by
soft fiberrestricted low fat
(20 30g) diet
3. Patient will
attend nutrition
counselling to
know how to
plan healthy and
delicious diet
that would suit
her appetite

Monitoring
After the
cholecystectomy,
the patient will
keep log of
dietary intake for
3 days for review
by dietician if fatrestricted diet is
followed
The patient will
weigh self daily
and keep log

Evaluation
White blood
cells, indirect
bilirubin and
cholesterol levels
are stable
Check if the
desirable body
weight is
attained after 28
weeks

Assessment
Chat review and patient
interview reveals the
following data:
Symptoms: Abdominal
pain and nausea. After
confinement,
abdominal fullness and
abdominal girth
increases each day
Nutrition Interview
Findings:
Food habits: drinks
hard liquor after work;
during weekends, eats
pulutan and have hard
drinks
Diet Prescription:
increased dietary
requirements except for
fat and sodium
Clinical Findings:
Very weak, listless, skin
and sclera is yellowish
in color
Laboratory data:
Direct bilirubin:
increased
SGOT: increased
Anthropometric Data:
Height: 54
Weight: 72kgs
DBW: 56 kg
BMI: 27.2 ~ Overweight
Personal Information:
Gender: Male

Diagnosis
Severe abdominal pain
and nausea related to
Laennecs Cirrhosis as
evidenced by alcoholic
diet and increased
direct bilirubin and
SGOT

Intervention
Nutrition Diagnosis 1:
Severe Abdominal pain
Objectives:
During the
hospitalization, the
patient will increase
protein and energy
intakes to maintain
nitrogen balance;
following sodium
restricted diet with a
diet rx of
________________
Patient will attend
nutrition education
counselling to fully
understand how to
modify the diet wherein
the patient will be
provided with lists of
acceptable foods and
menu and will know
how
recipes can be altered
so that favorite foods
can still be
incorporated into the
diet
Increase the appetite of
the patient and advice
to drink milk every day
and fill the diet with

Monitoring
The patient will
record food
intake everyday
as well as his
appetite
condition
Meals should be
frequent and in
small amounts
from time to
time. The patient
will also record
the time of
eating and the
amount of foods
eaten
Sign the
attendance sheet
during nutrition
education
counselling

Evaluation
If levels of SGOT
and direct
bilirubin stables,
then the
intervention is
effective
If the patient
reduced weight
close to his
desirable body
weight of 56 kg
Clinical signs of
yellowish skin
color and weak,
listlessness is not
evident any
more

Age: 36 y/o

energy dense foods

such as cheese, fruit
juice and cream sauces
To improve food intake,
patients should
consume small meals 4
to 6 times daily.
Restrict sodium as
necessary to control
ascites; 2000 mg
sodium per day is
adequate restriction in
most case

Assessment
Chat review and patient
interview reveals the
following data:
Symptoms: Dull,
gnawing pain in his
upper abdomen. Pain
eveident when hungry
and after a full meal
Nutrition Interview
Findings:
Food habits: consumes
10 cups of coffee
throughout the day;
Frequently misses
meals
Clinical Findings: Tarry
stools
Medical Exam and
Medication:
Medication: aspirin,
Maalox
Gastric X-ray: diagnosis
of gastric ulcer at the
lower curvature
Anthropometric Data:
Height: 55
Weight: 57 kgs

Diagnosis
2. Epigastric pain
related to
cholecystolithiasi
s diet as
evidenced by
diet history and
Increased
bilirubin and
cholesterol levels

Intervention
Nutrition Diagnosis 1:
Epigastric Pain
Objectives:
4. During the
hospitalization
Lorna will reduce
her
current weight from
77kg to 52 kg for 28
weeks; following a lowfat diet with a diet rx of
________________
5. During acute
attack, no food is
given to rest the
system.
Gradually the
patient is given
clear
fluids followed by
soft fiberrestricted low fat
(20 30g) diet
6. Patient will
attend nutrition

Monitoring
After the
cholecystectomy,
the patient will
keep log of
dietary intake for
3 days for review
by dietician if fatrestricted diet is
followed
The patient will
weigh self daily
and keep log
Sign the
attendance sheet
during nutrition
counselling

Evaluation
White blood
cells, indirect
bilirubin and
cholesterol levels
are stable
Check if the
desirable body
weight is
attained after 28
weeks

DBW: kg
BMI:
Personal Information:
Gender: Male
Age: 50 y/o
Vices:
Smokes cigarettes
Drinks vodka and and
liquor regularly

counselling to
know how to
plan healthy and
delicious diet
that would suit
her appetite