S3470C Nutrition Care Process – Case Study Analysis

Case Study

A client was referred to you for a nutrition assessment and diagnosis.

Case Study: Mr Lim Ah Poh

Referred Client:

Name: MrLim Ah Poh

Age: 54years old

Gender: Male

Ethnicity: Chinese

Height: 168cm

Weight: 90kg

Occupation: Administration Executive

Living siutation: Lives with wife and 1 daughter in a 3 room HDB flat

Highest education qualification: Secondary School

Diagnosed condition:

• Type 2 Diabetes Mellitues – Diagnosed2 years ago, on metformin
• Hypertension–Just diagnosed, have not started on medication

Recent Blood Test Results:

• HbA1c: 8.5%
• Fasting Glucose: 14.9 mmol/L
• Total Cholesterol: 4.8 mmol/L
• LDL: 2.9 mmol/L
• HDL: 1.1 mmol/L
• Triglycerides: 2.2 mmol/L
• Blood Pressure: 149/95 mmHg

Social & Lifestyle Factors:

• Financial struggles – Relies on savings, preparing daughter’s university education. Wife is housewife at home.
• Sedentary lifestyle –Apart from commuting to work and back home, Mr Lim don’t do any other exercise.
• Stress eating –Like to consume sweetened beverages
• Social interaction –Interacts mainly with colleagues and spend time with wife and daughter at home.

24 hours Dietary History:

Based on the information above, you are required to use the Nutrition Care Process (S.O.A.P) and the Nutrition Assessment Form to discuss the process of disease-nutrition care that your client should receive to manage his medical conditions.

Write a (S.O.A.P.) entry for the Mr Lim Ah Poh.

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Experts Answer on Above Questions on Nutrition Care Process

SOAP Entry – Mr Lim Ah Poh

S – Subjective

Analysis of the case of Mr Lim Ah Poh indicates that he was diagnosed with type two Diabetes mellitus 2 years ago, and recently with hypertension as well. His profile indicates that he consumes sugar sweetened beverages on a daily basis, and there is no any regular exercise being carried out. There are financial concerns as well which contributes to stress level.

O – Objective

An analysis of the dietary assessment indicates that Mr Lim consumes approximately 2.3 litres of sugary beverages on a daily basis, and also consumes fried foods regularly. There is excessive sodium as well as chilli sauce intake identified along with low vegetable consumption and late night snacking is also evident.

A- Assessment

The analysis indicates that the type two diabetes mellitus was not properly controlled by Lim despite there being issues like obesity, excessive intake of sugar sweetened beverages, high consumption of fried foods and physical inactivity. This excessive consumption of sweetened beverages is evident from HbA1c 8.5% and overweight/obesity from BMI of 31.9 kg/m2.

P- Plan

The nutritional intervention required is to replace all the sugary beverages with plain water or sugar free drinks, limit the intake of fried foods to once per week, replace soft drinks with guava or apple, limit processed foods to reduce sodium intake, and set a target weight loss of 5-10%.

M – Monitoring and Evaluation

It is important to monitor the reduction of HbA1c from 8.5% to 7% in 6 months, fasting glucose levels, blood pressure reduction below 130/80 mmHg, weight loss progress monthly, and monitoring of continuous improvement in the triglyceride levels during the blood test

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The above nutritional case study involving the analysis of type 2 diabetes, hypertension, dietary assessment, intervention planning and patient monitoring revealed significant findings. If you need a similar kind of assessment of practical case studies, visit our nursing assignment help page to get service from professional nursing experts. Not only with nursing tasks, our experts provide assignment help across all major subjects in Singapore.

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