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Nutrition in Healthcare: Resource Guide

Name of Disease:Cardiovascular: Hypertension

Researcher: Your Name

****ONLY document by exception, thus if an area does not apply, please remove from document. Replace the ‘XX’ text for each section.****

Subjective Documentation

Upon review of Medical Documentation what are important findings to look for. 

Constitutional:  XX

Cardiovascular: XX
HEENT: XX

Eyes –  XX

Ears –   XX

Nose –  XX

Throat – XX

Genitalia: XX
Neurologic: XX
Extremities: XX
Skin: XX
Chest/lungs: XX
Abdomen: XX
Vital Signs: XX
Labs: XX

Other coinciding disease states and/or symptoms common with your disease – XX

Common Food and/or Drug Allergies with this disease – XX

Common Drugs (and their class) prescribed for this disease – XX

How is this disease acquired? 

XX

Commonality of disease?

XX

Nutritional Needs

Food/Drug interactions

XX

Side effects of medications affecting eating (po intake)

XX

Side effects of medication affecting metabolism

XX

Side effects of disease affecting eating (po intake)

XX

Side effects of disease affecting metabolism and nutritional needs

XX

Does the patient need to be fed artificially? If so, how?

XX

Can patients feed themself? If not, how will the patient eat?

XX

What are common therapeutic diets prescribed for this disease state?

XX

What are common dysphagia diets prescribed for this disease state?

XX

Is it common for this patient to need increased oral nutrition supplementation? If so, what are some examples of what would be used in a healthcare setting? 

XX

What food(s) can the patient NOT eat?

XX

What food(s) are offered in limited quantities?

XX

What foods are the patients encouraged to eat?

XX

Is it common for a patient with this disease state to be able to be independent and then eventually be dependent for nutrition? For example as the disease progresses. 

XX

Nursing Application

Summarize ALL your findings in one paragraph and three action points below. 

Summary- 

XX

Action Points-

1. XX

2. XX

3. XX

References

1. XX

2. XX

3. XX

4. XX

5. XX