Printed by Christina Drobisch

ll740I) at 3ll0ll5

1:1 1

PM

Assessment

Reason forassessment:
2Day Assessment
Anth ro p o m etri c M eas u rem ents:
Ht: 179.1 cm (70.5")
Admit Wt: 76.3 kg (No edema)
%lBW: 102%
IBW: 74.2 kg
BMI: 23.8
HUwt status:normal

utrition-Focused Physical Fi ndi ngs:

Patient appears well-nourished and well-hydrated
Nutrition risk factors: High Risk Diagnosis
Risk for nutritional deficit:mild
N

Subjective:
Pt was atert and tatkative. He stated he has no food allergies and while at home he cooks breakfast
(chenios and banana) and lunch (tud<ey sandwhich, tomato, mayo, unsalted potato chips and bhocolate
boost). Pt has top and bottom dentures and stated that he is scheduled fo see the dentist about po.or
fitting bottom dentures. Pt said ill-fitting dentures do not affect intake. He's appetite has been good and
he enjoys the food. Spoke with pt about sending up a boost, consideing he normally takes boost at
home, he said he would like that.
Food and Nutritional lntake:
Diet Orders:
Procedures
. Diet Regular; No - patient to receive automatic trays; Sodium 3 GM; Heart Healthy
PO lntake is lnterupted d/t recent procedures Pt consumed 50% of breakfast the other morning, Pt
stated that when he comes back from procedures food is cold.
Allergies: No food allergies. Other Allergies: Penicillins and Vicodin

Client History:
Admission Diagnosis: CAD
CAD (coronary artery disease)
Diagnosis:

1.

Mechanically assisted ventilation

Past lHedical llistory
Diagnosis
Asthma
Coronary artery disease
Arthritis
Hypertension
Past Surgical istory
Procedure
Vascular surgery
Hernia repair

$NOMHD CT(R)
VENTILATOR FINDING
Date

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l-.1

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Laterality

Printed by DROBISCH, CHRISTINA

*ate

ll740ll at3ll0l20l5

1:16:34 PM

nted by Christina Drobisch

ll740l) at3ll0l15

1:11 PM

Tonsillectomy

Usual meds include: None

Current meds include: Dopamine, Surfak, Pepcid, Humalin, Prilosec, Propofol.

Biochemieal Data, Medical lesfs and Procedures:

Latr Rssults
Component
NA
K
CL

Value

Sate/Time
311012015 5:41 AM
311012015 5:41 AM
311012015 5:4'1 AM
3l1Ol2O15 5:41 AM
311012015 5:41 AM
311012015 5:41 AM
311012015 5:41 AM
31912015 9:13 PM

135

4.4
108

co2

23.0
174*

GLU
BUN

13

CREATININES

MG

1,14
2,0

TG, LDL, and Cholesterol:WNL

Results for VAN NES, HANS (MRN 200250089) as of 3l1Ol2O15 11:45
11

311012015 05:41

Calcium: 7.9 (L) -

Nutrition Diagnosis (Problem, Etiology,

Srgrns and Symptoms)

lnadequate energy intake related to Planned procedure, therapy or medication predicted to decrease
ability to consume sufficient energy or nutrients as evidenced by <50% of breakfast eaten and pt's food
(Progress: Not progressing related to Pt just had procedure and has only
being cold after procedure.
recieved one tray. .) and No nutrition diagnosis at this time.

Nutrition lnteruention: Will send chocolatte boost to pt room with lunch, to increase PO intake.

Monitoring and Evaluation: Goal: >75% of meals/supplements.

Fottow lJp:

*8

days

Christina Drobisch,
3t10t2015
11:41 AM
Asante lnpatient Nutrition

Printed by DROBISCH, CHRISTINA U740Il

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