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ADIME 2
Assessment:
Age: 87 Gender: F
Dx: CHF
PMHx: acute respiratory distress, fluid overload, normocytic anemia,
pleural effusions, chest pain, leukocytosis, tachycardia, aspiration PNA,
hyperthyroidism, hyperlipidemia, afib
Treatments/therapies/alternative medicine:
o None noted
Ht: 155 cm Wt: 64 kg
IBW: 55 kg ** for age %IBW: 116%
UBW: 70.5 73 kg %UBW: 89.5% (using 71.5 kg as UBW)
BMI: 26.7 this classifies the pt as overweight
Nutritional requirements:
o Mifflin St Jeor: 9.99(64kg) + 6.25(155cm) 4.92(87) 161 =
1019
1019 x 1.2 AF = 1223 kcals/day
o Kcal/kg: 25kcal x 64kg = 1600 kcals/day
Between 1220 1600 kcals/day
o Protein: 1 - 1.1g x 64kg = 64 - 70gm of protein/day
o Fluid: 25cc/kg= 1600 mL 1.6L per day
o Other necessary nutrients:
Iron and B12 due to vegan diet
Low sodium due to cardiac diet
Diet Orders:
o Vegan, cardiac
Assessment of current diet order:
o The current diet order does seem appropriate for this patient.
The patient follows a vegan diet due to personal and religious
beliefs. The cardiac portion of the diet was implemented because
of the Dx of CHF to help prevent further heart complications in
the future. The patients daughter reported that she already does
not add salt to her foods at home so limiting sodium as part of
the cardiac diet should not be an issue for this patient.
Labs
Labs Values Indications
NA 139 mEq/L This value indicates that the
patient is in good electrolyte
balance. The pts kidneys are
working properly to keep Na
balanced.
K+ 4 mEq/dL This value indicates that the
patient is in good electrolyte
balance and that her kidneys
are working properly.
HGB 8.3 g/dL L Possible causes include:
anemia, hyperthyroidism,
cirrhosis, many systematic
disease, HIV/AIDS
This value coincides with the
patients diagnosis of
normocytic anemia.
HCT 26.1% L Possible causes include:
Anemia, blood loss,
hemolysis, leukemia,
hyperthyroidism, cirrhosis,
over-hydration
This value coincides with the
patients diagnosis of
normocytic anemia.
RBC 3.06 mm L Possible causes include:
Anemia, hemorrhage, Fe
deficiency, systemic disease
This value coincides with the
patients diagnosis of
normocytic anemia.
Glucose 116 mg/dL This value indicates that the
pts insulin is functioning
properly to regulate blood
sugar levels.
BUN 24 mg/dL This indicates that the pts
kidneys are functioning
properly to remove urea from
the blood.
Creatinine 0.9 mg/dL This value also indicates good
kidney function because
creatinine is being cleared
from the blood normally.
Cl 98 mEq/L L Possible causes include:
diabetic acidosis, fever, acute
infections, metabolic
alkalosis, vomiting, K disease,
chronic respiratory acidosis,
SIADH
Bicarbonate 33 mmol/L H Possible causes include:
metabolic alkalosis,
respiratory acidosis,
emphysema, vomiting,
The abnormal lab values of RBC, Hgb, Hct, MCHC and platelet count as
well as the normal value of MCV are all indicative of the patients past
medical condition of normocytic anemia. The other abnormal lab values of
bicarbonate and Cl could be indicative of the patients acute respiratory
distress.
Meds:
Food/Nutrient delivery:
o Order vanilla Ensure PLUS from the diet office to be delivered to
the patients room TID
o If patient does not consume at least 50% or more of her
supplements, meals and snacks and continues to lose weight,
then the family should consider a tube feed to ensure no further
malnutrition.
o Assistance and encouragement will be provided to the patient,
either by family or staff, at each meal to ensure maximum intake
by the patient.
Nutrition education:
o Patient was unable to communicate and receive direct
information due to a language barrier, therefore education was
provided verbally to her daughter about a high protein, high
calorie diet and different meals and supplements that would be
appropriate for the patient, such as Ensure PLUS.
o The patients daughter also received verbal information about
different food choices that would follow the patient vegan
restrictions, such as yogurt and oatmeal for morning choices, and
soup, salad, and pasta for afternoon and evening choices.
o Education was also given to the patients family verbally along
with a handout on a cardiac diet the patient already follows a
cardiac diet at home and chooses not to salt food so they had a
good understanding of the information.
o The patients family could communicate this education to the
patient and all parties showed understanding and willingness to
comply.
Coordination of Care:
o A consultation with PT should occur to assess the patients ability
to perform ADLs such as ambulating, self-care, and feeding
herself on her own. Currently, the patient is not able to ambulate
well, needs assistance with self-care, and needs assistance and
encouragement to eat. PT should assess the current level the
patient is at and set goals to help the patient get back to her
baseline for these functions.
Monitoring and Evaluation:
Snack:
Food Amoun Calorie Carbohydrate Fat Protei
t s s (g) (g) n (g)
(kcals)
Cottage cup 154 5 7 18
cheese
Water 8 oz.
TOTALS 154 5 7 18
Lunch:
Food Amoun Calorie Carbohydrate Fat Protei
t s s (g) (g) n (g)
(kcals)
Low sodium cup 47 10 0 1
vegetable
soup
Wheat roll 1 98 17 2 3
Ensure 1 178 50 11 13
PLUS vanilla
Coffee 8 oz.
Water 8 oz.
TOTALS 323 77 13 17
Snack:
Food Amoun Calorie Carbohydrate Fat Protei
t s s (g) (g) n (g)
(kcals)
Apple 1 cup 57 15 0 0
sliced
Peanut 2T 195 5 17 8
butter
Water 8 oz.
TOTALS 252 20 17 8
Dinner:
Food Amount Calorie Carbohydrate Fat Protei
s s (g) (g) n (g)
(kcals)
Yogurt 6 oz. 173 32 2 7
Ensure 1 350 50 11 13
PLUS
vanilla
Water 8 oz.
TOTALS 397 94 13 21
"NCM Nutrition Care Manual Eat Right." Public Home Page. N.p., n.d. Web. 17
Feb. 2016.