Amanda Venuto

NTDT450
ADIME for Etta Rose

Overview:
Patient was admitted for direct acute exacerbation of COPD after inability to carry a
conversation. Patient’s chief complaint is shortness of breath. This is the first acute
exacerbation requiring hospitalization. Patient is alert and oriented.

Assessment:
Anthropometric:
 83 y/o female
 163 cm, 55 kg
 BMI= 20.7 (Normal)
 Daily weights ordered

Biomedical:
 Most recent ABG: High PaCO2 (55 mgmHg), Low pH (7.33)
 Low SaO2 (91%)
 Most recent Cl: Low Serum Cl- (96 mEq/L)
 High BUN (29 mg/dL), High Creatinine (2.3 mg/dL)
 High CO2 (40 mEq/L)
 High WBC (15000 cells/mL)

Client History:
 Medical Hx: Patient diagnosed with Stage III COPD approximately one month
ago; HTN since early 1960’s
 Smoked 1-2 ppd for 30 years until quitting at age 49
 Does not drink
 Recently retired realtor
 Family Hx: father died of pneumonia, mother died of breast cancer
 Dx has caused a change in independence

Food/Nutrition-Related History:
 Current Diet Order: Regular
 Diet at home (24 hour recall)
o Breakfast:1 cup of coffee with 1 teaspoon of creamer, ½ cup orange
juice,1 poached egg, ½ slice of white bread (toast)
o Lunch: 1 cup of cream of tomato soup, ½ slice of white bread (toast), ½ of
banana, 1 cup Pepsi
o 1 piece of KFC chicken leg, ½ cup mashed potato, 2 tablespoons of gravy,
½ cup orange juice
o Snack: ½ cup applesauce
 Unable to grocery shop
 Medications: albuterol inhaler PRN, nifedipine, tiotropium, fluticasone, Prisolec
  NKDA

Nutrition-Related Physical Findings:

 Has dentures
 Patient does not appear to be malnourished per nsg note
 +1 edema to bilateral lower extremities per physician’s note
 Oxygen mask per respiratory therapist note

Comparative Standards/Calculated Needs:

 1400 cal/d (Mifflin x 1.4)
 70g protein (1.3/kg)

Diagnosis:
Predicted inadequate energy intake related to exacerbation of COPD as evidenced by
caloric intake from 24-hour recall 400 calories less than recommendation

Intervention:
Prescription: 1400 kcal/day and 70g protein/day
Recommend: Increased energy diet by introduction of Ensure and consumption of small,
frequent, energy-dense meals
Goals: Increase caloric intake to prevent weight loss and maintain normal weight

Monitoring and Evaluation:

Monitor patient’s weight and caloric intake while in hospital