LOCAL TITLE: CLINICAL NUTRITION

STANDARD TITLE: NUTRITION DIETETICS NOTE

DATE OF NOTE: NOV 20, 2014@16:00
ENTRY DATE: NOV 24, 2014@11:13:46
RD: DODD,KATHERINE
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
MEDICAL NUTRITION THERAPY for: CHF, Palliative Care
Home or Phone Visit:
Initial or F/U Visit:
Present at visit:

Home
Initial
Pts dtr, Sherry

Identity confirmed by full name and SSN

90 minutes drive time
60 minutes face to face
Home visit conducted by dietetic intern, C. Drobisch, with RD oversight.
Summary:
Met with Mr. T at Spring Meadows Retirement home in Grants Pass. Mr. T
daughter Sherry was present for the initial visit and is very involved with her
father's treatment and quality of living.
Mr. T was awake and alert during
the visit, however frequently struggled with hearing. Sherry confirmed that Mr.
T takes a daily multivitamin (One a Day Plus Iron). Mr. T self-reported
his current weight to be 195lbs, Sherry confirmed this and expressed concern for
the 15-20lb weight gain in the last 2-3 months. Sherry explained that her
father's weight has increased due to being in the hospital and his decreased
mobility. Mr. T also has edema around his feet, ankles and calves, which
according to Sherry has gotten worse in the last two days. Mr. T expressed
that he enjoys the food served at his community facility and eats the majority
of his meals in the dining room. Mr. T admitted to adding salt to his food
and Sherry, who often eats with him in the dining room, confirmed this. Mr. T
has all of his lower teeth and most of his upper teeth. He has a removable
partial upper insert, which he doesn't use because he can eat fine with the
teeth he has. Mr. T has had no previous nutrition education and at the time
of the meeting had no nutrition related questions or concerns.
Mr. T has is on a regular diet and has been advised against dietary
restrictions due to age and prognosis. Although pt would likely benefit from a
Na reduction to assist with controlling edema, his long-time habits, food
preferences, and memory deficits are primary barriers to change. Will discuss
with HBPC team as it appears non-dietary interventions for managing his edema
will be most beneficial for this pt.
*******************************************************************************
-ASSESSMENT*CLIENT HISTORY********************
Pts age:
Pts gender:

93
MALE

DX/PMH:
Chronic right-sided congestive hear
CONGESTIVE HEART FAILURE 428.0
Encounter for palliative care * V66
Chronic osteomyelitis of the lower
Infective pneumonia (SNOMED CT 3123
Pain in joint involving shoulder re
ATRIAL FIBRILLATION 427.31, Onset 0
Abnormality of Gait (ICD-9-CM 781.2
Chronic Kidney Disease, Stage III (

BILATERAL HIP REPLACEMENTS 799.9

Chronic Obstructive Pulmonary Disea
Hypertension 401.9
Hyperlipidemia 272.4
Hypertrophy (Benign) of Prostate wi
COMPLETE HEART BLOCK 799.9
Carpal Tunnel Syndrome 354.0
*MEDICATION AND HERBAL SUPPLEMENT USE********************
Outpatient Medications
Status
=========================================================================
1)
ALBUTEROL 100/IPRATRO 20MCG 120D PO INHL INHALE 1
ACTIVE
PUFF BY MOUTH FOUR TIMES A DAY FOR SHORTNESS OF
BREATH
2)
ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3ML USE 1 VIAL
ACTIVE
PER NEBULIZER FOUR TIMES A DAY AS NEEDED FOR
SHORTNESS OF BREATH
3)
HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB TAKE 1/2
ACTIVE
TABLET HYDROCODONE 5MG/ACETAMINOPHEN 325 MG BY
MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN
4)
MOMETASONE FUROATE 220MCG ORAL INHL 60 INHALE 2
ACTIVE
INHALATIONS BY MOUTH EVERY EVENING FOR BREATHING RINSE MOUTH AFTER USE *DISCARD INHALER 45 DAYS
AFTER OPENING FOIL POUCH
5)
PREDNISONE 10MG TAKE ONE TABLET BY MOUTH DAILY TO
ACTIVE
REDUCE INFLAMMATION
6)
RIVAROXABAN 15MG TAB TAKE ONE TABLET BY MOUTH EVERY
ACTIVE
EVENING WITH EVENING MEAL TO PREVENT STROKES (FOR
ATRIAL FIBRILLATION/FLUTTER) NO ASPIRIN OR NSAIDS
WHILE TAKING RIVAROXABAN
7)
TAMSULOSIN HCL 0.4MG CAP TAKE ONE CAPSULE BY MOUTH
ACTIVE
TWICE A DAY FOR URINARY/PROSTATE PROBLEMS
8)
TIOTROPIUM 18MCG INHL CAP 30 INHALE 1 CAPSULE (18MCG) ACTIVE
IN INHALER BY MOUTH EVERY DAY FOR BREATHING *DO NOT
SWALLOW CAPSULE *DO NOT USE WITH
ATROVENT/IPRATROPIUM/ COMBIVENT OR DUONEB
Non-VA Medications
Status
=========================================================================
1)
Non-VA ACETAMINOPHEN 325MG 650MG MOUTH FOUR TIMES A
ACTIVE
DAY AS NEEDED
2)
Non-VA ACETAMINOPHEN/DIPHENHYDRAMINE TAB 1 TABLET
ACTIVE
(500/25 MG) MOUTH AT BEDTIME AS NEEDED
3)
Non-VA DOCUSATE CAP,ORAL 1 CAPSULE (100MG) MOUTH
ACTIVE
EVERY DAY
4)
Non-VA FUROSEMIDE 20MG TAB 20MG MOUTH DAILY
ACTIVE
5)
Non-VA GUAIFENESIN TAB ONE 12H EXTENDED RELEASE
ACTIVE
TABLET (600MG) MOUTH TWICE A DAY AS NEEDED
6)
Non-VA LISINOPRIL 5MG 5MG MOUTH EVERY DAY
ACTIVE
7)
Non-VA MULTIVITS W/MINERALS TAB/CAP ONE TABLET MOUTH
ACTIVE
DAILY
8)
Non-VA POTASSIUM CHLORIDE 10MEQ SA CAP 10MEQ MOUTH
ACTIVE
DAILY
16 Total Medications
ANY HERBS/SUPPLEMENTS:
ONE A DAY PLUS IRON
Relevant medications/herbs/supplements were reviewed.
*ANTHROPOMETRIC MEASUREMENTS********************

HEIGHT:
66.5 in [168.9 cm] (10/23/2014 13:30)
WEIGHT:
198 lbs
WEIGHT HISTORY:
10/23/2014 13:30
10/23/2013 11:39
06/13/2013 11:50
02/11/2013 09:12
02/15/2012 11:24

LB(KG)[BMI]
180(81.65)[29*]
180(81.65)[29*]
168(76.20)[27]
173(78.47)[28*]
174(78.93)[28*]

RECENT WT LOSS:
No, wt gain
UBW:
~180lbs
BMI:
32.9
BODY WT CLASSIFICATION:
Slightly high for age
*BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES********************
BP: 118/50 (10/23/2014 13:30)
LABORATORY DATA:
SLT - Lab Tests Selected
Collection DT
Specimen
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
10/14/2014 13:40 BLOOD
01/03/2014 12:07 BLOOD
10/14/2014 13:40 BLOOD
01/03/2014 12:07 BLOOD
01/03/2014 12:07 BLOOD
01/03/2014 12:07 BLOOD
01/03/2014 12:07 BLOOD
02/04/2013 09:47 BLOOD
02/04/2013 09:47 BLOOD
02/04/2013 09:47 BLOOD
02/04/2013 09:47 BLOOD

Test Name
CREATININE
UREA NITROGEN
GLUCOSE
SODIUM
POTASSIUM
CHLORIDE
CO2
CALCIUM
PROTEIN, TOTAL
ALBUMIN
TOT. BILIRUBIN
ALKALINE PHOSPHAT
AST
ALT
CHOLESTEROL
TRIGLYCERIDE
HDL
LDL-C

No HEMOGLOBIN A1C in the last 1Y

HEMOGLOBIN
HCT

15.5
47.0

01/03/2014 12:07
01/03/2014 12:07

*PATIENT HEALTH HISTORY********************

ANY DIFFICULTY WITH:
nausea/vomiting: NO
constipation/diarrhea: NO

Result
1.3
23
88
141
4.5
107
26.0
9.0
7.1
3.5
0.6
82
28
27
246 H
121
57
165 H

Units
mg/dL
mg/dL
mg/dL
mEq/L
mEq/L
mEq/L
mEq/L
mg/dL
g/dL
g/dL
mg/dL
U/L
U/L
U/L
mg/dL
mg/dL
mg/dL

Ref Range
0.8 - 1.5
7 - 23
71 - 109
131 - 142
3.6 - 5.4
95 - 108
21 - 32
8.4 - 10.2
6.5 - 8.2
3.5 - 5.0
0.1 - 1.1
45 - 129
15 - 41
10 - 41
Ref: <=200
Ref: <=150
Ref: >=40
Ref: <=129

ORAL HEALTHDENTURES: Partial Upper Insert (Not frequently worn)

Do you take them out at night? Clean them? Yes when they are worn
BRUSH/FLOSS: Yes
PAIN IN MOUTH: No
DIFFICULTY CHEWING: No
DIFFICULTY SWALLOWING: No
*PHYSICAL ACTIVITY AND FUNCTION*********************
NUTRITION-RELATED ADLS:
Physical ability to prepare food: No
Ability to self-feed: Yes
Cognitive ability to prepare food: No
Remembers to eat, recalls eating: Yes
Need for adaptive eating devices: No
MOBILITY: Chair bound
PHYSICAL ACTIVITY/EXERCISE PROGRAM: None
*NUTRITION-FOCUSED PHYSICAL EXAM (NFPE)********************
General observations: Edema both feet, ankles and calves.
*FOOD/NUTRITION-RELATED HISTORY*******************
FOOD ALLERGIES:NKA
APPETITIE: Good
FOODS PT LIKES TO EAT: Pt eats meals at his living facility and reports liking
most foods. If pt doesn't like main dish on menu, he can choose a substitute. Pt
reports not liking brussels sprouts.
PREVIOUS DIET EDUCATION: None
IS PT FOLLOWING ANY SPECIAL DIET: None
DIETARY INTAKE: 3 meals/day from facility menu
EATING OUT: Pt eats out very rarely with his daughter for special occasions.
FLUID/BEVERAGE INTAKE (cups/day):
Water: 3-4 cups per day
Coffee/Tea: 3, 4 oz cups of coffee a day w/ cream and sugar
Juice: None
Milk: None
Soda: None
*ACCESS TO FOOD********************
HOUSING/LIVING SITUATION: Retirement home
*******************************************************************************
-DIAGNOSISNUTRITION CLASSIFICATION STATUS:
Mildly Compromised
(Based on VHA Nutrition Classification Worksheet)

NUTRITION DIAGNOSIS:
DECREASED NUTRIENT NEED (sodium) related to CHF as evidenced by lower extremity
edema.
*******************************************************************************
-INTERVENTIONNutrition Rx: Regular diet
Food and/or Nutrient Delivery
Meals and Snacks- 3 meals/day
Supplements- None
Feeding Assistance- n/a
Feeding Environments- Dining Hall
Coordination of Nutrition Care
Will discuss at next HBPC TTM
*******************************************************************************
-MONITORING/EVALUATIONMNT Goal: Successful management of fluid retention, adequate intake/nutrition,
quality of life
WILL MONITOR:
VA nutrition classification status
Anthropometric measurements
Food and nutrient intake
Biochemical data, medical tests, and procedure data
NFPE findings
WILL EVALUATE changes based on future chart reviews and pt discussions.
FOLLOW-UP:
6-12 months or as clinically indicated
/es/ Katherine M. Dodd, MS, RD, CSG, LD
Registered Dietitian
Signed: 11/24/2014 11:17
Receipt Acknowledged By:
* AWAITING SIGNATURE *

SCHMIEDER,RENEE E