Kira Minot !

1
3 February, 2016/ 3:10pm

Assessment
Client History
22YOWF
Senior in college
Meds: 6-MP (50mg/d), Niferex
Lost 15# in 3 months
No known allergies
Med Dx: Crohns Disease
Current Diet: DAT

ADIME LGI

No food/ nutrition related knowledge

related to Crohns disease except personal
intolerance to high fat meals, lettuce, corn
PMH: UTI, anemia, surgery to drain
perirectal abscess, abscess returned so
colonoscopy was done showing extreme
inflammation and ulceration, TPN postsurgery for bowl rest

Anthropometric Measurements
Wt: 45.5kg
Ht: 160cm
BMI: 17.8kg/m2 (underweight)
IBW: 52.3kg
%IBW: 87% (mild deficit)
UBW: 52.3kg
%UBW: 87% (mild deficit)
% BW Change: 13% (severe wt loss)
Biochemical
No Labs available
Clinical
No RD NFPE available
MD Notes: Past diarrhea, severe abdominal pain, fatigue
Diet (Food/nutrition related history)
No 24 hour recall/diet history available
Nutrient Needs
EER (IF 1.5): 1750-1950kcal/d
Total Fat: 49g/d (25%kcals)
CHO: 263g/d (60%kcals)
Protein: 66g/d (15%kcals; 1.5g/kg)
Fluid: 1.6-1.8L/d
Motivation
Patient would like to prevent abscesses from returning, get her Crohns disease under control,
feel healthy, less tired, and function normally alongside her peers as college student.

Kira Minot !2

Diagnosis
PES Statements:
1. Unintended weight loss related to poor oral intake due to abdominal discomfort and diarrhea,
as evidenced by patients self report and medical records, an underweight BMI, and a 13%
BW change showing sever wt loss.
2. Increased nutrient needs related to anemia and recovery from inflammation, ulcerations, and
perirectal abscess as evidenced by fatigue, severe wt loss of 13%, an underweight BMI, and
recent transition back to solid foods after TPN.

Intervention
Goal #1: Increase patients weight beginning with diet of 1,750kcal/d for 2 weeks with an end
goal of 1,950kcal/d as tolerated. Diet will include 49g/d fat, 66g/d protein, 263g/d CHO, and
1.6-1.8L/d fluid.
Want weight gain of 1-2# in 2 weeks (increase kcal/d as appropriate)
Transition to regular diet
Increase pre and probiotic use
Increase antioxidant and omega-3 intake
Limit/ avoid foods high in oxalate and other trigger foods that may cause flare-ups
Educate on dietary components of Crohns disease
give sample diet plan & educational pamphlets
Goal #2: Increase nutrient intake with a high quality/complete diet of 1,750kcal/d for 2 weeks
with an end goal of 1,950kcal/d to reach increased nutrient needs. Diet will include 49g/d fat,
66g/d protein, 263g/d CHO, and 1.6-1.8L/d fluid.
Increase pre and probiotic use
Increase antioxidant and omega-3 intake
Limit/ avoid foods high in oxalate and other trigger foods that may cause flare-ups
Increase iron rich foods to go along with Niferex
Educate on dietary components of Crohns disease
give sample diet plan & educational pamphlets

Monitoring and Evaluation

RD to follow-up in 2 weeks to asses weight and nutrient intake/ levels.
Evaluate previously completed:
3-day food record for energy and nutrient intake (increase kcals if necessary for wt gain)
and adherence to sample diet given
trigger food diary for foods that flare up Crohns
Perform laboratory tests- vitamin and mineral profile (supplementation of glutamine,
arginine/ multivitamin with Ca, B12, Zn, Mg, Fe may be required)
Monitor tolerance to current diet/ improve any negative symptoms

Kira Minot !3
Indicator

Current Level of Indicator

Criteria for Success

Weight

100# (underweight)

1-2# wt gain

Nutrient Levels From

Laboratory Test

unknown

All nutrients listed above WNL

Patient Report of Symptoms

persistent abdominal pain,

fatigue, diarrhea, inflammation,
ulcerations

Reduction of these symptoms to

little or none. Ask about new
symptoms if any.

Food and Nutrition Knowledge

Related to Crohns Disease

Poor; newly diagnosed with

Crohns disease; intolerance to
high fat meals, lettuce, corn

Healthy foods to eat, trigger

foods to avoid, ways to correct
nutritional deficiencies, and
lifestyle factors to improve quality
of life

Diet

given a diet plan

Meets 75% of diet plan given

Kira Minot, Traveling RD

3 February, 2016/ 3:10pm