ADIME Note Template

For detailed description of each section Pg 119

Accepted Medical Abbreviations for MNT 415 assignments on page A-120-122

Assessment

Diagnosis

Date/Time

5/26/16 1300hrs

Pertinent
information
provided by
patient

Patient chief complaint is of stomach pain and diarrhea.

Patient experiences diarrhea after large meals and severe diarrhea with fried
foods or beef consumption. Patient has access to food and states good
appetite. Patient is not experiencing nausea or vomiting.
Lately patient is consuming noodle soups, some chicken, crackers and sprite.

Age; Gender;
Dx; PMH

36 yo Female Dx: Celiac Disease with secondary Malabsorption and Anemia

PMH: Undisclosed

Ht; Wt; UBW/

%UBW; IBW;
%IBW; BMI

Ht: 53 Wt:92# UBW:112# UBW%:82% (18% change in 1 month=severe

wt loss) IBW:115# IBW%: 80% ABW:121# BMI: 16.3

Labs

Tissue transglutaminase (tTG):positive (normal=negative)

Antiendomysial IgA antibody (EMA): positive (normal=negative)
Hgb (low): 10.5 g/dl Hct (low): 35% Ferritin (low): 12
albumin (low): 2.9 g/dl prealbumin (low): 14mg/dl

Meds

N/A

GI

bowel biopsy indicates flat mucosa and villus atrophy and hyper plastic
crypts- inflammatory infiltrate in lamina propria; diarrhea with no nausea or
vomiting.

I/O

N/A

Physical
Assessment

N/A

Skin

N/A

EER; EPR;
Fluid
requirements

EER: 1850 kcal (based on 35 kcal/kg[IBW]) EPR: 60 g (based on 1.0-1.2 g/

kg[IBW]) Fluids: 1850 ml (based on 1ml/kcal)

Current Diet

NPO

PES #1

Inadequate
energy intake
(NI-1.2)

severe weight loss of 10 # 18%

avoidance to
change in 1 month, BMI of 16.3
consume foods
R/T
AEB (underweight) and patient report
that cause
of meals consisting of soup,
stomach pain
chicken, crackers and sprite.
and diarrhea

PES #2

PES #3

Altered GI
function
(NC-1.4)

Altered
nutrition-related
laboratory values
(iron)
(NC-2.2)

Intervention

Nutrition
Prescription

R/T

impaired Gi
with villus
atrophy and
hyperplastic
crypts

AEB

bowel biopsy with positive

diagnostic indicators for Celiac
disease: +tTG and +EMA, low
hematological values, and
patients reported symptoms of
persistent diarrhea.

low hematological values: Hgb

knowledge
10.5 g/dl (reference: 12-15g/dl);
deficit of foods
Hct 35% (reference 37-47%);
that contradict
R/T
AEB Ferritin 12 ng/dl (reference:
celiac disease
20-120 ng/dl)
diet causing
anemia

Upon discharge discontinue current NPO diet and resume oral intake.
Correct Malnutrition and symptoms of celiac disease by following:
1. Increase caloric intake of 1850 kcal per day to 2300 kcal to achieve
weight gain 1-2# per week for a target weight goal of 115#.
2. Consumption of nutrient dense meals 3x and 2 snacks per day to meet
2300 kcal and 60 g protein per day.
3. Very important to adhere to Gluten-free food products. Avoid foods that
contain wheat, rye, malt or barley.
4. Follow a low fat regimen (25-50 g per day) and eliminate consumption
of fried foods.
5. Avoid foods with lactose containing ingredients,such as milk or dairy
products.
6. Follow a diet low in fiber, refined grains like rice, and constituents that
contribute to bulk in intestine.
7. Increase fluids to 2000 ml per day (approximately 8-10 cups) to meet
minimum fluid needs for adult.
With diarrhea symptoms present:
8. To prevent dehydration, recommend oral rehydration solution, such as
Pedialyte, as tolerated.
9. Avoid consumption caffeine, sugar alcohols such as sorbitol and fructose
products. Discontinue intake of Sprite.
When Diarrhea has subsided and stool consistency is stabilized:
10. Recommend intake of iron rich foods (3-4 servings a day) to normalize
ferritin, Hgb and Hct values.
11. Introduce fiber into the diet 25-35 grams per day to maintain stool
consistency.
12. When introducing lactose into diet, do so in small amounts (1 cup of
milk within 24 hr period) or as tolerated. If symptoms or diarrhea occur,
discontinue intake of lactose product and report symptoms to MD.

Monitoring/
Evaluation

Treatment
plan: nutrition
therapy,
education,
acquisition of
additional
information

1. Achieve tolerance to foods, ideal body weight and correct symptoms of

Celiac Disease.
2. Increase patients knowledge by providing handouts on gluten-free diet.
3. Prevent refractory Celiac disease by educating on sources of cross
contamination and hidden sources of gluten.
4. Patient will document food intake using a food log.
5. Educate on how to read food labels to target gluten containing foods,
high iron and fiber sources.
6. Promote hand hygiene and safe sanitation for prevention of diarrhea.
7. Refer patient to MD to conduct lactose intolerance testing after
symptoms of Celiac Disease have subsided.
8. Refer patient to community cooking classes for enhanced understanding
of gluten-free diet.

Plan(s) for
evaluating
outcomes of
interventions
listed above;
plan for
follow-up

1. Monitor nutritional status using Mini Nutritional Assessment tool.

2. Inspection of laboratory values, food records, and findings on physical
assessment ( i.e.weight) and tolerance to foods.
3. Review food logs to assess knowledge on items containing gluten,
adherence to gluten-free diet, iron, and fiber sources.
4. Collaborate with medical staff to review laboratory values indicative of
iron status and biopsy results.
5. Follow-up on MD notes for lactose intolerance test results.

Signature (&
name)

Alice Argueta

Alice Jennifer Argueta