NUTRITION CARE PROCESS

ADIME NOTE

Name: Julia Eltzroth

Admitting Dx: Uncontrolled Type II diabetes

Patient Initials: N/A

Age: 27

Gender: Male

NUTRITION ASSESSMENT Complete as applicable:

Past Med/Surgical
Poorly controlled Type II diabetes, hypertension, and morbid
History:
obesity.
Current Diet Order:

Controlled Carbohydrate Diet

Nutrition Support:

N/A

Anthropometric Data
Height
Admit weight
BMI (admit)
BMI Assessment (admit)
IBW

62
392 lbs, 178 kg
50.3
Obesity class III
190 lbs, 86.4 kg

% IBW
206%
% IBW reference
N/A
Food/Nutrition Related History:
Current Food & Fluid Intake:
Consumed 100% of meals given
(2200 kcal), ~110 g protein
Breakfast: toast 4 CHO, jam 4 CHO,
milk 1 CHO, TOTAL: 9 CHO
Mid-morning snack: 2 CHO, oreos 2
CHO, TOTAL CHO 4 CHO
Lunch: Sandwich 2 CHO, chips 2
CHO, coke 2 CHO, oreos 5 CHO,
milk 1 CHO, TOTAL: 12 CHO
Afternoon snack: 0 CHO
Dinner: tuna 2 CHO, garlic bread 4
CHO, TOTAL 6 CHO
HS snack: milk 2 CHO, oreos 4 CHO,
TOTAL 6 CHO
TOTAL per day: 37 CHO
Food and Fluid Intake History:
Usual intake: 3,810 kcal, 180 g
protein
ALLERGIES

UBW
% UBW
%UBW reference
Adjusted IBW
Wt change: provide time
reference
Evaluation of wt. change

N/A
N/A
N/A
240 lbs, 109.3 kg
Intentionally lost 208 lbs in 3
years (35%)
Not significant weight change

ESTIMATE ENERGY, PROTEIN, FLUID NEEDS-make sure to provide

measurements in kg, g, mL. Provide reference-E.g. current/ admit wt, UBW,
IBW, Adjusted IBW, etc. AND your method.
Calories/day: 2180-2725 kcal/day (20-25 kcal/kg using AIBW)
Grams Protein/day: 95-112 g/day(1.1-1.3 g protein/kg) (IBW)
Milliliters of fluid/day: 3,200-4,400 mL/day (AIBW, 30-40 mL/kg)

NUTRITION CARE PROCESS

ADIME NOTE

Nutrition Focused Physical Findings:

Relevant Medical Tests and Procedures:

-Morbidly obese
-Skin: warm and dry
-Edema of scrotum and penis
-GI: Bowel sounds active x4, abdomen not tender, not
distended

N/A

Nutrition-Related Labs: Blood sugar 255, Glucose 248 (H)

Nutrition-Related Meds: Metformin, Lisinopril
Summary of Nutrition Assessment:
adequately
nourished

X obese

at risk for
malnutrition

moderate
malnutrition

severe malnutrition

NUTRITION DIAGNOSIS: (Problem, Etiology, Signs/Symptoms Statement)

Excessive carbohydrate intake related to food and nutrition knowledge deficit AEB A1C of 11.7, capillary glucose
182 H, >500 glucose in urine, current kcal intake of 155% of needs, 37 CHO choices per day.
INCLUDE # OF CARB CHOICES HE CURRENTLY HAS(3-5 per meal is good)

NUTRITION INTERVENTION: Recommendations/Plan (Diet and/or nutrition support, collaboration/referrals of

care):
Meals and snacks:
-Decreased carbohydrate diet
Nutrition education:
-Nutrition relationship to health/diabetes management- carbohydrate choices, total carbohydrate intake

GOALS:
-Eat controlled carbohydrate diet with 3-5 carbohydrate choices per meal and 1-2 carbohydrate choices per snack
-Consume 19 or less carbohydrate choices per day
-Lose 1-2 lbs a week
-Add 1-2 servings of non-starchy vegetables per day

NUTRITION CARE PROCESS

ADIME NOTE

MONITORING/EVALUATION:
-Weight
-Total Carbohydrate intake
-Insulin to carbohydrate ratio
-Types of meals/snacks