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Katie Sprague

ADIME 2

Assessment:

Age: 87 Gender: F
Dx: CHF
PMHx: acute respiratory distress, fluid overload, normocytic anemia,
pleural effusions, chest pain, leukocytosis, tachycardia, aspiration PNA,
hyperthyroidism, hyperlipidemia, afib
Treatments/therapies/alternative medicine:
o None noted
Ht: 155 cm Wt: 64 kg
IBW: 55 kg ** for age %IBW: 116%
UBW: 70.5 73 kg %UBW: 89.5% (using 71.5 kg as UBW)
BMI: 26.7 this classifies the pt as overweight
Nutritional requirements:
o Mifflin St Jeor: 9.99(64kg) + 6.25(155cm) 4.92(87) 161 =
1019
1019 x 1.2 AF = 1223 kcals/day
o Kcal/kg: 25kcal x 64kg = 1600 kcals/day
Between 1220 1600 kcals/day
o Protein: 1 - 1.1g x 64kg = 64 - 70gm of protein/day
o Fluid: 25cc/kg= 1600 mL 1.6L per day
o Other necessary nutrients:
Iron and B12 due to vegan diet
Low sodium due to cardiac diet
Diet Orders:
o Vegan, cardiac
Assessment of current diet order:
o The current diet order does seem appropriate for this patient.
The patient follows a vegan diet due to personal and religious
beliefs. The cardiac portion of the diet was implemented because
of the Dx of CHF to help prevent further heart complications in
the future. The patients daughter reported that she already does
not add salt to her foods at home so limiting sodium as part of
the cardiac diet should not be an issue for this patient.
Labs
Labs Values Indications
NA 139 mEq/L This value indicates that the
patient is in good electrolyte
balance. The pts kidneys are
working properly to keep Na
balanced.
K+ 4 mEq/dL This value indicates that the
patient is in good electrolyte
balance and that her kidneys
are working properly.
HGB 8.3 g/dL L Possible causes include:
anemia, hyperthyroidism,
cirrhosis, many systematic
disease, HIV/AIDS
This value coincides with the
patients diagnosis of
normocytic anemia.
HCT 26.1% L Possible causes include:
Anemia, blood loss,
hemolysis, leukemia,
hyperthyroidism, cirrhosis,
over-hydration
This value coincides with the
patients diagnosis of
normocytic anemia.
RBC 3.06 mm L Possible causes include:
Anemia, hemorrhage, Fe
deficiency, systemic disease
This value coincides with the
patients diagnosis of
normocytic anemia.
Glucose 116 mg/dL This value indicates that the
pts insulin is functioning
properly to regulate blood
sugar levels.
BUN 24 mg/dL This indicates that the pts
kidneys are functioning
properly to remove urea from
the blood.
Creatinine 0.9 mg/dL This value also indicates good
kidney function because
creatinine is being cleared
from the blood normally.
Cl 98 mEq/L L Possible causes include:
diabetic acidosis, fever, acute
infections, metabolic
alkalosis, vomiting, K disease,
chronic respiratory acidosis,
SIADH
Bicarbonate 33 mmol/L H Possible causes include:
metabolic alkalosis,
respiratory acidosis,
emphysema, vomiting,
The abnormal lab values of RBC, Hgb, Hct, MCHC and platelet count as
well as the normal value of MCV are all indicative of the patients past
medical condition of normocytic anemia. The other abnormal lab values of
bicarbonate and Cl could be indicative of the patients acute respiratory
distress.
Meds:

Names Uses Drug nutrient


interactions
Cardizem CD Antiangina, Calcium intake may need to
diltiazem antihypertensive, Ca be decreased
channel blocker Low sodium diet should be
followed
Avoid natural licorice
Possible side effect: anorexia
Lopressor Antihypertensive, Decrease Ca and Na intake
metoprolol antianginal, CHF
treatment
Neurontin Antiepileptic Take two hours before or
gabapentin after Mg
Possible increased wt and
appetite
Pradaxa Stroke prevention Do not take with
dabigatran supplements
etexilate Take with food if there is GI
distress
Synthroid Thyroid hormone Take Fe, Ca, or Mg
levothyroxine supplements more than 4
hours before or after this
drug and 2 hours before or
after soy products
Decreased absorption of soy
milk, walnuts and high fiber
foods
Be cautious with grapefruit
and citrus foods

Nutrition focused physical findings:


o Mild subcutaneous fat wasting and mild muscle wasting R/T age
o Mild edema: LUE and RUE pitting 1+, LLE and RLE pitting 2+
o Alert, sitting upright
o Physical weakness, unable to ambulate as well as baseline for
patient
o Weight loss of 15-20 lbs PTA
Pertinent social Hx:
o Does not speak English (Punjabi)
o Very religious - beliefs affect food choices (no pork products,
vegan)
o Daughter and son nearby visiting patient
o Lives in an apartment with her spouse
o PTA: active woman, able to ambulate, cooks for herself and her
spouse
Nutrition history, Diet PTA ** obtained from pts daughter due to
language barrier
o Poor appetite and meal consumption for 3-4 weeks PTA
Pt consuming less than 50% of estimated energy needs
o Pt would consume Boost on a regular basis
o Does not cook with salt, oil or chili pepper
o Patient strictly follows a vegan diet
Summary of current intake:
o Pts appetite is slowly increasing (as reported by patients daughter)
o Consumption of less than 50% of estimated energy needs
(breakfast: a few bites of morning oatmeal and less than half of a
fruit cup)
o Pt currently needs assistance and encouragement to eat her
meals
Daughter visits every day and attempts to feed the patient
some food along with water
Diagnosis:
PES statement: Patient is assessed with severe protein-calorie malnutrition
R/T acute illness, CHF, and loss of appetite AEB <50% of estimated energy
needs for > 5 days and unintentional weight loss of > 5% over 1 month.
Intervention:

Food/Nutrient delivery:
o Order vanilla Ensure PLUS from the diet office to be delivered to
the patients room TID
o If patient does not consume at least 50% or more of her
supplements, meals and snacks and continues to lose weight,
then the family should consider a tube feed to ensure no further
malnutrition.
o Assistance and encouragement will be provided to the patient,
either by family or staff, at each meal to ensure maximum intake
by the patient.
Nutrition education:
o Patient was unable to communicate and receive direct
information due to a language barrier, therefore education was
provided verbally to her daughter about a high protein, high
calorie diet and different meals and supplements that would be
appropriate for the patient, such as Ensure PLUS.
o The patients daughter also received verbal information about
different food choices that would follow the patient vegan
restrictions, such as yogurt and oatmeal for morning choices, and
soup, salad, and pasta for afternoon and evening choices.
o Education was also given to the patients family verbally along
with a handout on a cardiac diet the patient already follows a
cardiac diet at home and chooses not to salt food so they had a
good understanding of the information.
o The patients family could communicate this education to the
patient and all parties showed understanding and willingness to
comply.
Coordination of Care:
o A consultation with PT should occur to assess the patients ability
to perform ADLs such as ambulating, self-care, and feeding
herself on her own. Currently, the patient is not able to ambulate
well, needs assistance with self-care, and needs assistance and
encouragement to eat. PT should assess the current level the
patient is at and set goals to help the patient get back to her
baseline for these functions.
Monitoring and Evaluation:

Food/Nutrition Related Outcomes:


o Patient will consume 50% or more of meals and snacks
o Patient will consume 75% or more of supplements
o Patient will receive vanilla Ensure plus TID
o Patient will continue to follow a cardiac diet
Anthropometric Measurement Outcomes:
o Patients weight will remain stable; no weight loss
Biochemical data, Medical Tests and Procedure Outcomes
o Patients abnormal lab values will begin to normalize
Hgb, Hct, RBC, MCHC, and platelet count will begin to
normalize to show improvement in the patients normocytic
anemia
Cl and bicarbonate will begin to normalize to show an
improvement in the patients respiratory distress
Iron and b12 levels should be monitored to ensure patient
is meeting her needs while on a vegan diet
Nutrition Focused Physical Findings:
o Patients age-related mild subcutaneous fat wasting and muscle
wasting will not increase
o Patients mild edema will improve by f/u
o Patient can ambulate and perform self-care at her baseline
function by f/u
o Patient can feed herself without help and encouragement by f/u
Nutrition education outcomes
o Patients daughter can state 3 high calorie, high protein foods
appropriate for the patients diet order
o Patients daughter can state 2 high calorie, high protein
supplement drinks that are appropriate for the patient to drink
on her diet order.
o Patients daughter can relay this information to her mother and
she can repeat it back to her to show understanding.
Addendum to ADIME
Current Dx: CHF
This condition occurs when the heart can no longer pump enough
blood to meet the needs of the rest of the body. Some symptoms are SOB,
loss of appetite, nausea, fatigue, and malnutrition. If the condition
progresses it can result in death. CHF patients are at a higher risk for
malnutrition due to side effects of the condition such as edema,
malabsorption in the gut, anorexia, and a decrease in consumption due to
overall weakness and fatigue from the extra energy needed to breath. The
MNT for this condition begins with educating the patient and their family on a
cardiac diet. The patient will need to understand the importance of limiting
Na intake and possibly fluid intake as well. The patient should also
understand the importance of taking in enough calories and protein to meet
their daily requirements to maintain a healthy weight and prevent
malnutrition. The diet includes limiting Na intake to less than 2 g per day and
limiting fluid intake to less than 2 L per day depending on the serum sodium
value of the patient (<130 mEq/L). The reasoning for this MNT is to help
prevent the patient from retaining water and causing further damage to the
heart muscle. It is also advised that patients on diuretics supplement with
thiamine and potassium to ensure their diet does not become deficient in
these nutrients. Additionally, patients are advised to limit or cease their
alcohol consumption depending on the severity of their CHF to prevent
further damage to the heart. If patients have advanced CHF, then enteral
nutrition may be necessary, using more concentrated formulas to be mindful
of any fluid restrictions.
Pertinent Drug/Nutrient Interaction Information:

* already included in ADIME


Menu Plan: vegan, cardiac, 1223 kcals/day, 77 -83 gm protein, 1.6 L per
day
** The patients daughter reported that the patient is more compliant with
drinking rather than eating, and requested Ensure plus TID. Therefore, this
patients meal plan will reflect Ensure PLUS as being a source of calories for
this patient. The Ensure Plus will be brought to the patient at each meal time,
but the patients daughter reported that she enjoys to sip on them
throughout the day, rather than drink them all at once at that meal time.
Breakfast:
Food Amount Calorie Carbohydrate Fat Protein
s s (g) (g) (g)
(kcals)
Oatmeal cup 71 15 1 2
Banana 53 15 0 1
Coffee 8 oz.
2% milk 6 oz. 92 9 2 6
Ensure 4 oz. 178 25 6 7
PLUS
vanilla
TOTALS 393 64 9 16

Snack:
Food Amoun Calorie Carbohydrate Fat Protei
t s s (g) (g) n (g)
(kcals)
Cottage cup 154 5 7 18
cheese
Water 8 oz.
TOTALS 154 5 7 18

Lunch:
Food Amoun Calorie Carbohydrate Fat Protei
t s s (g) (g) n (g)
(kcals)
Low sodium cup 47 10 0 1
vegetable
soup
Wheat roll 1 98 17 2 3
Ensure 1 178 50 11 13
PLUS vanilla
Coffee 8 oz.
Water 8 oz.
TOTALS 323 77 13 17

Snack:
Food Amoun Calorie Carbohydrate Fat Protei
t s s (g) (g) n (g)
(kcals)
Apple 1 cup 57 15 0 0
sliced
Peanut 2T 195 5 17 8
butter
Water 8 oz.
TOTALS 252 20 17 8

Dinner:
Food Amount Calorie Carbohydrate Fat Protei
s s (g) (g) n (g)
(kcals)
Yogurt 6 oz. 173 32 2 7

Fruit cup cup 46 12 0 1

Ensure 1 350 50 11 13
PLUS
vanilla
Water 8 oz.
TOTALS 397 94 13 21

Total amounts of nutrients:


Calories Carbohydrat Fat (g) Protein (g) Sodium Fluid
es (g) (mg) (mL)

1520 206 59 1750 1597


67

With this sample menu the patient is meeting her required


protein needs of 64-70 gm/day. She is also meeting her fluid needs
of about 1.6L per day. She is currently getting 4 oz. of Ensure PLUS
at each meal. If the patient is not willing to tolerate the solid foods,
then ensure PLUS may need to be increased to 6 or 8 oz. at each
meal to meet protein and calorie needs.
References:
Mahan, L. Kathleen., and Janice L. Raymond. Krause's Food & the Nutrition
Care Process. Print.

"NCM Nutrition Care Manual Eat Right." Public Home Page. N.p., n.d. Web. 17
Feb. 2016.