DIET4030 Crohn's Dz Case Study ADIME IP form
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Health Science
Date
Apr 30, 2024
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ADIME Form Inpatient
Patient Name:
Shawn Callahan
DOB:
10/18/1978
Date:
03/31/2024
Time:
14:30
Age:
45
Sex:
M
NUTRITION A
SSESSMENT
Adm Dx:
Severe exacerbation of Crohn’s Dz, Mild dehydration
PMH:
IBD: Crohn’s Dz, 4 small bowel resections
Current Labs (w/ assessment):
BMP BUN High: Indicates possible kidney dysfunction or dehydration, possibly caused by loss of fluids in diarrhea. BMP Glucose High: Possible insulin resistance or diabetes. Serum Potassium Low: Hypokalemia, possibly due to diarrhea and malabsorption as a result of Crohn’s. Serum Sodium High: Could be result of dehydration or diarrhea leading to loss of fluids. Low Hemoglobin and Hematocrit: Indicative of anemia, possibly chronic, possibly due to blood loss from intestinal inflammation/diarrheal loss or not meeting nutritional needs. High RBC count: Possibly a response
from the body to the anemia and could be indicative of dehydration. High Segmented neutrophils:
High WBC, indicative of inflammation in the body, most likely in the GI tract. Low Lymphocytes: Most likely due to nutritional deficiencies and can be a sign of high risk of infection.
Medications (w/ assessment):
Ciproflaxin: An antibiotic used to treat bacterial infections, including those that affect the GI tract. Side effects may include nausea, diarrhea, and bone pain. Metronidazole: An antibiotic used to treat infections by attacking certain bacteria that does need oxygen to survive and protozoa bacteria. Side effects may include dizziness, stomach upset, nausea, vomiting, loss of appetite, and diarrhea. Morphine sulfate: A narcotic analgesic that is used to manage moderate to severe pain. Side effects may include constipation, nausea or vomiting, drowsiness, dizziness, loss of appetite, and fainting. Methylprednisolone Acetate: A corticosteroid that is used to reduce inflammation and can be used to manage flares of Crohn’s dz. Side effects include weight gain, mood changes, vision problems, bleeding, increased hunger and dizziness.
ANTHROPOMETRICS
Ht/Lt:
68 in
IBW:
154
% IBW:
107.1%
Adm Wt:
165 lbs (74.8 kg)
UBW:
175 lbs
% UBW:
94.3%
Current Wt:
165 lbs
AIBW:
N/A
BMI:
25.1
Class:
Overweight
Est. Dry Wt:
N/A
Recent Wt. Hx:
Lost 10 lbs over past 2 wks
Patient interview Notes:
Pt reports symptoms of fatigue, persistent diarrhea, joint pain and swelling, nausea, anorexia, abdominal cramps and pain, frequent bowel movements, and sensations of incomplete evacuation. Pt reported a “7” on the pain scale; experiencing severe abdominal pain. Stated that father and paternal grandmother were known to have nervous stomachs. See intake PTA for statements regarding food and fluid intake. Denies recent international travel, consumption of undercooked or raw foods, or recent antibiotics use for an unrelated illness.
Denies constipation, dizziness, loss of consciousness, chest pain, acute weakness, vomiting, or fever.
Intake/Digestive Problems
Physical & Mental Status
Metabolic Stressors
Access
NPO x 1 day
Diarrhea
Constipation
Nausea
Vomiting
Food Allergy/Intol:
ETOH/Drugs
Anorexia
Chewing Problem
Poor Dentition
Swallowing Problem
Aspiration Precautions
Assist w/ Meals
Hearing Impaired
Limited Vision
Dementia
Language Barrier
Mental Status Changes
N/A
Post-op/Surgery
Fever/Infection
Wounds
Trauma/Fracture
Sepsis
Other:
PO
NGT
NJT
OGT
GT
JT
GJT
PEG
HICKMAN
CVL
PORTACATH
PIV
PICC
PHYSICAL ASSESSMENT
Notes on Physical Assessment:
Abnormal sunken eyes. Abnormal dry mucous membranes. Abnormal reduced skin turgor. Respiratory rate abnormal: increased. Heart rate abnormal: increased. Bowel sounds abnormal: hyperactive. Abnormal tender abdomen. Abnormal diarrhea x 12 per day. Abnormal appetite: cannot eat without abdominal pain. Abnormal activity: cannot do
regular daily activities due to diarrhea and pain. Rest of categories WNL.
Adequately Nourished
Obese
At risk for malnutrition
Malnourished ESTIMATED NUTRITON NEEDS & INTAKE ASSESSMENT
Intake PTA (Usual Intake, Calorie Count, and/or results from Intake Analysis):
Decreased intake for past 2 wks. Tolerance of
clear liquids and bland foods such as saltine crackers and white toast. 10 lbs wt loss over past 2 wks. Consuming <25% of estimated needs over past 2 wks.
Diet PTA:
When feeling well, High fiber diet. Over past 2 wks clear liquids and bland foods.
Current Diet Order:
NPO while awaiting surgery
Calculation Wt: Est Needs
Calorie Count/Intake
Assessment Results
% Goal Met by Current
Intake
Energy
BMR: 1610 kcal
Using: MSJ + 1.25 activity factor
2012 kcal
In past 2 wks, pt has been tolerating bland foods such as white toast and saltine crackers. Usually follows high-fiber diet.
<25%
Protein 1.5-2.5 g/kg
112g/d – 187 g/d
Tolerance of bland foods such as white toast and saltine crackers, not high in protein.
<25%
Fluid: Using Holliday Segar
2596 mL
Tolerance of clear liquids. Placed on IV once in hospital: D5W w/ 60 meq KCl @ 125 mL/hr <25%
NUTRITION D
IAGNOSTIC STATEMENTS (PES)
1.
Inadequate energy intake r/t severe exacerbation of Crohn’s dz AEB intake PTA showing decreased intake and 10# wt loss over past 2 wks.
2.
Inadequate fluid intake r/t dehydration as a result of severe exacerbation of Crohn’s dz AEB intake PTA showing decreased fluid intake, lab values such as high serum sodium and low serum potassium, and persistent diarrhea resulting in fluid loss.
3.
Condition related malnutrition r/t severe exacerbation of Crohn’s dz AEB intake PTA showing pt meeting <25% of estimated needs and 10# wt loss over past 2 wks.
GOALS
1.
Increase daily calorie consumption by at least 25% in one week.
2.
Replenish fluid and electrolyte loss by increasing fluid intake by at least 15% in the next three days.
3.
Increase daily protein consumption by at least 20% in one week.
4.
Manage hyperactive bowel movements and persistent diarrhea by reducing frequency of incidents by at least 50% in the next week.
I
NTERVENTIONS/RECOMMENDATIONS
1.
Advise patient to consume at least one bottle of Pedialyte per day in order to replenish electrolytes and fluid loss.
2.
Advise patient to consume at least one bottle of Ensure per day in order to increase daily calorie and protein consumption.
3.
Educate patient on fiber-restricted diet and inflammatory foods. Provide patient with educational handout of foods recommended to eat and foods to avoid.
4.
Recommend patient have small meals or snacks every 3-4 hours and avoid skipping meals.
5.
Encourage slow introduction of food and fluids based on tolerance beginning with bland foods and clear liquids.
M
ONITORING AND E
VALUATION:
I&O sheet
Labs:
BMP and CBC with differential to assess progression of restoration of abnormal lab values
Calorie Count x
days
Patient Meal Rounds
RD participation in Patient Care Team Rounds
Review changes in clinical status & discuss pt progress w/ team:
Assess adherence to interventions and progression with nutritional goals
Other:
Follow-Up: RD f/u in 1 week
to further evaluate
diet progress and adherence to nutrition education
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