2024 Pt #1 Melt ADIME Partial
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Central New Mexico Community College *
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425
Subject
Health Science
Date
Feb 20, 2024
Type
docx
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4
Uploaded by aromero356
ADIME for Patient #1 – Patty Melt, DOB: 1/18/19**
Today’s Date: February 5, 2022
Reason for RDN Assessment:
referral from admission nutrition screen for two day history of N/V/D/abd
pain
A: ASSESSMENT
Client History (CH) Domain
CH-1.1.1 Age: 25
CH-1.1.3
Sex: Female
CH-1.1.6
Language: English
CH-2.1.1
Individual client nutrition-related health history: unremarkable history; dislikes pre-select meals CH-2.1.1.5
Gastrointestinal: acute appendicitis (Primary)
CH-2-2.2
Surgical treatment: S/P lap appy on 2/2
Anthropometric Measurements (AD) Domain
AD-1.1.1.7
Stated Height: 5’ 6” = 66” = 167.6 cm
AD-1.1.2.1
Measured Weight: 137 lbs = 62.3 kg
AD-1.1.2.5 Stated UBW: 137 lbs
AD-1.1.5.1 BMI: 22.1
Biochemical Data, Medical Tests, and Procedures (BD) Domain:
Lab Test
NCPT
Code
Normal
Range
Result
Is Result
High or
Low?
Date
Tested
Possible Reasons
for Abnormal
Results
WBC
No code
3200 – 10600/UL
12.5
18.4
High
High
2/5
2/2
Leukocytosis w/leukemia, bacterial infection, hemorrhage, trauma or tissue injury, cancer
Nutrition-Focused Physical Findings (PD) Domain:
PD-1.1.1
Overall findings: appears healthy and well-nourished
PD-1.1.5
Digestive system: no current issues with appetite; states she is hungry but dislikes pre-
select hospital meals
PD-1.1.5.4
Abdominal pain: Pt reports RLQ abdominal pain for one-two days prior to admission, now resolved; c/o mild incisional pain
PD-1.1.5.11
Diarrhea: Pt reports diarrhea starting two days prior to admission; now resolved
PD-1.1.5.24
Nausea: Nausea for one day prior to admission - now resolved
PD-1.1.5.25
Normal bowel sounds: Per RN, Pt with normal bowel sounds to all four quadrants
PD-1.1.5.27
Vomiting: Pt reports vomiting for two days prior t admission; now resolved
PD-1.1.17
Skin: four surgical sites with sutures
PD-1.1.21
Vital signs: all WNL
Food/Nutrition-Related History (FH) Domain:
FH-1.2.1.1
Oral fluid estimated intake in 24 hours: 1900 - 2200 ml
FH-1.2.2.1
Estimated amount of food: 25% for two meals/Regular diet
FH-1.2.2.2
Types of food/meals: pre-select menus; Pt does not have room service menu and is unaware of room service availability
FH-2.2.1.1
General, healthful diet order: Regular diet, advanced on 2/5 at breakfast
FH-2.1.1.2.1
Previously prescribed diets: Clear Liquids from 2/3 – 2/4
FH-3.1.1
Prescription medication use: Medication
Classification
Potential Drug Nutrient Interactions
and Nutritional/GI Side Effects
Cefotan
2 gm IV every 12 hrs
antibiotic
May cause anorexia, N/V/D
Naproxen
275 mg every 6 hrs
Analgesic, NSAID, antiarthritic
Take w/food or milk; limit caffeine; avoid or limit natural products which affect coagulation (e.g. garlic, ginger, ginkgo, ginseng or horse chestnut); avoid alcohol; May cause N/C/dyspepsia/GI pain
Oxycontin
10 mg every 12 hrs prn (decreased on 2/4 from scheduled administration)
Analgesic, narcotic, opioid
May take w/food or milk to reduce GI distress; caution with grapefruit/related citrus; avoid alcohol;
may cause anorexia, dry mouth, N/V/C
FH-4.3.21 Food Preferences: intern took food preferences
Food/Nutrition-Related History (FH) Domain in Narrative Format:
Pt w/good appetite and requesting food based on preferences; Pt reported disliking pre-select trays. Pt is ambulating and denies N/V/D/C; denies food allergies or intolerances. Pt reports good appetite at home and stable weight prior to acute illness.
Intern took food preferences and provided menu to Pt. Pt without nutrition related questions/concerns at this time.
Intern encouraged intake of food and protein to promote healing from surgery; encouraged fluid intake for adequate hydration. Pt stated understanding.
Etiology Domain (EY):
EY-1.3 Knowledge etiology: Pt unaware of availability of room service menu choices and does not have menu
Assessment, Monitoring and Evaluation Tools Domain:
N/A
Progress Evaluation Domain: N/A
Comparative Standards (CS) Domain:
CS-1.1.1
Total energy estimated needs in 24 hours:
1550 – 1750 kcal
CS-1.1.2
Method for estimated total energy needs:
Mifflin-St. Jeor
CS-1.1.3
Total energy estimated needs per kg body wt:
25-28 kcal/kg for 62.3 kg
CS-2.2.1
Total protein estimated needs in 24 hours:
65 – 75 g
CS-2.2.2
Total protein estimated needs per kg body wt:
1.0 – 1.2 g/kg for 62.3 kg
CS-2.2.3 Method for estimated total protein needs:
grams/body wt
CS-3.1.1
Total fluid estimated needs:
1850 – 2050 mL
CS-3.1.2
Method for estimating needs:
30 mL/kg
CS-5.1.1
Ideal/reference body wt (IBW): 130 lbs (59.1 kg)
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Intern’s Interpretation of Assessment Data:
Pt is not eating due to food preferences and dislike of pre-select menus. Pt states she has a good appetite and would likely eat better if she picks her own food. The intervention of providing a menu and instructing her to order her meals will probably resolve inadequate intake.
Pt with normal bowel sounds and no N/V which indicates GI tract is functioning and that she can
tolerate regular food. Also, Pt tolerated CL diet.
WBC was elevated at admission and is still elevated, indicating an infection, but it has improved after surgery and with antibiotic.
BMI is WNL. Appetite was good prior to appendicitis and wt has been stable. Pt appears to be a
healthy well-nourished individual prior to admission and is at low nutrition risk assuming her intake improves if she can select her own menus. D - Nutrition Diagnosis
Nutrition Problem:
not eating enough because Pt doesn’t like pre-select menus and is unaware of ability
to order meals
NI-2.1 Inadequate oral intake
Related to
Pt unaware of option to order meals with room service
As evidenced by:
25% recorded intake, and
Pt’s report of dislike of preselect menus
Pt’s request to order her meals with room service.
I - Nutrition Intervention
M/E - Nutrition Monitoring and Evaluation