occurred: tL/04/L3 Recorded: 1-l/04/13

Abnormal?
N

By L35o NPDl Ps61ing,NichoI,e 1-407 NPD Dool-ing, Nichole Conf

Nurse tTfee Df,Bf., .,,,,,.,,..,,,,

DI.ET..
: ::::::::::

,,,,,,,,,,,,,,,,,Categor)r

DlqEa::y Note

ident,ial-?

LABS: cLU l-69 CA 7.3 ALB 2.7 WT. T84 HT.7O" BMf 25 (OVERWEIGHT) EST NEEDS:. 2034-2234KCAL 83-103c PRO 2L FLUID GOAL: PT GI FUNCTION TO NORMALIZE
]NTERVENTION:

NUTRITTON ASSESSMENT PROBLEM: A],TERED GI FUNCTION RT SEVERE COLITIS AED DIARRHEA, ABDOMINAL PA]N, AND BLOOD IN STOOLS X 10 DAYS PT HAD A SIGMOIDOSCOPY THAT REVEALED SEVERE COLITIS. PT RECENTLY DX WITH LYME DISEASE AND ON AMOXfCILIN. PT WAS ON CLIQ AT ADM AND IS CTIRRENTLY ON SOFT DIET. PT DTD NOT EAT BREAKFAST AS HE WAS HAVING AN MRI. PT SAID HE HAD 3 BOUTS OF FECAL URGENCY WITH LOOSE STOOLS AND SPOTTING OF BLOOD AFTER DINNER LAST N]GHT OF SOFT MASHED POTATOES AND COOKED CARROTS. PT FOLLOWS A LOW RESTDUE DIET AT HOME. WEIGHT 184-STABLE PER PT.

1. WILL PROVIDE FIBER D]ET 2. MON]TOR DIET ADV 3. MONITOR INTAKE, WEIGHT, 4. FOLI,OW HOSPTTAL PLAN OF

ED

LABS
CARE