Patient Information e a Name Sex Male Initial Assessments by Lauren Kwiatkowski at 5/28/2015 Author: Lauren Kwiatkowski Filed: 5/28/2015 1:19 PM Service: Nutrition Note Time: 5/28/2015 AM Editor: Lauren Kwiatkowski (Student (Other) eee eae nee eee Discussed pt with Dietetic Intern. Agree with assessment it} DOB 11/18/1932 ae ‘Author Type: Student (Other) Status: Attested 8:18 Cosigner: Sasha Nunes at 5/28/2015 1:19 PM Baa and recommendations. Sasha Nunes, RD, NUTRITION INITIAL ASSESSMENT Source of Referral: RN scr ASSE: ag a 82.0. male admitted to SMI 5 a history of lung cancer. Last poor po intake and unplanned weight loss IH on 5/27 unilateral complete paralysis of radiation and chemotherapy treatment was 12/23/14. Sip injection laryngoplasty for paralyzed right local cord on 5/27. Pt noted with stridor after ‘extubation and was found to have a paralyzed left cord whi ptin room, pt’s wife was at bedside. Pt is non-verbal and c ich required tracheostomy on 5/27. Met with ommunicated by writing answers on paper. Pts wife also assisted with answering questions. Pt reports reduced appetite since January. Pt's wife reports that pt saw a nutritionist who suggested eating 6 small meals daily and to focus on foods higher in fat. Pt reports eating about 4 meals daily due to early sat reports 25 lb weight loss over the past year. Pt reports dail Past Medical History Diagnosis Dry eye syndrome HSV infection left eye Thyroid dis "hypo" Heart disease Glaucoma suspect Gout CHF (congestive heart failure) BPH (benign prostatic hyperplasia) Anemia Lung cancer RULOBECT. 01/2013 Emphysema Arthritis PONV (postoperative nausea and vorniting) pt stated he has awaken in the middle of anesthesia Atrial fibrillation Cancer metastasized to vocal cord ase AD 2:52 2222 vito ars2815 tiety. Pt also has Ensure Plus twice daily. Pt ly BMs. Date DX. 2013 Page | of 4+ SIP radiation therapy < 4 wks LAST TX. 12/22/2014 + SIP chemotherapy, time since less than 4 weeks LAST TX. 12/23/2014 + Gross hematuria 02/28/2015 + Abdominal hernia Past Surgical History Procedure Lateralty Date + Cataract extraction Right 5/31/2012 + Corneal transplant Left twice + Lung lobectomy Right R upper lobe 2013 + Pericardectomy NA 2011 + Mitral valve repair NA 1994 + Penile prosthesis implant NA 2006 ANTHROPOMETRICS Adult Anthros Height: 172.7 cm (5' 8") Weight: 61.1 kg (134 Ib 11.2 oz) BMI (Calculated): 20.5 IBW: 154 Ibs (Hamwi) UBW: 155 Ibs per pt report ‘Weight Changes: Per EPIC weights, 21 lb (13.5%) weight loss in the past year (not significant) Wt Readings from EPIC: 05/27/15 61.1 kg (134 Ib 11.2 02) 04/1715 61.417 kg (135 Ib 6.4 oz) 04/08/15 63.05 kg (139 Ib) 02/11/15 64.955 kg (143 Ib 3.2 02) 02/04/15 63.594 kg (140 Ib 3.2 oz) 01/07/15 66.497 kg (146 Ib 9.6 oz) 12109114 67.586 kg (149 Ib) FOOD AND NUTRITION RELATED INFORMATION Diet Orders Diet NPO: NPO starting at 05/27 2110 Nutrition Route: NPO Appetite: n/a Impaired Intake: NPO Supplements: No Food Allergies: No Food Intolerances: No Cultural Preferences: No Food-Drug Interactions:None Gye. by Lauren Kwiatkowski at 5/28/15... Page 2 of 4EDUCATION: Need for Education? Discussed possible diet progression depending on MD's diet order. BIOMECHANICAL Imagingjtests/procedures: 5/27- injection laryngoplasty for paralyzed right local cord 5)27- tracheostomy ‘Scheduled Meds: + ceFAZolin 19 Intravenous Q8H SCH Continuous Infusions: None PRN Meds:.morphine, morphine Lab Results Component Value Date NA 140 4/3/2015 K 40 4/3/2015 cL 101 41312015 GLU iiss 4/3/2015 BUN 19 41312015 CREATININE 0.81 4/3/2015 coz 27 4/3/2015 CALCIUM 9.0 4/3/2015 ALBUMIN 3.4" 4/3/2015 BILITOT 06 4/3/2015 ALKPHOS 87 4/3/2015 AST 22 41312015 ALT 7 41312015 Labs reviewed. ‘Accu-checks: None PHYSICAL Altered Skin: surgical incision on neck and throat Braden scale: 15, NUTRITION DIAGNOSIS Inadequate energy intake related to decreased ability to consume suffi by pt currently NPO. Unintentional weight loss related to reduced appetite as evidenced by 21 Ib (13.5%) weight loss in the past year (not significant). it energy as evidenced INTERVENTION (RECOMMENDATIONS) Nutrition Diet Prescription: regular diet 1. Composition of meals/snacks (ND 1.2) ‘Advance to regular diet once medically able, texture per SLP Goal: Pt to have diet advanced past clears once medically able by next RD follow up 2. Medical food supplements (ND 3.1) ‘Add Ensure Complete TID (350 kcal, 13g protein each) once diet advanced inted by Lauren Kwiatkowski at 5/28/15... Page 3 of 4Goal: Pt to have Ensure Complete added to regimen by next RD follow up 3. Collaboration with other providers Recommend SLP eval Goal: Pt to have SLP eval by next RD follow up MONITORING/EVALUATION 1. types of food/meals (FH-1.2.2.2) Criteria: Diet advanced within 1-4 days 2. liquid meal replacement or supplement (FH-1.2.1.3) Criteria: Ensure Complete added within 1-4 days 3. Types of foodsimeals Criteria: consistency per SLP within 1-4 days Reassess according to Level of Care: within 1-4 days (High Risk). RD remains available prn Lauren Kwiatkowski, Dietetic Intern Note Routing History Routing history could not be found for this note. This is because the note has never been routed or because communication record creation was suppressed. (aaa =») 1 222 vitkosic ar 528/15... Page sof 4