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Andrew Crotty

2/25/16
ADIME
A : (Assessment) (5pts):
Age: 23 Gender: Female Dx: Anorexia *(not nervosa)we decided to treat as
malnutrition/FTT
PMHx: ADHD, OCD, ODD, Hyperthyroidism, Allergic Rhinitis, Constipation, Anxiety,
Altered mental status (acute hypertensive encephalopathy)
Ht: 5’4” or 1.63m Wt: 53.3kg (117lbs) IBW: 108 to 132lbs (120 +/- 10%) %IBW: 100
UBW: 129lbs %UBW: 91%
BMI: 20.1
Wt changes while in hospital: 9% in last eight days
Nut’l Requirements: (5pts)
kcal: Mifflin St Jeor X 1.3-1.4 = 1634 to 1760 kcal/d
30-35 kcal/kg = 1599 to 1866 kcal/d
Protein 1.3gm/kg = 69g pro/d
Fluid = 1cc/kcal = 1700cc/day
Calories from Carbohydrates (50%): 850 (213g carb)
Calories from Fat (30%): 510 (57g fat)
Calories from Protein (20%): 340 (68g pro)
Other nutrients as deemed necessary
With increased caloric intake there may be increased needs for thiamin and niacin due to
their roles in metabolism.
Catabolism may have increased loss of potassium, magnesium, phosphorus, and zinc.
Fluid and electrolytes may be required to adjust serum levels due to plausible organ
dysfunction occurring with severe malnutrition.
 Addressed with D5W
Diet Order: (Current and others in chronological order) (5pts):
Assessment of Appropriateness of current diet order
2/10/16 Regular diet with 8oz Original Ensure with every meal (PRIOR ADMISSION)

I believe a liberal diet is crucial in allowing a picky eater such as M.M. to increase her
caloric intake. This is suitable because the main focus is increasing caloric intake and
there are no other diagnoses that require crucial dietary modification. I also agree with
the addition of a dietary supplement in order to compensate for a relative lack of caloric
intake through food alone.
2/18/16 Regular Diet (CURRENT ADMISSION)
For reasons previously stated I agree with the order of a regular diet. The shortcoming of
this diet order is that it lacks a supplement, which had been effective during past
admissions. However, I was pleasantly surprised to see said supplement provided with
Her lunch. This indicated a new diet order had likely been processed since my review of
Her medical records. Ensure Plus should be considered in replacement of the original due
to the increased caloric content along with additional protein. Ensure plus TID will
supply an additional 39g protein and 1050 calories per day.
Labs: (5pts) Explain relevant lab values – both normal and
abnormal
2/18: 98.1 F

98/56 mmHg

I&O: unavailable

***I only collected the labs that you suggested but in hindsight I
would’ve collected more electrolytes (Cl and K), and minerals (Ca, Mg,
and PO4).
Gluc
18-Feb

79
109
17-Feb H


BUN
8
8

Creat

Na

Alb
3.0
0.75 146 H L
3.2
0.87
138 L

WBC

RBC
3.6
6.6 L

KETO
15 H

8.7 4.0 L

Glucose is seen to be elevated beyond its normal range of 70 to 99 mg/dL. This is
likely due to the severe malnutrition that is present.
Na is found to be higher than it’s ideal range of 136 to 144 mEq/L. This is likely
due to the electrolyte imbalance typically found when malnutrition is present.
Red blood cell counts were lower than the ideal range of 4.2 to 5.5, which
indicates the presence of anemia. With MCV, ferritin, transferrin, and serum Fe a
potential anemia can be identified. This could be addressed through
supplementation alongside restoration of normal eating patterns.
Ketones are typically present in urine when fat is being used as a fuel source over
prolonged periods. This is often the case with anorexia and due to the body’s state
of starvation.

Meds: (5pts)

D5 NaCl 0.45% ***wasn’t in use upon visitation, likely D/C
 Isotonic solution providing fluids and electrolytes
Sulfamethox/ Trimethoprim (bactrim)
 Antibiotic
 Take with food and >8oz water
 Interferes with Folate metabolism
 May cause anorexia, stomatitis, glossitis, N/V, diarrhea
Heparin++
 Anticoagulant
 May cause N/V, abdominal pain, GI bleeding, constipation, black tarry stools
Divalproex Na (valproic acid)
 Antiepileptic
 Take with meals and water
 May require Ca & Vitamin D supplementation
 May cause increased appetite, either increased or decreased weight, anorexia,
periodontal abscess, N&V, dyspenia, cramps, diarrhea, constipation, incontinence,
or gastroenteritis
 Avoid alcohol
Methimazole (propylthiouracil)
 Anti-hyperthyroid
 May cause: anti-vitamin K effect
Glycopyrrolate (rubinol)
 Anticholinergic
 May cause dry mouth, N&V, constipation, bloated feeling, or loss of taste
Haloperidol (Haldol)
 Antipsychotic
 Take with food or milk
 May cause increase appetite, increased or decreased weight, anorexia, dry mouth,
dyspedia, N/V, constipation, diarrhea
 Avoid alcohol
Nutrition Focused Physical Findings: (obesity, cachexia, decubitus, mental status) (5pts)
Upon examination M.M. appeared to be depleted in somatic muscle mass and
subcutaneous fat stores. Protrusion of collarbones were evident, furthermore suggesting
malnutrition. She also was seen to be visibly convulsing which indicated to me a
relatively high energy expenditure. This also indicated a strong likelihood that Her ability
to self-feed was impaired. Because of these factors, it appeared malnutrition would likely

be present. It did not appear edema was present. Her skin appeared to be of decent turgor.
No wounds were present. Patient presented an altered mental status due to acute
hypertensive encephalopathy. The administration of D5W had ceased prior to my
examination, therefore it’s caloric content wasn’t taken into consideration from an
intervention standpoint.
Pertinent Social Hx: (5pts)
M.M. is an ill appearing 23-year-old Eastern Indian. She presents increasing
lethargy along with decreased energy intake prior to admission from her Psychiatric
home. She had been admitted one week prior to this recent admission due to lithium
toxicity. However, her mental state failed to improve following discharge. CT scan found
hypo-density within bilateral occipital lobes suggesting hypotensive encephalopathy.
Patient has no past history of tobacco, alcohol, or illicit drug use. Patient isn’t
predisposed to any conditions due to family history.
Nutrition History, Diet PTA (5pts)
Prior to admission M.M. was reported to have minimal caloric intake, which was
continually declining. These reports were received from her Psychiatric Home and were
unable to be confirmed by that patient due to her altered mental status. For this same
reason, dietary recall was unable to be obtained. Based on the information available it
became apparent that lack of caloric intake contributed to the prevalent malnutrition as
meal consumption had been under 50% over an extended period of time.
Summary of Current Intake (5pts)
M.M. was observed consume one single pancake at breakfast. Upon my arrival
She had finished consuming Her second 32oz pitcher full of water of the morning. Her
nurse claimed it was typical for M.M. to fill Her stomach up with fluids and consume
minimal food. She also was able to inform me M.M. was a picky eater. I returned to
observe M.M. at mealtime and observed a meal consumption of 50% along with an
Ensure original supplement. Based on limited data available M.M. was seen abiding by
the addition of a dietary supplement to her meals and increased mealtime caloric
consumption.
D (Diagnosis) (5pts) – PES
Severe malnutrition related to psychological illness as evidenced by unintentional wt. loss
of >2% in one week and estimated energy intake <50%.
I (Intervention) (15 pts) – Stems from Nutritional Diagnosis and Etiology and must
determine patient-focused expected outcomes for each nutrition diagnosis
Organized into 4 categories: (Include only categories that pertain to your patient)

Food and/or Nutrient Delivery (meals, snacks, enteral and/or parenteral feeding;
supplements – as in commercial, food/drink based, or vitamin/mineral)




Increase PO intake with supplementation of Ensure Plus TID to provide
additional 1050 calories and 39 grams of protein to daily intake. This supplement
will also compensate for inadequacies in niacin, thiamin, potassium, magnesium,
phosphorus, and zinc, which are all likely present due to reasons previously
addressed.
Patient should consume at least 50% of meals
If pt does not cnsume Ensure Plus tid, NG tube may be necessary to to insure
adequate intake and replete nutrient stores
Recommend MVI/mineral supplement
Recommend further evaluation for Fe deficiency- ferririn, transferring, serun Fe
and Folate and B12 levels

M/E Monitoring and Evaluation (10pts) Nutrition care indicators that will reflect a
change in nutrition care provided
Organized into 4 categories: (Include only categories that pertain to your patient)
Food/Nutrition Related Outcomes (Food intake, supplement use)
Frequent mealtime observation could give insight towards dietary intake along with
compliance towards dietary modification. This could also determine compliance with
supplement use. It would be beneficial if progress were monitored in both circumstances.
Consider tube feed if supplement intake proves inadequate
Anthropometric Measurement Outcomes (Ht, Wt, BMI)
The weight of M.M. should be monitored. Her weight should ideally rise about one to
two pounds per week towards her usual body weight.
Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes,
gastric emptying)
Monitor electrolyes
Monitor hgb/hct, mcv, fe, folate, b12
Monitor I & o’s
Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat
wasting, swallow function, appetite)

As the patient begins to regain weight it is crucial for subcutaneous fat
and somatic muscle stores to be replenished. This occurrence could be
monitored subjectively upon evaluation. In accordance with this the
prevalence of convulsions may be monitored in order to adequately
address the elevated energy expenditure that accompanies them.
Input and output should be monitor in hopes avoiding fluid imbalances
that may result from re-feeding syndrome. Fluid balance could also be
monitored visually by subjectively examining for the presence of
edema or ascites.

ADDENDUM TO ADIME
Students must attach:
1. For current Dx (5pts) - MNT, Foods Allowed, Foods Not
Allowed, Diet Instruction Materials if appropriate.
Describe in your own words the rationale for diet
restrictions/modifications
*recall: treating undefined anorexia as malnutrition/ FTT
Failure to thrive is characterized by insufficient weight gain or unintentional
weight loss. In adults, failure to thrive is often the result of malnutrition, dehydration,
cognitive impairment, impaired physical functioning or depression. The common
denominator of all these scenarios is a lack of calories being consumed which could be
met with an increased caloric intake.1 In hopes of increasing caloric intake
supplementation may be required on top of a liberal diet. This liberal diet should ideally
consist of nutrient dense foods. Intravenous fluids and electrolytes may be needed to
compensate for imbalances. A multivitamin may also be utilized to address inadequate
intakes of vitamins and minerals. Foods with limited energy value should be avoided as it
results in the sensation of fullness without providing adequate calories. Caffeine should
also be avoided, as it may suppress appetite.2
2. Pertinent Drug/Nutrient Interaction Information if NOT
addressed in note (5pts)
Addressed in ADIME
3. Menu Plan or (10 pts)
Breakfast

1
2

Krause
NCM (anorexia nervosa)

Food
Ensure
plus
pancak
e

Amou
nt

Calori Carb
es
s (g)

1 cup
4" dia.

Fat
(g)

Prote
in (g)

355

50

11

13

86

11

4

3

Ca
(mg Mg
Phospho
)
(mg) rus (mg)
199
101
199
60
6
53

Niac
Thia
in
min
(mg
(mg)
)
0.4
5
0.1
0.6

Lunch
Food
Ensure
plus
WG bread
chicken
breast
banana
ketchup

Amount

Calorie
s

1 cup
2 slices
3 (1oz)
tenders
1 small
1 pkt

Carbs
(g)

Fat
(g)

Protein
(g)

355
138

50
22

11
2

13
6

246
90
6

15
23
2

15
0
0

16
1
0

Ca
Mg
Phosphorus
Thiamin
Niacin
(mg)
(mg)
(mg)
(mg)
(mg)
199
101
199
0.4
5
54
41
118
0.2
2.2
5
21
177
0.3
4.8
0.3
27.3
22.2
0
0.7
1.1
1.1
2
0
0.1
Dinner
Food
Ensure
plus
wild

Amoun
t
1 cup
1 cup

Calorie
s
355
166

Carbs
(g)

Fat
(g)
50
35

Protein
(g)
11
1

13
7

rice
apple
milk
2%

1 small
1 cup

75

18

0

3

122

12

5

8

Ca
Mg
Phosphorus
Thiamin
Niacin
(mg)
(mg)
(mg)
(mg)
(mg)
199
101
199
0.4
5
4.9
52.5
134
0.1
2.1
0.3
15
24
0
2.4
286
26.8
229
0.1
0.2

This menu contains 1994 calories, 79.4g protein, 288g carb, 61.4g fat,
and 100% daily value of calcium, magnesium, phosphorus, thiamin,
and niacin. Possible excess of calories shouldn’t be an issue in the case
of a patient with severe malnutrition.

FATS & FATTY ACIDS
Total Fat
VITAMINS
Thiamin
Niacin

TOTAL
61.4 g
TOTAL
1.9 mg
27.9 mg

%DV

CALORIE
INFORMATION

TOTAL

%DV

Calories
From Carbohydrate
From Fat
From Protein
From Alcohol
From Carbohydrate
From Fat
From Protein
From Alcohol

(8350
1994 kJ)
(4717
1127 kJ)
(2310
552 kJ)
(1324
316 kJ)
0 (0.0 kJ)
1127
552
316
~0.0

94
%DV
123
139

100

CARBOHYDRATES
Total Carbohydrate

TOTAL
288 g

%DV

MINERALS
Calcium
Iron
Magnesium
Phosphorus
Potassium
Sodium
Zinc
Copper
Manganese
Selenium
Fluoride

TOTAL
1109
18
492
1357
2966
1692
16.8
2.2
6.1
~106
~11.4

%DV
mg
mg
mg
mg
mg
mg
mg
mg
mg
mcg
mcg

96

111
100
123
136
85
70
112
111
303
~151

References:

Krause
Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L Raymond, and Marie V Krause. Krause's Food & the
Nutrition Care Process. 13th ed. St. Louis, Mo.: Elsevier/Saunders, 2012.

FMI
Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: FoodMedication Interactions, 2010. Print.

Nutrition Care Manual

Nutrientdata.com