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Sarah Leahy
April 17, 2014

ADIME 4

A: (Assessment)
Age: 61 Gender: Male Readmitted: 4/5/15
Previously signed self out against Dr. recommendations on 3/31/14
DX:
Chief Complaint:
o Abdominal pain and discomfort
o Rectal bleeding,
o Alcohol Intoxication
Medical Diagnosis: Rectal bleeding secondary to rectal mass, investigating the
potential for rectal cancer
o Patient has a scheduled colonoscopy to examine the severity of the mass
following alcohol withdrawal protocol
o Fatty Liver
o Alcohol detoxification and withdrawal protocol
PMHx
Alcoholism
Tobacco abuse
Coronary artery disease post MI
Hypertension

Ht: 63 = 190.5 cm Wt: 187.5 lb = 85 kg BMI: 23
IBW: 196 IBW Range: 176-215lb % IBW: 95%
Adj BW (>125%IBW): N/A UBW: N/A
Wt changes while in hospital: Patients weight has not changed since being admitted in the
hospital.

Nutritional Requirements:
Energy/Calorie Needs:
o Mifflin St Jeor X (AF) X (IF)
(9.99 x 85) + (6.25 x 190.5) (4.92 x 61)
849 + 1191 300
BEE= 1739
kcal per day = 1739 x 1.2 (mild infection and bleeding) = 2087 kcal/day
o Short cut: kcal/kg
25 kcal/kg = 2125 kcal
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o Average Kcal intake: 2100 kcal/day
Protein Needs:
o 1 g/kg = 85 g protein / day
Fluid: 1cc/kcal = approximately 2100 cc fluid
Other nutrients as deemed necessary:
o Thiamine, Folate, Vitamin B12,
o Antioxidant vitamins due to decreased absorption or storage in the body, and
increased excretion of fat from the liver
o Magnesium
o Riboflavin and zinc deficiencies increase risk of cancer

Diet Order: Patients current diet order is full liquids as he can tolerate and is willing to
consume. When he was admitted he was NPO to rest the gut during alcohol withdrawal protocol,
after about three days of being admitted he was given clear liquids and then asked for full liquids
because he was hungry.

Assessment of Appropriateness of current diet order: Current diet order is appropriate for
patients current state. He is on a full liquid and is able to receive whatever liquids he desires and
is able to tolerate. According to the patients chart he appeared to be moving through alcohol
withdrawal smoothly and was asking for food. However, he had became agitated in the past 24
hours and they had to increase medications can alter appetite and patient may go back to clear
liquids or NPO until withdrawal complications are complete.

Labs:
Lab Test Date Normal Range
Patients
Range
Interpretation
Glucose 4/9/14 74-100 mg/dL 99
Within Normal Range, important to
monitor while he is staying in the
hospital because of a prolonged period
of inactivity, potentially elevated due to
medication and being NPO for several
days.
BUN 4/9/14 7-18 mg/dL 8
Within normal limit, important to
monitor as an indicator of renal function,
dehydration, infection, excessive protein
intake or future MI, If levels drop could
indicate decreased liver function,
malnutrition, mal absorption of over
hydration of IV fluids
CREAT 4/9/14 0.6-1.3 mg/dL 0.96
Within normal limits, monitor for renal
function, or muscle wasting
GFR 4/9/14 >60 m/min/1.73 >60 Within normal limits, Should be
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m^2 monitored because decreased levels
could indicate decreased renal function,
or congestive heart failure
Na 4/9/14 136-145 mmol/L 140
Patients range was within normal limit,
however it is important to continue to
monitor levels due to history of
hypertension, coronary artery disease,
and heart attack
K 4/9/14 3.5-5.1 mmol/L 3.9
Within Normal Limits, should be
monitored because of rectal bleeding
and potential tissue damage, decreased
levels are associated with alcohol abuse,
malabsorption, and malnutrition.
Decreased K is also seen among
individuals with hepatic disease and
decreased renal function
Cl 4/9/14 98-107 mmol/L 105
Within normal limits, increased levels
could be associated with dehydration,
anemia, while decreased levels could be
associated with infection
CO2 4/9/14 21-32 mmol/L 25 Within Normal limits
Anion Gap 4/9/14 7-15 mmol/L 10 Within Normal limits
Ca 4/9/14 8.5-10.1 mg/dL 8.1 L
Below normal range, this may be due to
potential cancer diagnosis. Decreased
levels may also be due to malabsorption,
due to mass found in colon or may be
associated with starvation. This patient
is an alcoholic which means he may be
replacing most of his food intake with
alcohol.
Albumin 4/7/14 3.4-5.0 gm/dL 3.0 L
Below Normal Limits, decreased levels
of albumin can be associated with
hepatic disease, mal absorption,
malnutrition, low protein intake, cancer
and edema. Patient with level of 3.0 puts
him at mild-moderate risk of depletion
with protein malnutrition
Tot. Bilirubin 4/7/14 1.0 mg/dL 1.1 H
Above normal limits, increased levels
are associated with hepatitis, cirrhosis
(which has not yet be diagnosis in
patient, but he does suffer from a fatty
liver), biliary obstruction and prolonged
fasting
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Total Protein 4/7/14 6.3-8.2 gm/dL 6.1 L
Below Normal Limits, decreased levels
may be due to protein deficiency,
hepatic disease, malabsorption, or edema
CK 4/6/14 20-180 U/L 111
Within normal limits
Monitor levels to assess cardiac function
due to medical history of MI
MMB 4/6/14 0-116 ng/mL 0.6
Within normal limits
Monitor levels to assess cardiac function
due to medical history of MI
Troponin I 4/6/14 <0.1 ng/mL 0.11 H
Above Normal limits, increased levels
may be associated with unstable angina,
usually a marker for cardiac event
PT 4/5/14 9.7- 12.6 seconds 10.1 Within normal limits
INR 4/5/14 0.92- 1.10 seconds 0.92 Within normal limits
PTT 4/5/14 25-35 seconds 28 Within normal limits
Admitted
Blood Alcohol
4/5/14
0-300 mg/dL
>80= legal limit
173
Above normal Limit
>300 mg/dL considered fatal


Meds:
Medication Purpose

Side Effect Nutritional Concern
Protonix
(Pantoprazole)
Proton Pump
Inhibitor, Antigerd,
Antisecretory
Increase gastric pH and
secretion, N/D, Ab. pain,
Take with regards to
food, may decrease
absorption of iron and
vitamin B12, Ca
supplement is advised,
avoid gingko and SJW,
avoid alcohol,
Lopressor Antihypertensive,
MI treatment,
Cardioselective
Beta-blocker
Dry mouth, N/V/D/C,
dyspepsia, flatulence,
Caution with decreased
renal or hepatic function,
Possible to decrease BP
and cause hypotension,
Peripheral edema,
Take with regards to
food to increase
bioavailability,
decrease diet in sodium
and calories, avoid
natural licorice
Lipitor Antihyperlipidemic
(decrease chol or
TG, decrease risk
of CV events
N/C/D, adnominal pain,
edema, decreased risk of
fracture because of
decrease bone resorption
Take with regards to
food, Recommended
diet decrease fat,
cholesterol and
calories, Caution with
regards to grapefruits
and other citrus fruits,
avoid alcohol use,
5
Folic acid B complex vitamin,
Antianemic
Folate metabolism
inhibited by deficiency of
Vit. B12, Vit. C or Iron,
RDA: 400 ug/day,
Increase need in
alcoholics,
Thiamine B complex vitamin,
Used to prevent
Wernicke/
Korsakoff
syndrome in
chronic alcoholics
Nausea, RDA: 1.2 mg/day,
Alcohol inhibits
absorption, Alcoholism
increase risk of
deficiency and optic
neuropathy
Nitroglycerin Antiangina, relief
of acute heart attack
Dry, mouth, N/V,
Abdominal pain, headache,
hypotension, blurred
vision, monitor BP and
heart rate
Take on empty stomach
with a full glass of
water, avoid alcohol,
caution with congestive
heart failure, do not
take with sever
hypertension or anemia
Ativan and
Valium
Antianxiety,
skeletal muscle
relaxant,
Antiepileptic
Anorexia, decreased
weight, increased thirst,
Dry mouth, increase
salivation, N/V/D/C
Take with regards to
foods to reduce GI
distress, limit caffeine,
intake, caution with
grapefruit or related
citrus fruits, avoid
alcohol, may be habit
forming
Haldolperidol

Antipsychotic, Can cause a decrease in
appetite and weight
Take with food or milk
to decrease GI distress,
do not take with coffee
or tea,

Physical Assessment: I was not able to talk to patient because he was sleeping from increase
doses of Ativan and Valium. He looked thin and pale and almost cachexic looking.

Pertinent Social Hx: According to patients progress note in chart, patient lives alone in an
apartment and has one adult son who does not live near by. Patient is a retired political
consultant who works on occasion, however his work is affected by his chronic drinking. Patient
admits to drinking at least two-dozen beers daily and was drunk when he was admitted. Patient
had been admitted to JMMC approximately a week prior with chest discomfort, shortness of
breath, and abdominal discomfort. He received a scan to monitor what could be causing the
constant abdominal pain, however before the results were back he insisted on signing himself out
of the hospital. He has now been readmitted with more abdominal discomfort and discovery of
the rectal mass.

Nutrition Hx, Diet PTA: The most pertinent nutrition history is that this patient is an alcoholic
and has been drinking heavily for almost 20 years. Patient reports drinking 20-30 beers a day and
affects his ability to work regularly. His alcoholism has leaded to development of a fatty liver,
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altered kidney function, and a rectal mass that is being examined for the potential of being rectal
cancer.

Assessments of 24 hr. recall or diet hx if appropriate: A 24hr recall could not be taken
because patient was in a poor mental state and confused as to why he was in the hospital. The
previous night the patient had began to become unruly and threatened that he wanted to sign
himself out again. The doctors decided to increase doses of medication, which lead to decreased
mental state. Doctors have to wait for mental state to clear up before they perform colonoscopy
procedure to determine severity of rectal mass and potential for cancer diagnosis.

D (Diagnosis) - PES
Patient with altered GI function related to rectal mass as evidenced by CT scan and
secondary rectal bleeding
Patient with excessive alcohol intake related to alcohol dependence and abuse as
evidenced by increase ETOH of 173 mg/dL at admission and patient admission to
drinking 20-30 beers per day

I (Intervention) Stems from Nutritional Diagnosis and Etiology and must determine patient-
focused expected outcomes for each nutrition diagnosis

1. Food and/or Nutrient Delivery (meals, snacks; enteral and/or parenteral feeding;
supplements as in commercial, food/drink based, or vitamin/mineral)
Continue patient on Full liquid diet, with ensure supplement
Check Mg levels, which may be decreased in alcoholics
Continue with supplementation of B vitamins, folic acid and thiamine

2. Nutrition Education (purpose; priority modifications; survival info; nutrition
relationship to health and disease; recommended modifications)
Nutrition education is not appropriate at this time for this patient. Education may
be provided at a later time about a low residue diet after rectal mass is removed.

3. Coordination of Nutrition Care (team meeting; referral to RD with different expertise;
collaboration with other providers; referral to community agencies or programs)
Continue collaboration with GI consultant and staff to determine status of
patients health and discuss discovery of colonoscopy
Continue with coordination of care with nursing staff to determine patient PO
intake and appetite. Ensure nurses are noting when patient requests an increase in
intake.

M/E Monitoring and Evaluation Nutrition care indicators that will reflect a change in
nutrition care provided
Organized into 4 categories:
1. Food/Nutrition Related Outcomes (Food intake, supplement use)
Evaluate PO intake during alcohol withdrawal protocol and follow up when PO
intake is greater than 75% of meal
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2. Anthropometric Measurement Outcomes (Ht, Wt, BMI)
Monitor patients weight during his stay at JMMC to ensure he does not loss
weight from altered NPO and liquid diet.
3. Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes,
gastric emptying)
Monitor process of alcohol withdrawal protocol, ensure patient receives adequate
electrolytes
Monitor patients albumin and protein levels related to malabsorption and mal
nutrition associated with alcoholism
4. Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat
wasting, swallow function, appetite)
Monitor patients appetite as he goes through alcohol withdrawal, patient is usually
NPO or clear liquid until they request increase in food intake. Patient has
previously requested food and diet was increased to full liquid as tolerable.

ADDENDUM TO ADIME Students must attach:
1. For current Dx - MNT, Foods Allowed, Foods Not Allowed, Diet Instruction
Materials if appropriate. Describe in your own words the rationale for diet
restrictions/modifications

MNT and rational for diet restriction/modification for full liquid diet:
Full liquid diets are a transitional diet used when moving from NPO/clear liquid to
soft consistently diet. This patient is going through alcohol withdrawal in which most
individuals are NPO for an extended period of time and increased to clear liquid until
they are able to handle consuming solid food. In this patients case he is also suffering
from a colorectal mass, which was resulting in altered GI function and patients
ability to transition diets. He will stay on a liquid diet until doctors determine what is
occurring in his colon. The purpose of a liquid diet is to provide adequate calories,
protein, and fat, however, they do not provide a diet adequate in vitamins, minerals or
fiber.

Foods allowed and not allowed:
Patients are allowed to consume any foods or beverages that are liquid at room
temperature. Individuals should avoid milk and dairy products when a liquid diet is
first introduced, until it is determined that the gut can handle lactose.

Diet Instruction material:
Instructional material is not appropriate for this patient at this time. He has to finish
going through alcohol withdrawal protocol and receive his colonoscopy. Before his
diet can be progressed any further his doctors and GI consultant have to determine the
severity of the condition.

Alcoholism
o Alcoholism is a result of excessive drinking in a regular pattern, in this patients case
of daily excessive drinking. The organ that is most seriously affected is the liver and
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one of the first signs of alcohol disease is a fatty liver, which is present in this patient.
This can cause altered liver function and the liver enzymes needed to break down the
alcohol. Diet for individuals recovering from changes in liver cells may find
themselves in a hypercatabolic and metabolic state resulting in increase calorie and
protein meals that are nutrient dense. Individuals digestive tract and pancreas can
also be affected due to excessive alcohol consumption. It is important to monitor the
guts ability to absorb CHO, AA and fat and the potential for a decrease in protection
through out the digestive tract and inflammation of the pancreas may result in altered
enzyme function. This patient is also at increased risk for developing cancer, he is
being investigated for colrectum cancer due to increased levels of acetaldehyde, a
byproduct of excessive ethanol intake and tobacco abuse
Coronary artery disease (CAD) Post Myocardial infraction:
o Myocardial infraction (MI) is caused by increased cholesterol and lipids in the blood,
resulting in the build up of plaque in the arterial walls leading to and from the heart.
The build up of too much plaque can cause blood flow to be blocked and can lead to a
heart attack. Nutritional therapy for individuals who survive from a heart attack
should limit intake of saturated fat, cholesterol and trans fats in their diet. It is also
important to focus on weight maintenance and increasing an individuals intake of
vegetables, fruits and fiber. Smoking, excessive alcohol consumption, inadequate diet
and other lifestyle choices can contribute to individuals chances of experiencing a
heart attack.
Hypertension
o Hypertension is elevated arterial blood pressure, and is a cause of most cardiovascular
damage. Normal blood pressure for an individual is around 120/80, an individual who
suffers from hypertension has a blood pressure greater than 140/90 to greater. Risk
factors for the development of hypertension include age, family history, low physical
activity, poor dietary intake, and excess body weight. The medical nutritional therapy
suggested for this disease is to decrease intake of saturated fat, total fat, cholesterol
and sodium.

2. Pertinent Drug/Nutrient Interaction Information if NOT addressed in note
-- Already addressed in note, please see above

3. Explain relevant lab values both normal and abnormal
-- Already addressed in note, please see above

4. Menu Plan or Nutrition Support Regimen for Discharge Diet If Appropriate

Macronutrient Distribution: Full liquid diet w/ Ensure supplements, 2100 kcal
CHO: 58% daily intake
304.5g CHO x (4cal/g) = 1218 kcal CHO
Protein: 16 % of daily intake
85g x (4 kcal/g)= 340 kcal protein
Fat: 26% daily intake
60.7g x (9 kcal/g) = 546 kcal Fat
Fluid 1 cc/kcal= 2100 cc fluid/day
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Calories
(Kcal)
Protein
(g)
Fat
(g)
CHO
(g)
Fluids
(mL)
Breakfast:
8oz Ensure Plus 350 13 11 51 236.5
1 cup cream of wheat 110 3 0 23
Snack:
8oz Ensure 250 9 6 45 236.5
4 oz Water 118
Lunch:
1 cup tomato soup 144 6 2 23 236.5
8oz Sherbet Shake* 330 13 10 15 236.5
Snack:
8oz Ensure 250 9 6 45 236.5
4oz water 118
Dinner:
8oz Ensure Plus 350 13 11 51 236.5
1 cup Cream of
mushroom soup
126 6 2 16 236.5
Snack:
8oz Ensure 250 9g 6g 236.5
Total: 2160 kcal 81g 54g 314g 2128 ml
*Sherbet shake: 4oz sherbet, 3 fl oz. ginger ale, and 2 scoops of Beneprotein


5. References
Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual. Retrieved from Academy
of Nutrition and Dietetics Web Site: http://nutritioncaremanual.org/auth.cfm?p=%2Find
ex%2Ecfm%3F&err=NotLoggedIn

Escott-Stump, Sylvia. Nutrition and Diagnosis Related Car. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, a Wolters Kluwer business, 2012. Print.

Mahan, Kathleen. (2012). Krause's Food & the Nutrition Care Process (13th ed.). St. Louis,
Missouri : Elsevier Inc.

Piland C, Adams K, eds. Pocket Resource for Nutrition Assessment (2009). 7
th
edition, Chicago,
IL: Dietetics in Health Care Communities, Dietetic Practice Group for the American
Dietetic Association; 2009.

Zaneta Pronsky, S. J. (2012). Food Medication Interactions (17th ed.). Birchrunville: Food
Medication Interactions.