Heading

A
(3 pts)

Gastroenterology Case Study

S
53 yo
Caucasian
Female
BMI= 28.4
IBW= 125
TEE= 2139 kcals
Kcals= 2625kcals
Fluid=2625ml/kg
Protein= 94g
Onset: pt. states I have always had a funny stomach, however, in the past year, my belly
has gotten worse
CC: severe LLQ pain and diarrhea
Dx: diverticulitis in sigmoid and descending colon (following colonoscopy)
Alleviating Factors: consumption of gaseous foods, ex: navy beans and cabbage worsen
symptoms
Pt. quit taking stool volume expanders due to poor taste and quit drinking plenty of water
due to increased trips to the bathroom. pain occurs more frequently.
O
Hematocrit: 35%
Hemoglobin: 11.0 g/dl
FOBT: positive
Chlorine: 97 mEq/L
Sodium: 133 mEq/L
MCV: 80.0 m
WBC: 13 x 10/ mm

D
Dx:
____points

A
(Each PES
statement is
worth 4
points)

Dx:

Limited adherence to nutrition-related recommendations NB-1.6 related to unwilling or

disinterested in applying/learning information as evidenced by
worsened symptoms: rectal bleeding, server lower quadrant pain, and poor
compliance/management of diverticulitis

____points
Dx:

Altered GI Function NC-1.4 related to alteration in gastrointestinal tract structure and/or

function as evidenced by diverticulitis and partial colostomy.

____points
I (M/E)

____points

Intervention: 6.5
pts

I:

M/E:
____points

Inadequate fiber intake NI-5.8.5 related to prolonged adherence to a low-fiber diet as

evidenced by food recall report and pt. statement acknowledgement of ending diet
prematurely due to feeling better.

M/E;
2.5 pts)

Increased fiber diet ND-1.2.7.1, to recommended range of 21g/day

Nutrition relationship to health/diseases E-1.4, to ensure pt. understanding of colostomy
diet education
Self-monitoring C-2.3
Types of food/meals FH-1.2.2.2
Total fiber intake FH-1.5.6.1
Nutrition quality of life responses FH-8.1.1

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