CVD ADIME

Assessment:
Overview Information:
69-year-old male patient direct admit to ICU from clinic with c/o SOB, decompensated heart failure, hypoxia,
orthopnea, and severe dyspnea
Client History (CH):
Medical hx: HTN past 10 yrs, atrial fib and CHF 5 yrs, hyperlipidemia
Past surgeries: None
Allergies: None
Current medications/supplements: Furosemide, Coreg, Amiodarone hydrochloride, Spironalactone,
Coumadin, Lisinopril, BiDil, Natrecor, NaCl
Physical activity: ‘Mildly limited’ ADLs due to SOB and edema (bed rest)
Social hx: Smoked 1 pack per day for 20 years but quit 2 year ago. Social drinking only
Family hx: Coronary artery disease

Anthropometric Measurements (AD):

Ht.: 72 in (6’0”)
Wt.: 81.8 kg (180 lb.)
UBW/weight hx: UBW 168 lb (Pt. reported recent 12 lb. wt gain)
BMI: 24.4 (normal)

Biochemical Data, Medical Test and Procedures (BD):

Glucose, Serum 122 mg/dL High
BUN 54 mg/dL High
Creatinine, Serum 1.6 mg/dL High
Sodium, Serum 133 mEq/L Low
Hemoglobin 11.3 g/dL Low
Hematocrit 30% Low
Platelet count 220 Low
WBC 8.3 cells/mL Low
Cholesterol 220 mg/dL High

Nutrition-Focused Physical Findings (PD):

Physical appearance: BLE edema 3+, difficulty breathing, lower extremities red and shiny, muscle and fat
losses noticeable; decreased urine output in last 2-3 days.
Appetite: Pt. reports mild nausea

Food/Nutrition Related History (FH):

Food and Nutrient Intake: See 24-h recall. Recall shows kcal intake of approximately 1,150 kcal using
NutritionistPro.
Current diet order: Clear liquid diet

Comparative Standards/Calculated Needs:

Calculated energy needs: (using Mifflin UBW w/ AF 1.25) 1,956 kcal/day
Calculated protein needs: (using 1.4 g PRO/kg UBW) 107 g PRO/day

1
Nutrition Diagnosis:

Inadequate energy intake related to current diet order of clear liquids only as evidenced by an 800-calorie
deficit as compared to his needs.

Nutrition Intervention:
 Prescription: Change current diet order (current: clear liquids only)
 Recommend: Change diet to fluid restricted
 Goals: Diet order will be changed to fluid restricted diet as soon as possible

 Prescription: Increase calorie needs to 1,956 kcal per day and a restrict fluid to 1500-2000 mL per day.
Prescribe 1 Ensure Plus supplements per day to provide 350 kcal and 13 g protein
 Recommend: Educate patient on calorically dense foods and fluid restriction
 Goals: Patient will be knowledgeable about fluid restriction and calorically dense foods by next visit

Nutrition Monitoring and Evaluation:

 Indicator: Daily caloric intake is increasing
 Criteria: Pt. reports food recall of at least 1700 kcal by next visit. Eventual goal of 1,960 kcal.
 Indicator: Ensure Plus supplement intake
 Criteria: Pt. reports taking Ensure Plus once per day
 Indicator: Fluid restriction
 Criteria: Pt. reports conscientiousness about fluid intake by next visit