Progress Report Overview

Student: Caitlin Alfano

Activity: NTR211 Fall 2020 Simulation 2 Shawn Callahan

Start Time: 10/28/2020 19:22:14

End Time: 11/09/2020 14:23:29

Total Time: 00:46:58

Actions

Note at 11/09/2020 14:23:07

NTR211 Fall 2020 Simulation 2 Shawn Callahan
Documentation
Student: Caitlin Alfano
Activity Start: 10/28/2020 19:22:14
Activity Completion: 11/09/2020 14:23:29
Activity Completion: 00:46:58

Patient Data

Patient: Shawn Callahan DOB: 10/18/1975

Age/Sex: 45 yo M MR#: MR-0635
Location: General Hospital Admit Date: 11/27/2016

Notes

Note at 11/09/2020 14:22:26

Progress Note

Basic Information

Date:

11/09/2020 14:22:26

Author:
Caitlin Alfano

Location:
General Hospital

Note

Note:

ASSESSMENT
Anthropometrics:
Age: 45y/o
DOB: 10/18/1974
Gender: Male
Current weight: 165 lb (75kg)
IBW: 106 + (6x8 in)= 154lbs
%IBW: 165/154x100=107%
UBW (6 months ago): 185 lb
%UBW: 89.2%
Weight change: 11% weight loss
Height: 68 in (5’8’)
BMI: went from 28 to 25 in 6 months
Latest BP: 128/82
Latest temperature: 98.6 (37.1℃)
Estimated energy, protein & fluid needs
Energy: Range- 1.2 (ambulatory) to 1.5 ( major surgery)
1612.35 kcal x 1.3=2096 kcal
1612.35 kcal x 1.5=3144 kcal
Protein: General inflammation (1-1.2g/kg)= 75g-90g
Fluid: 35mL/75kg=2625
Physical exam:
There is a visible hollow look under the patient's eyes. The patient has increased skin tenting. The patient has dry oral mucosa
and significant fat loss from the tricep region.
Diet history/subjective info/food preferences Diet order
The patient reported feeling better post loop ileostomy, wants to go back to working as an accountant. Patient expresses severe
pain, nausea, discomfort, and cramping in the lower quadrant. The patient has persistent diarrhea (12x/day). His urgent need
to move his bowels has led to severe dehydration and a decreased desire to consume adequate oral intake. The patient states
that for the past 6 months as his Crohn's disease has flared up his appetite has not been good. He reports he has limited
access to food because of working in an office. Many times he will eat a few bites of whatever is catered at the office. Outside of
the office the patient eats takeout (e.g. fast food). The patient reported it isn't worth cooking food because he can only take a
few bites before going to the bathroom. The patient reported that he only drinks about 3 cups of water a day. Currently the
patient is NPO, no swallowing issues, no diarrhea, constipation, or vomiting since surgery.
Pertinent Labs
BUN- 35 mg/dL*
CO2- 24 mEq/L
Creatinine- 1.2 mg/dL
Glucose- 117 mg/dL*
Serum Chloride- 101 mEq/L
Serum Potassium- 3.4 mEq/L*
Serum Sodium- 152 mEq/L*
(* abnormal lab values)
Pertinent Medications & Interactions
Sodium chloride: Electrolyte replenishers
Remicade: Can help w/ UC, crohns, and arthritis
Past Medical History Current Admitting DIagnosis
The patient has a medical history of: Crohn’s disease ( diagnosed at 19 y/o); and mild dehydration.The patients father and
paternal grandmother were known to have “nervous stomachs”. Within the family there are no known autoimmune disorders
and no food allergies are reported. The patient has undergone surgery with a loop ileostomy to address the ulcerative colitis.
DIAGNOSIS
Malnutrition (NC-4.1-1.2) related to inadequate oral intake in the setting of non-resolving colitis treated with a loop ileostomy
procedure as evidenced by unintentional weight loss of >10%, fat loss at the tricep, hollowed look under the eyes, dehydration,
and persistent diarrhea (12x/day).
INTERVENTION
The patient will be transitioning from being NPO into a low fiber, low-lactose, high fluid diet for the next 6-8 weeks post loop
ileostomy. The patient will include one-low fiber food for every meal for the next 6-8 weeks. Once this goal is accomplished the
patient will increase to 2 low fiber foods with every meal for the following 6-8 weeks.
MONITORING & EVALUATION
The patient will use a food diary to document food items and take note of what is being tolerated vs. not tolerated. This will
help aid in sustaining adequate oral intake and promote a positive transition back into eating with the new loop ileostomy.
After the patient reaches 6-8 weeks post surgery, education will continue as the patient's diet progresses. In addition, a
reassessment will occur to evaluate the effectiveness of the intervention and to monitor if adjustments have to be made.