Homer Xiang ADIME Note 2021

Assessment:

Overview Information:
82 y.o. Asian male admitted to a long-term care facility from a hospital setting. Patient arrives for
rehabilitation following complications of CVA with fall risk and NKA. Patient is reported to have active
Osteoporosis, Flaccid hemiplegia, Deep Vein Thrombosis, Intracerebral Hemorrhage, and resolved Aneurysm.

Client History:
Medical hx: Osteoporosis (chronic), Flaccid hemiplegia (acute), Deep Vein Thrombosis (acute),
Intracerebral Hemorrhage (acute), Benign Neoplasm of Colon (chronic), Elevated Prostate Specific
Antigen (chronic), Diabetes Mellitus Type II (chronic)
Family hx: Mother is deceased. Father died of cancer of an unknown type. There is a grandmother with
history of stroke.
Past Surgeries: brain surgery for aneurysm
Allergies: no known medical allergies
Current Medications/supplements: heparin sodium, porcine 5000 UNT per 0.5 ML Prefilled Syringe -
Dose: 5000 Units, Magnesium Oxide 400 MG Oral Tablet - Dose: 400mg daily
Social History: The patient is married. The patient has smoked one pack per day for 30 years. He does
not drink alcoholic beverages. He has no pets. He is retired. Hobbies include fishing, reading and
building model cars.
Functional History: Independent prior to admission. Bed mobility: supine-to-sit, mod assist. Transfers:
sit-to-stand, min-to-mod assistance of 2. Ambulate: 2 steps attempted but not performed. Sitting:
balance for 15 minutes, min assist. Upper and lower extremity. ADLs: mod assist. Bowel and bladder:
max assist. Feeding: dependent.

Anthropometric Measurements:
Ht.: 66 in
Wt.: 124 lbs
UBW/weight hx: 138lbs 3 m.o. ago
%UBW: 124 lb/138 lb = 0.898 = 90%  10% loss in 3 months
BMI: 20.0(normal)

Biochemical Data, Medical Test and Procedures:

Low protein (3.8)
Low hemoglobin (12.3)
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 Low hematocrit (40%)
Low MCV (74)
High WBC (11500)
Low Urobilirubin (0.4)
Low Squamous epithelial cells (0)

Nutrition-Focused Physical Findings:

Physical appearance: moderate muscle loss  Skin: wrinkled, shoulder: moderate swallow clavicle,
able to see bones under the skin, leg: able to see bones under the skin, bones and muscles are kind of
separated
Appetite: poor

Food/Nutrition Related History:

Food and Nutrient Intake: EN order (Infuse Kate Farms Standard 1.4 at 35 ml/hr, 250 ml free water
every 6 hours, provides 1176 kcal energy and 51.7 g protein), PEG tube placement; EN tolerance: slight
and distention, positive bowel sounds, positive bowel movement, gastric residuals 80-100
Physical Activity: minimal, laying on bed for most of the time
Knowledge/Attitudes/Beliefs: no known information

Comparative Standards/Calculated Needs:

Estimated Energy Needs: 1577 kcal/daily (Mifflin St. Jeor: 1212.91 * 1.3 {IF} =1577)
Estimated Protein Needs: 84.5 grams/daily (56.4 * 1.5 {IF})

Nutrition Diagnosis:
PES Statement:
P: Acute disease or injury related malnutrition (NC-4.1.3)
E: related to CVA
S: as evidenced by 14lbs weight loss in 3 months, severe muscle wasting, and inadequate EN calorie intake.

Intervention:
Prescription: To be able to meet calorie and protein needs of 1577 kcal/day and 96 grams protein/day to
prevent further weight loss
Recommend: Recommend: Modify composition of enteral nutrition (ND-2.1.1). Change EN formula to Replete
at 66 ml/hr to provide 1584 cal/day and 101 g PRO/day.
1577 kcal/day / 1 kacl/ml = 1577 ml/day
1577 ml/day / 24 hrs/day = 65.7 ml/hr = 66 ml/hr
66 ml/hr * 24 hr = 1584 ml
1584 ml * 1 cal/ml = 1584 cal
1584 ml * 0.064 g PRO/ml = 101 g PRO
Goals: meet calorie & protein needs

Monitoring/Evaluation:
1. Indicator: Energy Intake (FH 1.1.1)
Criteria: He will consume at least 75% of his calorie goal of 1188 cal/day within the next 3 days

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2. Indicator: Protein Intake (FH 1.5.3)
Criteria: He will consume at least 75% of his protein needs of 76 grams/day within the next 3 days

3. Indicator: Weight (AD-1.1.2)

Criteria: patient will gradually gain body weight when weighed weekly

4. Indicator: EN tolerance
Criteria: tolerating EN