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Name/Date/Time: 1/20/2022
1.2-1.5 gm pro/kg
NUTRITION DIAGNOSIS
PES Statement(s) Severe malnutrition in the context of chronic illness related to
January 2022 Page 1 of 3
Problem, Etiology, Signs inadequate oral intake as evidenced by weight loss 13.2% x 2
and Symptoms weeks, likely intake meeting <75% estimated needs >1 month,
and severe fat and muscle loss in all regions assessed above.
NUTRITION INTERVENTION
Nutrition Prescription Energy needs: 1555-1680+ kcal
Also Complete a Narrative ADIME Note for the same patient with the following Format:
The patient is a 76-year-old male who lives alone. He has a history of hypertension, and was brought to the hospital for
weakness, persistent vomiting, poor appetite, and weight loss. Patient reports eating poorly for at least the last 3 weeks.
In the last two weeks he has lost 15 lb (13%) significant. GI has been consulted for odynophagia and vomiting. An EGD is
scheduled today at 1500. Patient is receiving D5 at 125 ml/hr which provides 510 kcal.
Nutrition Diagnosis:
Severe malnutrition in the context of chronic illness related to inadequate oral intake as evidenced by weight loss 13.2%
x 2 weeks, likely intake meeting <75% estimated needs >1-month, severe fat loss and muscle loss in all regions assessed
above.
Nutrition Intervention:
Advance diet per GI findings. Once diet is advanced trial Chocolate Ensure Enlive TID. Once plan of care is better known,
will follow up for any education needs.
Nutrition Monitoring/Evaluation:
Once diet is advanced monitor daily intake of meals and supplements. Daily weights should also be monitored. Will
continue to monitor labs and medical tests as well.