UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

(Points ADIME

10 A: (Assessment)

Age: 58 Gender: Male

Pt chief complaint, admit signs and symptoms, MD admit diagnosis for pt

Patient was admitted to the hospital on 2/5/23 due to a GI bleed. He experienced vomiting blood while at
home and noticed dark, almost black stools with some clots. Also felt nauseous, dizzy, and weak when
arriving at the ER. The MD was concerned about visceral bleeding and the patient was admitted for an
upper GI bleed with early hemodynamic instability and acute blood loss anemia.

Treatments (interventions)/Therapies; ie respiratory therapy, IV replacement, PT/OT/SLP, chemo,

radiation, dialysis, CT scan, EGD, surgeries and how it relates to your patient’s nutritional status

After admission, the patient was NPO except for meds and IVF. If necessary, a blood transfusion would be
ordered. IV received were Octreotide to help his severe diarrhea and Rocephin to treat any possible
infections d/t potential variceal bleed. An EGD was ordered to rule out an esophageal bleed from likely
Hep C cirrhosis. Pt was a heroin user for 4 years and has untreated Hep C (since 2003). Treatment of Hep
C is being considered and a one time dose of vitamin K was provided since the GI bleed is unlikely from
dietary origin. In the AM, pt will have an abdominal ultrasound and GI endoscopy.

PMH (in order of importance)

Acute Upper GI Bleed - bleeding from the esophagus, stomach, or duodenum

Acute blood loss anemia - abrupt drop in RBC from blood loss

Elevated INR - International normalized ratio is a blood test that indicates how well blood is able to clot;
elevated means blood is taking longer to clot

Chronic Hep C w/o hepatic coma, untreated - Lack of treatment can lead to advanced liver disease and
hepatic coma ( losing consciousness)

Uncomplicated opioid dependence - Susceptibility to withdrawal symptoms

Hyperglycemia - high blood sugar

Hematemesis w/ nausea - vomiting blood from internal bleeding

Anxiety

Depression

Ht: 5’7” Current/admit Wt: 176lb 6.4oz/ 80.2kg (2/6/23) IBW: 148lb/67.1kg UBW (if different):
in # and kg
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

BMI and BMI classification:

27.63 Overweight

History of Weight Changes (Include amount, period of time, voluntary or involuntary, % of original weight)

No Hx of wt changes in chart, verbally noted he was 198# a month ago

Px reported wt gain was expressed at previous MD visits - decided to lose wt on his own

5 Nutritional Requirements:

Wt you are using for calculations: 80.2kg

kcal: Mifflin St Jeor X injury factor = 2,043 kcals/day

*Used 1.3 injury factor since pt was in bed during visit and is recovering from a bleed in the stomach.

kcal/kg = 25kcal/kg = 2,005 kcal/day

Protein g/kg = 1.2g-1.5g*80.2kg = 96g-120.3g/day

Fluid 1mL/kcal = 2,000mL/day

Average healthy adult: 30mL/kg body weight (80.2kg)= 2,406 mL/day

5 Diet Order: (Current and others since admit in chronological order)

Effective 2/8/23-

1. Low fat (50g fat, low cholesterol, low saturated fat)

2. Low fiber/low residue
3. No red food dye

Effective 2/5/23 (admission)-

1. NPO

Assessment of appropriateness of current diet order

UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

The recommended diet is appropriate for the pt’s needs, except for the low fat diet. No indication of
weight concerns noted in the chart and appearance of pt seemed normal. Pt is 58 and has a BMI
classification of overweight. This is not usually a huge concern at this point and some moderate lifestyle
changes could be adjusted to keep the pt healthy. Requiring a cut in macronutrients, such as fat, during
stay is not necessary. The rest of the current diet order is appropriate since low fiber/residue and no red
food dye are best for pt’s undergoing GI distress or damage.

5 Labs: Explain relevant lab values

Normal
Name of Lab Range Patients Value/s Date/s Interpretation

WBC 4-11 10.2, 11.7 2/9/23 High - Possible infection and

thou/uL inflammatory response
11.4, 9.0, 11.5 2/8/23

16.7, 16.4 2/7/23

RBC 4.5-6.2 3.18, 3.25 2/9/23 Low- Signifies internal bleeding

2.4, 2.82, 2.08, 2.95 2/8/23

2.48, 2.36 2/7/23

HGB 13-17.7 9.7, 10.0 2/9/23 Low- Internal bleeding

7.4, 8.5, 9.4, 9.0 2/8/23

7.7, 7.2 2/7/23

HCT 39-54 29.5, 30.0 2/9/23 Low - Internal bleeding

21.9, 25.7, 28.2, 27.2 2/8/23

23.1, 21.5 2/7/23

Platelet Count 150-450 91 2/9/23 Low - Blood loss

75, 68, 94, 98 2/8/23

97, 99 2/7/23

Glucose 65-99 107 2/9/23 High - common during

mg/dL injury/infections
98 2/8/23
- unlikely dietary factor
104 2/7/23

138 2/6/23

158 2/5/23

Sodium 136-145 138 2/9/23 Normal

140 2/8/23
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

140 2/7/23

Potassium 3.4-5.3 3.9 2/9/23 Normal

3.8 2/8/23

4.2 2/7/23

Magnesium 1.6-2.7 2.2 2/9/23 Normal

2.0 2/7/23

BUN 8-21 22 2/9/23 High - increased urea common

w/ bleeding d/t protein
28 2/8/23
breakdown and absorption
37 2/7/23

Creatinine 0.5-1.3 0.9 2/9/23 Normal

0.9 2/8/23

0.8 2/7/23

5 Meds, pertinent Drug/Nutrient Interaction information related to admit dx and nutrition intervention –
use shared drug file

DRUG NAME
how it works, why Main side effects to look for,
generic (Brand) CATEGORY /when use food/drug interactions….

Buprenorphine- Opioid partial Opioid dependence or Headache, nausea, vomiting,

Naloxone (Suboxone) agonist addiction - Diminishes hyperhidrosis, constipation,
withdrawal symptoms s/s of withdrawal, insomnia,
and cravings, increases pain and peripheral edema
safety in cases of
overdose, & lowers
misuse potential Nutrition - Avoid alcohol

Bupropion (Wellbutrin) Antidepressant Depression & seasonal Insomnia, nausea, pharyngitis,

affective disorder; wt loss, constipation, dizziness,
headache, seizures and
Changes levels of
suicidal thoughts
certain chemicals in the
brain

Nutrition - Avoid alcohol

Ceftriaxone (Rocephin) Antibiotic Bacterial infections or Symptoms of blood cell

prevent infection from disorder, diarrhea, rash, or
surgery abnormal liver function tests

Nutrition - NKDNI
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

Nadolol (Corgard) Beta-Blocker Angina or hypertension Bradycardia, cardiac failure,

rhythm/conduction
disturbances, symptoms of
peripheral vascular
insufficiency, hypotension,
dizziness, and fatigue

Nutrition - Avoid alcohol,

multivitamins with minerals,
green tea, high cholesterol

Pantoprazole (Protonix) Proton pump Decreases acid in Diarrhea & nausea

stomach; treats erosive
esophagitis
Nutrition - NKDNI

5 Nutrition Focused Physical Findings: (physical appearance, muscle and fat wasting, swallow function,
appetite)

Pt was alert and talkative during the visit. Was mostly looking at cell phone, but still responsive in
conversation when he was addressed with a question. Appearance seemed normal, no indications of
excessive weight concerns and normal fat distribution. Stated his appetite was good when reintroduced
to food after being NPO at admission.

5 Pertinent Social Hx: (education, occupation, social economic status, ethnic or religious influence,
psychological background) Focus on factors that affect eating habits, ability to procure, store, and prepare
food (food insecurity).

● Lives at home with sister and brother-in-law

● Does his own food shopping, but doesn’t cook - consumes microwavable food and fast food
● Seeking financial and housing assistance
● Received consult to Healthy Aging - Family is looking for help with housing and communication
resources
● No indication of food insecurity

5 Nutrition History, Diet PTA (include quality of intake in terms of meetings needs,
medication/herbal/vitamin supplement intake, knowledge of diet, food beliefs, and physical activity)

During the visit with pt, he was cheerful and busy playing on his phone. Pt stated he doesn’t do any
cooking at home, but buys microwavable foods and gets fast food often. He enjoyed the meal he was
provided after being NPO and has been consuming the whole plate, he reported. Chart reflected his
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

statement, indicating 100% of meals have been consumed. Pt stated his doctor said to him he was gaining
weight in the past and has been trying to lose weight. “I decided on my own to lose weight after”. He said
he doesn’t follow any particle diets at home when asked if he eats low fat or watches his cholesterol or
sodium intake. Has no hx of diabetes or high blood sugar.

5 Summary of Current Intake ( Nutritional Adequacy of the patient’s most recent nutrient intake via 24
hour recall or intake documented from oral, tube feeding, IV. Intake information may be obtained from
the patient, family, diet order, or nursing notes. Please assess the adequacy of intake in terms of
protein, carbohydrate, fat, calorie, vitamins, minerals, fluids, as it pertains to your patient.)

Pt is currently eating 100% of meals and enjoying them. During discussion with pt, it was unclear if pt
understood his current diet orders. He was compliant when discussing a low fiber diet and was interested
in receiving education about how he should be eating after he is discharged. Pt indicated he was trying to
lose weight at home, however did not express any changes he was actively applying to reach his goal. Pt
does not cook for himself and relies on convenience foods, and declined eating any fruits and vegetables.
Medical records do not indicate any previous nutrition counseling. Pt was given a low fiber handout with
sample meals and a high fiber handout so he could understand more about which foods he should be
consuming after discharge and recovery.

5 D (Diagnosis) PES, Nutritional Problem/Diagnosis Related To Etiology As evidenced By Signs/Symptoms

– EACH TIME GO TO eNCPT and review your diagnosis term etiology and signs/symptoms

PES: Food and nutrition related knowledge deficit related lack of prior nutrition-related education as
evidenced by poor diet choices and client reporting frequent use of microwavable and fast food.

15 I (Intervention) is based on your Nutritional Diagnosis Etiology and must determine patient-focused
expected outcomes for each nutrition diagnosis

● Food and/or Nutrient Delivery (meals, snacks, enteral and/or parenteral feeding; supplements – as in
commercial, food/drink based, or vitamin/mineral)

Pt should continue consuming a low fiber/residue diet while recovering from GI bleed in the hospital.
After the pt is discharged from the hospital and follows up with his MD, he should receive clearance by
MD to gradually increase fiber intake to normal. This will help reduce any stress on his digestive system
and allow proper healing. Gradually increasing fiber intake should be emphasized to avoid any further
digestive issues. If given time, patient would benefit from further discussion about general nutritional
education, including tips for cooking at home and choosing healthier convenience foods. I would also
investigate more about the barriers of cooking for himself and the reason for convenience foods.
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

Working on cooking habits and focusing on fiber intake would most likely lead pt to consuming more
nutrient dense foods, in term help him reach his goal of decreasing his wt moderately.

● Nutrition Education (purpose; priority modifications; survival info; nutrition relationship to health and
disease; recommended modifications)

Pt has already received educational material about fiber so I would discuss the contents of materials
closer, emphasizing reading food labels when he is home. I was not able to discuss MyPlate, so I would go
over the importance of eating a variety of foods and easy ways to set up a balanced plate. During
discussion, I would work with him to find ways to choose healthy microwavable meal options and more
nutritious take out options. I would also take the time to find resources such as cooking classes offered
locally and possible food assistance if any concerns about food security presented during further
discussion with him.

● Coordination of Nutrition Care (team meeting; referral to RD with different expertise; collaboration
with other providers; referral to community agencies or programs)

The pt did not discuss any food security concerns, but food assistance (ie: SNAP, pantries) may be
warranted. Referring to community centers that offer cooking classes, if he is interested. Since he
expressed interest in reversing his weight gain, a referral to an RD would allow him to gain more
nutritional education so he is better equipped to meet his goals and work on increasing overall nutrient
variety in his diet.

10 M/E (Monitoring and Evaluation) Nutrition care indicators that will reflect a change in nutrition care
provided. is based on your Nutritional Diagnosis signs and symptoms of your AEB. You will not have all
of these.

● Food/Nutrition Related Outcomes (change in food intake, supplement use?)

o Aim to include each food group per meal per USDA MyPlate

o Maintain low fiber/residue diet ~ 8g/day

o Gradually increase fiber intake to DRI of 38g/day for males after discharge and cleared by
MD

● Anthropometric Measurement Outcomes (Ht, Wt, BMI) uncommon to see a change between
inpatient assessments
o Maintain current weight
● Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes, gastric
emptying)
o Monitor glucose level as injury/infection improves (65-99 mg/dL)

● Nutrition-Focused Physical Findings Outcomes ( appetite, swallow function more uncommon

change in muscle/fat wasting)
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

● Nutrition Education Outcomes Knowledge (what will your patient tell you in the teach-back?)

o Pt is able to read food labels and monitor his own dietary fiber intake

Meal Plan

5 1. For current Dx explain is the patient diet appropriate: Foods Allowed, Foods Not Allowed, Diet
Instruction Materials if appropriate. Describe in your own words the rationale for diet
restrictions/modifications and what changes you would make if needed.

The patient's current diet order is a low fiber/low residue diet while he is recovering from his GI bleed.
Red food dyes are being excluded to observe his stool output accurately. A low fat diet is not needed at
this time, but focusing on ways to get more variety into his diet will be beneficial. A slight weight loss
would be beneficial for overhealth, but does not need to be emphasized. Post discharge, pt should be
recommended to stay on a low fiber diet to continue reducing stress on GI until cleared by MD to begin
gradually increasing fiber back to normal again. Emphasizing fiber rich foods with pt could simultaneously
increase intake of more nutrient rich foods as well.

Pt should focus on getting a more varied diet and consuming all food groups, referencing My Plate. I
would encourage the pt to drink adequate water, 2L-2.5L/day, and slowly increase fiber intake to the
recommended, 38g/day for men, after cleared by MD post discharge.
10

2. Menu Plan or Nutrition Support Regimen for Discharge “Diet “Must be of your own design.
Include pertinent nutrient analysis; calories, macronutrients, fluid, pertinent vitamin/minerals
totaled by meal and snack and for the day. Nutrient analysis may be computed with Cronometer,
Nutribase, ADA exchanges.
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___

5 References - must follow Academy formatting for references – see HuskyCT

Academy of Nutrition and Dietetics. Nutrition Care Manual.

http://www.nutritioncaremanual.org. Accessed 2/14/2023

Prescription Drug Information, Interactions & Side Effects. Drugs.com. https://www.drugs.com/.

MyFitnessPal, Food Diary. https://www.myfitnesspal.com/.

Mayo Clinic, Diseases and Conditions. https://www.mayoclinic.org/diseases-conditions/.

Client Ed/Meal Plans. Nutrition Care Manual. https://www.nutritioncaremanual.org/category.cfm?

ncm_category_id=1&ncm_heading=Meal%20Plans&client_ed=1. Accessed 2/14/2023

100 Total
UCONN ADIME TEMPLATE Student Name ______Courtney LeDuc_________ Pt initials ___DC___