ADIME Nutrition Documentation Form Section: __NA__

Names: Heather Hennessey, Amber Hill, Sarah Peterson

Nutrition Note: Case Study 12 Date:4/21/14 Time:8am

A: Nutrition Assessment (Assessment info related to Nutrition Dx)

Anthropometrics
Client Hx Nutrition-Focused Physical Findings
Dx Hepatitis C 3y/a Woman
Seasonal allergies Dry mucous membranes; no lesions 26 yr old
Fx HTN, diverticulitis, cholecystitis, carpal enlarged esophageal vein Height: 5’8”
tunnel, diabetes mellitus, peptic ulcer disease, bruising on lower arms/legs Weight: 125 lbs
bilateral breast cancer, leukemia, cirrhosis, telangiectasias on chest BMI: 19.0
amyotrophic lateral sclerosis abdominal appearance is distended
skin color pale
urine is amber/cloudy

Food/Nutrition-Related Hx & Comparative Biochemical, Medical Tests & Procedures

Standards(Usual Intake, Recent Intake, Diet
Order, PA) Albumin: 2.1 g/dL
fatigue and weakness Prealbumin: 15 mg/dL
Anorexia- lost 10# /6 months Protein: 5.4 g/dL
Nausea and vomiting Bilirubin: 3.7 mg/dL
No tobacco use Creatinine:1.4 mg/dL
Alcohol use RBC: 4.1
pt report of lack of appetite, has not eaten for 2 Hgb: 10.9 g/dL
days Hct: 35.9%
Usual Intake: Protein 1+
Calcium fortified OJ Bilirubin 1+
Soup and crackers, diet coke
Chinese or Italian carryout
Food purchase/prep by self/significant other

D: Nutrition Diagnosis (PES statement)

1. Malnutrition (protein-energy) (NI-5.2) related to inadequate protein-energy intake (NI-5.3) as evidenced by albumin
2.1g/dL, prealbumin 15mg/dL, protein 5.4g/dL, creatinine 1.4mg/dL, pt usual intake report, and fatigue/weakness.
2.Limited adherence to nutrition-related recommendations (NB-1.6)for treatment of liver cirrhosis r /t (NI-1.1) food and
nutrition related knowledge deficiency as evidenced by 24-hr recall lacking in small and frequent meals, inadequate
fluid intake (<1680ml), amber colored urine, patient report of alcohol consumption.
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I: Nutrition Intervention (Prescription, Goal and Intervention)

1. Upon release, gradually increase protein intake to range of 68g- 89g/ d, protein-modified diet (ND1.2.3) for the next
2 months until next appointment. For example, adding a protein shake to lunch, or eggs with breakfast.
2. Prior to release, educate patient on nutrition relationship to health/disease (E 1.1) specifically related to alcohol,
fluid intake, and meal frequency/size. Set goal to initially add an additional snack each day, working up to 4 smaller
more frequent meals per day (ND 1.3) for the next.
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M & E: Monitoring and Evaluation

PES 1: Monitor total protein intake (FH 1.5.2.1) through pt self report, reevaluation of labs.
PES 2: Monitor adherence to previously prescribed diets(FH-2.1.2.1) for liver cirrhosis through 24-hr recall, pt self
report, reevaluation of lab values.