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Case Study Adime Note

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848 views

Case Study Adime Note

Uploaded by

api-240616135
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Nutrition Assessment Patient Interview: Pt.

c/o terrible diarrhea for a while now, no energy, fatigue and weakness, lost a tremendous amount of weight. Admitting Dx: __Celiac Disease_____ PMH: Gave birth 3 months ago, smoker. Family History: CAD (father). Patient is a _36_ y/o Caucasian Female Ht. 53 Wt. 92 lbs BMI 16.3 %IBW__80%_ %UBW_82%_ UBW timeframe: _3 months____ Diet order: Post fecal fat test diet, consuming a regular bland diet Average Meal Intake: N/A I/Os: N/A GI: Pt experiences hunger but unable to tolerate foods. Stool: Diarrhea no matter what she eats esp. fried foods. Foul smelling. Abdomen not distended. Pertinent Labs: albumin: 2.9, total protein: 5.5, prealbumin: 13, HGB: 9.5, HCT: 34, MCHC: 30, Ferritin: 12, +AGA, +EMA, fecal fat: 11.5 Pertinent Medications: MV, kaopectate Physical exam/skin: Skin- pale, Appearance-thin

Other info: s/p endoscopy- small bowel biopsy results state flat mucosa with villus atrophy and hyperplastic crypts- inflammatory infiltrate in lamina propria. ****************************************************************************************** Nutrition Diagnosis/Diagnoses: (PES Statements) 1. Impaired nutrient utilization (NC-2.1) related to flat mucosa with villus atrophy and hyperplastic crypts as evidenced by 18% weight loss over past 3 mos, mildly depleted energy stores, low lab values of hmg, hct, albumin, prealbumin, transferrin. 2. Nutrition-related knowledge deficit related to new diagnosis of celiac disease as evidenced by no prior education for current diagnosis, high consumption of gluten filled products not c/w gluten-free diet ****************************************************************************************

Nutrition Intervention: Individualized Treatment Goals to Address Nutrition Diagnosis 1. 2. 3. 4. No further weight loss/ Improve energy stores Replete protein status 4-6 g/day Improve lab values of Albumin, prealbumin, Hgb, Hct, MCV Patient consumes foods compliant with gluten-free diet and lactose free diet

Intervention Statements (Use Intervention Sheets) 1. Modify diet: Recommend lactose and gluten free diet (ND-1.4). 2. Medical food supplements: Two Cal HN and Glutamine supplementation to promote intestinal healing and increase energy stores (ND-3.1.3.) 3. Nutrition education: Nutrition relationship to celiac disease, gluten free diet (E-1.4). 4. Skill development: Identify gluten filled products by reading labels (E-2.2) .

****************************************************************************************** Monitoring and Evaluation 1. Weight and adequate energy and protein for weight gain and repletion goals. 2. Monitor pertinant labs Albumin, prealbumin, Hgb, Hct, MCV (should regulate with progression of gluten-free diet) 3. Follow up as outpatient to give more extensive education 4. Monitor adherence to gluten-free and lactose free diet, Pt. complete a two-three day food record, recommend modifications accordingly 5. Symptoms/tolerance of new diet. (appetite, diarrhea, abdominal pain- if tolerance acceptable reintroduce lactose)

Signed _____________________________________ Date: ______________________

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