Download Sodexo Dietetic Internship Assessment Form

Sodexo Dietetic Internship
Assessment Form
Age: 50 yo
Admitting Dx: SIRS & adrenal insufficiency
Current Diet Order: NPO
PMH: Polyglandular autoimmune syndrome (Addison’s disease, Hashimoto’s thyroiditis, T1DM), CAD, iron
deficiency anemia, pneumonia
Ht: 66” / 167.64 cm
Wt: 220 lbs / 100 kg
BMI indicates:
BMI: 35.6
30 – 39.9 (obese)
Percent of Weight Loss : N/A, no weight loss
UBW: 220 lbs / 100 kg
IBW: 143 lbs / 65 kg
Estimated Macronutrient Needs:
calories per day: 1820-1950 kcals
based on: 28-30 kcals/kg IBW 2/2 hypermetabolic condition
gm Protein per day: 78-85 g
based on: 1.2-1.3 g/kg IBW 2/2 hypermetabolic condition
ml Fluid per day: 1950 cc
based on: 30 cc/kg
Intake History:
PO prior to adm: Poor
Current PO Intake: N/A
Diet History Obtained: Yes
Chewing/Swallowing Issues: No
Obtained from: Patient
Vitamin/Mineral/Oral Supplements: None
Nausea/Vomiting: None reported since admittance
Food Allergies: NKFA
Constipation/Diarrhea: None reported
Lab Results:
136 109 33
4.3
16 1.64
Other Significant Labs: Hbg = 8.9 ; Hct = 28.5 ; ALT&AST elevated
Physical Assessment Findings:
Pt had swollen face, fluid retention, alopecia (not listed in chart)
Present Diet:▢adequate▢ Recommend: clear liquid DM diet à full liquid DM diet à 1800 kcal DM, cardiac diet
Medications: Cipro, nexium, flagyl, Zofran, Xarelto, Lasix, solu-CORTEF IV, levoxyl, K-Dur, NaCl IV, on self-
PES
(Problem)
osis
Diagn
managed insulin pump
(Etiology)
Nutrition Diagnosis: Inadequate oral food and beverage intake
Related to: unable to meet needs on current diet order
(Signs/Symptoms)
As Evidenced By: NPO status
▢ Food and Nutrition Delivery: initiate nutrition within 24-48 hours as medically feasible, starting with
clear liquid DM diet, monitor tolerance and advance to 1800 kcal DM, cardiac diet as feasible
▢ Nutrition Education: discussed diet progression with patient and reasons for NPO status; discussed DM
diet with patient (patient expressed understanding and good compliance) as well as role of steroids in blood
▢ Nutrition Counseling: Patient understands DM diet but focuses less on Addison’s and hypothyroid diet
changes she can make. Discuss iron-deficiency anemia and good sources of iron. Given current state, anemia
may be disease rather than diet related, but with a history of iron-deficiency anemia, it will be important to
follow-up with the patient regarding iron intake. May also need hepatitis education going forward.
▢ Coordination of Care: Refer to: Endocrine, outpatient dietitian, other specialists pending diagnosis
Goals: 1. Advance diet within 24-48 hours as medically feasible. 2. With diet advancement, meet >/= 75%
nutrient needs as medically feasible with continued euglycemia (FS <150; fasting BG <130, random BG <180)
List: PO intake and tolerance when medically feasible
luate
or/Eva
Monit
Intervention/Goals
sugar changes
DM diet knowledge and adherence; BG
Going forward, anemia, Addison’s diet, and thyroid diet knowledge
Completed by Sodexo Dietetic Intern: Gabrielle Wade