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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