Cheathem_D_NAM_1.1.b.3.

GI_Complication_NCP

Nutrition Prescription: Clear Liquid Advancing to GI Soft Diet as Tolerated: 2096 kcal/day (MSJ x 1.3 AF), 98 gm/day of protein (1.3 gm/kg – increased protein needs RT post-
surgical wound healing), 262 gm/day of carbohydrates (50% of estimated energy needs), 2096 mL/day of fluids (1 mL/kcal).

Assess Priority Diagnosis Intervention Monitoring Evaluation

FOOD/NUTRITION-RELATED HISTORY
Food & Nutrient Intake: Current diet pattern at home
Food and/or
was not reported. Nutrient Delivery
Food and Nutrient Administration: The pt.’s current (ND)
diet order of Clear Liquid provides approximately 671
kcals and 10 gm of protein per day. This current order Meals and Snacks
only meets 32% of the pt.’s energy needs and 10% of (1)
7 Day F/U
estimated protein needs. Mechanically Altered
Calculated & estimated needs include: -Monitor changes in
Diet (ND-1.2.1.2): -Pt will have
diet order
-2096 kcal/day Energy Inadequate protein- When medically advanced to GI
-98 gm/day PRO energy intake RT appropriate, advance
-Monitor toleration
Soft Diet order.
-262 gm/day CHO as tolerated to GI soft
decreased ability to diet.
of diet
-Pt will be
-2096 mL/day Fluids consume sufficient tolerating GI Soft
Medication and CAM: -Monitor % of
nutrients AEB pt is Nutrition Diet well
1 meals eaten
-Norco 7.5-325 mg q.6.hrs moderately tolerating Supplement
-Crestor 5 mg QD Clear Liquid Diet, Therapy (3) -Pt will be
-Monitor/Compare
Knowledge/Beliefs: The pt verbalized his consuming > 75%
only meeting 10% of Medical Food
% meals eaten to
of meals.
understanding of the essential role nutrition and protein needs and Supplement
nutrient
recovery and was eager to learn what he can do to help prescription/ needs.
32% of energy needs. Therapy (3.1) -Pt will be
meet his nutrient needs. meeting > 75% of
Behavior: The pt was alert and attentive and willing to Commercial nutrient
take part in activities and actions to influence the Beverage (ND-3.1.1): prescription/needs.
Provide Ensure Clear
achievement of nutrition-related goals. TID to help provide
Factors Affecting Access to Food and Food/Nutrition- an additional 600
Related Supplies: Not reported by pt. kcals and 21 gm of
Physical Activity: Per pt interview and discussion, the protein per day.
pt explained that he is moderately active at home to
“stay in shape”.
Cheathem_D_NAM_1.1.b.3.GI_Complication_NCP
ANTHROPOMETRIC MEASUREMENTS
Height: 5’9” Weight: 74.4 kg
UBW: 74.4 kg % UBW: 100%
IBW: 70.7 kg % IBW: 105%
BMI:24.22 kg/m2 No wt change observed
Food and/or
Nutrient Delivery
BIOCHEMICAL DATA, MEDICAL TESTS, AND (ND)
PROCEDURES
Lab data: Meals and Snacks
Lab Value 10/30/19 10/26/19 (1)
Sodium 140 ✓ 139 ✓ Mechanically Altered
(mmol/L) Diet (ND-1.2.1.2):
7 Day F/U
Potassium When medically
3.7 ✓ 3.7 ✓ -Pt will have
(mmol/L) appropriate, advance -Monitor changes in
advanced to GI
Chloride Increased protein as tolerated to GI soft diet order
Soft Diet order.
103 ✓ 104 ✓ needs RT alteration in diet.
(mmol/L) -Monitor toleration
CO2 (mmol/L) 29 ✓ 22 ✓ GI function AEB Nutrition of diet
-Pt will be
diagnosis and tolerating GI Soft
BUN (mg/dL) 17 ✓ 14 ✓ Supplement
Diet well
Creatinine 2 treatment of complete Therapy (3) -Monitor % of
0.80 ✓ 1.0 ✓ small bowel meals eaten
(mg/dL) Medical Food
-Pt will be
Glucose obstruction and consuming > 75%
110 ­ 129 ­ Supplement -Monitor/Compare
(mg/dL) healing surgical Therapy (3.1) % meals eaten to
of meals.
Calcium wound. nutrient
8.8 ✓ 9.8 ✓ -Pt will be
(mg/dL) Commercial prescription/nutrient
meeting > 75% of
Beverage (ND-3.1.1): needs.
GFR Provide Ensure Clear
nutrient
>90 ✓ >90 ✓ prescription/needs.
(mL/min/1.732) TID to help provide
Tests: Open Laparoscopy an additional 600
NUTRITION-FOCUSED PHYSICAL FINDINGS kcals and 21 gm of
protein per day.
Pt was observed sitting up in chair at bedside, alert and
attentive. No signs of muscle wasting or inappropriate
loss of subcutaneous fat was witnessed. The pt appeared
to be a healthy weight and reports a poor appetite
related to pain and discomfort from his operation.
When the pt does eat, he is able to moderately tolerate
clear liquids as he eats very slowly to avoid nausea and
vomiting.
Cheathem_D_NAM_1.1.b.3.GI_Complication_NCP
CLIENT HISTORY
Reason for Admission/Assessment:
-The pt was admitted to the hospital with abdominal
pain with no relief from conservative efforts. An
exploratory laparotomy was done to identify a
significant complete bowel obstruction caused by a
single band.
-Consult for a registered dietitian was requested as the
pt was NPO for 5 consecutive days and he is not
meeting nutrient-related needs.
Personal History:
-Age: 47
-Gender: Male
-Race: White
-Language: English
-Education: Not Reported
-Family Role: Husband
Patient/Client/Family Medical/Health History:
-Pt.’s Medical Hx: HLD, cervical radiculopathy,
allergies, depression, MI, anemia, T2DM, anxiety,
emphysema, OP, arthritis, GERD, convulsions/seizures,
asthma, glaucoma, sickle cell anemia, stroke, cancer,
HIV, HTN, CHF, CKD, CAD, COPD, meningitis,
tuberculosis.
-Family Medical Hx: Mother and father had a hx of
HDL and HTN.
Treatments/Therapy:
-Appendectomy (2017)
-Small Intestine Surgery (2017)
-CABG (2017)
-Colon Surgery (2017)
Social History: Per chart review, the patient has no
history of tobacco use, alcohol use, or drug use.