Jillayne Gee

Client History: 52-year old female w/family Admitted for stroke Dementia Type 2 DM w/diabetic gastroparesis and

retinopathy with blindness in 1 eye Lives with family but unknown who makes

pt’s food Chronic kidney disease stage 4 Cholecystectomy

Food/Nutrition History: Diet order is low fat or fat controlled, low

cholesterol, and 2 gm NA+ diet. Nurse reported low intake (amount

unavailable) possibly due to poor appetite, gastroporesis, stroke, dementia, or unknown causes

Meds—Disacodyl, Ondansetron, insulin, and vit. D, Reglan

No information about diet history

Anthropometrics: WT 152# HT 62” BMI 27.8 30# weight loss in the past four months

indicating 17% wt loss, classified as severe weight loss, possibly a result of pt’s gastroparesis

Biochemical: PAB 17.3 and AB 2.3 Glucose 79 and A1C 7.2 Cholesterol 340 and triglycerides 211 Creatinine 3.11 and BUN 49

Physical Exam: Blind in one eye due to retinopathy Confused

Comparative Standards: 1000-1750 kcals (20-35 kcals/kg), 50-60 g pro

(IBW, 1.1-1.2 g/kg), and 1000-1750 ml fluid (1 ml/kcal)

Diagnosis 1 PES Statement: Inadequate oral intake related

to poor appetite due to stroke, dementia, diabetic gastroparesis, or unknown causes AEB 17% weight loss x 4 months and nurse reporting low intake.

Nutrition Prescription: Recommend 1000-1750 kcals, 50-60 g pro,

and 1000-1750 ml fluid

Individual Intervention: 1. Food and/or Nutrient Delivery (ND-3.1.1)

▪ Order Ensure to be given tid between meals x LOS.

2. Nutrition Education (E-1) ▪ Discuss with pt’s family the importance her receiving

adequate kcals and pro and gaining weight.

▪ Educate family of about supplements high in kcals and pro, power packing, and foods high in protein.

3. Coordination of Nutrition Care (RC-1.3) ▪ Request meal assistance if pt has trouble feeding self.

Individual Intervention:

Goal(s) for each intervention

1. Pt will consume >70% of supplements x 2 days.

2. Family will be able to verbalize two ways to increase pt’s kcals and pro.

3. Pt will consume 50-70% of meals x 2 days.

4. Pt will maintain weight x LOS.

Indicators: Food intake

▪ 50-70% of meals

Weight

▪ 152# or more