Sunteți pe pagina 1din 2

Assessment

Overview Information: 56 y/o Hispanic male admitted to the hospital for hypoalkemia and hyperglycemia s/s of
vomiting and nausea. Diagnosed with T2DM almost 1 year ago. DVT precautions, fall risk, full code, morphine
allergy.

Client History (CH):


Medical hx: non compliant diabetic, HTN, hyperlipidemia, coronary artery disease, GERD,
osteoarthritis.
Past Surgeries: Laproscopic cholecystectomy 6 years ago, athroscopy left knee 3 years ago
Allergies: Morphine
Current Medications/supplements: Regular Insulin, 100 UNT/ML Injectable Solution [Humulin R] -
Dose: Dose per sliding scale, Lantus 100 UNT/ML Injectable Solution - Dose: 22 Units, furosemide 40
MG per 4 ML Prefilled Syringe - Dose: 40 mg, potassium chloride 40 MEQ/L / sodium chloride 0.9 %
Injectable Solution - Dose: 1000 mL, Protonix IV 40 MG per 10 ML Injectable Solution, ondansetron
(as ondansetron hydrochloride) 4 MG per 2 ML Prefilled Syringe, Dilaudid 2 MG/ML Injectable
Solution, Lorazepam 4 MG/ML Injectable Solution [Ativan] PRN
Physical Activity: senior accountant, works from home, ADLs until hospitalization, has daughter who
is a practicing pharmacist

Anthropometric Measurements (AD):


Ht.: 165.1 cm
Wt.: 115 kg
BMI: 42.1 (obese)

Biochemical Data, Medical Test and Procedures (BD):


High PaCO2 42.8, 44 (ref 38 42), high HCO3 29 (ref 22 28), high pH 7.44 (ref 7.38 7.42), high
glucose 196, 315, 360, 395 (ref 70 115), high BUN 27 (ref 7 20), low serum chloride 98 (ref 98 107), low
serum potassium 3.6 (3.5 - 5.0), high creatine serum 1.02 (ref 0.6 1.5), high serum protein 7.9 (ref 3.6 4.8),
high A1c 11.5 (ref 4 5.6), high osmolality 338 (ref 275 295)

Nutrition-Focused Physical Findings (PD):


Physical appearance: abnormal throat and mouth, abnormal abdomen, pain, discomfort, NG tube,
unintended weight loss of 7 lbs over the last few weeks
Appetite: abnormal, acute anorexia, hasnt eaten anything for about a week due to nausea and vomiting,
decreased apetite for the past few weeks

Food/Nutrition Related History (FH):


Food and Nutrient Intake: NPO ice chips sparingly
24 hour recall 2,898 calories, 143 g protein
Admits to 4 5 beers per week, quit smoking, denies drug use

Comparative Standards/Calculated Needs:


Mifflin St. Jeor (AF 1.2) = 2,288 kcal/day
0.8 g/kg protein/day x 115 kg = 95 g/day

Nutrition Diagnosis:

P: overweight/obesity (NC 3.3)


E: related to: intake of 2,900 kcal/day, excessive dietary cholesterol intake
S: as evidenced by: 24 hour recall and BMI of 41.2
1
Nutrition Intervention:
Prescription: Maintain intake of ~ 2,288 kcal/day and 95 g protein and consistent carbohydrate intake
throughout the day
o Glucerna 1.5 at 125 mL/hr, 4 hours on, 4 hours off (every 8 hours, or 3x/day) until patient is able
to eat on his own
Recommend: nutrition education on health and disease, specifically diabetes
Goals: monitor intake, maintain healthy blood glucose levels, increase fruit and vegetable intake

Nutrition Monitoring and Evaluation:


Indicator: calorie intake
Criteria: patients intake will be monitored daily while on tube feeding. When patient is able to eat on
his own, he will complete a 3 day recall before every follow up visit
Indicator: weight loss
Criteria: patient will lose weight at a rate of 0.5 kg/week
Indicator: blood glucose levels
Criteria: patient will maintain healthy blood glucose levels as well as self monitor effectively

S-ar putea să vă placă și