Adime chart note example 1 PDF

Preview

Summary

study...

Description

Nutrition Services Jan. 26, 2020 2:35pm

Olivia de Havilland ID# 1234545

Assessment: 70 y.o. ♀ Dx Celiac Disease. Hx of MI 8 mos. ago, osteopenia. Ct. presented with diarrhea, elbow rash, fatigue and bloating. Meds: Crestor. Ht 157cm; Wt 69kg; BMI 28; UBW 75kg. Labs: Albumin 25 ↓, TC 4.1, folate 2.8↓, Hgb 106↓, B12 Shillings test ↓, fecal fat 16 ↑, positive celiac blood test. Physical activity: lightly active, walking 15 minutes 2-3x/week. Social Hx: Married, lives with husband, enjoys cooking. Ct made heart healthy behaviour changes since MI (walking, ↑ fibre). Dietary requirements: 2070 kcals/d, 55-69g protein/d, 2070mL fluid/d. Current intake: 2200kcal/d, 80g protein, frequent consumption of gluten (bread, wheat cereal, pasta, etc). Diagnosis: Food and nutrition knowledge deficit related to new diagnosis of celiac disease as evidenced by Dx. of celiac disease, daily diarrhea, wt. loss of 6kg in 6 mos., Albumin 25 ↓, Hgb 106↓, daily intake of gluten containing foods. Intervention: Goals: 1. Pt. to consume a gluten-free diet. 2. Decrease frequency and severity of diarrhea. Nutrition Education: Gluten-free diet and low residue diet. Provided gluten-free and low residue diet handouts. Referred ct. to Canadian Celiac Society Website and resources. Enrolled in Celiac cooking class. Nutrition Counselling: Used problem solving to plan gluten free, low residue diet. Monitoring and Evaluation: Next appointment in 1 mo. Ct. to complete 3 day food record, check for gluten, nutrient adequacy. Monitor wt, albumin, Hgb, pt. report of diarrhea, bloating. Laura Forbes RD

Laura Forbes...