Progress Report Overview
Student: Maya Yoder
Activity: Writing an ADIME Note (CVA)
Start Time: 07/17/2020 11:16:11
End Time: 07/17/2020 13:50:21
Total Time: 01:43:56
Actions
Note at 07/17/2020 13:49:59
Writing an ADIME Note (CVA) Documentation
Student: Maya Yoder
Activity Start: 07/17/2020 11:16:11
Activity Completion: 07/17/2020 13:50:21
Activity Completion: 01:43:56
Patient Data
Patient: Terrance Clarkson, Sr. DOB: 04/16/1928
Age/Sex: 92 yo M MR#: KFG8765
Location: Valley View Therapy Center Admit Date: 07/16/2020
Notes
Note at 07/17/2020 11:16:33
Educational ADIME
Basic Information
Date:
07/17/2020 11:16:33
Author:
Maya Yoder
Location:
Valley View Therapy Center
Nutrition Assessment
Client history:
Terrance Clarkson is a 92 year old male who presented in the hospital with weakness of his left side following a stroke he had 8
days prior. He has a history of T2DM, CAD, hyperlipidemia, peripheral vascular disease, has had 3 CABGs and recently fractured
his ankle. He is also currently an anticoagulation, aspiration, and fall risk. He lives alone but is cared for regularly by his
grandchildren. He does not report smoking or drinking currently. Has a history of depression.
Current medications list: Acetaminophen Liquid PO 500 mg/15 mL PO Q6H PRN for mild pain. Calcium/Vitamin D Tab 1 Tablet
PO Daily. Hypromellose 0.4% SOLN, 2 Drops each eye Q12H PRN for dry eyes. Losartan Potassium tab 25mg PO Daily. Hold for
SBP <100. Omeprazole 20 mg PO Daily. Simvastatin tab 80mg PO QHS. Coumadin 5 mg tab PO QHS. Furosemide 40 mg/5 mL
oral solution PO every morning. Metformin 500 mg BID. Regular insulin per sliding scale SQ before meal and at bedtime.
Biochemical data, medical tests and procedures:
No lab data exists at this time.
Anthropometric measurements:
The patient is 72 inches (6 feet) and currently weighs 172lbs with a reported weight loss of 11 pounds in 9 days. His current BMI
is 23.3
Physical exam finding (nutrition focused):
Changes in vision in the left eye (decreased ability), hard of hearing, bruising throughout. SOB when moving. Decreased
appetite, slowed and slurred speech with weakness and fatigue. Pain and stiffness present along with hemiplegia on the left
side.
Reported decrease in appetite, but normal bowel sounds were heard
Has a PEG tube (clean) and a catheter (clear, yellow urine)
1+ edema at left wrist and hand and left lower extremity below the knee
Food and nutrition history:
Consumes a very bland diet with little to no fruits and vegetables (all white foods).
Eats three small meals a day and has only one snack
All evidence of 24 hour recall
Reportedly consumed 30% of meal in hospital
Upon evaluation with a speech therapist, the patient has been put on a mechanical soft diet with regular liquids and should be
seated upright for meals with someone in the room.
Comparative standards:
Work with a physical therapist to regain strength. Work with a speech therapist to enhance speaking skills and regain ability to
eat a normal consistency diet. Work with a pharmacist to ensure prescriptions taken do not interact with other prescriptions he
is on. Work with nursing staff to ensure the medication is taken in full and on time. Work with doctors to ensure the patient is
recovering fully from his CVA and all medications / therapies are continually beneficial.
Total energy estimated needs:
2,245kcals
Total protein estimated needs:
104g per day
Total fluid estimated needs:
2 Liters per day
Nutrition Diagnosis
(P) Problem:
Inadequate energy intake related to decreased food consumption and increased energy needs.
(E) Etiology (r/t):
Related to a recent stroke.
(S) S/S (aeb):
As evidence by an 11 pound weight loss in 9 days.
Nutrition Intervention
Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of Nutrition Care RC, Population Based
Nutrition Action P
Nutrition prescription:
Mechanical soft diet that consists of 2,200 calories and roughly 100 grams of protein with at least 2L of water.
Intervention:
Increased energy diet to 2,200 calories a day.
Increased protein diet to about 100 grams of protein a day.
Goal:
Maintain usual body weight, increase strength from CVA, and maintain ability to consume a mechanical soft diet.
Nutrition Monitoring and Evaluation
Indicator:
Follow the nutrition prescription assigned and check in with an RDN in 2 days to ensure there is no further decrease in weight.
Signed:
Maya Catharine Yoder
Date:
7/17/2020
Time:
1:50
