SURGERY

INTERN: ALLANA BOONE

P R E C E P T O R : C H R I S T I N E D E PA U L

PATIENT HX

C.G. 64 Y.O Caucasian Male

Surgical Phys: Vladimir Kiselev
Nurse Practitioner: Susan Cooke
Ward: 5A
PMH: dysphagia, acute bronchitis, athropathy of
cervical spine, muscle spasms, colonic polyps,
diverticulitis, internal hemorrhoids, HTN, COPD,
surgical stenosis, tobacco use
Chief complaint: Infrarenal abdominal aortic
aneurysm, aortoiliac occlusive disease

MEDICATIONS

Docusate Na
Oxycodone
Budesonide/Formoter
Hydrochlorothiazide (HCTZ)
Metoprolol Tartrate
Albuterol
Simply Thick Oral Gel (Honey)
Amlodipine Besylate
Atorvastatin
Bupropion HCl
Povidone Iodine
Nicotine
Metronidazole
Fondaparinux
NaCl
Boost Glucose Control
Acetaminophen
Aspirin

ANTHROPOMETRICS

Height: 5 8 (173 cm)

Weight: 120.2 lbs (54.6 kg)
UBW: 128 lbs (64.1 kg)
%UBW: 94%
IBW: 154 lbs (70 kg)
%IBW: 78%
BMI: 18.3 (underweight)
Significant Weight Change:
9# x 1 mo (significant, 7% weight loss)

BIOCHEMICAL DATA, MEDICAL TESTS,

AND PROCEDURES

FOOD/NUTRITION-RELATED HISTORY

BACKGROUND ON DISEASE OR DX

SIGNIFICANT EVENTS DURING CURRENT

ADMISSION

COMPARATIVE STANDARDS
Energy requirement: 1750 Kcal/day
Kcal/ kg equation: Based on actual body weight, caloric
factor of 32

Protein requirement: 66 gm/day

Based on actual body weight, protein level of 1.2

Fluid requirement: 1750 ml/day

NUTRITION DIAGNOSES
Previous:
Inadequate kcals/pro po
Related to: increased needs; medical issues
As evidenced by: need for supplements
(ON GOING/UPDATED)

New:
Weight
Involuntary weight loss
Related to: medical issues, increased needs
As evidenced by: significant weight loss
Functional
Swallowing difficulty
Related to: aspiration risk
As evidenced by: Speech pathologists recommendations for dysph ad diet with
honey-like liquids

NUTRITION INTERVENTION

FOOD AND/OR NUTRIENT DELIVERY

Diet Order
Dysphagia Advanced Diet w/ Honey-like liquids

Nutritional Supplements
Honey-like Boost+ tid
Per serving: 360 kcal, 14 g PRO

Ensure Powder TID for patient at home to

Simply Thick - Honey

NUTRITION EDUCATION AND/OR

COUNSELING
Discussed the importance of following a thickened
liquids diet.
Reviewed risks of non-compliance.
Explained which foods were allowed on his
recommended diet - Dysphagia advanced.
Discussed Ensure powder supplement that will be
provided after d/c- mixing directions, how to
flavor, what can it be added to.
Handouts: Thickened Liquids, List of Foods
Allowed/Not Allowed: Dysphagia Advanced Diet,
Flavoring/Mixing Suggestions for Ensure

COORDINATION OF NUTRITION CARE

Recommend drawing pre-albumin and CRP once
patient has been on Dysphagia Ad - Honey-like
diet for 3 days.
Pt. with low t-chol, on statin -consider
reevaluating need/dosage of statin
Upon d/c, will ordered consult for McCafferty RD
to f/u re: compliance of recommended diet,
weight status, PO intake, new rx

NUTRITION MONITORING & EVALUATION

Previous:
Tube feeding
Goal: Tolerate tf w/ no n/v/abd distention --resolved, no longer on TF
Pre-albumin
Goal: >15 w/ nl crp --partially met

New:
Diet
Goal: Tolerate Dysphagia Advanced Diet - Honey-like liquids w/ no n/v/abd distention
PO intake
Goal: >/=75% of meals/supplements
Weight
Goal: Wt gain of 1/2-2 lb. per week towards BMI >18.5
CRP
Goal: WNL or downtrending