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450 Adime Etta Rose
450 Adime Etta Rose
450 Adime Etta Rose
NTDT450
ADIME for Etta Rose
Overview:
Patient was admitted for direct acute exacerbation of COPD after inability to carry a
conversation. Patient’s chief complaint is shortness of breath. This is the first acute
exacerbation requiring hospitalization. Patient is alert and oriented.
Assessment:
Anthropometric:
83 y/o female
163 cm, 55 kg
BMI= 20.7 (Normal)
Daily weights ordered
Biomedical:
Most recent ABG: High PaCO2 (55 mgmHg), Low pH (7.33)
Low SaO2 (91%)
Most recent Cl: Low Serum Cl- (96 mEq/L)
High BUN (29 mg/dL), High Creatinine (2.3 mg/dL)
High CO2 (40 mEq/L)
High WBC (15000 cells/mL)
Client History:
Medical Hx: Patient diagnosed with Stage III COPD approximately one month
ago; HTN since early 1960’s
Smoked 1-2 ppd for 30 years until quitting at age 49
Does not drink
Recently retired realtor
Family Hx: father died of pneumonia, mother died of breast cancer
Dx has caused a change in independence
Food/Nutrition-Related History:
Current Diet Order: Regular
Diet at home (24 hour recall)
o Breakfast:1 cup of coffee with 1 teaspoon of creamer, ½ cup orange
juice,1 poached egg, ½ slice of white bread (toast)
o Lunch: 1 cup of cream of tomato soup, ½ slice of white bread (toast), ½ of
banana, 1 cup Pepsi
o 1 piece of KFC chicken leg, ½ cup mashed potato, 2 tablespoons of gravy,
½ cup orange juice
o Snack: ½ cup applesauce
Unable to grocery shop
Medications: albuterol inhaler PRN, nifedipine, tiotropium, fluticasone, Prisolec
NKDA
Diagnosis:
Predicted inadequate energy intake related to exacerbation of COPD as evidenced by
caloric intake from 24-hour recall 400 calories less than recommendation
Intervention:
Prescription: 1400 kcal/day and 70g protein/day
Recommend: Increased energy diet by introduction of Ensure and consumption of small,
frequent, energy-dense meals
Goals: Increase caloric intake to prevent weight loss and maintain normal weight