ADIME Progress Note- Template Only

Name: Jesse Terris

Disease State: Oncology

Name/Date/Time:

Consultation For: Consult for RN admission screen of 14-23 lb weight loss and
decreased appetite.

NUTRITION MONITORING AND EVALUATION

Weight: 148 lb (67.2 kg) BMI: 23.91

Height 5’ 6”

Estimated Energy Needs 1680-2016 kcals

Estimated Protein Needs 80-100 grams

Food/Nutrition-Related History Anthropometric Measures

Patient isn’t one that eats meals, he is more of a He is 5’ 6” and weights 148 lbs. His BMI is 23.91 and in the last 3
grazer and prefers snacks. months he has lost 15 lbs (9.2%, significant).

Biochemical Data, Medical Tests and Procedures Nutrition-Focused Physical Findings

BG POC 257-279 mg/dL x 24 hours. Subcutaneous fat loss: Muscle Wasting:
- Orbital: Moderate - Temple: Moderate
- Triceps: Mild/Moderate - Clavicle: Severe
- - Shoulder: Moderate
- - Interosseous: Moderate

Nutrition Assessment, Monitoring

Client History
Patient has a history is
Diabetes, hypertension, and
prostate cancer.
Comparative Standards
and Evaluation Tools
Nutrition physical focused exam 25-30 kcal/kg for calories
1.2-1.5 grams/kg for protein.

CURRENT NUTRITION DIAGNOSIS

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PES Statement(s) Inadequate oral intake related to decreased ability to consume
sufficient energy as evidenced by poor po, weight loss, and
Problem, Etiology, Signs decreased appetite.
and Symptoms
Non-severe malnutrition in the context of chronic illness (cancer
recurrence with ongoing symptoms) related to inadequate oral
intake as evidenced by weight loss 9.7% x 3 months, moderate
orbital fat loss and severe muscle wasting at clavicles and
moderate in shoulder region.
NUTRITION INTERVENTION
Nutrition Prescription Energy needs: 1680-2016 kcal

Protein: 80-100 grams

Fluid: 1680-2016 ml
Aims/Goals (SMART) Encourage patient to eat 3 meals a day even if they are small.

Detail of Intervention/Plan Have patient ordering 3 meals a day and trying to consume at
least 50% of them. As well as sending 2 protein supplements a
day to help increase caloric intake.
NUTRITION MONITORING AND EVALUATION
Tick all that apply Food/Nutrient/Energy Nutrition Assessment/Monitoring and Evaluation
Tools
Anthropometrics
Labs (specify)
Behavior or
Knowledge/Beliefs/Attitudes
Specific Indicators, This patient would be considered moderate for nutritional risk. This means an RD will follow
Criteria and Time up with the patient within 3 to 5 days. Checking in to see how appetite is doing and if they are
frame ordering 3 meals a day. Also checking to see if they like the protein supplements and if not if
they would like to try a different flavor.
What will you assess
during follow-up
consultations?

January 2022 Page 2 of 3

Also Complete a Narrative ADIME Note for the same patient with the following Format:

Nutrition Assessment:

This patient lives alone but has a close friend that visits almost daily. He has a history of diabetes, hypertension, and

prostate cancer. He presented to the hospital with left flank pain. The CT showed recurrent tumor in the prostatectomy

bed measuring up to 6.4 cm which invades the urinary bladder and lower rectum. At visit today patient says he doesn’t

eat many meals that he is more of a grazer. In the last 3 months he has lost 15 lbs (9.2%, significant).

Nutrition Diagnosis:

Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by poor po, weight loss,

and decreased appetite.

Non-severe malnutrition in the context of chronic illness (cancer recurrence with ongoing symptoms) related to

inadequate oral intake as evidenced by weight loss 9.7% x 3 months, moderate orbital fat loss and severe muscle

wasting at clavicles and moderate in shoulder region.

Nutrition Intervention:

While at the hospital the patient will be on a 180 gm carbohydrate consistent diet due to his diabetes. The goal is for

him to order 3 meals a day and consume at least 50% of these meals. With every lunch tray we will send chocolate

Glucerna and with every dinner tray we will send strawberry Glucerna to add extra calories and protein to his diet.

Nutrition Monitoring/Evaluation:

We will monitor his food and supplement intake to see how much he is consuming. Due to him loosing weight we will

monitor for any weight changes during his stay. Lastly, we will look at test and procedures that he has done.

Modified from Nutrition Care Professionals; Updated 1/1/2022

January 2022 Page 3 of 3