Progress Report Overview

Student: Brandi Kam

Activity: Youssef Ahmadi

Start Time: 01/13/2023 23:54:04

End Time: 01/13/2023 23:59:15

Total Time: 00:05:11

Actions

Note at 01/13/2023 23:58:55

Youssef Ahmadi Documentation
Student: Brandi Kam
Activity Start: 01/13/2023 23:54:04
Activity Completion: 01/13/2023 23:59:15
Activity Completion: 00:05:11

Patient Data

Patient: Youssef Ahmadi DOB: 09/17/1979

Age/Sex: 43 yo M MR#: MR197263
Location: General Hospital Admit Date: 01/09/2023

Notes

Note at 01/13/2023 23:54:10

Nutrition ADIME Note

Basic Information

Date:

01/13/2023 23:54:10

Author:
Brandi Kam

Location:
General Hospital

Assessment:

The patient is a 46 year old male, history of TIA, HIV, HTN, GERD, diverticulitis and ESRD on PD who was admitted with abdominal
pain, nausea and vomiting and found to have peritonitis. Complains of headache and abdominal bloating. Abdominal pain is
improved.

Admitting dx:

Peritonitis

PMH:
ESRD, stage 5 chronic kidney disease, was on PD which is peritoneal dialysis. In this treatment, the wall acts as a selective membrane
and helps in removing toxins, excess fluid, and fixing electrolyte imbalances.
Medical History: GERD, HIV, hypertension, renal disease - ESRD on peritoneal dialysis (PD), other - diverticulitis
Past Family History: No autoimmune disease, No blood disorders, No cancer, No cardiac disorders, No diabetes, No gastrointestinal
disorder, Yes hypertension, No neurologic problems, No psychiatric problems, No renal disease, No respiratory disorders, No
thyroid disease, No other family illness
Psychiatric History: Yes: anxiety

Ht:

178 cm

Wt:

99.7 kg

BMI:

31.47

IBW:

68.4 kg

UBW:

101 kg

Diet Rx:

Renal diet/advance diet

Nutrition focused physical exam:

N/A

Relevant meds:
Antibiotics
Acetaminophen (Tylenol) 650 mg PO Q6H PRN Reason: Pain Rated 1-3 (Mild Pain)
Hydrocodone Bitart/Acetaminophen (Norco) 1 each PO Q4H PRN Reason: Pain Rated 4-7 (Moderate Pain) Alprazolam (Xanax) 0.25
mg PO BID PRN Reason: Anxiety
Aspirin (Ecotrin) 81 mg PO DAILY SCH
Calcium Acetate (Phoslo) 1,334 mg PO TIDWM SCH
Cinacalcet (Sensipar) 60 mg PO DAILY SCH
Ciprofloxacin (Cipro 500 Mg/5 Ml) 250 mg PO Q24H SCH
Cefepime HCl 1 gm/ Sodium (Chloride) 100 mls @ 200 mls/hr IVPB Q12H SCH
Darunavir (Prezista) 800 mg PO WSUP SCH
Enoxaparin Sodium (Lovenox) 40 mg SUBQ DAILY SCH
Hydromorphone HCl (Dilaudid) 1 mg IV Q4H PRN Reason: Pain Rated > 7 (Severe Pain)
Labetalol HCl (Trandate) 200 mg PO DAILY SCH
Nifedipine (Procardia Xl) 60 mg PO BID SCH
Paricalcitol 2mcg Caps (Patient Using Own Meds) 0 capsule PO DAILY SCH
Ondansetron HCl (Zofran) 4 mg IV Q4H PRN Reason: Nausea
Ritonavir (Norvir) 100 mg PO WSUP SCH
Sodium Bicarbonate (Sodium Bicarbonate) 650 mg PO TIDAC SCH
Vitamin B Complex/Folic Acid (Nephrocaps Softgel) 1 capsule PO DAILY SCH

Relevant labs:

WBC 9.3
RBC 3.83 L
HGB 10.4 L
HCT 32 L
MCV 83.5
MCH 27.3
MCHC 32.6
RDW 16.6 H
PLT 175
MPV 8.1
NA 138
K 4.4
CL 104 D
CO2 22
ANION GAP 12
BUN 66 H
CR 11.7 H
EST GFR (AFRICAN) 6 L
EST GFR 5 L
BUN/CR RATIO 5.6 L GLUCOSE 118 H
CALC OSM 298
CA 9.4
RANDOM VANCOMYCIN 16.57

Dietary restrictions:

N/A

Food preferences:

Cultural foods since his 24h diet recall shows that this patient prefers to eat foods from his culture

Estimated Nutrition Requirements

 Kcal:

2380-3332 kcals/day

Protein:

95.2-114.2g/day of protein

Fluid:

2380 mL – 3332 mL/day

Diagnosis (nutrition):

Inadequate energy intake related to chronic condition and abdominal pain due to peritonitis as evidenced by unintended weight loss
of 1.3kgs in one month.

Nutrition goal(s):

Goal would be to eat nutrient dense foods with enough calories/energy and protein in order to not lose more weight

Intervention

Recommendation:

- Increase protein density of PO meals with 75% of total protein derived from bioactive protein as tolerated by patient.
- Modify PO diet to include small, mineral-restricted (Na+, K+, P), nutrient-dense meals to increase oral intake to 80% of daily
meals.
- Limit fluid intake to 1.2 L/day based on fluid output
- Provide patient and caretaker with evidence-based information and hand-outs regarding Renal diabetic diet as well as
nutritional needs for HD.

Collaboration of care:

- Patient and caretaker will state understanding of Renal diabetic diet and nutritional needs for HD during HD consults and
follow-ups.
- Nurses will help in taking weekly weight measurements to monitor the patient's weight
- Doctor will monitor lab values daily to make sure there is improvement in the patient's health
- Nephrologist will help review patient's dialysis treatment and ensure their diet is supporting optimal treatment

Monitor/evaluate:

Monitor weekly weight. Patient will maintain weight within 2% x 1 week. Monitor meal intake. Patient will meet energy intake of 2300
Kcal/day, protein intake of 76g, 50% bioactive protein; limit fluid intake to 1.2 L/day; 2 gm K+, 2 gm Na+, 800 mg.