Progress Report Overview

Student: Brandi Kam

Activity: ​Shawn Callahan Scene 1

Start Time: 01/16/2023 15:03:30

End Time: 01/16/2023 15:14:13

Total Time: 00:10:43

Actions

Note at 01/16/2023 15:13:52

​Shawn Callahan Scene 1 Documentation
Student: Brandi Kam
Activity Start: 01/16/2023 15:03:30
Activity Completion: 01/16/2023 15:14:13
Activity Completion: 00:10:43

Patient Data

Patient: Shawn Callahan DOB: 10/18/1977

Age/Sex: 45 yo M MR#: MR-0635
Location: General Hospital Admit Date: 01/16/2023

Notes

Note at 01/16/2023 15:03:40

Nutrition ADIME Note

Basic Information

Date:

01/16/2023 15:03:40

Author:
Brandi Kam

Location:
General Hospital

Assessment:

Patient's admitting diagnosis is exacerbation from non-resolving colitis resulting in dehydration and severe pain. Has a historyof
Crohn's disease since 19 yo. Has had 4 related surgeries since dx. Pt is a divorced father of two but not much else is knownabout
social history. BMI indicative pt being slightly overweight but does show signs of malnutrition/high risk of malnutrition.Loop
ileostomy procedure scheduled for non-resolving colitis and exacerbation of Crohn's Disease

Admitting dx:

Loop ileostomy procedure for non-resolving colitis and exacerbation of Crohn's Disease

PMH:
Severe Crohn's disease since age 194 small bowel resections and a few minor procedures for various complications related to
Crohn's

Family History:
Paternal family history of GI symptoms. Paternal grandmother died of brain cancer in early middle age and father diedfrom MVA in
early middle age. No other known family history of autoimmune disorders.

Ht:

172.72 cm

Wt:

76 kg

BMI:

25.1

IBW:

154 lbs

Diet Rx:

Current - NPO

Nutrition focused physical exam:

Weight assessment:
Pt BMI is 25.1 indicating slightly overweight, but showing signs of mild to moderate malnutrition

Intake and digestive problems: Crohn's disease

Relevant meds:

Methylprednisolone: Should be taken with food to decrease GI effects

Metronidazole: Monitor Na
Ciprofloxacin: Caution Ca intake

Skin - Intact

Relevant labs:
BMP (Basic Metabolic Panel):
BUN: 35 mg/dL (High - 7 to 20)
Glucose: 117 mg/dL (High - 70 to 115)
Serum potassium: 3.4 mEq/L (Low - 3.5 to 5.0)
Serum sodium: 152 mEq/L (High - 135 to 145)

CBC with Differential:

Hemoglobin:12.4 g/dl (Low - 13.5 to 16.5)
Hematocrit: 37% (Low - 41 to 50)RBC's (x 106 /ml): 6.2ml (High - 4.5 to 5.5)
Segmented neutrophils: 63% (High - 54 to 62)
Lymphocytes: 23% (Low - 24 to 44)

Food preferences:

N/A

Assistance with meals:

Full independance

Estimated Nutrition Requirements

Kcal:

1910- 2290 kcal/day

Protein:

100-115 g/day

Fluid:

2000 ml/day

Diagnosis (nutrition):

Inadequate fluid intake related to increased fluid losses as evidenced exacerbation of severe colitis resulting alteredGI function,
diarrhea, and planned loop ileostomy procedure

Malnutrition diagnosis:

No Noted malnutrition

Intervention

Recommendation:

Maintain fluid intake before procedure to prevent further dehydration

Monitor/evaluate:

Monitor electrolytes, BUN, and creatine

Keep track of signs of malnutrition and monitor weight loss/gain.