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    Mithsa Chanthavong at 01 - 13 - 2023 11 - 32 PM

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    schoolgirl7796
    The progress report summarizes Brandi Kam's work with patient Mithsa Chanthavong from January 13th to 14th 2023. It includes details of the patient's medical history, current condition, vital signs, lab results, and Brandi's nutrition assessment and recommendations. Brandi found the patient to be malnourished and prescribed a diet plan focused on increased calorie and protein intake through enteral support, while restricting sodium and fat intake. Follow up with palliative care was also recommended.

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    Mithsa Chanthavong at 01 - 13 - 2023 11 - 32 PM

    Uploaded by

    schoolgirl7796
    32 views4 pages
    The progress report summarizes Brandi Kam's work with patient Mithsa Chanthavong from January 13th to 14th 2023. It includes details of the patient's medical history, current condition, vital signs, lab results, and Brandi's nutrition assessment and recommendations. Brandi found the patient to be malnourished and prescribed a diet plan focused on increased calorie and protein intake through enteral support, while restricting sodium and fat intake. Follow up with palliative care was also recommended.

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    Mithsa Chanthavong at 01_13_2023 11_32 PM

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    The progress report summarizes Brandi Kam's work with patient Mithsa Chanthavong from January 13th to 14th 2023. It includes details of the patient's medical history, current condition, vital signs, lab results, and Brandi's nutrition assessment and recommendations. Brandi found the patient to be malnourished and prescribed a diet plan focused on increased calorie and protein intake through enteral support, while restricting sodium and fat intake. Follow up with palliative care was also recommended.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views4 pages

    Mithsa Chanthavong at 01 - 13 - 2023 11 - 32 PM

    Uploaded by

    schoolgirl7796
    The progress report summarizes Brandi Kam's work with patient Mithsa Chanthavong from January 13th to 14th 2023. It includes details of the patient's medical history, current condition, vital signs, lab results, and Brandi's nutrition assessment and recommendations. Brandi found the patient to be malnourished and prescribed a diet plan focused on increased calorie and protein intake through enteral support, while restricting sodium and fat intake. Follow up with palliative care was also recommended.

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    © All Rights Reserved
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    of 4

    Progress Report Overview

    Student: Brandi Kam

    Activity: Mithsa Chanthavong

    Start Time: 01/13/2023 23:32:29

    End Time: 01/14/2023 22:55:12

    Total Time: 22:01:44

    Actions

    Note at 01/14/2023 22:55:00


    Mithsa Chanthavong Documentation
    Student: Brandi Kam
    Activity Start: 01/13/2023 23:32:29
    Activity Completion: 01/14/2023 22:55:12
    Activity Completion: 22:01:44

    Patient Data

    Patient: Mithsa Chanthavong DOB: 11/01/1960


    Age/Sex: 62 yo F MR#: MR2587451
    Location: General Hospital Admit Date: 01/12/2023

    Notes

    Note at 01/14/2023 22:31:36

    Nutrition ADIME Note

    Basic Information

    Date:

    01/14/2023 22:31:36

    Author:
    Brandi Kam

    Location:
    General Hospital

    Assessment:

    Patient is a 62-year-old female with previously identified cirrhosis presenting with encephalopathy and leukocytosis, responding to
    IV Zosyn.

    Admitting dx:

    Hypokalemia with abdominal pain and jaundice

    PMH:
    Narcolepsy
    non-Hodgkin's lymphoma
    lupus
    depression
    anxiety
    chronic pain on morphine
    portal venous thrombosis

    Ht:

    157.5 cm

    Wt:

    43.1 kg

    BMI:

    17.4

    Diet Rx:

    Current: Reg diet thin lip -- Advance to --> 2gm sodium w/ PO: Ensure TwoCal HN (BID)

    Nutrition focused physical exam:

    Extremities: Atraumatic, normal ROM, good gross strength. 2+ bilateral lower extremity pitting edema, to the feet and ankles good
    distal pulses 2+, less 2 second capillary refill.

    Skin: Warm, dry, no rash

    Relevant labs:

    Fluid Source: Peritoneal


    Fluid Color: Yellow
    Fluid Appearance: Clear
    Fluid WBC: 30 mm3
    Fluid RBC: 31 mm3
    Fluid Neutrophils: 6%
    Fluid Lymphocytes: 46%
    Fluid Monocytes: 48%
    Fluid Albumin: <0.6 g/dL
    Fluid LDH: 37 U/L

    WBC is 11.2, hemoglobin is 7, platelet count 179, Bilirubin 5.7, direct fraction 3.6, AST 78, ALT 25, alkaline phosphatase 196 which is
    stable. Albumin is 1.7, which is low. INR is 1.4.

    Estimated Nutrition Requirements

    Kcal:

    1500 - 1725 kcal


    Protein:

    69 gm

    Diagnosis (nutrition):

    Inadequate protein-energy intake rt inability to consume adequate amounts of food, impaired nutrient absorption and digestion,
    and increased energy expenditure aeb inadequate intake based diet recall and lab results.

    Malnutrition diagnosis:

    Yes. Would flag as malnutrition intervention.

    Nutrition goal(s):

    Calorie recommendations – 35- 40 kcal/kg day


    Protein intake – up to 1.6g/kg per day
    Total calories from fat – No more than 690 kcal
    Carbohydrate consumed throughout the day
    2 grams Na/day (Sodium restriction)
    Consider enteral and parenteral support

    Intervention

    Recommendation:

    Calorie recommendations – 35 to 40 kcal/kg per day


    Protein intake – Up to 1.6 g/kg per day
    Vegetable and dairy sources recommended for patients with mild encephalopathy
    30% or less of total calories from fat
    Carbohydrate consumed throughout the day
    Restrict sodium
    Consider enteral and parenteral support

    Collaboration of care:

    Continue supportive care, continue antibiotics. Will advance diet and activity. Follow up with palliative care and family in
    regards to goals of care.

    Monitor/evaluate:

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