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Diet 3255

ADIME #3
Tyler Leeman
Manchester Memorial Hospital

Patient Initials: G.C.


Age: 46
Gender: M
Admission date: 3-25-18

Chief Complaint and Admitting Diagnosis:


 Headaches
o Nausea/vomiting
 Cryptococcal meningoencephalitis
o Inflammation and infection of the meninges, which are membranes covering the
brain and spinal cord.
o More common in individuals with a compromise immune system (AIDS)

Treatments/Therapies/Alternative Medicine (respiratory therapy, IV replacement, PT/OT/SLP,


chemo, radiation, dialysis, and how it relates to your patient’s nutritional status)

 IV:
o D5W and IV fluids.
 Respiratory:
o Nasal Cannula
 Biopsy
o Lumbar puncture to check cerebrospinal fluid sample

Past Medical History:


 AIDS
 Lymphoma
 Deep vein thrombosis

Anthropometric Data:
Height: 6’1”
Weight: 165 lbs. (75 kg)
IBW: 184 lbs. (83.6kg)
IBW%: 89.6%
UBW: 172 lbs. (78.2kg)
UBW%: 95.9%

History of Weight Changes:


Nutrition assessment indicating patient had lost 10 lbs. in the past month, but after speaking
with the patient he let me know he had been hovering around a weight of 165 lbs. for 2-3
months.

BMI: 21.8 (normal weight)

Nutritional Requirements:

REE= [10 x 75.06] + [6.25 x 185.4] – [5 x 46] +5


= 750.6 + 1158.75 – 230 + 5
= 1684 kcal (1.3 Activity factor)
= 2189 kcal

Kcal/kg:
25kcal x 78.1 kg = 1954 kcal

REE= 2071 kcal

Protein:
0.8-1.0 g/kg
0.8 x 75.06 = 60 g protein
1.0 x 75.06= 75 g protein

Range= 60-75 g protein

Fluid:
75.06 kg x 30 mL= 2251 mL

1mL/kcal
1 mL x 2071 kcal = 2071 mL

Diet order:
Patient currently on a regular diet.

Appropriateness:
I feel a regular diet is appropriate for this patient. I suggested drinking an Ensure in-between
meals and he was receptive to the idea and wanted to try it. My main goal for him would be to
increase his oral intake. I spoke with him and gave him some tips on how to increase his food
consumption through the day. Keeping snacks nearby in his room and trying to eat during the
parts of his day when he isn’t having headaches and nausea/vomiting.

Labs:
Lab Test Normal Range Patient Value Date Interpretation
Sodium 136-145 mmol/L 141 mmol/L 3-29-18 WNL, No
concern for an
electrolyte
imbalance with
this patient
Potassium 3.5-5.1 mmol/L 3.2 mmol/L 3-29-18 Low , could be
due to a GI loss
or his IV could
have been
lacking
potassium. Also
could be due to
his vomiting
Albumin 3.4-5.0 g/dL 2.8 g/dL 3-29-18 Low , could be
due to a low
protein intake
from diet or
malabsorption
BUN 7-18 mg/dL 14 mg/dL 3-29-18 WNL, no
concerns with
kidney function
with this patient
Creatinine 0.550-1.3 mg/dL 0.65 mg/dL 3-29-18 WNL, no
concerns with
kidney function
with this patient
Hemoglobin 13.5-18 g/dL 13.1 g/dL 3-25-18 Low, decreased
levels related to
his HIV/AIDS
Hematocrit 40-52% 38.8% 3-29-18 Low, Decreased
level mainly
related to
HIV/AIDS or
anemia
Platelet Count 150-480 K/uL 126 K/uL 3-29-18 Low, Decreased
level due to
HIV/AIDS or his
cryptococcal
meningitis
infection
WBC 3.7-10.3 K/uL 3.1 K/uL 3-29-18 Low, Decreased
level due to
HIV/AIDS or his
cryptococcal
meningitis
infection

Medications:
1. Amphotericin
a. Purpose: Antifungal, Cryptococcal meningitis treatment in HIV
b. Side effects:
i. Anorexia
ii. Decreased weight
iii. Nausea/vomiting
iv. Stomach pain
v. Dyspepsia
vi. diarrhea
2. Oxycodone
a. Purpose: Narcotic, Opioid
b. Side effects:
i. Anorexia
ii. Dry mouth
iii. Dyspepsia
iv. Gastritis
v. Nausea/vomiting
vi. Diarrhea
vii. constipation
3. Ondansetron
a. Purpose: Antiemetic, antinauseant
b. Side effects:
i. Dry mouth
ii. Abdominal pain
iii. Constipation
iv. Diarrhea
4. Flucytosine
a. Purpose: Antifungal
b. Side effects:
i. Chest pain
ii. Decreased urine output
iii. Numbness/tingling
5. Azithromycin
a. Purpose: antibiotic
b. Side effects:
i. Stomatitis with IV
ii. Nausea/vomiting
iii. Abdominal pain
iv. Diarrhea

Nutrition Focused Physical Findings:


Patient did not display any signs of muscle or fat wasting and physical and overall physical
appearance was normal. Only concern was patients consistently low appetite.

Pertinent Social History:


Patient reports unprotected sex with multiple HIV positive male partners. Some tobacco and
alcohol use, but no recreational drug use. He currently works as a truck driver for UPS and lives
with several roommates. He has refused multiple attempt by physicians to start antiretroviral
therapy. Patient has a history of depression so getting patient outlook of his prognosis is
important.

Nutrition History:
Patient says he likes most food except vegetables. Intake was recently consistently low due to
constant headaches. He refused to use any dietary supplements because he wants all calories
to come from food. Patient also has a history of refusing antiretroviral therapy.

Summary of Current Intake:


Current intake is very low because of poor appetite due to constant headaches. Intake of
breakfast on 3-27-18 was greater than 75%, however it only consisted of two fruit cups. On 3-
28-18 recorded consumption of breakfast and dinner were both less than 50%. When I spoke
with him on 3-29-18 he ate greater than 75% of his breakfast, however it was a small amount of
food only consisting of a bowl of cream of wheat and a fruit cup. Current intake is not reaching
patient energy, protein or fluid needs. Patient currently reported no feelings of hunger
throughout the day. Previously refused supplements because he wanted to have all of his
calories come from food, but when I spoke to him on 3-29-18 he was willing to start drinking
Ensure in order to increase his energy intake.

Diagnosis:

Inadequate energy intake related to poor appetite linked to headaches, nausea and vomiting as
evidenced by patient self-report of low oral intake less than 50% of meals for 3 days.
Intervention:

 Food and/or Nutrient Delivery (meals, snacks, enteral and/or parenteral feeding;
supplements – as in commercial, food/drink based, or vitamin/mineral)
o Strawberry Ensure in-between meals in order to help him reach estimated calorie
and protein needs
o Frequent smaller meals instead of large meals throughout the day
o Provide energy dense snacks patient can keep nearby to increase calorie intake
when feeling well enough to eat
 Nutrition Education (purpose; priority modifications; survival info; nutrition relationship to
health and disease; recommended modifications)
o Educate patient on importance of eating frequent energy dense meals and having
snacks nearby throughout the day in order to maintain weight & help return him
to his normal weight.
o Educate him on neutropenic type diet to avoid foodborne illnesses due to his
compromised/weakened immune system
 Washing raw produce
 Cooking foods to proper cooking temperatures
 Coordination of Nutrition Care (team meeting; referral to RD with different expertise;
collaboration with other providers; referral to community agencies or programs)
o Collaborate with nursing team to explain importance of patient increasing oral
intake. Necessary to track number of food items on patient tray and amount of
each meal consumed.
o Prevent patient hunger

Monitoring and evaluation:

 Food/Nutrition Related Outcomes (Food intake, supplement use)


o Monitor patient’s meal and Ensure consumption
 Goal for patient to order three or more food items per meal
 Extra items can be kept in room to eat as a snack at a later time
 Goal for patient to be consuming 75-100% of all meals
 Goal of consuming 3 Ensures per day in-between meals or when he is
feeling his best
 Anthropometric Measurement Outcomes (Ht, Wt, BMI)
o Monitor body weight, prevent weight loss below 165lbs.
 Goal: patient to maintain bodyweight of 165 lbs. – 172 lbs.
 Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes, gastric
emptying)
o Monitor pre-albumin and transferrin levels
o Pre-albumin:
 Monitor and ensure it stays within normal limits
o Transferrin:
 Monitor and ensure it stays within normal limits
 Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat
wasting, swallow function, appetite)
o Monitor patient appetite:
 Goal: Patient will consume 75-100% of all meals
 Nutrition Education Outcomes Knowledge based, “pt able to state 3 prepared foods high
in Na”
o Patient will be able to state at least three food items ok to eat with a
neutropenic style diet
o Patient will be able to state at least 3 food items not allowed in his diet due to
his weakened immune system
o Patient will be able to state the proper cooking temperature of at least 3 food
groups
o Patient will be able to state 3 new ways to increase his calorie intake while
having intermittent headaches

Meal Plan:
 I would focus educating the patient on food safety and ways to eat and consume a high
amount of calories when he is feeling well enough to eat.
o Small frequent meals may work better than larger meals
 Allowed:
o He is on a regular diet and the majority of foods are available for him to include
in his diet in order to increase his intake and help return him to his usual body
weight.
 Not Allowed
o He should stay away from:
 unpasteurized or raw dairy products
 cheeses made from unpasteurized or raw milk
 raw/undercooked eggs, meat or poultry
 sliced deli meats
 unwashed raw fruit and vegetables/unpasteurized fruit and vegetable
products (juice, cider, etc.)
 roasted nuts in the shell
 uncooked grain products.
 With his CD4 low due to his HIV we really want to take safety measures like washing
produce and cooking meats to the proper temperature to avoid a foodborne illness
because he is at an increased risk.
 When he is eating we will try to focus on high calorie foods like breaded meats, adding
sauces/gravies, and whole milk products.

Estimated Needs:

Calories: 2071 kcal

Protein: 75 g protein

Meal: Food Item: Calories Protein (g) Fat (g) Carbohydrate


(kcal) (g)
Breakfast 2 Eggs fried in 198 12 16 1
oil
1 slice whole 71 3 1 12
wheat bread
2 tbsp. peanut 195 8 17 5
butter
1 cup fruit 91 1 0 23
cup/salad
2 cups water 0 0 0 0
Snack: 1 bottle Ensure 242 9 6 38
(8oz.)
(strawberry)
Lunch:
1 cup whole 172 7 1 37
wheat spaghetti
½ cup tomato 60 2 2 9
sauce
4 small 110 9 2 4
meatballs (beef)
2 cup water 0 0 0 0
Snack: 1 bottle Ensure 242 9 6 38
(8oz.)
(strawberry)
1 cup water 0 0 0 0
Dinner: 1 medium 191 27 3 11
breaded
chicken breast
1 tbsp. BBQ 27 0 0 6
sauce
1 cup cooked 27 4 1 11
broccoli
1 cup cooked 215 5 2 45
brown rice
2 cups water 0 0 0 0
Snack 1 bottle Ensure 242 9 6 38
(8oz.)
(strawberry)
Total: 2109 kcal 105g 63g 279g

Fluid: 1652 mL (water)


Remaining amount obtained through Ensure

References:

Food and Medication Interactions 18th Edition


Nutrition Care Manual: https://www.nutritioncaremanual.org
Krause’s Food and The Nutrition Care Process 14th Edition
Diet 3255 Clinical Resources Packet
https://www.healthline.com/health/meningitis-cryptococcal

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