2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.

______

Points ADIME
10 A: (Assessment)
Age 71y Gender F
Pt chief complaint, admit signs and symptoms, MD admit diagnosis for pt
Patient A.N. is a 71-year-old female admitted to Backus Hospital on February 27, 2019 with complaints of
epigastric abdominal pain that increased when deep breathing and rigor chills. A.N. reported her abdomen
has been tender to touch over the last 2 weeks. In the morning upon admission, A.N. reported she awoke with
nausea, shaking, breathing fast, and noticed an increase in urination. Upon arrival at the hospital, A.N had a
low-grade temperature of 100⁰F and tachycardia (heart-rate exceeding normal resting rate 1). Lab work upon
admission revealed anemia, thrombocytopenia, hypokalemia, and transaminitis. Urinalysis suggested an
infection. Patient A.N. was diagnosed with Pyelonephritis.
Pyelonephritis is a urinary tract infection (UTI) causes by a bacteria or virus that typically infects the bladder
and travels and infects one or both of the kidneys resulting in a kidney infection. 2 Chills, fever and painful
urination, increased heart-rate and pulse may occur. Antibiotics and increased fluids are typically prescribed
to treat the condition. 2
Treatments/Therapies/Alternative Medicine (respiratory therapy, IV replacement, PT/OT/SLP, chemo,
radiation, dialysis, and how it relates to your patient’s nutritional status)
Patient reports she has not received chemotherapy since November. Upon admission she began receiving
IV antibiotics in order to treat the infection more aggressively to prevent serious health problems from
occurring. An abdominal and pelvic CT were performed and found hydronephrosis, pyelonephritis and
metastatic disease. 2 Chest XR views were performed to assess the breathing discomfort reported by A.N.
PMHx (in order of importance)
Hydronephrosis is when there is a build-up of urine that cannot drain out from the kidney causing a blockage
resulting in swelling of the kidney. Main symptoms are pain in the side and back, abdomen or groin. UTI is
on of the causes of hydronephrosis.3 Due to A.N.’s renal impairment from pyelonephritis and related frequent
urination is related to the development of hydronephrosis.
Hypokalemia is when the levels of potassium in the blood are significantly low (below 3.6mmol/L). Large
losses of gastrointestinal fluid containing potassium, insulin delivery and excessive losses of urine and
diabetic ketoacidosis.1 The body’s potassium levels are controlled by the kidneys which allow excess
potassium to leave the body through urine and sweat.1 Due to A.N.’s renal impairment from pyelonephritis
and related frequent urination is related to the development of hypokalemia.
Anemia is when there is lack of oxygen and carbon dioxide transported between the blood to the tissue cells
because red blood cells are deficient in size, number or amount of hemoglobin. 1 Commonly anemia is caused
by an inadequate intake of iron, protein, certain vitamins (B12), copper. Nutritional recommendations are
increasing absorbable iron in diet, combine vitamin C with iron foods, increase proteins such as meat, fish or
poultry and decrease tea or coffee consumption. 1 Due to A.N.’s pancreatic neuroendocrine tumor and
metastatic malignant neuroendocrine tumor to the liver, she has developed anemia, thrombocytopenia and
transaminitis.
Thrombocytopenia is when the blood platelet count associated with blood clotting is low. This commonly
occurs from conditions such as leukemia or an immune system problem often associated with chemotherapy.
4 Due to A.N.’s pancreatic neuroendocrine tumor and metastatic malignant neuroendocrine tumor to the liver,
she has developed thrombocytopenia.
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

Transaminitis (hypertransaminasemia) is when the levels of enzymes called transaminases used in the liver
for nutrient breakdown and filtering toxins are extremely high. When levels of these enzymes are too high,
they can move into the blood stream. This condition typically indicates an underlying cause and therefore
often is used as a diagnostic tool. 5 Due to A.N.’s pancreatic neuroendocrine tumor and metastatic malignant
neuroendocrine tumor to the liver, she has developed transaminitis.
Primary pancreatic neuroendocrine tumor is a type of tumor that can be benign or malignant and
typically grow slower than exocrine tumors. Abnormal growth of endocrine (hormone-producing) cells in
the pancreas can cause the development of a tumor. Typically, the tumors that form are non-functional (do
not produce any hormones) and therefore can go undiagnosed until it becomes advanced resulting in pain
or jaundice. 7
Metastatic malignant neuroendocrine tumor to liver is a type of cancerous tumor developed in the liver
that has progressed to a stage IV cancer, which has caused the cancer cells to spread to other parts of the
body. 8
Hypertension (HTN), also known as high blood pressure is when blood pressure levels exceed 120/80mmhg.
Damage to organs such as cardiac, peripheral, renal, or retinopathy organ systems can result when blood
pressure is too high. 1 HTN has maybe subcategories; prehypertension (120-139/80-89mmhg), Stage 1 HTN
(149-159/90-99mmhg) and Stage 2 HTN (149-159/90-99mmhg) and can be further categorized as primary
HTN (diet and genetic related) and secondary HTN (due to another disease). 1
Bilateral Pretibial Edema is fluid accumulation of the lower leg anterior to the shin (tibia)caused by local
cause or systemic disease such as heart failure or kidney disease. 6
Whipple procedure with laparoscopy is a common surgery to remove pancreatic cancer. This type of
procedure is performed on tumors in the head or neck of the pancreas not in the body or tail. Small
incisions are made in the abdominal wall and a long thin tube is inserted. This procedure can be performed
only on tumors that are not metastatic. Through this procedure the surgeon is able to reduce blood loss and
risk of infection compared to Whipple procedures that do not use Laparoscopic procedures. 9

Ht: 1.626m 5’4” Wt: 123lb UBW: 117 %UBW: 105% Wt changes: 6lb increase
𝐶𝑢𝑟𝑟𝑒𝑛𝑡 𝑊𝑒𝑖𝑔ℎ𝑡
Usual Weight %: 𝑈𝑠𝑢𝑎𝑙 𝑊𝑒𝑖𝑔ℎ𝑡
∗ 100
123
= 117 ∗ 100 = 105%
BMI and BMI classification
BMI calculation: kg/ m2
278 lbs/ 2.2 (kg/ lb) = 126kg
5 feet 8 inches = 68 inches* 2.54 (cm/ in) = 173 cm = 1.73m
50.8 kg / 1.524 m2 = 22→ Normal

History of Weight Changes (Include amount, period of time, voluntary or involuntary, % of original
weight)
Patient has had weight fluctuations since chemotherapy treatment starting in 2012. A.N. reports her weight
fluctuated depending on her appetite. When her appetite is low, she is unable to eat and looses weight. Before
chemotherapy treatment her weight was 145, her usual body weight upon start of treatment was between 130-
134. The last year her weight has been around 117lb with a lowest weight of 112lb. Her current weight
appears to be stable.
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

5 Nutritional Requirements:
kcal: Mifflin St Jeor X injury factor =

Energy needs=1500kcal
*1.3 injury factor is recommended for those who are malnourished. Since patient A.N. is moderately
malnourished, I increased injury factor to 1.4.
kcal/kg =
25-30kcal/kg=25-30kcal*56.2kg=1405-1686kcal
*Since patient is critically ill due to cancer in her pancreas and liver as well as malnutrition 25-30kcal/kg
was used. 1600kcal will be the calorie needs used for A.N. due to higher calorie needs.
Protein gm/kg =
1.5g/kg=1.5g x 56.2kg= 84g proteins
*Since patient is critically ill due to cancer in her pancreas and liver as well as malnutrition ranged of 1.2-
2g/kg for protein was used. Since patient is malnourished but is also petite, 1.5g/kg was used.
Fluid =
Method 4: (kg body wt- 20) x 15 + 1500=(56.2-20) x 15 + 1500=2,043ml
Method 1: 30ml/kg=30ml/kg x 56.2kg=1686 (rounding to nearest 100)= 1700ml free water
*Due to edema, I would restrict fluid needs therefore method 1 with 1700ml will be used for fluid needs.

5 Diet Order: (Current and others since admit in chronological order)

Cardiac; 2g Na (low sodium), low fat
(50g fat, low cholesterol, low saturated fat)

Assessment of appropriateness of current diet order

This diet is suitable because due to the patient’s edema she needs a sodium restricted diet and due to HTN
and low fat due to intolerance of fat resulting in diarrhea. Although patient needs higher protein and calories
due to malnutrition. If edema improves and patient is able to tolerate food with healthier fats (mono/poly
unsaturated fats) may consider to liberalize diet. Due to higher calorie/protein needs additional
supplementation (ensure/magic cup)
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

5 Labs: Explain relevant lab values

Name of Lab Test Normal Range Patients Value Date Interpretation

Platelet count 150-440 103 uL 104 103 uL 2/28/19 Low, due to

HGB 14 - 18 g/dL 8.4g/dL 2/28/19 Thrombocytopenia related to
HCT 42 – 52 % 25.9% 2/28/19 cancer in liver and pancreas

High, may present with

macrocytic anemia due to
compromised GI function
related to pancreatic and liver
cancer causing b12 and/or
MCH 33-36g/dL 32.2g/dL 2/28/19 folate deficiency. 1
4.7 – 6.1 2.61 (was 2.9 on
RBC cells/mcL 2/27) 2/28/19 Low, related to
Thrombocytopenia
WBC 5 – 10 k/cmm 8.1k/cmm 2/28/19 WNL

8.1mg/dL (8.5 on Low, absorption issues due to

Calcium 8.5-10.2mg/dL 2/27) 2/28/19 pancreatic cancer affecting
pancreatic function 1
3.0g/dL (3.5 on Low, related to low protein
Albumin 3.5-5.5g/dL 2/27) 2/28/19 intake due to compromised
appetite
BUN 10 - 20 mg/dL 15mg/dL 2/28/19 WNL

Creatinine 0.5 – 1.1 mg/dL 1.0mg/dL 2/28/19 WNL

136 – 145
Sodium mmol/L 140mmol/L 2/28/19 WNL,

WNL, was low when initially

admitted due to hypokalemia
3.6 mol/L(3.0 from pyelonephritis and
Potassium 3.5 – 5.0 mol/L 2/27) 2/28/19 improved due to antibiotic
treatment.
Glucose 70 - 100 mg/dL 80mg/dL 2/28/19 WNL

Chloride 98 – 106 mEq/L 103mE/L 2/28/19 WNL

CO2 27mEq/L 2/28/19 WNL

23 – 29 mEq/L
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

5 Meds, pertinent Drug/Nutrient Interaction Information related to admit dx and nutrition intervention
Source: Webmd

Drug/Generic
Name Purpose
CefTRIAXONE Antibiotics injection to fight
(ROCEPHIN) bacterial infections
Heparin (Porcine)
Injection Prevent and treat blood clots
Nadolol
(CORGARA) HTN, beta blocker
Contains digestive enzymes
to help break down and
digest food when pancreas
cannot make or does not
Pancrelipase release enough digestive
(CREON) enzymes to digest food
Side Effect Nutritional Concerns
Loss of appetite, nausea,
vomiting, upset stomach,
diarrhea, headache,
dizziness, overactive
reflexes, pain or swelling
to the tongue, sweating or
vaginal itch/discharge May interfere with lab tests such as urine
glucose test.
Mild pain/redness/irritation Can cause stomach bleeding which is
at injection site, bleeding increased if consuming alcohol. The
medication contains sodium.
Dizziness, drowsiness,
weakness, and cough, cold
hands and feet (reduces Avoid Alcohol or marijuana
blood flow) Medication may make it hard to control
blood sugars (if diabetic)
Diarrhea, abdominal
pain/cramps, or nausea, tell
doctor if experiencing
abdominal discomfort or
frequent/painful urination. Take by mouth with food.

For stomach and esophagus

problems (Acid reflux).
PANTOprazole Decreases the amount of acid Take by mouth with or without food.
(PROTONIX) the stomach makes Headache or diarrhea Possible b12 deficiency if taken for 3 years
or more.
Potassium Chloride Treat low amounts of Upset stomach, nausea,
(KLOR_CON Mio) potassium in the blood vomiting, gas or diarrhea Mix with a glass of cold water or juice to
reduce stomach upset.
5 Nutrition Focused Physical Findings: (physical appearance, muscle and fat wasting, swallow function,
appetite)
Alert and oriented, able to converse and relay details. Frail elderly woman, appetite has been fluctuating due
to cancer of the pancreas and liver. Skin looks clean, dry and no rash. Hair is thin and frail due to
chemotherapy treatment. Having upper abdominal pain, no pain in lower abdomen area. Classified with
moderate malnutrition due to level of fat loss assessed. Bilateral pretibial edema present. Teeth intact, no
issues chewing or swallowing.
Malnutrition Assessment performed:

 Subcutaneous fat: Mild in orbital region, midaxillary line at the crest/ribs and cheek region, moderate
in upper arm region
 Muscle wasting: Moderate in temple region, clavicle region, moderate in shoulder/Acromion
process/clavicle region, and hand region, mild in scapula region.
 Fluid accumulation- Bilateral Pretibial Edema
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

5 Pertinent Social Hx: (education, occupation, social economic status, ethnic or religious influence,
psychological background) Focus on factors that affect eating habits, ability to procure, store, and prepare
food.
A.N. came to America in 2012 from Nigeria where she worked as a home economics teacher with a focus
in nutrition. She has 10 children and 21 grandchildren. She currently lives with her daughter, an RN who
she is close with. Her daughter does most of the shopping but A.N. reports she cooks her own food. Her
and her daughter often eat meals together. A.N. is health contentious, she eats lots of vegetables and tries to
diversify her diet. Patient has been battling cancer since 2012. She enjoys knitting hats, scarfs, jackets and
sweaters for family, friends and especially young children.

5 Nutrition History, Diet PTA (include medication/herbal/vitamin supplement intake, knowledge of diet, food
beliefs, and physical activity)
Patient A.N. eats mostly a Nigerian cuisine with foods such as cassava, plantains, suya, porridge and soups
like Eddoe and Ndole. She loves soup, especially porridge (plantains with fish). She eats a variety of
vegetables (carrots, spinach, broccoli, green beans, potatoes), chicken, fish, eggs, fruits, rice and beans,
yogurt, oatmeal. She avoids high fat foods due to GI dysfunction from pancreatic cancer. At home patient
reports having clear ensure supplements in addition to her meals. Her appetite typically has been good at
home. Patient is ambulatory and moves around as best as she can throughout the day. Patient is aware of her
higher calorie needs, inquired how to accomplish this for meals/snacks.

5 Summary of Current Intake (Nutritional Adequacy of the patient’s most recent nutrient intake via 24 hour
recall or intake documented from oral, tube feeding, IV. Intake information may be obtained from the patient,
family, diet order, or nursing notes. Please assess the adequacy of intake in terms of protein, carbohydrate,
fat, calorie, vitamins, minerals, fluids, as it pertains to your patient.)

Patient reports reduced intake days before admission but appetite is good now. A.N. has not consumed
ensure while in hospital but typically does at home. Patient is on a low sodium (2g Na), low fat (50g), low
saturated fat, low cholesterol diet. Current diet order meets patient’s needs but additional supplementation
may be beneficial to help meet higher calorie needs. Patient A.N. has been eating lots of lean meats, fruits
ad vegetables while in the hospital. No 24-hour recall was taken.

5 D (Diagnosis) PES, Nutritional Problem/Diagnosis Related To Etiology As evidenced By Signs/Symptoms

Inadequate oral intake (NC-2.1) related to pancreatic and liver cancer and Whipple procedure with
laparoscopy as evidenced by poor appetite, moderate muscle wasting, mild subcutaneous fat loss, bilateral
pretibial edema

15 I (Intervention) Stems from Nutritional Diagnosis and Etiology and must determine patient-focused
expected outcomes for each nutrition diagnosis
 Food and/or Nutrient Delivery (meals, snacks, enteral and/or parenteral feeding; supplements – as in
commercial, food/drink based, or vitamin/mineral)
 Nutrition Education (purpose; priority modifications; survival info; nutrition relationship to health and
disease; recommended modifications)
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

 Coordination of Nutrition Care (team meeting; referral to RD with different expertise; collaboration
with other providers; referral to community agencies or programs)

Food and/or Nutrient Delivery:

-Continue Ensure high protein 2x/day or Magic Cup
-High calorie and protein meals/snacks due to higher calorie needs
Nutrition Education:
 Educate patient on how to increase calorie/protein intake at meals and snacks (Avocado if tolerated
with toast, peanut butter if tolerated with apples, nuts if tolerated with dates)
 Educated patient on increased protein modifications such as Banza chickpea pasta with 28g
protein/serving
 Discussed about supplement options other than ensure such as magic cup

*Patient is aware she needs to increase her calories/protein and is aware of her fluctuating appetite affecting
her intake and the related concerns. Patient desired education on how to accomplish this.

Coordination of Nutrition Care:

 Referral to RD specialized in oncology

 Communicate with primary Dr. managing A.N.’s chronic conditions

10 M/E (Monitoring and Evaluation) Nutrition care indicators that will reflect a change in nutrition care
provided
 Food/Nutrition Related Outcomes (Food intake, supplement use)
 Anthropometric Measurement Outcomes (Ht, Wt, BMI)
 Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes, gastric
emptying)
 Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat wasting, swallow
function, appetite)
 Nutrition Education Outcomes Knowledge based, “pt able to state 3 prepared foods high in Na”

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

 Patient will meet at least 75% of needs
 Monitor patient’s fat tolerance (especially with unsaturated fats & Omega 3’s)
 Monitor patients supplement intake (ensure/magic cup)
 Monitor fluid intake
 Monitor nutrition prescription
Anthropometric Measurement Outcomes (Ht, Wt, BMI)
 Patient will continue to maintain current weight of 123lb
 Monitor weight trends
Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes, gastric emptying)
 Monitor platelet count, HCT, HGB, RBC blood values (related to anemia and Thrombocytopenia)
 Monitor calcium blood values
 Maintain Potassium blood levels within normal range
 Monitor Albumin blood values
 Monitor urination frequency and stool consistency
 Continue to monitor pancrelipase
Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat wasting, swallow
function, appetite)
 Monitor fluid accumulation (bilateral pretibial edema)
 Monitor appetite
 Monitor abdominal pain
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

Nutrition Education Outcomes

 Patient will be able to state high calorie protein meals/snacks
 Patient will increase high calorie/protein foods during meals and snacks
Meal Plan
5 1. For current Dx explain: Foods Allowed, Foods Not Allowed, Diet Instruction Materials if
appropriate. Describe in your own words the rationale for diet restrictions/modifications

Allowed to have all foods (especially vegetables and fruits) except those that are high in sodium or fat.
Patient must limit foods with added salt or sodium rich foods. Incorporate ensure or magic cup 2x/day.

2. Menu Plan or Nutrition Support Regimen for Discharge “Diet “Must be of your own design.
Include pertinent nutrient analysis; calories, macronutrients, fluid, pertinent vitamin/minerals.
10 Nutrient analysis may be computed with Nutribase, ADA exchanges, Supertracker.

Breakfast
 ½ cup cooked oatmeal with 1/4 cup fat free milk and ½ tbsp sugar
-104.5kcal | 3g Protein | 21.5g Carbohydrates | 1g fat
 1 cup fresh berries
-60kcal | 15g Carbohydrates
 1 hard-boiled egg
-75kcal | 7g Protein | 5g fat
Total Calories: 239.5kcal | 10g Protein | 36.5g Carbohydrates | 6g fat
Snack
 Ensure high protein 10
-160kcal | 16g Protein | 19g Carbohydrates | 2g fat
 1 small banana
-60kcal | 15g Carbohydrates
Total Calories: 220kcal | 16g Protein | 34g Carbohydrates | 2g fat

Lunch
 1 cup porridge with 1/3 cup plantain and 4oz tilapia
-340kcal | 34g Protein | 30g Carbohydrates | 10g fat
 1 Orange
-60kcal | 15g Carbohydrates
Total Calories: 400kcal | 34g Protein | 45g Carbohydrates | 10g fat

Snack
 1 small apple
-60kcal | 15g Carbohydrates
 1 tbsp peanut butter
-100kcal | 7g Protein | 8g fat
Total Calories: 160kcal | 7g Protein | 15g Carbohydrates | 8g fat

Dinner
 1 suya (spicy grilled beef kebab) 11
-102kcal | 12g Protein | 5g fat
 ½ cup Rice and ½ cup pinto beans
-160kcal | 6g Protein | 30g Carbohydrates | 2g fat
 ½ cup sautéed collard greens
-25kcal | 2g Protein | 5g Carbohydrates
 Vanilla Magic cup 12
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

-290kcal | 9g Protein | 38g Carbohydrates | 11g fat

Total Calories: 577kcal | 29g Protein | 73g Carbohydrates | 18g fat

TOTAL FOR ALL MEALS: 1596kcal | 96g Protein | 203.5g Carbohydrates | 44g fat

*Calories were 4kcal below calculated needs of 1600kcal. Protein was 12g above calculated needs of 84g,
due to patient’s higher protein/calorie needs this is suitable. 6g below diet restriction of 50g fat. Higher
protein/calorie foods were incorporated with patient’s traditional Nigerian foods. 2 supplements were
used, ensure as apart of a snack and magic cup as a higher calorie/protein dessert.
5 References
1. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's
Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier/Saunders, 2012.
2. Kidney Infection (Pyelonephritis). National Institute of Diabetes and Digestive Kidney Disease.
https://www.niddk.nih.gov/health-information/urologic-diseases/kidney-infection-pyelonephritis.
Accessed March 2, 2019.
3. Hydronephrosis. National Kidney Foundation.
https://www.kidney.org/atoz/content/hydronephrosis. Accessed March 2, 2019.
4. Thrombocytopenia (low platelet count). Mayo Clinic. https://www.mayoclinic.org/diseases-
conditions/thrombocytopenia/symptoms-causes/syc-20378293 Accessed March 2, 2019.
5. What Causes Transaminitis? Healthline. https://www.healthline.com/health/transaminitis.
Accessed March 2, 2019.
6. Pretibial Edema. The Free Dictionary. https://medical-
dictionary.thefreedictionary.com/pretibial+edema. Accessed March 2, 2019.
7. Pancreatic Neuroendocrine Tumors. Pancreatic Cancer Action Network.
https://www.pancan.org/facing-pancreatic-cancer/about-pancreatic-cancer/types-of-pancreatic-
cancer/endocrine-pancreatic-neuroendocrine-tumors/. Accessed March 2, 2019.
8. Neuroendocrine Tumors. Cancer Treatment Centers of America.
https://www.cancercenter.com/cancer-types/neuroendocrine-tumors. Accessed March 2, 2019.
9. Whipple Procedure. The National Pancreas Foundation. https://pancreasfoundation.org/patient-
information/pancreatic-cancer/treatment-of-pancreatic-cancer/whipple-procedure/. Accessed
March 2, 2019.
10. Ensure High Protein Vanilla. Ensure. https://ensure.com/nutrition-products/ensure-high-
protein/vanilla-shake. Accessed March 6, 2019.
11. Suya (Spicy grilled kebab). Immaculate bites. https://www.africanbites.com/suyaspicy-grilled-
kebab/. Accessed March 6, 2019.
12. Magic Cup Vanilla. Hormel Health Labs. http://www.hormelhealthlabs.com/magic-cup-vanilla-48-
4oz. Accessed March 6, 2019.
100 Total
2019 UCONN ADIME #2 Student Name _Carley Bedell__ Pt initials __A.N.______

updated.1.16.2018 jw