Cystic Fibrosis Complete ADIME AND SOAP note - – GRADED CASE RC (Rob) is a 15 year, 3 month old male admitted to the hospital for worsening pulmonary function & weight loss. He lives with parents and 3 siblings - mom prepares food at home. Medical Dx. is CF in exacerbation. His Height: 160 cm. Admission weight 40 kg. On his previous visit to the clinic 3 months ago, his weight was 44 kg. At 12 years old, his height was 144 cm., at 11 years old, his height was 139 cm. and at 10 years old his height was 134 cm. He tells you that he used to be a swimmer and would like to return to competition. He swims 1 mile daily even though he has to take rests. Rob is allergic to soy protein. Diet order: High Calorie, High Protein, High Salt, High Fat. During hospital stay, calorie counts show that pt. is consuming an average of 1800 calories per day RC has moderate lung disease, as evidenced by his FEV1 of 70%. Ideal BMI is >50th%. (BMI >50th% relates to decreased mortality for individuals with Cystic Fibrosis). As he has grown older, the symptoms have become more severe, with respiratory tract infections occurring regularly. Medications include bronchodilators, corticosteroids, Dnase to improve flow of lung secretions and frequent antibiotics. He wears an oscillating vest for 20 minutes/ day to loosen his lung secretions. His physicians want to prevent bronchiectasis, and pneumonia from bacterial infections. Determination of Energy, Protein and Fluid Requirements: Pediatrics, Syllabus, page 20. Page Finish this part~ 1 RC reports to you that when he has respiratory distress, he feels tired and listless and eats less. When you interview him about his diet he reports to you the following: to help with digestion of his food, Rob takes pancreatic enzyme replacements (Zenpep). He also takes a specialized vitamin preparation (AquADEK). Steatorrhea is not a problem as long as he takes his enzymes. But since he has been in high school with a larger campus, he forgets to carry his enzymes with him. He states that he has a poor appetite. RC reports that he drinks Chocolate Boost when his parents can afford to buy it. RC’s 24-hour recall: Breakfast: 12 ounces orange juice and a granola bar Lunch: Hamburger and medium fries with 16 ounces soda PM snack: 2 brownies and a glass of whole milk Dinner: 1 small pork chop, 1 cup rice with gravy, a raw carrot and 12 ounces soda Snack: 2 medium pizza slices Total Fluid Needs: Use Holliday-Segar Method Total Energy Needs: Using the Schofield Equation, determine BMR, then multiply by 1.2 for Cystic Fibrosis w/ (PI). Using that disease-adjusted BMR, then multiply by hospital based activity factor. Finally, add 500 calories for weight gain. Show all work Protein: (Pedi formula in Syllabus), then multiply by 1.8. Protein g. should be ~15 % of total calories- adjust upwards if necessary. Medications in hospital are the same as at home plus the addition of Ciprofloxin and rapid-acting insulin injections with every meal and snack. Laboratory Values: CRP 16 210 Retinol Binding Protein 1.4 Vitamin E: .2 Vitamin A: Vitamin D: 16 ng/dl FBG: 10 FOR THIS CASE, YOUR NOTE WILL BE A FOLLOW-UP NOTE. You saw RC when he was first admitted and you have continued to follow his progress. On day 12 of his hospitalization, you re-assess. You find that the patient’s average oral intake is 1800 calories and 40 grams protein per day. He has lost 2 more kg. in the hospital. In addition, his FBG is now 210 and his 2 hr. post-prandial glucose is 250. The patient is started on insulin. One of your recommendations will be for overnight nasogastric tube feedings to supplement his caloric intake. His formula will be Promote, a high protein, polymeric formula. Promote contains 1 calorie per ml or 1000 calories per liter, and 62 grams protein per liter. The tube feedings will run from 1 AM to 9 AM (he is a teenager!) Determine how many calories he is eating, compare to his energy requirements during his hospital stay and plan to provide the remainder from tube feedings. Begin at half the necessary amount and increase over 3 days to reach goal. Formula rate is expressed as ________ml per hour. Also: do not forget this part also!!! TOTAL ENERGY EXPENDITURE Page Pediatrics, syllabus, page 20 2 In paragraph form, explain why CRP is relevant in CF. Also, explain relationship between inflammation and RBP as well as how RBP relates to Vit A. How does the need for very high calories influence protein requirements? Are you worried that the protein estimate is too high? Why or why not? TEE= Result of Harris Benedict Equation OR Mifllin St Jeor Equation X Activity OR Injury Factor SAMPLE ACTIVITY FACTORS: FACTOR Confined to bed 1.2 Out of bed, low activity 1.2-1.3 Average activity 1.5-1.75 2.0 Determining Fluid Needs Fluid needs may be restricted or increased as a result of a person’s disease, condition, activity level, or existence in extremes of temperature SAMPLE INJURY FACTORS: INJURY TYPE FACTOR Burns: 40%BSA 1.8-2.0 Cancer 1.1-1.7 Major Surgery 1.1-1.3 Moderate Infection 1.2-1.4 Multiple trauma with patient on ventilator 1.5-1.7 Severe Infection 1.4-1.8 Skeletal Trauma 1.2-1.4 Skeletal or head trauma (steroid treated) 1.6-1.8 Wound healing 1.2-1.6 USING CALORIC REQUIREMENTS Fluid Needs= 1 ml of fluid for every calorie intake. This is for minimal needs only. Use chart below. USING BODY WEIGHT Fluid Needs = kg body weight X fluid factor > 75 yo or inactive 25ml X kg body wt 55-75 yo or moderately active 30ml X kg body wt 20-55 yo or moderately active 35ml X kg body wt 16-30 yo or highly active 40ml X kg body wt The Holliday Segar Method For Adults over 20kg 20 ml/kg for each kg >20 + 1500mL 3 Highly active Page ACTIVITY LEVEL ADIME Form- In-patient Date: Time: Age: Sex: NUTRITION ASSESSMENT Chief Complaint: Adm. Diagnosis: PMH: Current Labs (denote high with + and low with – after the number). Medications/Treatments. Interpret laboratory values, based on the case patient include reasons for all, based on the case patient ANTHROPOMETRICS Ht: Admit Wt: or Current Wt: Estimated Dry Wt. Pediatrics: or IBW: % IBW: UBW: % UBW: Recent Wt. Hx: Wt. % BMI: BMI Class (adults only) UBW % Ht. or length % BMI % Weight for length% Pediatrics: z-scores Patient/Family Interview Notes: Intake/Digestive Problems  NPO ______days Physical & Mental Status  Hearing Impaired  Diarrhea  Anorexia  Constipation  Chewing Problem  Nausea/Vomiting  Poor Dentition Food Intolerance  Swallowing Problem _______________  Aspiration Precautions  Food Allergy  Assist w/ Meals ________________  Limited Vision  Dementia  Language Barrier  Mental Status Changes  ETOH/Drugs  N/A Metabolic Stressors Access  PO  Post-op/Surgery  NJT  Fever/Infection  NGT  Wounds  JT  NJT  Trauma/Fracture  GT  Sepsis  Other_______________  PIV PHYSICAL ASSESSMENT Notes on Visual Physical Assessment: examples: thin, dry hair, visibly low subcutaneous fat  Adequately Nourished  Obese  At risk for malnutrition  Malnourished ESTIMATED NUTRITON NEEDS & INTAKE ASSESSMENT Quantified Intake PTA or in hospital (Usual Intake, Calorie Count, and/or results from Intake Analysis): 4 Current Diet Order/Nutrition Support: Estimated Nutrition Needs Page Special Diet PTA: BMR________ Maintenance kcal__________ Protein(g) Fluid(ml) _______ _______ Disease or stress factor______ Calories added or subtracted for weight gain/ loss_________ Activity factor______ Total kcal:_______ Method used:_________________________ NUTRITION DIAGNOSTIC STATEMENTS (PES)1 2. GOALS 1. PO intake will increase to 50-75% of meals/supplements consistently within days. 2. 3. INTERVENTIONS/RECOMMENDATIONS 1. 2. 3. 4. 5. MONITORING AND EVALUATION:  I&0 Form  Laboratory values__________________________________________________________________________ __________________________________________________________________________________________________________  Calorie Count X ______ days  Patient Meal Rounds  RD participation in Patient Care Team Rounds Page 5  Review changes in clinical status & discuss pt. progress with team including: _____________________________________________ _____________________________________________________________________________________________________________  Other: _____________________________________________________________________________________________________ RD f/u in _______days to further evaluate ______________________________________________________ Signature and Credentials: Date: SOAP Format S: Type in succinct sentences. What the patient or family tells you. Example: Pt. reports weight loss of 10 # over 3 weeks. She c/o nausea and vomiting. Type information about food intake or 24 hour recall here. O: Diagnosis(es), PMH Medications: Diet Order Results of tests or procedures Lab Values: All anthropometrics Estimated Nutrient, Protein and Fluid Needs: A: 1. PES statements: 6 2. Page  Follow-Up: P: Combination of same information that would be in the Intervention, Monitoring and Evaluation sections on ADIME Form. You can write one intervention or multiple interventions. 1. 2. Page 7 3., etc.
Purchase answer to see full attachment