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1. finish the ADIME form and SOAP note.2. Look at the document that I uploaded.3. For the Pediatrics, Syllabus, page 20, I already put it into the document.
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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: <0-20%BSA 1.2-1.5 Burns: 20-40%BSA 1.5-1.8 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.

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