ADIME Progress Note- Template Only
Name: Jesse Terris
Disease State: Malnutrition
Name/Date/Time: 1/20/2022
Consultation For: Malnutrition consulted from PA from nutrition screen
NUTRITION MONITORING AND EVALUATION
Monitoring and Evaluation Indicators and status: Consult
45.1 kg (99lbs)
Weight: BMI: 13.48
IBW: 80.9 kg
(56%)
Height 6’ (72 inches, 182cm, 1.82m)
Estimated Energy Needs: 1555-1680+ (30-35kcal/kg)
Estimated Protein Needs: 54-68g (1.2-1.5 g/kg)
Estimated Fluid Needs: 1680mL
Food/Nutrition-Related History Anthropometric Measures
Pt has been vomiting after consuming foods but is The patient is a 6’ male who weighs 99 lbs. He has a BMI of
able to hold down some liquids. 13.48. In the last 2 weeks he has lost 15 lbs (13.2%) which is
significant.
Biochemical Data, Medical Tests and Procedures Nutrition-Focused Physical Findings
Currently his Na is 157, which is high. Subcutaneous fat loss: Muscle wasting:
BUN/Creatinine 71/1.99, high. An EGD is planned Orbital: severe Temple: severe
today at 1500. Triceps: severe Clavicle: severe
jf Shoulder: severe
k Interosseous: severe
Nutrition Assessment, Monitoring
Client History Comparative Standards
and Evaluation Tools
History of hypertension Nutrition focused physical exam 30-35+ kcal/kg
1.2-1.5 gm pro/kg
NUTRITION DIAGNOSIS
PES Statement(s) Severe malnutrition in the context of chronic illness related to
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Problem, Etiology, Signs inadequate oral intake as evidenced by weight loss 13.2% x 2
and Symptoms weeks, likely intake meeting <75% estimated needs >1 month,
and severe fat and muscle loss in all regions assessed above.
NUTRITION INTERVENTION
Nutrition Prescription Energy needs: 1555-1680+ kcal
Protein need: 54-68 gm protein
Aims/Goals (SMART) Increase PO and gain 0.5 to 1 lb a week to get patient back at a
healthy weight.
Detail of Intervention/Plan Patient is currently NPO, diet advancement per GI
Once diet is advance trial Chocolate Ensure Enlive TID.
NUTRITION MONITORING AND EVALUATION
Tick all that apply Food/Nutrient/Energy Nutrition Assessment/Monitoring and Evaluation
Tools
Anthropometrics
Labs (specify)
Behavior or
Knowledge/Beliefs/Attitudes
Specific Indicators, The patient is classified as high therefore he will be seen within the next 3 days. Patient has
Criteria and Time altered mental status right now, but at follow up I will try to obtain more background
frame information.
What will you assess
during follow-up
consultations?
Also Complete a Narrative ADIME Note for the same patient with the following Format:
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Nutrition Assessment:
The patient is a 76-year-old male who lives alone. He has a history of hypertension, and was brought to the hospital for
weakness, persistent vomiting, poor appetite, and weight loss. Patient reports eating poorly for at least the last 3 weeks.
In the last two weeks he has lost 15 lb (13%) significant. GI has been consulted for odynophagia and vomiting. An EGD is
scheduled today at 1500. Patient is receiving D5 at 125 ml/hr which provides 510 kcal.
Nutrition Diagnosis:
Severe malnutrition in the context of chronic illness related to inadequate oral intake as evidenced by weight loss 13.2%
x 2 weeks, likely intake meeting <75% estimated needs >1-month, severe fat loss and muscle loss in all regions assessed
above.
Nutrition Intervention:
Advance diet per GI findings. Once diet is advanced trial Chocolate Ensure Enlive TID. Once plan of care is better known,
will follow up for any education needs.
Nutrition Monitoring/Evaluation:
Once diet is advanced monitor daily intake of meals and supplements. Daily weights should also be monitored. Will
continue to monitor labs and medical tests as well.
Modified from Nutrition Care Professionals; Updated 1/1/2022
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