DIET4030 Crohn's Dz Case Study ADIME IP form

ADIME Form Inpatient Patient Name: Shawn Callahan DOB: 10/18/1978 Date: 03/31/2024 Time: 14:30 Age: 45 Sex: M NUTRITION A SSESSMENT Adm Dx: Severe exacerbation of Crohn’s Dz, Mild dehydration PMH: IBD: Crohn’s Dz, 4 small bowel resections Current Labs (w/ assessment): BMP BUN High: Indicates possible kidney dysfunction or dehydration, possibly caused by loss of fluids in diarrhea. BMP Glucose High: Possible insulin resistance or diabetes. Serum Potassium Low: Hypokalemia, possibly due to diarrhea and malabsorption as a result of Crohn’s. Serum Sodium High: Could be result of dehydration or diarrhea leading to loss of fluids. Low Hemoglobin and Hematocrit: Indicative of anemia, possibly chronic, possibly due to blood loss from intestinal inflammation/diarrheal loss or not meeting nutritional needs. High RBC count: Possibly a response from the body to the anemia and could be indicative of dehydration. High Segmented neutrophils: High WBC, indicative of inflammation in the body, most likely in the GI tract. Low Lymphocytes: Most likely due to nutritional deficiencies and can be a sign of high risk of infection. Medications (w/ assessment): Ciproflaxin: An antibiotic used to treat bacterial infections, including those that affect the GI tract. Side effects may include nausea, diarrhea, and bone pain. Metronidazole: An antibiotic used to treat infections by attacking certain bacteria that does need oxygen to survive and protozoa bacteria. Side effects may include dizziness, stomach upset, nausea, vomiting, loss of appetite, and diarrhea. Morphine sulfate: A narcotic analgesic that is used to manage moderate to severe pain. Side effects may include constipation, nausea or vomiting, drowsiness, dizziness, loss of appetite, and fainting. Methylprednisolone Acetate: A corticosteroid that is used to reduce inflammation and can be used to manage flares of Crohn’s dz. Side effects include weight gain, mood changes, vision problems, bleeding, increased hunger and dizziness. ANTHROPOMETRICS Ht/Lt: 68 in IBW: 154 % IBW: 107.1% Adm Wt: 165 lbs (74.8 kg) UBW: 175 lbs % UBW: 94.3% Current Wt: 165 lbs AIBW: N/A BMI: 25.1 Class: Overweight Est. Dry Wt: N/A Recent Wt. Hx: Lost 10 lbs over past 2 wks Patient interview Notes: Pt reports symptoms of fatigue, persistent diarrhea, joint pain and swelling, nausea, anorexia, abdominal cramps and pain, frequent bowel movements, and sensations of incomplete evacuation. Pt reported a “7” on the pain scale; experiencing severe abdominal pain. Stated that father and paternal grandmother were known to have nervous stomachs. See intake PTA for statements regarding food and fluid intake. Denies recent international travel, consumption of undercooked or raw foods, or recent antibiotics use for an unrelated illness. Denies constipation, dizziness, loss of consciousness, chest pain, acute weakness, vomiting, or fever. Intake/Digestive Problems Physical & Mental Status Metabolic Stressors Access  NPO x 1 day  Diarrhea  Constipation  Nausea  Vomiting  Food Allergy/Intol:  ETOH/Drugs  Anorexia  Chewing Problem  Poor Dentition  Swallowing Problem  Aspiration Precautions  Assist w/ Meals  Hearing Impaired  Limited Vision  Dementia  Language Barrier  Mental Status Changes  N/A  Post-op/Surgery  Fever/Infection  Wounds  Trauma/Fracture  Sepsis  Other:  PO  NGT  NJT  OGT  GT  JT  GJT  PEG  HICKMAN  CVL  PORTACATH  PIV  PICC PHYSICAL ASSESSMENT Notes on Physical Assessment: Abnormal sunken eyes. Abnormal dry mucous membranes. Abnormal reduced skin turgor. Respiratory rate abnormal: increased. Heart rate abnormal: increased. Bowel sounds abnormal: hyperactive. Abnormal tender abdomen. Abnormal diarrhea x 12 per day. Abnormal appetite: cannot eat without abdominal pain. Abnormal activity: cannot do regular daily activities due to diarrhea and pain. Rest of categories WNL.  Adequately Nourished  Obese  At risk for malnutrition  Malnourished ESTIMATED NUTRITON NEEDS & INTAKE ASSESSMENT Intake PTA (Usual Intake, Calorie Count, and/or results from Intake Analysis): Decreased intake for past 2 wks. Tolerance of