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ADIME Note- Jacqueline Swarbrick

A: Age: 64
Height: 5’8”
Weight: 118 (one month ago)
BMI: 17.9 - underweight
IBW: 148
%of IBW: 80%
B: Co2 51- High
HCO3 34- high
Ph 7.36- normal
CI 94mmol/L- Low
MCV 104.2fL- high
Alb 2.2 g/dL- low
Assessment (pertinent Prealb 8.1 mg/dL- low
subjective and objective Creatinine .3mg/d- low
measures) C: Pale in color, smoker, outline of bones in
shoulders.
Medications: Oxygen 3.0 liters, Theodur
100mg ID, Maxide 50 mg QD, Prednisone
10 mg QD, multivitamin, ventolin inhaler 4
puffs QID and prn, ASA ½ QD, and
Metamucil
D: Kcal: 54 x 30 = 1609kcal/day
Protein: 54 x 1.3 = 70.2g/day
Fluid: 118/2 = 59 ounces/day
30-45% of diet should be fats
F: Uses dentures, Cannot walk or stand for
much time, weak.
Acute disease malnutrition related to
fully compensated metabolic alkalosis as
evident by HCO3 of 34, Co2 of 51 and pH
Diagnosis [PES statement(s)] of 7.36
Inadequate oral intake related to
pulmonary cachexia as evident by weight
loss andBMI of 17.9.
Tests: Have more tests to check for ARDS and
macrocytic anemia.
Dietary: Kcal: 54 x 30 = 1609kcal/day
Intervention(s) (nutrition
Protein: 54 x 1.3 = 70.2g/day
prescription, treatments, Fluid: 118/2 = 59 ounces/day
education, request tests) 30-45% of diet should be fats
Education: Talk with him about having easy food to
eat, as well to keep foods next to his
bed or chair, such as ensure.
Dietary: Check for weight gain and strength.
Monitoring and Evaluation
Labs: Check HCO3 , Co2, Alb, and MCV levels.