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Running Head: ADIME NOTE #1

ADIME Note #1
Catherine Veliz
NTRS 415B
California State University Los Angeles

ADIME NOTE #1

4/27/15 12:45 p.m.

Assessment: Patient was admitted to the hospital with myocardial infarction after
complaints of chest pain. The patient currently resides with her daughter and her family.
TWs daughter prepares all meals for her mother, however, she has not been educated on
the renal diet her mother has been prescribed. Patient explains that she follows a renal
diet at home. The patient states that she doesnt consume bananas, oranges, tomatoes, or
potatoes because they contain too much potassium. The nurse working with TW has
observed that the patient is consuming about 60% of her daily meals.
69 y/o Female; HT: 58; WT: 163#; UBW: 156#; %UBW: 104%; IBW: 140#; %IBW:
116%; BMI: 24.5 (Normal Body weight)
Labs: K+: 5.8mg/dL; BUN: 108ml/dL; Cr: 10.8mg/dL; Hgb: 11.0 mg/dL; Hct: 26; Phos:
6.5 mg/dL; Alb: 2.5 mg/dL; Mg: 3.2mg/dL; Chol: 272 mg/dL; RBG: 186 mg/dL
Medications: Bumes, Phos-lo, Epogen, Nephrovite, Glipzide, Zocor,
Physical Assessment: Edema in lower extremities.
EER: 2127 Kcal/ day 2482 Kcal/ day (Bases on 30-35 Kcal/kg); EPR: 85 g/day (based
on 1.2 g/Kg); Fluids: 1 L/day
Current Diet: Renal Diabetic Diet
Diagnosis:
Undesirable food choices related to Food and nutrition-related knowledge deficit
evidenced by high cholesterol of 272 mg/dL.
Inadequate energy intake related to poor appetite as evidenced by consumption of 60% of
meals per nursing notes.
Excessive potassium intake related to nutrient knowledge deficit as evidenced by high
potassium levels of 5.8 mg/dL.
Intervention:
1. Patient was prescribed a Renal Diabetic Diet by the doctor; patient should
continue to follow this diet.
2. Recommend that patient consume 2127 Kcal/ day 2482 Kcal/ day to ensure
adequate needs are being met and to prevent unintended weight loss.
3. Recommend eating six small meals throughout the day, and to refrain from
skipping meals.

ADIME NOTE #1

4. Recommend increasing protein intake to 85 grams per day to help restore albumin
to normal levels. (Based on 1.2g/Kg)
5. Recommend patient limits cholesterol intake to 200 mg/day, to assist in lowering
cholesterol levels.
6. Recommend patient limits Potassium intake to 2836 mg/day (based on 40 mg/Kg
SBW)
7. Give patient and daughter a tip sheet on foods that contain high levels of
potassium to limit consumption.
8. Recommend a class for patients daughter on how to prepare foods for a renal
diet.
9. Recommend a fluid restriction of 1 Liter/ day.
Monitoring/Evaluation:
1. Patient will continue to follow the Renal Diabetic diet as prescribed by the doctor.
2. Patient will eat six small frequent meals a day, consuming 2127 Kcal/day 2482
Kcal/day.
3. Patient will increase protein intake to 85 g/day, which will be monitored through
evaluation of albumin levels.
4. Patient will decrease cholesterol consumption to 200mg/day, which will be
monitored by evaluation of cholesterol levels.
5. Patient will limit potassium intake to 2836 mg/day, which will be monitored by
evaluation of potassium levels.
6. Patient will limit fluids to 1 Liter/day.
7. Patient will follow up with and are RD to monitor the success of the diet plan.
Lab values will be taken to measure patient progress.
Catherine Veliz