at History (CH) Domain .1.1 .1.3 .1.6 Age: 60 Sex: male Language: English 1.1.10 Tobacco use: 42 year tobacco use, 2 packs cigarettes daily, discontinued cigarette use two years ago 2.1.1 Client nutr-related hx: poor appetite since a few days prior to admission 2.1.1.13 Respiratory Disease Hx: acute bronchitis (primary), COPD exacerbation, COPD hropometric Measurements (AD) Domain 1.1.1.7 Stated Ht: 1.1.2.1 Measured Wt: 5' 6" 66" 1.68 m 145 lbs = 66 kg 1.1.2.5 Usual stated body wt: 142 to 147 lbs 1.1.5.1 BMI: 1-Nutrition Intervention - Interns, for your Intervention goals: 23.4, appropriate wt for ht • Assume the Pt is on a pre-select diet that provides 2000 to 2200 kcal and 75 to 85 grams of protein daily • The available supplement is Ensure Plus. Research kcal and gm protein for an 8-oz container (240 mL or 237 mL). ⚫ For your goals, estimate that the Pt will drink on average of 75% of two Ensure Plus daily; in other words, he will average about 1.5 Ensure Plus daily. • How many kcal and gm protein will he consume from the Ensure (1.5 cans daily)? You need to put this in your ADIME note-something like: "Goal intake of Ensure Plus is 75% of two bottles daily which will provide_ and gm protein". kcal To meet 100% of estimated needs with food and the Ensure, what is your goal for his food intake - in other words, if he drinks 1.5 Ensure Plus daily, what percentage of his meals will he need to eat to meet 100% of comparative standards? You need to chart the goal intake -something like: "Goal intake of meals is %" INTERNS – Use eNCPT codes and data descriptors for Interventions. Identify goals: CG- Implement Interventions: Admission: Mon 2/1 Today is wed 2/3 Referred to RDN from RN shift assessment: poor appetite Med Hx: 60 YOM acute bronchitis, COPD exacerbation, hx of 42 year tobacco use, 2 packs cigarettes daily, discontinued cigarette use 2 years ago Anthropometrics: Ht: 5'10" Integument: skin is intact Oxygen: 4 L via nasal canula. Labs: WNL Wt: 171 lbs Meds: NS at 75 mL/hr, IV levaquin, albuterol inhaler Patient #7: Brock O'Lee; DOB 1/20/19** Diet: Regular Oral Intake: Food: 43% average for 6 meals, ranging from 10% to 50% Fluid: 2/2: 1200 mL Chief Nutrition Problem

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Intervention goals and intervention (separate them please) as a RDN for pt
at History (CH) Domain
.1.1
.1.3
.1.6
Age: 60
Sex: male
Language: English
1.1.10 Tobacco use: 42 year tobacco use, 2 packs cigarettes daily,
discontinued cigarette use two years ago
2.1.1
Client nutr-related hx:
poor appetite since a few days prior to admission
2.1.1.13 Respiratory Disease Hx: acute bronchitis (primary), COPD exacerbation, COPD
hropometric Measurements (AD) Domain
1.1.1.7 Stated Ht:
1.1.2.1 Measured Wt:
5' 6" 66" 1.68 m
145 lbs = 66 kg
1.1.2.5 Usual stated body wt: 142 to 147 lbs
1.1.5.1 BMI:
1-Nutrition Intervention -
Interns, for your Intervention goals:
23.4, appropriate wt for ht
• Assume the Pt is on a pre-select diet that provides 2000 to
2200 kcal and 75 to 85 grams of protein daily
• The available supplement is Ensure Plus. Research kcal and
gm protein for an 8-oz container (240 mL or 237 mL).
⚫ For your goals, estimate that the Pt will drink on average of
75% of two Ensure Plus daily; in other words, he will
average about 1.5 Ensure Plus daily.
• How many kcal and gm protein will he consume from the
Ensure (1.5 cans daily)? You need to put this in your
ADIME note-something like: "Goal intake of Ensure Plus
is 75% of two bottles daily which will provide_
and
gm protein".
kcal
To meet 100% of estimated needs with food and the Ensure,
what is your goal for his food intake - in other words, if he
drinks 1.5 Ensure Plus daily, what percentage of his meals
will he need to eat to meet 100% of comparative standards?
You need to chart the goal intake -something like: "Goal
intake of meals is %"
INTERNS – Use eNCPT codes and data descriptors
for Interventions.
Identify goals:
CG-
Implement Interventions:
Admission: Mon 2/1
Today is wed 2/3
Referred to RDN from RN shift assessment: poor appetite
Med Hx: 60 YOM acute bronchitis, COPD exacerbation, hx of 42 year tobacco
use, 2 packs cigarettes daily, discontinued cigarette use
2 years ago
Anthropometrics: Ht: 5'10"
Integument: skin is intact
Oxygen: 4 L via nasal canula.
Labs: WNL
Wt: 171 lbs
Meds: NS at 75 mL/hr, IV levaquin, albuterol inhaler
Patient #7: Brock O'Lee; DOB 1/20/19**
Diet: Regular
Oral Intake:
Food: 43% average for 6 meals, ranging from 10% to 50%
Fluid: 2/2: 1200 mL
Chief Nutrition Problem
Transcribed Image Text:at History (CH) Domain .1.1 .1.3 .1.6 Age: 60 Sex: male Language: English 1.1.10 Tobacco use: 42 year tobacco use, 2 packs cigarettes daily, discontinued cigarette use two years ago 2.1.1 Client nutr-related hx: poor appetite since a few days prior to admission 2.1.1.13 Respiratory Disease Hx: acute bronchitis (primary), COPD exacerbation, COPD hropometric Measurements (AD) Domain 1.1.1.7 Stated Ht: 1.1.2.1 Measured Wt: 5' 6" 66" 1.68 m 145 lbs = 66 kg 1.1.2.5 Usual stated body wt: 142 to 147 lbs 1.1.5.1 BMI: 1-Nutrition Intervention - Interns, for your Intervention goals: 23.4, appropriate wt for ht • Assume the Pt is on a pre-select diet that provides 2000 to 2200 kcal and 75 to 85 grams of protein daily • The available supplement is Ensure Plus. Research kcal and gm protein for an 8-oz container (240 mL or 237 mL). ⚫ For your goals, estimate that the Pt will drink on average of 75% of two Ensure Plus daily; in other words, he will average about 1.5 Ensure Plus daily. • How many kcal and gm protein will he consume from the Ensure (1.5 cans daily)? You need to put this in your ADIME note-something like: "Goal intake of Ensure Plus is 75% of two bottles daily which will provide_ and gm protein". kcal To meet 100% of estimated needs with food and the Ensure, what is your goal for his food intake - in other words, if he drinks 1.5 Ensure Plus daily, what percentage of his meals will he need to eat to meet 100% of comparative standards? You need to chart the goal intake -something like: "Goal intake of meals is %" INTERNS – Use eNCPT codes and data descriptors for Interventions. Identify goals: CG- Implement Interventions: Admission: Mon 2/1 Today is wed 2/3 Referred to RDN from RN shift assessment: poor appetite Med Hx: 60 YOM acute bronchitis, COPD exacerbation, hx of 42 year tobacco use, 2 packs cigarettes daily, discontinued cigarette use 2 years ago Anthropometrics: Ht: 5'10" Integument: skin is intact Oxygen: 4 L via nasal canula. Labs: WNL Wt: 171 lbs Meds: NS at 75 mL/hr, IV levaquin, albuterol inhaler Patient #7: Brock O'Lee; DOB 1/20/19** Diet: Regular Oral Intake: Food: 43% average for 6 meals, ranging from 10% to 50% Fluid: 2/2: 1200 mL Chief Nutrition Problem
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