CHS ADIME

Reason For Referral Dr. Emily Carter, GP, referred the patient due to concerns about unintentional weight loss and poor dietary intake. Method of Visit In-person visit with the client and her daughter present. Consent obtained: Consent for assessment and intervention was obtained from the client and her daughter. Client's goal Client's goal: To gain weight and improve energy levels. Daughter's goal: To learn how to prepare nutritious meals for her mother. Assessment Anthropometrics: Current weight 55 kg, height 165 cm. Recent weight loss of 5 kg over the past 3 months (8% of usual weight). Relevant medications: Lisinopril 10mg daily, Metoprolol 25mg twice daily, and a daily multivitamin. Relevant blood test results: Recent blood work shows low albumin and prealbumin levels. Relevant medical history: Hypertension, history of a stroke, and dysphagia. Diet history: Client reports consuming small portions of food, primarily soft foods due to swallowing difficulties. Fluid intake is adequate. Social: Client lives with her daughter, who provides support with meals and medication reminders. The client also receives support from a home health aide three times a week. Tools used for health or disease status or risk assessment, reassessment, monitoring and evaluation: Mini Nutritional Assessment (MNA) score of 18, indicating risk of malnutrition. Etiology category: Altered GI function related to dysphagia. Comparative standards: Compared to the client's previous weight and BMI. Evaluation of progress towards nutrition-related goal(s) and resolution of a nutrition diagnosis: The client's progress will be evaluated based on weight gain, improved nutritional intake, and symptom management. Nutrition Diagnosis: Inadequate oral food/beverage intake related to dysphagia as evidenced by unintentional weight loss and poor dietary intake. Nutrition Interventions: Goal Planning: The client and her daughter will work together to achieve the client's goals of weight gain and improved energy levels. Nutrition Prescription Planning: The client will be prescribed a high-calorie, high-protein diet with modified textures to accommodate her dysphagia. The plan includes small, frequent meals and snacks. Food and/or Nutrient Delivery: The daughter will prepare meals, and the home health aide will assist with feeding if needed. The dietitian will provide a list of appropriate foods and recipes. Supplements will be provided as needed. Education: The dietitian will provide education on the importance of adequate nutrition, the use of texture-modified diets, and strategies to manage dysphagia. Handouts on high-calorie, high-protein recipes will be provided. The daughter will receive education on meal preparation. Nutrition Counseling: The dietitian will provide counseling to the client and her daughter on meal planning, food choices, and strategies to improve nutritional intake. The dietitian will collaborate with the client and her daughter to establish food and nutrition goals and action plans to foster client ability to self-care and promote health. Coordination of Care: The dietitian will coordinate care with the client's GP and speech therapist. Monitoring and Evaluation Weight will be monitored weekly by the daughter. Symptoms will be monitored daily by the client and her daughter. Nutritional intake will be assessed weekly by the dietitian using a food diary. Evaluation Food and Nutrition-Related History Outcomes: The client's food and nutrient intakes, supplement use, knowledge and or beliefs or attitudes, behavior changes, food and supply availability, functional capacity, and client-centered measure will be evaluated. Anthropometric Measurement Outcomes: Body weight change will be monitored. Biochemical Data, Medical Tests, and Procedure Outcomes: Lab data will be reviewed. Physical Exam Finding Outcomes: Findings from a physical exam, interview or health record will be reviewed. Who is going to contact whom and by approximately when: The dietitian will contact the client and her daughter in two weeks to assess progress.