ADIME Notes for Medical Nutrition Therapy

Resident Name: John Doe Date: 1 November 2024 Time: 10:00 AM RD Name: Dr. Emily Carter, RD, CDE (A) Assessment: Age: 65 Gender: Male Weight: 85 kg Height: 175 cm Body Mass Index (BMI): 27.8 Usual Body Weight (UBW): 82 kg Weight History: 30 days ago: 84 kg, 90 days ago: 83 kg, 180 days ago: 82 kg IBW/%IBW: 70 kg / 121% Appetite: Good Food Allergies/Intolerance: None Food Preferences: Prefers Mediterranean diet Adaptive Devices: None Current diet order: Low-sodium, diabetic diet % intake of meals: 75% Supplement order: Protein shake, 1 per day % intake of supplement: 100% Chewing or swallowing difficulty: None Feeding Assistance: Independent Skin condition: Normal Medical diagnosis: Type 2 Diabetes, Hypertension Pertinent labs: HbA1c: 7.2%, LDL: 130 mg/dL Pertinent medications: Metformin, Lisinopril Nutritional Focused Physical Exam (NFPE): Appearance: Well-nourished Body Fat: Adequate Orbital: Mild Triceps: Moderate Fat overlying ribs: Mild Muscle Mass: Temple: Moderate Pectoralis: Moderate Delt: Moderate Hand: Moderate Back: Moderate Thigh: Moderate Hydration Status: Adequate Malnutrition Status: Not present Daily Estimated Nutrition Needs: Per 85 kg Total calories (kcal): 2000 kcal (Mifflin-St Jeor Equation) Total protein (g/kg): 1.0 g/kg (85 g) Total fluids (ml): 2500 ml (based on weight and activity level) Does current meal and supplement intake meet estimated needs? Yes (D) Nutrition Diagnosis: Excessive carbohydrate intake related to lack of knowledge as evidenced by elevated HbA1c levels. Nutrition goals (SMART): - Reduce HbA1c to below 7% within 3 months. - Achieve 80% meal intake compliance with low-sodium, diabetic diet. - Maintain weight at 85 kg. Care plan has been updated to reflect current nutrition goals. (I) Nutrition Interventions/Recommendations: - Educate on carbohydrate counting and portion control. - Recommend daily physical activity of at least 30 minutes. - Adjust diet to include more whole grains and vegetables. - Communicate RD interventions and recommendations to Nursing staff and Physician. Care plan has been updated to reflect current RD interventions and recommendation. (M/E) Monitoring and Evaluation Plan: - Monitor weight weekly. - Track meal intake compliance daily. - Re-evaluate HbA1c and lipid profile in 3 months. - Schedule follow-up appointment in 4 weeks.