Question

request a completed 24-hour recall in nutritional assessment and a completed nutritional assessment report that uses ADIME format, each phase, preparation, opening phase, exploration-education phases, and closing phase. Summarizing what happens in each phase. Also includes a completed client concerns and strengths log, and lifestyle management form.

Answer 1

ADIME stands for:

• Assessment
• Diagnosis
• Intervention
• Monitoring & Evaluation

Assessment categories:(includes 5):

• Food/Nutrition-related Hx
• Anthropometric Measurements
• Biochemical Data, Med Tests & Procedures
• Nutrition-Focused Physical Findings
• Client History

PES stands for :

• Problem or Nutri Diagnosis Label
• Etiology (cause or contributing factors)
• Sign/Symptoms: data used to determine that the patient has the nutrition Diagnosis specified

The purpose of the assessment is to obtain, verify & interpret data needed to identify nutrition-related problems, their causes & significance.

The assessment can be obtained from the patient/client through interview, observation & measurements, a medical record & the referring health care provider.

The purpose of the Diagnosis is to identify & describe a specific nutrition problem that can be resolved or improved through nutrition intervention by a food/nutritional professional.

3 Diagnosis categories:

• Intake: compared to actual or est. needs
• Clinical: nutritional problems related to medical conditions
• Behavioral-Environmental: knowledge, attitudes, beliefs, access to food, food safety

4 Intervention categories:

• Food &/or Nutrient Delivery
• Nutrition education
• Nutrition Counseling
• Coordination of nutrient care

* ADMIE Nutrition Documentation Form

Name:................... Section: Monday   

Nutrition Note: Case study4 Date: 5/3/2013

Time: 0900

Client History	Nutrition-Focused Physical Findings	Anthropometrics
Name: Mr.Rockson Age: 35 Sex: Male Hispanic Patient History:High  cholesterol, asthma Family History: Father suffering from high blood cholesterol	Obese Feeling excess of flatulence over a period of 1 month	Height :5'9" weight: 97.5 kg BMI: 31.7kg/m2

Food/Nutrition-Related history and comparative standards	Biochemical, Medical Tests and Procedures
Gained 15 kg in the last 5 years Food intake: There is an increased intake over the past year related to steroid effects or increased hungry related to steroids Medicine: prednisolone 10 mg OD Energy intake: 4360 calories	Cholesterol:200mg/dl HDL-C:20mg/dl LDL:165 mg/dl TG:178mg/dl

Nutrition Diagnosis:(PES statement)

1.Knowledge deficit related to food and nutrition intake (specific diet for maintaining cholesterol) as evidenced by dietary recall containing high-fat foods.

2.Obesity-related to excessive intake of food as evidenced by excessive weight gain from the past history and 24-hour recall assessment

Nursing Intervention:

PES:1:

Goal: increase nutrition-related knowledge regarding the diet that having low fat

Intervention:

• Restrict foods that contain high fat and calories.
• Encourage him to avoid eating junk foods
• Avoid him to eat fried items
• Educate him regarding a healthy low-fat diet

PES:2:

Goal: -To maintain a healthy weight

Minimize the weight or helps in weight loss to a healthy extent

Intervention:

Plan and prescribe a 2,500 calorie diet by step by step

Helps the patient in planning and making a healthy dietary choice by using the  TLC (Therapeutic Lifestyle Changes) eating plan

Provide education regarding cholesterol-free diet

TLC diet:

<7% saturated fat,<200mg/d cholesterol, increased physical activity to 30 minutes that is 3 day per week,10-25g/d viscous (soluble) fiber,2g/d of plant stanols/sterols

*Patient should consume the refer to the following:

i)Vegetables : 3-5 servings/day(without added fat,sauce or salt)

ii)Fruits: 2-4 servings per day

iii)Dairy products: 2-3 servings per day(fat-free or low-fat milk, Yogurt, cottage cheese, and cheese)

iii)Eggs :<2 egg yolks/week

iv)Meat/Poultry/Fish: <5 oz/day

v)Fat/oils: Unsaturated oils, seeds, and nuts

*Monitoring and Evaluation:(Mand E):

i)Monitor dietary pattern using a Food Frequency Questionnaire (FFQ), is a limited checklist of foods and beverages with a frequency response section.every 6 weeks.

ii)Monitor the weight by using the same weighing machine