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ADIME NOTE- CASE STUDY #23Samantha MikesicNoland, Ruth12/02/2014Time: 13:00Assessment:77-year-old womanPatient Summary: Husband stated she woke up normal, midmorning she became dizzy and couldn’t talk or move the right side of her body.Dx: Lacunar ischemic stroke; dysphagia in esophageal transit phase and reduced esophageal peristalsis.Hx: HTN x10 years, Hyperlipidemia x 2 years, Hysterectomy 10 years ago, medications at home include: Captopril 25 mg 2x daily and lovastatin 20 mg once daily.Social Hx: Education: high school diploma. Currently lives with husband, Robert. Mrs. Noland and spouse purchase and prepare food at home. Family Hx: NoncontributoryPhysical Assessment: Acute onset of right facial numbness with pale color and cool skin temperature, hemiplegia and muscle weakness in right arm and right leg, wears glasses for myopia, dry mucous membranes, dysarthria with tongue deviation, cranial nerves III, V, VII, XII impaired, motor function and strength diminished, planar reflex decreased on right side, normal bowel sounds x4, abnormal lipoprotein profile, hyperlipidemia, increased BP: 138/88 mmHg, HTN, high sodium and energy intake, sedentary lifestyle.Current Diet Order: NPO except medications for 24 hrs.Usual Intake: around 1900 kcal/day, protein intake around 90 g. Multivitamin/mineral supplement daily, 500 mg calcium 3x daily.Intake in hospital: NPO upon admit + medications. Move to pureed diet and progress if patient is able to.Ht: 5’2” (157.5 cm), Wt: 165 # (75 kg), UBW: 165 #, % UBW: N/A due to dysarthria, BMI: 30.2 kg/m2REE Mifflin: 10 x 75kg + 6.25 x 157.5cm -5 x 77 years of age + 5 = 1354.4X stress factor 1.1-1.21489.8 – 1625.3 kcal/dayNeeds: 1490-1625 kcal/day, 93-102 g/kg/bw and 1875 ml/day.Nutrition Related Lab Values:Hyperlipidemia: lipoprotein profile increased cholesterol: 210 mg/dL, increased LDL: 155 mg/dL, decreased HDL: 40 mg/dL, increased LDL/HDL ratio: 3.875 and increased triglycerides: 198 mg/dLHypertension: inc BP 138/88 mmHg, Sodium: 141 mEq/L, potassium: 3.8 mEq/L, Calcium: 9.2 mg/dLMedications in hospital: single dose 67.5 mg rtPa IV, 650 mg PO acetaminophen PRN g 4-6 hr, IVF: 0.9% NS @ 75 mL/hr. Other: no heparin, warfarin, or aspirin for 24 hrs.\Diagnosis:Excessive fat intake related to hyperlipidemia as evidenced by increased cholesterol levels 210 mg/dL, increased LDL 155 mg/dL, decreased HDL 40 mg/dL and increased triglycerides 198 mg/dL. Swallowing and masticatory difficulty related to dysphagia with tongue deviation as evidenced by paresis of right side of face, aphasia, damage to cranial nerves III, V, VII, XII and dysphagia in esophageal transit with reduced esophageal peristalsis.Intervention:Provide nutrition education on Dysphagia self-feeding dietTexture modified diet, meet with SLP for consistency evaluationProvide feeding assistance based on patients abilities (due to right-sided hemiparesis)Monitoring and Evaluation:Determine progress made in diet regarding sources of fat intake, sodium content and calorie intake.Monitor lab values for abnormalities; consult with SLP for consistency and make changes as needed; monitor tolerance for new diet and update as needed Monitor and maintain protein levels to prevent pressure ulcers Goals:Maintain current weight while applying national dysphagia diet guidelines with adequate nutrient and energy parametersReduce blood pressure levels to 120/80 mm Hg or lower and manage hyperlipidemia with goals of >55 mg/dL HDL, <130 mg/dL LDL, and 120-199 mg/dL Cholesterol; also reduce salt and fat intakeIncrease calcium and potassium intake from diet to restore lipoprotein status ................
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