CVD Adime
CVD Adime
CVD Adime
Assessment:
Overview Information:
69-year-old male patient direct admit to ICU from clinic with c/o SOB, decompensated heart failure, hypoxia,
orthopnea, and severe dyspnea
Client History (CH):
Medical hx: HTN past 10 yrs, atrial fib and CHF 5 yrs, hyperlipidemia
Past surgeries: None
Allergies: None
Current medications/supplements: Furosemide, Coreg, Amiodarone hydrochloride, Spironalactone,
Coumadin, Lisinopril, BiDil, Natrecor, NaCl
Physical activity: ‘Mildly limited’ ADLs due to SOB and edema (bed rest)
Social hx: Smoked 1 pack per day for 20 years but quit 2 year ago. Social drinking only
Family hx: Coronary artery disease
1
Nutrition Diagnosis:
Inadequate energy intake related to current diet order of clear liquids only as evidenced by an 800-calorie
deficit as compared to his needs.
Nutrition Intervention:
Prescription: Change current diet order (current: clear liquids only)
Recommend: Change diet to fluid restricted
Goals: Diet order will be changed to fluid restricted diet as soon as possible
Prescription: Increase calorie needs to 1,956 kcal per day and a restrict fluid to 1500-2000 mL per day.
Prescribe 1 Ensure Plus supplements per day to provide 350 kcal and 13 g protein
Recommend: Educate patient on calorically dense foods and fluid restriction
Goals: Patient will be knowledgeable about fluid restriction and calorically dense foods by next visit