Write an ADIME note for your initial nutrition assessment

Question

What will be an ideal response?

Answer 1

Date, Time

A: 32 YO Hispanic male
PMH: previous type 2 diabetes diagnosis
Family Hx: MI—father, type 2 diabetes—mother, ovarian cancer—mother
Medications: None, discontinued use of metformin
Dx: Type 1 diabetes – with DKA
Cardiac: tachycardia
Abdomen: non-distended, bowel sounds x 4 quadrants
Labs: glucose: 550 mg/dL, HbA1c: 10.2%; CO2 31; osmolality 304.4; phosphate 2.1; Na 130; TG 175; cholesterol 210; LDL 137; HDL 38 . Antibodies present at diagnosis: ICA, IAA, GADA, c-peptide 0.09 – consistent with T1DM/LADA.
D: Altered nutrition-related laboratory values related to lack of insulin production as evidenced by serum glucose of 550 mg/dL, HbA1C of 10.2%, osmolality of 304.4 mOsm, +4 presence of urinary ketones, serum pH of 7.31, and C-peptide of 0.09 ng/mL
I: Goal: maintain optimal metabolic outcomes to prevent micro and macrovascular complications
Normalize glucose levels
• Fasting: 80-110 mg/dL
• Preprandial: 80-130 mg/dL
• Postprandial: <180 mg/dL
• A1c: <7%
Modify lifestyle habits including dietary intake and physical activity to prevent further complications
• Patient will begin intensive insulin therapy with TDD 30 units, 15 units basal (glargine), and ICR 17 g:1 unit rapid-acting insulin Novolog (bolus insulin)
• Provide education for carbohydrate counting using written materials, food labels, and restaurant menus.
• Patient will incorporate physical activity such as walking, jogging, and other activities for 150 min./week.
• Provide education to recognize and treat hypoglycemia.
M/E:
Patient will have new HbA1c measured in 3 months
Patient will adhere to SBMG by recording blood glucose levels pre and post meals.
Patient will correctly dose rapid acting insulin for carbohydrate in meals and snacks.
Patient will avoid any episodes of hypoglycemia and/or effectively manage any periods of hypoglycemia.

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