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    Final Adime Note Anemiacasestudy

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    A 31-year-old pregnant woman presented with anemia and inadequate weight gain. She was diagnosed with hypochromic microcytic anemia and inadequate energy, iron, and folate intake due to nausea and limited food preferences. Interventions included an energy-modified diet to increase calorie intake and weight gain, continuing iron and prenatal vitamin supplements, and nutrition education. Her calorie and nutrient intake, as well as lab values and supplement adherence, would be monitored.

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    Final Adime Note Anemiacasestudy

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    api-253526841
    471 views2 pages
    A 31-year-old pregnant woman presented with anemia and inadequate weight gain. She was diagnosed with hypochromic microcytic anemia and inadequate energy, iron, and folate intake due to nausea and limited food preferences. Interventions included an energy-modified diet to increase calorie intake and weight gain, continuing iron and prenatal vitamin supplements, and nutrition education. Her calorie and nutrient intake, as well as lab values and supplement adherence, would be monitored.

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    final adime note anemiacasestudy

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    A 31-year-old pregnant woman presented with anemia and inadequate weight gain. She was diagnosed with hypochromic microcytic anemia and inadequate energy, iron, and folate intake due to nausea and limited food preferences. Interventions included an energy-modified diet to increase calorie intake and weight gain, continuing iron and prenatal vitamin supplements, and nutrition education. Her calorie and nutrient intake, as well as lab values and supplement adherence, would be monitored.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    471 views2 pages

    Final Adime Note Anemiacasestudy

    Uploaded by

    api-253526841
    A 31-year-old pregnant woman presented with anemia and inadequate weight gain. She was diagnosed with hypochromic microcytic anemia and inadequate energy, iron, and folate intake due to nausea and limited food preferences. Interventions included an energy-modified diet to increase calorie intake and weight gain, continuing iron and prenatal vitamin supplements, and nutrition education. Her calorie and nutrient intake, as well as lab values and supplement adherence, would be monitored.

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    Case Study 1

    Group 9: Pumpkins

    Nutrition Care

    Progress Note

    ASSESSMENT

    DIAGNOSIS

    INTERVENTION

    MONITORING & EVALUATION

    31 y.o F w/ gravida 3, para 2


    Dxs of: Hypochromic
    Microcytic Anemia; 23 week
    gestation with normal
    ultrasound

    Inadequate energy intake (NI1.2-10634) R/T nausea during


    the first trimester of pregnancy
    and limited food preferences
    AEB pregnancy weight gain
    that is 7# or 50% short of the
    recommended weight gain
    (14#) for patients prepregnancy BMI and length of
    gestation.

    Energy-modified diet (ND 1.2.210830) to increase caloric intake


    and increase pregnancy weight
    gain to a healthy level.

    Monitor for weight gain (AD1.1.4)

    Meds: Prenatal vitamins;


    ferrous sulfate
    Skin: Pale, warm and dry
    Eyes: Sclera pale
    Lab values (abnormal):
    RBC - 3.8 x 10 /mm
    Hgb - 9.1 g/dL3
    MCV - 72 m
    TIBC - 465 g/dL
    Ferritin - 10 g/dL
    Folate 2 ng/dL
    Hct - 33%
    6

    Wt: 142# (64.5 kg)


    UBW: 135# (61.4 kg)
    Ht: 55
    IBW: 125#
    BMI: 22.5, normal

    Diet: NPO
    (only while admitted).
    Appetite: Self-reported as

    Inadequate mineral intake


    (iron) (NI-5.10.1-10712) R/T
    increased nutrient needs
    during pregnancy AEB 19.4 mg
    of iron intake according to 24hour-recall (PTA) relative to the
    RDA of 27 mg for pregnant
    women as well as a low
    plasma ferritin level of 10
    ug/dL, a low hemoglobin level
    of 9.1 g/dL, and an increased
    TIBC value of 465 ug/dL.

    DATE & TIME:

    Continue taking iron supplements


    (ND - 3.2.4 10541) and prenatal
    vitamins. Advise pt to take
    supplements with food to increase
    tolerance and minimize GI upset.
    Take iron supplements alongside
    foods high in vitamin C to maximize
    absorption.
    Provide nutrition education r/t
    increased nutritional needs during
    pregnancy and relationship of
    nutrition to maternal and fetal
    health/disease (E 1.4-10591).

    10/14/2014 08:00

    Monitor her calorie intake (FH1.1.1.1)


    Monitor lab values where
    available, particularly plasma
    ferritin, transferrin, Hgb, TIBC,
    MCV, iron, folate, and vitamin C
    (BD-1.10; BD-1.13)
    Monitor tolerance of and
    adherence to taking iron
    supplements and prenatal
    vitamins, including associated GI
    distress.

    Provide nutrition education,


    specifically skills to select iron-rich
    foods (E 2.2-10597).
    Referral to community
    agencies/programs (WIC) (RC 1.610625).
    Vitamin-modified diet (ND 1.2.910837) to increase vitamin C and
    15

    Case Study 1
    good, but does not like many
    foods; 24-hour recall of dietary
    intake PTA indicated PO
    intake of 1,752 kcal, protein
    intake of 46.6 g, iron intake of
    19.4 mg, and folate intake of
    733 g DFE.

    Group 9: Pumpkins
    folate consumption.
    Mineral-modified diet (ND 1.2.1010838) to increase iron intake so
    that she can be weaned off of the
    iron supplement.

    EEN: 2,025 kcal/day


    (HBEx1.2 activity factor+350
    kcal for 2nd pregnancy)
    67.5 g protein/day
    (61.36 kg x 1.1 g/kg/day)
    Fluids: 2,000-2,400 mL/day
    (specific calculation: 64.545
    kg x 35 mL/kg = 2,259 mL)

    Signature & Credential: Alainna Baxley, Kelsey Conyers, Xiaolu Hou, and Sarah Liu, (future) RDs

    16

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