Progress Report Overview
Student: Tyhisha Melhado
Activity: Tom Bosley
Start Time: 09/27/2023 13:03:36
End Time: 11/06/2023 07:59:29
Total Time: 25:28:41
Actions
Note at 11/06/2023 07:57:58 Note at 11/06/2023 06:25:52
Tom Bosley Documentation
Student: Tyhisha Melhado
Activity Start: 09/27/2023 13:03:36
Activity Completion: 11/06/2023 07:59:29
Activity Completion: 25:28:41
Patient Data
Patient: Tom Bosley DOB: 03/22/1954
Age/Sex: 69 yo M MR#: MR-1299
Location: Central Clinic
Notes
Note at 11/03/2023 16:53:02
ADIME Note
Basic Information
Date:
11/03/2023 16:53:02
Author:
Tyhisha Melhado
Location:
Central Clinic
Patient name:
Tom Bosley
Assessment
Diagnosis:
Uncontrolled Type 2 DM and hypercholesterolemia
Age:
69
Gender:
Male
Race:
White
Client History
Medical history:
Uncontrolled Type 2 DM and hypercholesterolemia
Medical diagnoses:
Uncontrolled Type 2 DM and hypercholesterolemia
Family history:
Maternal history reveals Type 2 DM.
Social history:
Married, retired hardware store owner. Former smoker, stopping more than 10 years ago. Drinks 8 oz of red wine with
dinner regularly.
Current medications:
Lipitor
Nutrition-related medications:
Atorvastatin (Lipitor) - Avoid grapefruit/related citrus (limes, pomelo, Seville oranges) and red yeast rice. Supplementation
with CoQ10 may be recommended
Current supplements:
N/A
Anthropometric history
Height:
70"
Weight at admission:
218 lbs/98.9 kg
Current Weight:
218 lbs/98.9 kg
BMI:
31.3 kg/m2; Obese Class I
% Weight change:
11%; Weight Gain
IBW:
166 lbs
% IBW:
131%; Obesity
UBW:
196 lbs
% UBW:
111%; No Risk
Weight assessment:
Pt is classified Obese Class I per BMI assessment, with an 11% weight gain over the past year.
Biochemical history, medical tests, labs, and procedures:
Blood glucose - 166 mg/dL (H)
HgA1C - 8.1% (H)
Triglyceride - 177 mg/dL (H)
Cholesterol - 201 mg/dL (H)
Urine Microalbumin - 45 mg (H),
Consistent with uncontrolled DM and hypercholesterolemia diagnosis
Nutrition Focused Physical Exam
Skin Assessment
Intact
Feeding Ability
Independent
Oral Motor
Intact
Muscle and fat store assessment:
No visible muscle/fat wasting
If other, please explain:
Foot pain
Food and Nutrition History
Current diet order:
n/a
Assessment of usual intake:
Consists largely of bread with butter, fries, or pasta with cheese sauce
Assessment of current intake:
n/a
Supplements/herbals:
n/a
Food allergies and intolerances:
NKFA
Intake and digestive problems:
No PMH of GI problems
Assessment of Nutritional Status/Nutrition Risk
No malnutrition noted
Nutrition Recommendations
kcal/day based on:
1088 - 1385 kcal/day based on 11-14 kcal/kg (ABW 98.9 kg)
g protein/day based on:
113 - 151 g/day based on 1.5-2 g/kg (IBW 75.3 kg)
mL fluid/day based on:
2473 - 2967 mL/day based on 25-30 mL/kg (ABW 98.9 kg)
Nutrition assessment summary:
Pt presents with uncontrolled type 2 DM and hypercholesterolemia. Assessment reveals an obese male with a 22lb weight gain
within the past year. No evidence of muscle wasting, experiences foot pain. Intake consisting largely of refined grains and
saturated fat. Limited knowledge on diabetes and hypercholesterolemia. No records of glucose self monitoring. Active once a
week. Daily Lipitor intake.
Diagnosis
Nutrition Diagnosis:
Food and Nutrition Related Knowledge Deficit
PES Statement:
Food and Nutrition Related Knowledge Deficit (new) rt lack of controlled sat fat intake and diabetes
education/intervention strategies (knowledge) as evidenced by 8.1% A1c, 177 mg/dL triglyceride, 201 mg/dL
cholesterol, and a diet recall consisting largely of bread with butter, fries, and pasta with cheese sauce.
Nutrition Intervention
Food and nutrition delivery:
Meals and Snacks: General healthful diet. Carbohydrate modified diet: Consistent carbohydrate diet. Fat modified diet
– Saturated fat modified diet: Decreased saturated fat diet. Cholesterol modified diet: Decreased cholesterol diet.
Recommend consistent carbohydrate diet of 60g/meal and 15g/snack within one week. Pt is advised to decrease
consumption of foods containing butter, cheese, and refined grains, by at least half (replacing with whole grains) and
decrease consumption of simple carbohydrate foods (to once a day) within the next week. In addition, pt is
recommended to decrease consumption of red meat, reducing intake to no more than 0.5 serving/day within the
next week. Pt should increase intake of fruits, vegetables, nuts/seeds, and lean meats (poultry, fish, and turkey).
Nutrition education:
Content related nutrition education: Verbal and written education regarding general healthy diet (increased fr/veg,
fish, poultry, nuts, low fat dairy, whole grains) and diabetes education consisting of importance of regular testing.
Education will include foods associated with carbohydrate intake (including discussions on glycemic index) and
implementing the carb counting method (45-75 g/meal 15-30 g/snack). Pt should be encouraged to decrease
consumption of simple carbohydrate foods such as refined grains as shown from his diet recall.
Education on nutrition’s influence on health:
Verbal and written education regarding the impact of following these guidelines on the reduction of DM and
hypercholesterolemia, as these conditions may lead to more serious conditions (stroke, kidney damage, angina,
and/or nerve damage).
Physical activity guidance: Pt is recommended to follow AHA guidelines on exercise which consists of 150 min/wk
moderate intensity aerobic exercise or 75 min vigorous, or combination of the two, with resistance training at least 2
days/wk.
Bioactive substance management: Recommended to avoid alcohol due to Lipitor interaction.
Nutrition related laboratory result interpretation: Verbal and written education regarding glucose and A1c result as
well as triglycerides and cholesterol lipid lab panels. Discussion will include the definitions/what is being tested in
layman’s terms and importance of the test, the normal values compared to the lab values obtained by the patient,
and goals to decrease values over specified time frame. Education will also include self-monitoring of glucose at home
to track values over time.
Monitoring and Evaluation
Food and nutrient intake:
Food Intake - Types of Food. Evaluate the pt’s intake to see adherence of general healthy diet, specifically noting the types of fat
and carbohydrate consumed.
Alcohol Intake - Alcohol Intake in one week. Monitor whether pt adhered to nutrition orders to avoid alcohol due to Lipitor
interaction.
Fat Intake – Measured fat intake: Total fat measured intake in 24 hours. Saturated Fat measured intake in 24 hours. Monitor
total fat and saturated fat intake and evaluate whether further interventions are needed.
Cholesterol Intake – Cholesterol measured intake in 24 hours. Monitor cholesterol and evaluate whether further interventions
are needed.
Carbohydrate Intake – Measured carbohydrate intake: Total carbohydrate measured intake in 24 hours. Simple carbohydrate
measured intake in 24 hours. Carbohydrate measured intake in one meal. Monitor total carbohydrate and simple carbohydrate
over the course of 24 hours to note client’s understanding of severity of tracking intake (looking for some sort of adherence not
a drastic change this soon). Carbohydrate intake for one meal should be monitored to note pt’s understanding of carbohydrate
distribution over the day (looking for adherence to specified g/meal or snack).
Food and Nutrition Skill – Nutrition skill of individual client. Monitor whether the pt can successfully check blood glucose levels
with a glucometer. Pt will be able to count carbs per meal, fulfilling no greater than 65 carbs per meal and 20 carbs per snack.
Physical Activity – Physical Activity history. Consistency. Frequency. Duration. Intensity. Type of physical activity. Monitor pt’s
physical activity (initially over the course of a week), noting the frequency and type of activity including its duration and
intensity.
Anthropometric measurements
Weight Change - Weight Loss of 1lb over a week.
Biochemical data:
Glucose/Endocrine Profile: Glucose, casual. Pt will have glu WNL within a week (new goal).
Lipid Profile - Cholesterol, serum. Triglycerides, serum. Pt will have cholesterol and triglycerides WNL within a week (new goal).
Signature/credential/date:
Tyhisha Melhado, DPD student
Note at 02/20/2017 02:11:33
Diabetic Nursing Assessment Details
Basic Information
Date: 02/20/2017 02:11:33
Author: Cathy Rhoades, RN
Location: Central Clinic
Title: Diabetic Nursing Assessment
Note: Tom is a retired 69-year-old man with a 2-year history of type 2 diabetes. Although he was
diagnosed two years ago, he had symptoms indicating hyperglycemia for 2 years before
diagnosis. He had fasting blood glucose records indicating values of 118-127 mg/dl, which
were described to him as indicative of "borderline diabetes." He also remembered past
episodes of nocturia associated with large pasta meals and rich deserts. At the time of initial
diagnosis, he was advised to lose weight (at least 20 lb.), but no further action was taken.
Referred by his family physician to this diabetes specialty clinic, he presents with recent weight
gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and
increase his exercise for the past 6 months without success. He had been started on glyburide
(Diabeta) one year ago, 2.5 mg every morning, but had stopped taking it because of dizziness,
often accompanied by sweating and a feeling of mild agitation, in the late afternoon.
He also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated
cholesterol and elevated triglycerides). He has tolerated this medication and adheres to the
daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema
sylvestre, and a "pancreas elixir" in an attempt to improve his diabetes control. He stopped
these supplements when he did not see any positive results.
He does not test his blood glucose levels at home and expresses doubt that this procedure
would help him improve his diabetes control. "What would knowing the numbers do for me?,"
he asks. "The doctor already knows the sugars are high."
He states that he has, "Never been sick a day in my life." He recently retired from the
hardware business and has become very active in a variety of volunteer organizations. He lives
with his wife of 48 years and has two married children and four grandchildren. Although his
mother had type 2 diabetes, he has limited knowledge regarding diabetes self-care
management and states that he does not understand why he has diabetes since he never eats
sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and
weight-loss supplements, and she frequently scans the Internet for the latest diabetes
remedies.
During the past year, he has gained 22 lb. Since retiring, he has been more physically active,
playing golf once a week and gardening, but he has been unable to lose more than 2-3 lb. He
has never seen a dietitian and has not been instructed in self-monitoring of blood glucose.
He has never had a full diet history, but brief discussion reveals his normal dinners consist of
meat and french fries or pasta with cheese sauce and he consumes three to four slices of
buttered bread most evenings. During the day, he often has "a slice or two" of bread with
butter or margarine. He also eats 3-4 pieces of fresh fruit per day at meals and as snacks. He
eats chicken and fish a few times per week, but prefers read meat. His wife has offered to
make him meatless meals, but he finds them "tasteless" and "unsatisfying." He drinks 8 oz. of
red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports,
"when the cost of cigarettes topped a buck-fifty."
The medical documents that he brings to this appointment indicate that his hemoglobin A1C
(A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and
166/88 mmHg on three separate occasions during the past year at his local Family Clinic.
Although he was told that his blood pressure was "up a little," he was not aware of the need to
keep his blood pressure at or below target levels for both cardiovascular and renal health.
John has never had a foot exam as part of his primary care exams, nor has he been instructed
in preventive foot care. His medical records indicate that he has had no surgeries or
hospitalizations, his immunizations are up to date, and, in general, he has been remarkably
healthy for many years.
Initial Physical Exam
Weight: 218 lb
Height: 5'10"
Overall appearance: Obese male, no evidence of muscle wasting
Skin: Warm, dry, no rashes
Eyes: Corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no
arteriolovenous nicking, no retinopathy
Thyroid: Nonpalpable
Lungs: Clear to auscultation
Heart: Rate and rhythm regular, no murmurs or gallops
Vascular assessment: No carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+
bilaterally
Neurological assessment: Bilateral diminished vibratory sense to the forefoot, absent ankle
reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle
Lab Results/Vitals
Fasting capillary glucose: 166 mg/dl
Urine microalbumin: 45 mg (normal: <30 mg)
Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg
Pulse: 88 bpm
Respirations 20 per minute
Dx/Plan
Uncontrolled T2DM: RD consult, medication review
Foot Pain: Refer to primary care
--C. Rhoades, RN, Diabetic Nurse Educator
