ADIME Initial Nutrition Intake

Name / Date / Time

Arthur Pendelton, 15/05/2024, 14:30 AWST

Reason for Referral/Presenting Complaint/Diagnosis

The patient was referred from the physiotherapy musculoskeletal clinic for nutrition assessment and intervention due to unintentional weight loss and suboptimal dietary intake impacting physical rehabilitation post-right total hip arthroplasty (THA).

A - Nutrition Assessment

Age: 76 years Height: 174 cm Weight: 62.5 kg BMI: 20.6 kg/m² Estimated Energy Needs: 7,800 kJ/day (calculated via Schofield equation with 1.4 activity factor for rehabilitation) Estimated Protein Needs: 75–94 g/day (calculated at 1.2–1.5 g/kg/day for post-op tissue repair and sarcopenia management) Other (specify): Fluid requirements estimated at 2,100 mL/day (35 mL/kg/day).

Client History: Patient is 4 weeks post-right THA with a PMHx of OA, HTN, and hyperlipidaemia. Current medications include perindopril 5 mg PO daily, atorvastatin 20 mg PO nocte, paracetamol (Panadol®) 1,000 mg PO QID, and colecalciferol 25 mcg PO daily. He lives alone in a single-storey house in Perth and mobilises with a four-wheeled walker. He experiences post-op fatigue and pain when standing for > 10 minutes, limiting his ability to shop and prepare meals. Daughter visits once weekly to assist with groceries. Food/Nutrition-Related History: Prior to surgery, the patient consumed three regular meals daily. Since discharge, intake has decreased to two small meals per day, relying heavily on tea and toast for breakfast and tinned soup or frozen meals for dinner. He reports poor appetite and early satiety. No known food allergies or intolerances. He currently takes no oral nutritional supplements (ONS) and has received no prior dietetic input. Estimated current intake is approximately 4,800 kJ/day and 42 g protein/day.

Anthropometric Measurements: Usual body weight (UBW) 68.0 kg (2 months ago); 5.5 kg (8.1 %) unintentional weight loss over 2 months. Calf circumference: 31.5 cm (indicates low muscle mass). Biochemical Data, Medical Tests and Procedures:

• Hb: 128 g/L (low-normal)
• Albumin: 34 g/L
• CRP: 12 mg/L
• 25-OH Vitamin D: 58 nmol/L Physical Exam Findings: Mild temporal and clavicular muscle wasting observed. Mild subcutaneous fat loss in orbital and triceps regions. Mucous membranes moist; no peripheral oedema. Assessment, Monitoring and Evaluation Tools: Patient-Generated Subjective Global Assessment (PG-SGA): Score 9, Category B (Moderately malnourished). Comparative Standards: Nutrient Reference Values for Australia and New Zealand (NRVs) and ESPEN guidelines on clinical nutrition and hydration in geriatrics.

D - Nutrition Diagnosis

PES Statement(s)

Inadequate protein-energy intake (NI-5.3) related to post-operative fatigue, reduced mobility limiting meal preparation, and early satiety as evidenced by estimated intake meeting 62 % of energy and 50 % of protein requirements, and 8.1 % weight loss over 2 months.

Etiology Category

Physical function, Physiologic metabolic

I - Nutrition Intervention

Aims/Goals (SMART):

• Patient will consume at least 7,500 kJ and 75 g of protein daily within 2 weeks to support physiotherapy rehabilitation.
• Patient will stabilise weight at ≥ 62.5 kg and prevent further weight loss over the next 4 weeks.
• Patient will consume 1 serving of high-protein ONS daily between meals for the next 4 weeks.

Goal Progress Evaluation

New goal identified

Nutrition Prescription

High-energy, high-protein diet providing 7,800 kJ/day and 80 g protein/day, normal texture, normal fluids.

Details of Intervention/Plan

Food and/or Nutrient Delivery (ND):

• Commence high-protein, high-energy ONS (e.g., Sustagen Hospital Formula® made with 200 mL full-cream milk) 1x daily between morning meals.
• Transition to energy-dense, pre-prepared home-delivered meals (e.g., Meals on Wheels or high-protein commercial options) for main meal to reduce standing time. Nutrition Education (E):
• Educated patient on the role of protein in muscle protein synthesis and wound healing to improve physiotherapy outcomes and strength.
• Provided written resource on food fortification (adding skim milk powder, cheese, butter, and olive oil to soups and porridge). Nutrition Counseling (C):
• Utilised motivational interviewing to address barriers to eating when fatigued; agreed on "little and often" grazing strategy (6 small meals/snacks daily). Coordination of Nutrition Care by Nutrition Professional (RC):
• Liaised with treating physiotherapist to schedule ONS consumption 30–60 minutes post-exercise sessions to optimise muscle recovery.
• Referred to My Aged Care for domestic assistance with meal preparation and shopping. Nutrition Intervention Encounter Context (IC):
• Outpatient clinic face-to-face consultation.

M/E - Nutrition Monitoring and Evaluation

Specific Indicators, Criteria and Time Frame

• Total energy and protein intake via 24-hour recall: Target > 75 % of estimated requirements at 2-week review.
• Body weight: Target maintenance or gain of 0.5 kg at 4-week review.
• Compliance with ONS: Target 1 serving/day (7/7 days per week) at 2-week review.
• Functional strength (Handgrip Strength): Target improvement of > 2 kg at 4-week review in conjunction with physiotherapy.

Nutrition Monitoring and Evaluation Terminology Domain

Food/Nutrition-related History (FH)

• Parameter: Total energy intake (FH-1.1.1.1) and Total protein intake (FH-1.5.2.1)
• Indicator for Success: Patient achieving ≥ 7,500 kJ/day and ≥ 75 g protein/day
• Time Frame for Measurement: 2 weeks

Behavior Determination (FH-5): Monitor adherence to grazing meal pattern and daily ONS consumption at 2 weeks. Anthropometric Measurements (AD): Monitor weight (AD-1.1.2) at 2 and 4 weeks to confirm weight stabilisation. Physical Exam Findings (PD): Reassess muscle mass stores via NFPE and calf circumference at 8 weeks. Assessment, Monitoring & Evaluation Tools (AT): Repeat PG-SGA at 8 weeks to evaluate resolution of malnutrition status.