ADIME Nutrition Care Documentation

Reason for Visit

Reason for visit: Evaluation of meal preparation, feeding independence, and unintended weight loss following recent right-hemisphere CVA with mild left-sided hemiparesis.

Assessment

• Male, 68 yo, DOB 14/05/1956 (MRN: 849-204-11)
• PMH: Ischemic CVA (3 weeks ago), HTN, hyperlipidemia, osteoarthritis. FH: Maternal HTN, paternal CAD. SH: Retired accountant, lives in single-story home with spouse; spouse works part-time, leaving pt alone for lunch.
• Height: 175 cm, Weight: 68.0 kg, BMI: 22.2 kg/m², Weight pattern: Unintentional loss of 4.5 kg over past 4 weeks, IBW (Hamwi): 72.7 kg
• Goal to arrest weight loss and regain 2.0 kg over next 8 weeks; lost 6.2% body weight in 1 month.
• BM q2-3d, mild constipation; denies N/V/D, no dysphagia on thin liquids or regular solids per SLP clearance.
• Mild temporalis and clavicular muscle wasting; trace bilateral lower extremity edema; skin turgor intact.

Medications

• lisinopril 20 mg PO daily
• atorvastatin (Lipitor®) 40 mg PO daily
• clopidogrel (Plavix®) 75 mg PO daily

Supplements

• cholecalciferol (Vitamin D3) 1,000 IU PO daily
• docusate sodium (Colace®) 100 mg PO BID PRN

Labs (10/03/2025): Na 139 mmol/L, K 4.1 mmol/L, Cr 0.9 mg/dL, Albumin 3.4 g/dL, HbA1c 5.6%, Vit D 28 ng/mL. VFSS (02/03/2025): Normal swallow phase, no aspiration.

Diet pattern: 2 meals and 1 snack per day (frequently skips lunch).

• Breakfast: 1 cup instant oatmeal made with water, 1 cup black coffee.

• Lunch: Often skipped when spouse is at work due to difficulty opening packages and cutting food one-handed; occasionally 1 banana.

• Dinner: Prepared by spouse; 90 g baked chicken or fish, 0.5 cup mashed potatoes, 0.5 cup steamed carrots.

• Snacks: 4-6 saltine crackers in evening.

• Drinks/Water: ~1,000 mL water/day, 1 cup coffee.

• Prefers savory, warm meals; no known food allergies (NKFA); adequate financial access to food, but physical access limited by left upper extremity (LUE) weakness and impaired fine motor coordination during daytime hours.

• Previously followed DASH diet for HTN with good adherence prior to stroke.

• Denies history of disordered eating; current irregular eating routine is strictly secondary to functional fatigue and frustration with one-handed meal preparation.

Physical Activity

• Currently participates in outpatient PT/OT 2x/week for 45 mins/session; walks 10 mins daily at home with quad cane.
• LUE hemiparesis, reduced grip strength, and impaired dynamic standing balance limiting prolonged standing at kitchen counter.
• Interested in returning to neighborhood walking and light gardening.

Lifestyle And Social Factors

• Retired.
• Fair sleep quality; 6 hours/night; wakes 1-2x nightly for nocturia, no loud snoring.
• Moderate stress related to loss of independence; manages via deep breathing exercises and family support.

Summary

68 yo male s/p CVA presenting with 6.2% unintentional weight loss over 1 month, primarily driven by reduced caloric intake during the day when alone. Pt struggles with IADLs specifically related to meal prep and feeding due to LUE hemiparesis and fatigue when standing. Swallow function is intact. Intervention focuses on adaptive kitchen equipment, energy conservation techniques during meal prep, and nutrient-dense convenience foods to restore weight and functional independence.

Diagnosis

• Underweight (ICD-10: R63.6) and Reduced mobility (ICD-10: Z74.09)
• Inadequate oral intake (NI-2.1) related to upper extremity motor deficit and difficulty preparing meals independently as evidenced by skipping lunch 4-5x/week and 4.5 kg (6.2%) unintentional weight loss in 1 month.

Intervention

• 2,100 kcal/day, 85-95 g protein/day (1.2-1.4 g/kg), and 1,800 mL fluid/day.
• Add 1 oral nutrition supplement (ONS) daily; incorporate pre-cut, easy-open nutrient-dense foods for lunch; increase healthy fats (olive oil, nut butters) in oatmeal and dinner sides.
• Educated on energy conservation for meal prep (sitting on perching stool at counter, sliding items rather than lifting) and adaptive equipment use (rocker knife, Dycem non-slip mat, plate guard, easy-grip jar opener).
• Motivational interviewing and problem-solving therapy to build self-efficacy in independent daytime self-feeding.
• Coordinated with outpatient Registered Dietitian (RD) for ongoing macronutrient monitoring and SLP/PT for continued motor recovery.
• 1. Pt will utilize a Dycem mat and rocker knife to independently prepare and consume a complete lunch at least 5 days/week over the next 2 weeks.
• 2. Pt will consume 1 high-protein ONS (e.g., Ensure Plus®) or Greek yogurt cup with easy-peel lid daily for the next 2 weeks to support weight stabilization.

Monitoring And Evaluation

• Monitor weekly weight at home, daily lunch intake log, BM frequency, and functional tolerance/fatigue levels during independent meal preparation tasks.
• Follow-up OT/Nutrition review in 2 weeks (approx. 08/04/2025 at 10:00 America/Denver) to reassess weight trend and mastery of adaptive feeding equipment.