ADIME

Celiac Disease

Date

Pertinent information
provided by patient

Age; Gender; Dx; PMH

Ht; Wt; UBW/%UBW;

IBW; %IBW; BMI

Assessment

Labs

Positive test for:

TTG (indicator of Celiac disease)
EMA antibodies antiendomysial (indicator of Celiac disease)
Meds
GI
I/O
Physical Assessment
Skin
EER; EPR;
Fluid requirements

Current Diet
PES #1

Diagnosis

May 27, 2015

Patient states she is hungry all of the time and when she eats (especially large amounts) she
usually has immediate diarrhea. Patient states when eating fried foods or beef her diarrhea
worsens. She does not claim to be vomiting or nausea.


Age: KM 36 yo, female
Diet history: Patient states she eats noodle soups, chicken, crackers, sprite, fried foods, and beef.
Admitting diagnosis: celiac disease
Malabsorption; anemia

Height: 53; 160 cm.
Current Weight: 92 lbs 41.8 kg (82% of UBW; 80% of IBW)
UBW: 112 lbs (1 month ago) 50.9 kg
18% weight loss in 1 month; severe weight loss
IBW: 115 lbs 52.3 kg
BMI: 16.3 Underweight

Albumin 2.9g/dL (low)
Prealbumin 14mg/dL (low)
Hgb 10.5 g/dL (low)
Hct 35% (low)
Ferritin 12 micrograms/dL (low)

PES #2

NA

Bowel biopsy results: flat mucosa, villus atrophy, and hyperplastic crypts-inflammatory infiltrate
in lamina propia.
NPO
NA
NA
EER: 1,569 kcal/day (based on 30kcal/kg of IBW
Protein: 41 g/day (.8g/kg based on IBW)
Fluid: 1,500 ml (1ml/kcal based on EER for IBW)



NPO

AEB

Unintended
R/T
severe weight
weight loss
diarrhea and

loss of 18% (20
malabsorption
lbs. of UBW) in 1
month.

AEB

Impaired
Low ferritin (12
nutrient
micrograms/dL),
utilization
hemoglobin
R/T
(10.5 g/dL), and
altered GI

hematocrit
function
(35%) levels;
bowel biopsy of
flat mucosa,
villus atrophy,
and hyperplastic

PES #3

Monitoring/
Evaluation

Intervention

Nutrition Prescription

Treatment plan:
nutrition therapy,
education, acquisition
of additional
information

Plan(s) for evaluating

outcomes of
interventions listed
above; plan for follow-
up

Signature (& name)

cryptsinflammatory
infiltrate in
lamina propia
(damage to
intestinal
mucosa).

AEB

Undesirable
diet history of
R/T
food choices
consuming foods
knowledge

with gluten,
deficit
reported by
patient.
After approval of PO, recommend/order gluten-free and lactose free diet order by avoiding
wheat, rye, barley, malt, oats, and dairy. Restrict lactose (milk and dairy) foods until
damaged intestinal villi are regenerated, and then add lactose to diet as tolerated.

Increase caloric needs to 2000 per day until IBW of 115 lbs. (1-2 lb. gain per week) is
reached, then 1500 kcal/day. Increase iron intake to 18mg/day.



Before dismissal, educate patient on foods with gluten and lactose by teaching her how to
read food labels in order to identify products with gluten and lactose. Have patient keep
food diary and write down any GI symptoms (diarrhea, nausea, and vomiting). Provide
client with iron rich food sources.






In hospital, collaborate with nursing unit to monitor weight gain and tolerance of foods with
I/O. Monitor intake with calorie count. Evaluate change in hematocrit, hemoglobin, and
ferritin levels.

After dismissal, at home, measure weight weekly. Patients weight will stabilize at IBW of
115 lbs. Check food diary to determine compliance with gluten-free diet, iron content, and
daily kcals. Have patient meet with doctor to check for stable lab values of hematocrit,
hemoglobin, and ferritin.




Liz Neahring