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FSN429.SoapNote3

FSN429.SoapNote3 - SOAP note/10:00 S Pt states that...

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SOAP note October 19, 2011/10:00 S. Pt states that oncologist had requested advice on Enteral feeds. Pt has breast cancer and had a NG tube placed today as an outpatient. Pt has poor appetite , leading to a hard time with chemotherapy treatments. She reports no vomiting, though nausea , especially in the morning. She lives alone, but she can administer her feeds herself. She has been losing weight (35# in the past 3 months). The NG tube was placed to support her nutritionally and help her stop losing weight. She has been on IV fluids for the past 3 days at home to bring her hydration status back to normal prior to the NG placement. O. 54 YOWF Ht: 66’ Wt: 120# BMI: 19.42 kg/m2 IBW: 130# (92% IBW) UBW: 155# (77%UBW) 23% weight loss in the past month. Labs: Serum Alb: 3.5 mg/dl EER (1.5 stress factor): 2400-2500 kcal/day (30 kcal/kg) Estimated protein requirement: 65.4- 76.3 gm/day (1.2-1.4 gm pro/kg) Fluid Requirement: 1635-1908 ml (30-35 mL/kg) A. (PES) Inadequate energy intake related to lack of appetite from chemotherapy as evidenced by weight loss of 35# within the past 3 months and reported nausea in the mornings.
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