Case Study 11

Cirrhosis (Inpatient)
Dana Elmore
 ACTIVITY 11.2
NUTRITION PROGRESS NOTE (ADIME) – DAY 2
OTHER RESOURCES EHR
Nutrition Progress Note Templates Electronic Health Record
– Ava Williamson Cirrhosis (Inpatient)
ADIME
Ava Williamson’s Story
SOAP

PRACTICE CONSIDERATION
Tool Kit Clinical Tools
Documentation of the NCP
ADIME Documentation
Use of Patient-Generated Subjective Global
SOAP Documentation
Assessment (PG-SGA)

i Complete an EHR medical-record entry (progress note) including key data from Nutrition
. Assessment, Diagnosis, Intervention, and Monitoring and Evaluation.

The following template is based on EHR Nutrition Progress Notes developed by clinical dietitians
from several hospitals. The patient’s Demographic History, Medical Diagnoses, Laboratory Results
and Anthropometric Data are listed in the EHR. The remaining text fields are open for your entries.

Day of Service: Hospital, Day 2, 1100 hrs (11:00 a.m.)

Dietitian Name: _Dana Elmore_______________

Consult Orders: Inpatient consult to Dietitian [1324564] ordered by Myers MD at 11:00 p.m.

Williamson, Ava. 70 y/o female w/ a diagnosis of liver cirrhosis,

ascites, and related complications. Ava is at risk of malnutrition and
Nutrition Consultation For:
displays significant dietary and lifestyle challenges, including
alcohol dependency.

NUTRITION ASSESSMENT SUMMARY (1,2)

Diet Order
High-energy, high-protein, NAS, 1 L fluid restricted, avoid free water

Consult Diagnosis
Liver failure, transaminitis, ascites, cirrhosis, peritonitis, ETOH abuse, elevated GGT, hyponatremia,
hypokalemia, anemia, portal hypertension

Patient/Client/Family Medical/Health History

GERD, uncomplicated diverticular disease, OA knees/hip

Personal Data
70 yo female

Nutritional Intake and Recent History:

 Pre-admission diet was low in nutrient-dense foods, with significant alcohol intake that
contributed to her current malnutrition risk.

Physical Findings and Functional Status:

 (If any signs of malnutrition i.e, muscle wasting, fluid retention, or signs of malnutrition
(e.g., loss of subcutaneous fat, edema).

Biochemical Markers and Trends:

 Electrolyte Imbalance: Persistent hyponatremia and hypokalemia are critical in the setting
of liver failure and may need correction.
 Anemia: Low hemoglobin, hematocrit, and ferritin indicate anemia, likely exacerbated by
malnutrition and chronic disease.
 Protein Levels: Low albumin points to poor nutritional status and compromised liver
synthesis capacity, typical in liver failure.

Behavioral and Environmental Factors:

 Has family support but does live alone, may affect her adherence to a diet and alcohol
reduction plan.
 Alcohol Dependency: H/o dependency on alcohol for relaxation and sleep, noting her
reluctance to view this as an addiction.

ANTHROPOMETRY (1,2)

MEASURES ER DAY 1 DAY 2

Height (cm [feet]) 157.5 (5'2")

Weight (kg [lb]) 72.89 (160.7) 72.89 (160.7) 72.89 (160.7)

BMI (kg/m2) 29.4 29.4 29.4

BIOCHEMICAL DATA, MEDICAL TESTS & PROCEDURES (SELECT WHICH DATA TO INCLUDE) (1,2)

DATE TEST RESULT TICK IF RELEVANT

Electrolyte/Renal Profile

BUN (8-21 mg/dL) 32 X

Creatinine (0.8-1.3 mg/dL) 0.9

Day 2 Sodium (135-145 mmol/L) 125 X

Potassium (3.5-5.2
2.9 X
mmol/L)

White Cell Profile

Day 2 WBC (4.8-11.8 mm3) 16 295

Gastrointestinal Profile

Alkaline phosphatase
161 X
(35-104 U/L)

Alanine aminotransferase
73 X
(5-50 U/L)

Aspartate
aminotransferase 61 X
(10-35 U/L)
Day 2
Gamma-glutamyl
transferase 80 X
(3-60 IU/L)

Prolonged prothrombin
INR >1.3 (Day 1)
time (12 sec)

Bilirubin (> 1.5mg/dL)

1.8 (Day 1)

Glucose/Endocrine Profile

Glucose, fasting
Day 2 110
(65-99 mg/dL)

Inflammatory Profile

C-reactive protein
Day 1 11.1 X
(<3 mg/L)

Day 2 Hemoglobin (12-15 g/dL) 7.8

Hematocrit (37-47%) 29.2

 Ferritin (20-120 mm3) 16 (Day 1) X

Protein Profile

Day 2 Albumin (3.5-5.0 g/dL) 2.8 X

Lipid Profile

Triglycerides
Day 1 255
(35-135 mg/dL)

COMPARATIVE STANDARDS – ESTIMATED NEEDS

Estimated Energy
Needs
Using a standard range of 25-35 kcal/kg based on her weight (71.89 kg on Day
2)
 71.89 kg x 25 kcal = 1797.25 kcal/day
 71.89 g x 35 kcal = 2516.15 kcal/day

OR

BMR = (10 × weight in kg) + (6.25 × height in cm) − (5 × age) − 161

BMR=(10 × 71.89) + (6.25 × 157.5) − (5 × 70) − 161
= 718.9 + 984.38 – 350 – 161 = 1,192.28 kcal

Stress Factor: 1.2- 1.5

1,192.28 x 1.2 = 1430.7
1.192.28 x 1.5 = 1788.42

Estimated Protein
Needs
(With cirrhosis: 1.2-1.5kg/day)
85−108 g protein/day

Sodium Due to ascites and fluid retention, a sodium restriction is recommended, typically
2 grams per day or no added salt (NAS).

Estimated Fluid
Needs
A fluid restriction of 1 liter (1,000 mL) per day, as noted in the Day 2 diet order.

OR

Weight-Based: 35-45 ml/kg/day = 71 kg x 35 ml = 2485 , 71 kg x 45 ml = 3195,

 2485-3195 ml/day
Adjusted Weight Range: 2.0 – 2.5 L/day based on weight
ASPEN: 20-40 ml/day = 71 kg x 20 ml = 1420 , 71 kg x 40 ml = 2840, 1420-2840
ml/day

NUTRITION DIAGNOSIS (1,3)

PES Statement(s) Malnutrition (undernutrition) (NC-4.1) related to inadequate

Problem, Etiology, dietary intake as evidenced by low albumin (2.8 g/dL), low
Signs and Symptoms ferritin (16 mm), elevated BUN (32 mg/dL), diet recall, reduced
appetite, and presence of ascites.

Inadequate Protein Energy Intake (NI-5.2) related to decreased

ability to consume sufficient protein and energy intake due to
poor appetite, alcohol dependence, and limited meal
preparation skills, as evidenced by low albumin (2.8 g/dL),
elevated AST (58 U/L), ALT ( 65 U/L), dietary intake of <1,200
kcal/day, and insufficient protein intake (<30 g/day).

Not ready for nutrition-related behavior change (NB-1.3) related

to a lack of perceived need to change alcohol intake and low
motivation to modify dietary patterns, as evidenced by ongoing
alcohol dependency (consuming a bottle of wine daily and
regular port with coffee) and reluctance to reduce intake despite
elevated liver enzymes (ALT 73 U/L, AST 61 U/L, GGT 80 U/L),
low serum albumin (2.8 g/dL), hyponatremia (sodium 128
mEq/L), and elevated triglycerides (255 mg/dL), which
contribute to worsening liver disease and nutritional
compromise

NUTRITION INTERVENTION (1,4)

Nutritional Goals:
Nutrition
 High-energy, high-protein diet
Prescription
 Sodium-restricted to manage ascites and fluid retention
 Fluid restriction to prevent further complications related to liver disease
 Increase nutrient-dense food intake to address malnutrition
 S:
Aims/Goals  Increase daily caloric intake to meet energy needs (estimated at ~1,800
(SMART) kcal/day).
 Achieve protein intake of 1.2-1.5 g/kg body weight (approximately 85-100
g/day).
 Reduce sodium intake to less than 2,000 mg/day.
 Limit fluid intake to 1 L/day, avoiding free water.
M:
 Monitor weight weekly to assess for stability or gradual weight gain (aim
for 0.5 kg/week).
 Track dietary intake through a 24-hour recall and food diary to ensure
adherence to caloric and protein goals.
A:
 Utilize accessible and affordable nutrient-dense foods to ensure
adherence to the diet.
 Provide meal planning resources tailored to Ava's cooking capabilities and
kitchen space.
R:

 Goals are tailored to address Ava’s malnutrition, liver disease, and overall
health, considering her lifestyle and preferences.
T:
 Evaluate progress while admitted and discuss before discharge, with a
follow-up appointment to reassess nutritional status and make necessary
adjustments.

Diet:
Detail of
 Breakfast: Increase protein (e.g., eggs or Greek yogurt) and
Intervention/Plan
include fruits or whole grains.
 Lunch: Incorporate lean proteins (e.g., chicken or turkey), whole
grains (e.g., quinoa or brown rice), and a variety of vegetables.
 Dinner: Focus on protein-rich foods (e.g., fish or legumes) with
vegetables and healthy fats (e.g., avocado).
 Snacks: Encourage nutrient-dense options like nuts, cheese,
and smoothies made with fruits and protein powder.
 Fluids:
 Limit fluid intake to 1 L/day, avoiding free water (e.g., plain
water, tea) to help manage ascites.
 Encourage fluid intake through high-energy beverages (e.g.,
protein shakes) and nutrient-rich soups.
 Sodium:
 Limit sodium to less than 2,000 mg/day by avoiding processed
foods, adding herbs/spices for flavor, and reading food labels.
 Supplements:
 Consider protein supplements/powder/shakes to help meet
protein goals if dietary intake is insufficient.
Education and Counseling:
 Provide education on the importance of a balanced diet and the
impact of alcohol on liver health.
 Discuss meal planning strategies that align with her financial
and storage limitations.
  Offer resources for budgeting and shopping for nutrient-dense
foods.
Support and Follow-Up:
 Schedule follow-up appointments to monitor progress and make
necessary adjustments.
 Encourage involvement of family members in meal preparation
and support for lifestyle changes.

During the initial consultation, Ava expressed her willingness to improve her
nutritional status but was reluctant to discuss her alcohol consumption. The RD
provided a safe space for her to share her concerns and emphasized the
importance of nutrition in managing her liver disease. Ava was engaged and
receptive to suggestions for meal planning and dietary modifications. The RD
RD Interaction
Summary focused on building a rapport and established a plan that aligned with Ava's
preferences and lifestyle.

NUTRITION MONITORING & EVALUATION (1,2)

Tick if Relevant X Food/Nutrient/Energy Labs (specify)

Anthropometrics X Behavior or Knowledge

/Beliefs/Attitudes

Specific Indicators, Indicators:

Criteria and  Nutritional Intake:
Time frame  Caloric Intake: Aim for >1,800 kcal/day.
 Protein Intake: Target 85-100 g/day.
Assessment  Sodium Intake: <2,000 mg/day.
parameters for follow-  Fluid Intake: Adhere to 1 L/day restriction.
up consultations  Biochemical Data:
 Track liver function tests (ALT, AST, GGT) and albumin levels.
 Clinical Symptoms:
 Assess for malnutrition symptoms (fatigue, weight loss) and liver disease
complications (ascites, jaundice).
Criteria:
 Nutritional Intake:
 Consistent caloric and protein intake met.
 Sodium and fluid restrictions adhered to.
 Weight Management:
 Stable or increased weight by 0.5 kg/week.
 Biochemical Data:
 Improvement in liver function tests and albumin >3.0 g/dL.
 Clinical Symptoms:
 Improvement in malnutrition symptoms and no new complications.
Time Frame
  Initial Follow-Up: 4 weeks post-discharge.
 Ongoing Monitoring: Every 4-6 weeks, or as needed.
 Biochemical Testing: Every 8-12 weeks, or as clinically indicated.
 Assessment Parameters for Follow-Up
 Dietary Recall: Conduct a 24-hour recall.
 Weight and Measurements: Record weight and calculate BMI.
 Biochemical Review: Assess liver function tests and electrolytes.
 Symptom Assessment: Evaluate malnutrition and liver disease
symptoms.
 Behavioral Assessment: Discuss adherence and emotional barriers.
 Family Involvement: Encourage family support in meal preparation.

YOUR NAME DATE: Day 2 11:00 a.m.

Registered Dietitian
Time spent with chart and patient: _45___ minutes

ACTIVITY 11.3
NUTRITION PROGRESS NOTE (ADIME)
 – DAY 3 (DISCHARGE)
OTHER RESOURCES EHR
Nutrition Progress Note Templates Electronic Health Record
– Ava Williamson Cirrhosis (Inpatient)
ADIME
Ava Williamson’s Story
SOAP

PRACTICE CONSIDERATION
Tool Kit Clinical Tools
Documentation of the NCP
ADIME Documentation
SOAP Documentation

i Complete an EHR medical-record entry (progress note) including key data from Nutrition
. Assessment, Diagnosis, Intervention, and Monitoring and Evaluation.

The following template is based on EHR Nutrition Progress Notes developed by clinical dietitians
from several hospitals. The patient’s Demographic History, Medical Diagnoses, Laboratory
Results and Anthropometric Data are listed in the EHR. The remaining text fields are open for
your entries.

Day of Service: Hospital, Day 3, 1500 hrs (3:00 p.m.)

Dietitian Name: _Dana Elmore_______________

Consult Orders: Inpatient consult to Dietitian [1324564] ordered by Myers, MD.

Williamson, Ava. 70 y/o female w/ a diagnosis of liver cirrhosis,

ascites, and related complications. Ava is at risk of malnutrition and
Nutrition Consultation For:
displays significant dietary and lifestyle challenges, including
alcohol dependency.

NUTRITION DIAGNOSIS (1,2)

PES Statement(s) Malnutrition (undernutrition) (NC-4.1) related to inadequate

Problem, Etiology, dietary intake as evidenced by low albumin (2.8 g/dL), low
Signs and Symptoms ferritin (16 mm), elevated BUN (32 mg/dL), diet recall, reduced
appetite, and presence of ascites.

Inadequate Protein Energy Intake (NI-5.2) related to decreased

ability to consume sufficient protein and energy intake due to
poor appetite, alcohol dependence, and limited meal
preparation skills, as evidenced by low albumin (2.8 g/dL),
elevated AST (58 U/L), ALT ( 65 U/L), dietary intake of <1,200
kcal/day, and insufficient protein intake (<30 g/day).

Not ready for nutrition-related behavior change (NB-1.3) related

to a lack of perceived need to change alcohol intake and low
motivation to modify dietary patterns, as evidenced by ongoing
alcohol dependency (consuming a bottle of wine daily and
regular port with coffee) and reluctance to reduce intake despite
elevated liver enzymes (ALT 73 U/L, AST 61 U/L, GGT 80 U/L),
low serum albumin (2.8 g/dL), hyponatremia (sodium 128
mEq/L), and elevated triglycerides (255 mg/dL), which
contribute to worsening liver disease and nutritional
compromise

 Update any relevant PES (Problem, Etiology,

Signs/Symptoms) statements based on the latest
assessment:

COMPARATIVE STANDARDS – ESTIMATED NEEDS

Estimated Energy
Needs
Using a standard range of 25-35 kcal/kg based on her weight (71.89 kg on Day
2)
 71.89 kg x 25 kcal = 1797.25 kcal/day
 71.89 g x 35 kcal = 2516.15 kcal/day

OR

BMR = (10 × weight in kg) + (6.25 × height in cm) − (5 × age) − 161

BMR=(10 × 71.89) + (6.25 × 157.5) − (5 × 70) − 161
= 718.9 + 984.38 – 350 – 161 = 1,192.28 kcal

Stress Factor: 1.2- 1.5

1,192.28 x 1.2 = 1430.7
1.192.28 x 1.5 = 1788.42
Estimated Protein
Needs
(With cirrhosis: 1.2-1.5kg/day)
85−108 g protein/day

Sodium Due to ascites and fluid retention, a sodium restriction is recommended, typically
2 grams per day or no added salt (NAS).

Estimated Fluid
Needs
A fluid restriction of 1 liter (1,000 mL) per day, as noted in the Day 2 diet order.

OR

Weight-Based: 35-45 ml/kg/day = 71 kg x 35 ml = 2485 , 71 kg x 45 ml = 3195,

2485-3195 ml/day
Adjusted Weight Range: 2.0 – 2.5 L/day based on weight
ASPEN: 20-40 ml/day = 71 kg x 20 ml = 1420 , 71 kg x 40 ml = 2840, 1420-2840
ml/day

NUTRITION INTERVENTION (1,3)

Nutritional Goals:
Nutrition
 Confirm the high-energy, high-protein diet
Prescription
 Confirm sodium-restricted to manage ascites and fluid retention
 Confirm fluid restriction to prevent further complications related to liver
disease
 Confirm increase nutrient-dense food intake to address malnutrition

S:
Aims/Goals  Increase daily caloric intake to meet energy needs (estimated at ~1,800
(SMART) kcal/day).
 Achieve protein intake of 1.2-1.5 g/kg body weight (approximately 85-100
g/day).
 Reduce sodium intake to less than 2,000 mg/day.
 Limit fluid intake to 1 L/day, avoiding free water.
M:
 Monitor weight weekly to assess for stability or gradual weight gain (aim
for 0.5 kg/week).
 Track dietary intake through a 24-hour recall and food diary to ensure
adherence to caloric and protein goals.
 LT, AST, and GGT will decrease toward normal ranges, and albumin will
rise to >3.0 g/dL.
 A:
 Utilize accessible and affordable nutrient-dense foods to ensure
adherence to the diet.
 Provide meal planning resources tailored to Ava's cooking capabilities and
kitchen space.
 Utilize meal planning strategies discussed during her discharge education.
 With adherence to the dietary plan and follow-up care, these
improvements are realistic.
R:

 Goals are tailored to address Ava’s malnutrition, liver disease, and overall
health, considering her lifestyle and preferences.
T:
Evaluate progress within 4 weeks post-discharge, with a follow-up appointment
to reassess nutritional status and make necessary adjustments.

Diet:
Detail of
 Breakfast: Increase protein (e.g., eggs or Greek yogurt) and
Intervention/Plan
include fruits or whole grains.
 Lunch: Incorporate lean proteins (e.g., chicken or turkey), whole
grains (e.g., quinoa or brown rice), and a variety of vegetables.
 Dinner: Focus on protein-rich foods (e.g., fish or legumes) with
vegetables and healthy fats (e.g., avocado).
 Snacks: Encourage nutrient-dense options like nuts, cheese,
and smoothies made with fruits and protein powder.
 Fluids:
 Limit fluid intake to 1 L/day, avoiding free water (e.g., plain
water, tea) to help manage ascites.
 Encourage fluid intake through high-energy beverages (e.g.,
protein shakes) and nutrient-rich soups.
 Sodium:
 Limit sodium to less than 2,000 mg/day by avoiding processed
foods, adding herbs/spices for flavor, and reading food labels.
 Supplements:
 Consider protein supplements/powder/shakes to help meet
protein goals if dietary intake is insufficient.
Education and Counseling:
Provide education on the importance of a balanced diet and the
impact of alcohol on liver health.
 Discuss meal planning strategies that align with her financial
and storage limitations.
 Offer resources for budgeting and shopping for nutrient-dense
foods.
Support and Follow-Up:
 Schedule follow-up appointments to monitor progress and make
necessary adjustments.
 Encourage involvement of family members in meal preparation
and support for lifestyle changes.

RD Interaction The interaction focused on empowering Ava with the knowledge and resources
 necessary to manage her nutrition post-discharge. Continuous support and
monitoring will be essential to her recovery and overall health. Ava was advised
Summary
to reach out to the dietitian or healthcare team with any concerns or questions
before her follow-up appointment.

NUTRITION ASSESSMENT SUMMARY (1,4)

Diet Order
High-energy, high-protein, NAS

Consult Diagnosis
Liver failure, transaminitis, ascites, cirrhosis, peritonitis, ETOH abuse, elevated GGT, hyponatremia,
hypokalemia, anemia, portal hypertension

Patient/Client/Family Medical/Health History

GERD, uncomplicated diverticular disease, OA knees/hip

Personal Data
70 yo female

Nutritional Intake and Recent History:

 Review dietary recall to assess compliance with the nutrition prescription.

Physical Findings and Functional Status:

 (If any signs of malnutrition i.e, muscle wasting, fluid retention, or signs of malnutrition
(e.g., loss of subcutaneous fat, edema).

Biochemical Markers and Trends:

 Electrolyte Imbalance: Persistent hyponatremia and hypokalemia are critical in the setting
of liver failure and may need correction.
 Anemia: Low hemoglobin, hematocrit, and ferritin indicate anemia, likely exacerbated by
malnutrition and chronic disease.
 Protein Levels: Low albumin points to poor nutritional status and compromised liver
synthesis capacity, typical in liver failure.
 Assess for any changes in malnutrition symptoms, ascites, or other complications since
admission/day 2 consultation

Behavioral and Environmental Factors:

 Has family support but does live alone, may affect her adherence to a diet and alcohol
reduction plan.
 Alcohol Dependency: H/o dependency on alcohol for relaxation and sleep, noting her
reluctance to view this as an addiction.

ANTHROPOMETRY (1,4)
MEASURES ER DAY 1 DAY 2

Height (cm [feet]) 157.5 (5'2")

Weight (kg [lb]) 72.89 (160.7) 72.89 (160.7) 72.89 (160.7)

BMI (kg/m2) 29.4 29.4 29.4

BIOCHEMICAL DATA, MEDICAL TESTS & PROCEDURES (SELECT WHICH DATA TO INCLUDE) (1,4)

DATE TEST RESULT TICK IF RELEVANT

Electrolyte/Renal Profile
BUN (8-21 mg/dL) 31 X

Creatinine (0.8-1.3 mg/dL) 0.8

Day 2 Sodium (135-145 mmol/L) 131

Potassium
4
(3.5-5.2 mmol/L)

White Cell Profile

Day 2 WBC (4.8-11.8 mm3) 16 895 X

Gastrointestinal Profile

Alkaline phosphatase
150 x
(35-104 U/L)

Alanine aminotransferase
71 X
(5-50 U/L)

Aspartate
aminotransferase 60 X
Day 2 (10-35 U/L)

Gamma-glutamyl
transferase 78 X
(3-60 IU/L)

Prolonged prothrombin
INR >1.3 (Day 1)
time (12 sec)

Bilirubin (> 1.5mg/dL) 1.8 (Day 1) X

Glucose/Endocrine Profile

Glucose, fasting
Day 2 135
(65-99 mg/dL)

Inflammatory Profile
 C-reactive protein
Day 1 11.1
(<3 mg/L)

Hemoglobin (12-15 g/dL) 7.7

Day 2 Hematocrit (37-47%) 29

Ferritin (20-120 mm3) 16 (Day 1)

Protein Profile

Day 2 Albumin (3.5-5.0 g/dL) 2.6 X

Lipid Profile
Triglycerides
Day 1 255 X
(35-135 mg/dL)

NUTRITION MONITORING & EVALUATION (1,2)

Tick if Relevant X Food/Nutrient/Energy Labs (specify)

Anthropometrics X Behavior or Knowledge

/Beliefs/Attitudes

Specific Indicators, Indicators:

Criteria and  Nutritional Intake:
Time frame  Caloric Intake: Aim for >1,800 kcal/day.
 Protein Intake: Target 85-100 g/day (Reassess based on liver function &
Assessment malnutrition)
parameters for follow-  Sodium Intake: <2,000 mg/day. (Reinforce)
up consultations  Fluid Intake: Adhere to 1 L/day restriction. (Reinforce)
 Biochemical Data:
 Track liver function tests (ALT, AST, GGT) and albumin levels.
 Clinical Symptoms:
 Assess for malnutrition symptoms (fatigue, weight loss) and liver disease
complications (ascites, jaundice). (Evaluate new symptoms or changes
since Day 2/admission).
Criteria:
 Nutritional Intake:
 Consistent caloric and protein intake met.
 Sodium and fluid restrictions adhered to.
 Weight Management:
 Stable or increased weight by 0.5 kg/week.
 Biochemical Data:
 Improvement in liver function tests and albumin >3.0 g/dL.
 Clinical Symptoms:
 Improvement in malnutrition symptoms and no new complications.
Time Frame
 Initial Follow-Up: 4 weeks post-discharge.
 Ongoing Monitoring: Every 4-6 weeks, or as needed.
 Biochemical Testing: Every 8-12 weeks, or as clinically indicated.
  Assessment Parameters for Follow-Up
 Dietary Recall: Conduct a 24-hour recall.
 Weight and Measurements: Record weight and calculate BMI.
 Biochemical Review: Assess liver function tests and electrolytes.
 Symptom Assessment: Evaluate malnutrition and liver disease
symptoms.
 Behavioral Assessment: Discuss adherence and emotional barriers.
Family Involvement: Encourage family support in meal preparation.

YOUR NAME DATE: Day 3 3:00 p.m.

Registered Dietitian
Time spent with chart and patient: _30___ minutes