Nutrition in Healthcare: Resource Guide Name of Disease: Pediatrics: Ages 0-2 Cleft Lip and Palate Researcher: XX ****ONLY document by exception, thus if an area does not apply, please remove from document. Replace the ‘XX’ text for each section.**** Subjective Documentation Upon review of Medical Documentation what are important findings to look for. Constitutional: XX Cardiovascular: XX HEENT: XX Eyes – XX Ears – XX Nose – XX Throat – XX Genitalia: XX Neurologic: XX Extremities: XX Skin: XX Chest/lungs: XX Abdomen: XX Vital Signs: XX Labs: XX Other coinciding disease states and/or symptoms common with your disease – XX Common Food and/or Drug Allergies with this disease – XX Common Drugs (and their class) prescribed for this disease – XX How is this disease acquired? XX Commonality of disease? XX Nutritional Needs Food/Drug interactions XX Side effects of medications affecting eating (po intake) XX Side effects of medication affecting metabolism XX Side effects of disease affecting eating (po intake) XX Side effects of disease affecting metabolism and nutritional needs XX Does the patient need to be fed artificially? If so, how? XX Can patients feed themself? If not, how will the patient eat? XX What are common therapeutic diets prescribed for this disease state? XX What are common dysphagia diets prescribed for this disease state? XX Is it common for this patient to need increased oral nutrition supplementation? If so, what are some examples of what would be used in a healthcare setting? XX What food(s) can the patient NOT eat? XX What food(s) are offered in limited quantities? XX What foods are the patients encouraged to eat? XX Is it common for a patient with this disease state to be able to be independent and then eventually be dependent for nutrition? For example as the disease progresses. XX Nursing Application Summarize ALL your findings in one paragraph and three action points below. Summary- XX Action Points- 1. XX 2. XX 3. XX References 1. XX 2. XX 3. XX 4. XX 5. XX
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