Nutrition Weight Dysphagia

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Trace DC48-13

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1. Purpose and clinical relevance

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Stable weight/intake

Weight 152 lb (vs 151), intake 75% on the IDDSI Level 5 diet, no coughing/wet voice with precautions — no significant change (below K0300 threshold); supports Section K and the nutrition goal.

Enteral tolerance

PEG feed at the ordered rate, residual within policy, tolerated without distension; site clean; free-water flushes given — skilled tolerance/site monitoring required; supports the Section K feeding-tube item.

Therapeutic-diet monitoring

On a renal/cardiac therapeutic diet, intake 80%, labs/edema reviewed against the diet rationale — RN monitoring confirms the diet is meeting its purpose; supports Section K.

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