Nutrition Care Process



Nutrition Care Process

“A systematic problem-solving method…to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care.”

1. Patient Information:

|Initials |AA |Medical Dx For This Admit |Quadriplegic, Infantile Cerebral|

| | | |Palsy (CP) |

|Age |6 years | | |

|Gender |Male | | |

|Ethnicity/Religion |----- |Physician |Dr. Murphy |

|Occupation |----- |Insurance Coverage |Medicaid |

|Allergies/Intolerances |NKDA |Care Giver (If Needed) |----- |

2. Medical Hx:

| |Identify |

|Family / Social Hx |Born in refugee camp in Kenya. Family unable to meet his needs – moved to SDCH in 2008. |

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|Past Medical / Surgical Hx |Medical: epilepsy, pneumonias, sleep apnea (obstructive), congenital dislocation of the hip, |

| |scoliosis, periventricular leukomalacia, esophageal reflux, asthma and mixed development disorder. |

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| |Surgical: tonsillectomy, adenoidectomy, supraglottoplasty (2002), tracheostomy (2008), |

| |fundoplication with G-tube and subsequent revisions of hiatal hernia and a baclofen pump. |

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|Symptoms Related to Current |Patient is stable at this time. |

|Diagnosis | |

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|Summary of Important Events While in Hospital |Over the last 4 years: gastrostomy, tracheostomy and dysphagia. |

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|Procedures Done While in Hospital (Include Dates) or Procedures |None – AA transfers to Primary Children’s Medical Center for |

|that are Planned |procedures, but has not had any recently. |

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3. Anthropometrics:

Current Weight: 17.9 kg

Current Height: 107 cm

UBW: ~17-18 kg

IBW: 19-20 kg (determined by growth chart; 50%tile for his height)

% IBW: 94% [17.9 kg/19 kg x 100]

BMI: 15.6 [17.9 kg/1.07 cm/1.07 cm]

Weight History:

|Date/Time |Weight |

|9/23/2012 |17.9 kg |

|9/16/2012 |17.9 kg |

|9/9/2012 |18.1 kg |

|9/2/2012 |17 kg |

|8/26/2012 |17.7 kg |

|7/29/2012 |16.9 kg |

|6/24/2012 |17 kg |

|5/27/2012 |16.3 kg |

|4/29/2012 |17.1 kg |

|3/25/2012 |17.4 kg |

Interpret weight history and give possible explanations for variation in the weights recorded. Include in your explanation recent weight loss prior to admission and state whether the weight loss was intentional or unintentional: AA has remained weight stable for the last six months. The tube feeds have been adequately meeting nutritional needs to maintain the patient’s weight. However, the tube feed supplementation has recently been increased in attempt to meet target weight of 19-20 kg. AA is smaller than all other children of the same age due to the condition; therefore the patient’s IBW is determined using 50%tile for weight/height ratio.

4. Estimated Energy Needs (1): 650 – 850 kcals/day (6-8 kcal/cm ht)

o Calculation:

1. 6 kcals x 107 cm = 650 kcals

2. 8 kcals x 107 cm = 850 kcals

Male ECE = (66.47 + 13.74 W + 5.07 H – 6.76 A) X (activity factor)

Female ECE = (655.1 + 9.56 W + 1.85 H – 4.68 A) X (activity factor)

* For obese patients (> 125% of IBW), use formula for obesity

Estimated Energy Needs (2): 66.47 + 13.74(17.9 kg) + 5.07(107cm) – 6.76(6 years) x 1.2 = ~975 kcals/day

o These needs are slightly high for AA’s needs; kcal/kg is more accurate for this patient’s condition and nutritional needs.

For calculations use:

ABW if BMI < 27 and use IBW if BMI > 27

|Patient’s age |Kcal/kg |

|18-64 |25-30 kcal/kg |

|65-79 |24-26 kcal/kg |

|> 80 years |22-25 kcal/kg |

|Critical care patients |22-24 kcal/kg |

|Extensive wound care or RF with goal for |If tolerance allows, consider extra 2-5 kcal/kg |

|anabolism | |

|Morbid obesity |20 kcal/kg |

* Use higher range if patient hypermetabolic, hepatic disease, increased activity level, wounds

and renal failure. Use lower range if obese, activity is low, metabolic intolerance present

My calculated recommendations for this patient at South Davis Community Hospital were formulated using the following standard estimates of 6-8 kcal/cm ht energy needs, 1.2-1.5 g/kg protein needs, and 90-110 mL/kg fluid needs.

Justification for my calculated recommendations: Energy/caloric needs are based off of cm of height, due to the patient’s age. AA has a lower caloric need due to the cerebral palsy and quadriplegic diagnoses. The patient has very minimal to no activity in a day; therefore the patient doesn’t require quite as many calories to maintain. AA’s protein needs remain at 1.2-1.5 g/kg for muscle maintenance. The patient’s fluid needs are based off the standard of a 5-6 year old.

Kcal/day: 650 – 850 kcals/day (6-8 kcal/cm ht)

o Calculation:

1. 6 kcal x 107 cm ht = ~650 kcals

2. 8 kcal x 107 cm ht = ~850 kcals

Grams of protein/day: 22-27 g (1.2-1.5 g/kg)

o Calculation

1. 17.9 kg x 1.2 g/kg = ~22 g

2. 17.9 kg x 1.5 g/kg = ~27 g

Fluid needs/day: ~1600 – 2000 mL/day (90-110 mL/kg)

o Calculation:

1. 17.9 kg x 90 mL = ~1600

2. 17.9 kg x 110 mL = ~2000

Nitrogen needs/day: 3.52 – 4.32 g/day

o Calculation:

1. 22 g/6.25 = 3.52

2. 27 g/6.25 = 4.32

NPC:N ratio: 25:1 [used median calories (750 kcals) and protein (24.5 g) to calculate]

o Calculation:

1. 24.5 g x 4 kcal/g = 98 kcals (calories from protein)

2. 750 kcals – 98 kcals = 652 kcals (non-protein calories)

3. 24.5 g pro/6.25 = 3.92 (nitrogen needs at 126 g/protein)

4. 98 kcals/3.92 = 25:1 (NPC:N ratio at 24.5 g protein)

5. Biochemical: (latest 2/21/2012)

Laboratory Information

| |Date |Date | |

|Test |6/28 |2/21 |Normal |

|Hct |----- |39.9 |35-44% |

|Hgb |----- |13.2 |11.5-14.5 g/dL |

|MCV |----- |88.3 |77-95 um^3/RBC |

|CRP |----- |8.4 H | ................
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