Nutrition Database



Intern Name Dawn OrtizPatient’s DOB10/31/41 Age73 SexF Today’s Date 11/11/14Admit Date10/13/14 Admitting DiagnosisPost endoscopic retrograde cholangiopancreatogram (ERCP), pancreatic colonic massPrior Medical History Gastroenterostomy, bilateral vagotomyDiet OrderRegular + TPN at 60 mL/hr SupplementsEnsure BIDIf applicable, describe food intake since admission or past 5 daysFood intake has been minimal over the past 5 days, pt was only on TPN after she developed an abdominal fistula. During the healing process, MD started her on liquids and gradually advanced to regular diet, however pt is still not currently eating enough to discontinue the TPN yet. I have been performing calorie counts for the past 3 days and determined she is only consuming an average of 25% of her meals.Any Food Allergies / Intolerances?Gluten intolerant Height (in inches and cm) 62 in; 157.5 cm Weight (in pounds and kg)141#; 64 kg Weight History x Loss Gain…if weight Δ, how much in what time frame? Was loss/gain intentional or unintentional?Unintentional wt loss of 3 kg; over 1 monthUsual Body Weight (UBW)67 kg Ideal Body Weight (IBW) 50.1 kg % IBW137% BMI25.8 Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)Divorced and retired, very nice and religious lady, six children, 15 grandchildren, she lives with one of her daughters, no alcohol or drug abuse, food secure, cooks with her daughter, lots of support.Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)Drug name(s)IndicationNutritional ImplicationLovenoxAnticoagulantnoneProtonixProton pump inhibitor Suppresses the production of gastric acidCarafateAntiulcer agentGERD treatmentMegaceCancer treatment, stop tumor growth Appetite stimulant Nutrition related laboratory valuesLab TestLab value – indicate if abnormal high or low ( or )Nutritional significance if abnormalCan a nutrition intervention help to correct this abnormal lab value? How?Na136 mmol/LNormal K4.2 mmol/LNormal BUN30 mg/dL ↑Elevated—indicates kidney disease, CHF or dehydration, in this case I believe due to excessive protein catabolism and the gastrointestinal bleeding. Increasing protein and fluid intake should help correct.CREAT0.5 mg/dLNormal Albumin2.6g/dL↓Low—not used to assess nutritional status at my hospital, likely due to inflammation/metabolically stressed patient/malabsorption. Increased energy and protein intake may help.Prealb10.2 mg/dL↓Low—not used to assess nutritional status at my hospital (but better indicator of short term malnutrition than albumin), likely due to inflammation/trauma/malabsorption. Increased energy and protein intake may help.Glucose96 mg/dLNormal HgbA1CHemoglobin 8.5 g/dL↓Low—iron deficiency, blood loss. Iron supplementation and protein intake may help.Hematocrit 25.8%↓Low—iron deficiency, blood loss. Iron supplementation and protein intake may help.MCV91 fLNormal MCH30 pgNormal Iron (Fe)Transferrin Sat (%)FerritinVitamin B12FolateCa8.4 mg/dLNormalPhos3.9 mg/dLNormal Mg2.1 mg/dLNormal Is Patients Skin Intact?Yes No xIf no, Surgical Wound x with GI drain Decubitus Ulcer If decubitus ulcer, list stage (I-IV) and site(s)Is decubitus ulcerImproving? Getting worse? Is any of the following present? Nausea Vomiting Diarrhea Constipation Difficulty Chewing Difficulty Swallowing Unable to feed self Malabsorption Early Satiety x Taste Changes Reminder….for calculations, what was the patient’s height (cm) and weight (kg) again? 157.5cm64kgMale Female x Age 73Any stress factors, activity factors to consider? At the time I was seeing the pt, her main stress factor was the fistula.Calculate Energy Needs using1) Harris-Benedict ------------------------------------ 1224kcal2) Mifflin St. Jeor -------------------------------------- 1093kcal3) kcal/kg ----------------------------------------------- 1210-1375 kcal4) Ireton Jones (only use in critically ill) ------- kcal5) Penn State 2010 equation ---------------------- kcalWhat formula did you ultimately use for the Pt & why? Kcal/kg, because this is my hospital’s standard formula. I adjusted for pt being 137% IBW, feeding wt is 55kg.Show your work for three of the five methods above used:1) REE = 655 + (9.7 x 64kg) + (1.85 x 157.5cm) – (4.7 x 73) = 1224 kcal/day2) -161 + (10 x 64kg) + (6.25 x 157.5cm) – ( 5 x 73) - 5 = 1093 kcal/day3) 22-25 kcal/kg/day22 kcal x 55kg= 1210 kcal/day25 kcal x 55kg= 1375 kcal/dayCalculate Protein NeedsHow many g/kg would you use & why? 1.5 g/kg for increased protein needs for fistula in adult > 65 yearsShow your work:1.5g x 55kg = 83 g/day83g/dayCalculate Fluid Needs using1) ml/kg depending on age ----------------- 1375-1650ml/day2) Holliday-Segar method -------------------ml/day3) RDA method ---------------------------------ml/day4) urine output (urine out +500ml/day)-1420ml/dayWhat formula did you ultimately use for the Pt & why?? 25-30 mL/day is my hospital’s standard for adults > 65 yearsShow your work for two of the four methods above used:1) 25 mL x 55 kg= 1375 mL/day30 mL x 55 kg= 1650 mL/day4) 920 mL + 500 mL = 1420 mLParenteral Calculations: What is the macronutrient composition of the TPN recommended by the physician? Rate? ___60_____mL/hrfor how long? 24hr x 12hr/day ______hr/day Any PO intake? No Yes x, explain ____________PO intake too low to discontinue TPN ________________________Total volume/24hr ___1440_______ mL2-in-1 Solution x3-in-1 Solution CarbohydrateConcentration? D___10%_____Amount of Dextrose (in grams) in 1000mL__104______ gkcal from Dextrose in 1000mL (grams * 3.4 kcal/g) ____354____ kcalTotal kcal from Dextrose provided / 24hr? ___510_____ kcal (did you check total volume/24hr?)ProteinConcentration? ___5.5_____ % SolutionAmount of AA (in grams) in 1000mL___55____ gkcal from AA in 1000mL (grams * 4 kcal/g) ___220_____ kcalTotal kcal from AA provided / 24hr? ____320____ kcal (did you check total volume/24hr?)Lipids10% (1.1kcal/mL) 20% (2kcal/mL) NONEmL of lipid solution provided in 24 hr (if hung separately) ________ mLAmount of lipids infused in g/day ________ gkcal from lipids infused per day ________ kcal (did you check total volume/24hr?)-2256234762500Does the prescription meet the calculated nutrition needs?PN provides:____770____ Kcal___80_____ g Pro____1440____ mL Fluid per day. Compare toEst. Needs: ____1210-1375____ Kcal___83_____ g Pro____1375-1650____ mL FluidPN meets how much of calculated needs in %? ____64____% kcal ____96____ % Pro ____105%____ % FluidDo you have any recommendations?Continue to work with patient to make sure she is happy with her food selections to promote PO intake, so we can eventually discontinue TPN.N/AEnteral Calculations: What is the macronutrient composition of the Enteral Feedings recommended by the physician? Formula____________________Bolus? How frequent? ____________Continuous? NG PEG Other _________________Any PO intake? No Yes , explain ______________________________________________________________ Rate? ________mL/hrfor how long? 24hr 12hr/day ______hr/day Total volume (per day) of formula as ordered __________ mL/dayPer 1000mL this formula provides:__________ kcal__________ g Pro__________ mL free waterAs per total volume (per day) this formula provides:__________ kcal ( ________ kcal/kg)__________ g Pro (________ g Pro/kg)__________ mL free water Any stoppage time to the feedings? yes why? / how long? _________________________ no If you answered yes above, for how long did the TF run, and what percentage of formula was infused versus what was ordered for the day? ________________________ %Additional water flushes per day - __________ mL / day(also ask nursing how much water is given with medication and try to add to get an idea of fluid given)-22542528544500Total fluid provided (total free water plus additional flushes) __________ mL/day (_______ mL/kcal)Does the prescription meet the calculated nutrition needs?TF provides:________ Kcal________ g Pro________ mL Fluid per day. Compare toEst. Needs: ________ Kcal________ g Pro________ mL FluidTF meets how much of calculated needs in %? ________% kcal ________ % Pro ________ % FluidDo you have any recommendations?Interaction with the IDT (Interdisciplinary Team)Indicate if you had interactions with any of these other health care team members while providing nutrition care / patient careDescribe interactions with or referrals made to any of thesehealth care team professionals:Nursing (RN)Discussed calorie counts and pt actual intake.Physician (MD)Strategized with the endocrinologist to modify TPN solution and reduce the rate to increase natural hunger and therefore PO intake.Social Worker (SW)Speech Therapist (ST/SLP)Discussed swallow evaluations with speech to advance patients diet to regular foods (pt hated pureed foods!)Physical Therapist (PT)Often visited with pt while she was doing repetitive exercises with PT.Occupational Therapist (OT)Respiratory Therapist (RRT)Woundcare / Ostomy NursePhysician’s Assistant (PA)PharmacyDiscussed patient at nutrition support team rounds to come up with the best TPN solution to meet the patient’s needsNutrition Diagnosis (P-E-S) Statement (write 2)Problem: Altered GI functionrelated to (Etiology): pancreatic colonic mass and abdominal fistula presentas evidenced by Signs and Symptoms: need for TPN due to inadequate PO intakeProblem: Inadequate oral intake related to (Etiology): PO intake less than 25% of meals, per calorie countas evidenced by Signs and Symptoms: need for TPN because pt’s PO intake is not meeting needs of 1210-1375 kcal/day.Interventions (your recommendation as a dietetic intern)Continue current nutrition therapy planEncourage energy and protein intake by incorporating meal preferences into menu planningContinue to decrease TPN volume to help decrease early satiety and encourage PO intake Add a daily multivitamin with minerals Refer to social work to help patient find bariatric and cancer support groups upon dischargeMonitoring and Evaluation (how do you monitor this patient, how do you measure progress?)Monitor PO intake after calorie count, make sure patient is meeting energy and protein needs from PO diet alone before discontinuing TPNMonitor nutrition-related labs to determine additional needs or improvementMonitor supplement intake, tolerance and preferencesEducate patient and family on how to eat a well-balanced meals at home that are in compliance with bariatric surgery (small, frequent meals and low fat diet), use teach back method to check for understanding-9906036004500Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not familiar with)? This was the first time I encountered an abdominal fistula and learned about the healing process, including reducing the size of the drain for the internal wound. It was an interesting case because we were giving her nutrition support from multiple sources. A big motivation for her to eat was that when she was consuming adequate calories, we could discontinue the TPN and she could go home! ................
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