Nutrition Database



Intern Name Dawn OrtizPatient’s DOB06/03/58 Age56 SexM Today’s Date December 4, 2014Admit Date11/25/14 Admitting DiagnosisSeizure, lactic acidosis Prior Medical History eating disorder, spinal bifida Diet OrderNPO, TPN and EN SupplementsnoneIf applicable, describe food intake since admission or past 5 dayspt is too weak to eat and has been on and off ventilator since admission, failed swallow evaluation on 12/2. Any Food Allergies / Intolerances?None knownHeight (in inches and cm) 61 in, 155cm Weight (in pounds and kg)88#, 40kg Weight History x Loss Gain…if weight Δ, how much in what time frame? Was loss/gain intentional or unintentional?32# wt loss in 3 monthsUsual Body Weight (UBW)55kg Ideal Body Weight (IBW)52kg % IBW77% BMI16.6 Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)Per brother and sister in law, pt has a 20 year history with anorexia, it has always been aggravated by stressful situations and his mother was recently hospitalized, after his father with dementia fell on her. Patient lives alone and prepares his own meals and is food secure. No history of drug or alcohol abuse. Prior to admission patient stopped eating and drinking completely. He was collapsed and was able to call 911. He told the paramedics that he wants to live and needs help.Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)Drug name(s)IndicationNutritional ImplicationPepcidTreatment of stomach ulcers and GERDH2 antagonistFlagylAntibiotic NoneKeppraAnticonvulsantMay cause decreased appetite SennaLaxative Stimulates bowels (d/c’d today because pt having diarrhea)Vancomycin Antibiotic NoneNutrition 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?Na139 mmol/LNormalK4.4 mmol/LNormal (being replaced)BUN21 mg/dLNormal CREAT0.4 mg/dL↓Low—muscle wasting, increasing energy and protein may helpAlbumin2.9 g/dL↓Low—stressed and malnutrition, increasing energy and protein may helpPrealb3.7 mg/dL↓Low—stressed and malnutrition, increasing energy and protein may helpGlucose109 mg/dLNormal HgbA1CH/HMCVMCHIron (Fe)Transferrin Sat (%)FerritinVitamin B12FolateCa8.3 mg/dL↓Low—osteoporosis indicator, increasing calcium and vitamin D intake may helpPhos3.2 mg/dLNormal (being replaced)Mg1.9 mg/dLNormal (being replaced)Is Patients Skin Intact?Yes x No If no, Surgical Wound 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 x Constipation Difficulty Chewing Difficulty Swallowing xUnable to feed self Malabsorption x Early Satiety Taste Changes Reminder….for calculations, what was the patient’s height (cm) and weight (kg) again? 155cm40kgMale x Female Age 56Any stress factors, activity factors to consider? Malnutrition Calculate Energy Needs using1) Harris-Benedict ------------------------------------ 1013kcal2) Mifflin St. Jeor -------------------------------------- 1094kcal3) kcal/kg ----------------------------------------------- 1400-1600 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 and the pt has very high caloric needsShow your work for three of the five methods above used:1) BMR = 66.5 + (13.8 x 40kg) + (5 x 155 cm) – (6.8 x 56) = 1013 kcal/day2) (10 x 40kg) + (6.25 x 155cm) – (5 x 56) + 5 = 1094 kcal/day3) 35-40 kcal/kg/day35 x 40= 1400 kcal/day40 x 40= 1600 kcal/dayCalculate Protein NeedsHow many g/kg would you use & why? 1.5-2 g/kg for increased protein needs for cachexia in adult < 65 yearsShow your work:1.5g x 40kg = 60 g/day2.0g x 40kg = 80 g/day60-80g/dayCalculate Fluid Needs using1) ml/kg depending on age -----------------1200-1400ml/day2) Holliday-Segar method -------------------ml/day3) RDA method ---------------------------------ml/day4) urine output (urine out +500ml/day)-1625ml/dayWhat formula did you ultimately use for the Pt & why?? 30-35 mL/day is my hospital’s standard for adults < 65 yearsShow your work for two of the four methods above used:1) 30 mL x 40 kg= 1200 mL/day35 mL x 40 kg= 1400 mL/day4) 1125 mL + 500 mL = 1625 mLParenteral Calculations: What is the macronutrient composition of the TPN recommended by the physician? Rate? ___50_____mL/hrfor how long? 24hr x 12hr/day ______hr/day Any PO intake? No x Yes , explain ____________________________________________________________Total volume/24hr ___1200_______ mL2-in-1 Solution 3-in-1 Solution xCarbohydrateConcentration? D__10%______Amount of Dextrose (in grams) in 1000mL___100_____ gkcal from Dextrose in 1000mL (grams * 3.4 kcal/g) ____340____ kcalTotal kcal from Dextrose provided / 24hr? ___408_____ kcal (did you check total volume/24hr?)ProteinConcentration? __5.4______ % SolutionAmount of AA (in grams) in 1000mL___54_____ gkcal from AA in 1000mL (grams * 4 kcal/g) ___216_____ kcalTotal kcal from AA provided / 24hr? ___260_____ kcal (did you check total volume/24hr?)Lipids10% (1.1kcal/mL) 20% (2kcal/mL) x mL of lipid solution provided in 24 hr (if hung separately) ________ mLAmount of lipids infused in g/day ____25____ gkcal from lipids infused per day ___225_____ kcal (did you check total volume/24hr?)-2256234762500Does the prescription meet the calculated nutrition needs?PN provides:___893___ Kcal___54____ g Pro_____1220__ mL Fluid per day. Compare toEst. Needs: __1400-1600______ Kcal__60-80______ g Pro___1200-1400_____ mL FluidPN meets how much of calculated needs in %? ___62____% kcal __0.90____ % Pro ___1000____ % FluidDo you have any recommendations?See below for EN to meet nutrition estimated needs Enteral Calculations: What is the macronutrient composition of the Enteral Feedings recommended by the physician? Formula___Fibersource HN________________Bolus? How frequent? ____________Continuous? xNG x PEG Other _________________Any PO intake? No Yes , explain _______none___________________________________________________ Rate? ___20_____mL/hrfor how long? 24hr x 12hr/day ______hr/day Total volume (per day) of formula as ordered ___480____ mL/dayPer 1000mL this formula provides:___1200_______ kcal___54_____ g Pro____810______ mL free waterAs per total volume (per day) this formula provides:____576______ kcal ( _14______ kcal/kg)___26_______ g Pro (____0.7____ g Pro/kg)___389_______ mL free water Any stoppage time to the feedings? yes why? / how long? _________________________ no xIf 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 - _____0_____ 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:___576____ Kcal_____26___ g Pro___480_____ mL Fluid per day. Compare toEst. Needs: __1400-1600______ Kcal__60-80______ g Pro____1200-1400____ mL FluidTF meets how much of calculated needs in %? ___41____% kcal ___43____ % Pro ___40___ % FluidDo you have any recommendations? TF + TPN meets est. needs: total kcal= 1469, total protein= 80 g, total fluid= 1700 mL. Once patient is more stable another swallow evaluation should be completed by speech to hopefully advance to a PO diet. The plan is to discontinue nutrition support when needs can be met by PO diet alone.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)Many conversations with RN about general pt status, family involvement, frequent stools and tube feeding, we started with an NG that the pt kept pulling out and then moved to the OG tube for EN.Physician (MD)Worked closely with endocrinologist to make sure pt is meeting needs with TPN and EN combination Social Worker (SW)Detailed conversation with multiple social workers about pt status and what the next step will be if the pt recovers.Speech Therapist (ST/SLP)Conversations regarding swallow test evaluation and pt being too lethargic to participate in the test, discussed attempting again when pt is able.Physical Therapist (PT)Occupational Therapist (OT)Respiratory Therapist (RRT)Ordered a metabolic cart, however the pt was extubated, so we cancelled.Woundcare / Ostomy NursePhysician’s Assistant (PA)OtherNutrition Diagnosis (P-E-S) Statement (write 2)Problem: Disordered eating patternrelated to (Etiology): restrictive eating beliefs as evidenced by Signs and Symptoms: minimal to no PO intake for 10 days and wt loss of 32# in the past 3 months Problem: Malnutrition related to (Etiology): minimal to no PO intake for 10 days and wt loss of 32# in the past 3 months as evidenced by Signs and Symptoms: BMI of 16.6Interventions (your recommendation as a dietetic intern)Continue current nutrition therapy Reassess tube feeding and TPN based on patient’s nutrition related lab valuesRecommend replacing magnesium, potassium and phosphorus Notified social worker of the case and gave the history based on my interactions with the familyRecommend multivitamin with minerals, including thiamine, zinc and folate supplementation Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)Monitor tube feeding toleranceMonitor PN toleranceMonitor nutrition related labs for signs of refeeding syndrome Trend weightsMonitor bowel movements to check for absorption of nutrients-9906036004500Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not familiar with)? Initially, this patient was unable to eat because he was intubated, currently he is on EN and TPN because he is too weak to swallow. It will be interesting to observe his progress and see if he will eat enough on a PO diet for nutrition support to be discontinued. ................
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