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 |LK |Medical Dx For This Admit |Prematurity, Respiratory |

| | | |Failure, IUGR |

|Age |Newborn (21 do/34+ wks PMA as | | |

| |of last f/u assmt.) | | |

|Gender |Male | | |

|Occupation |NA |Insurance Coverage | |

|Allergies/Intolerances |NKA |Care Giver (If Needed) |Mother |

2. Medical Hx:

| |Identify |

|Family / Social Hx | |

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|Past Medical / Surgical Hx |Mom with PIH, Delivered via C-section, APGARS 8/9 |

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|Symptoms Related to Current |Respiratory Distress, required VT (vapotherm), grade 2 bilateral brain bleeds |

|Diagnosis | |

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|Summary of Important Events While in Hospital |Watching grade 2 brain bleed. |

| |Advancing enteral feeding per guidelines |

| |Transitioned to RA (Room Air) |

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|Procedures Done While in Hospital (Include Dates) or Procedures |Fix tongue tie-planned (not done, passed swallow eval) |

|that are Planned |On 9/23 received Darbepoetin |

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3. Anthropometrics:

Current Weight: _1276 gm (0 %ile)__ Current Height: _39 cm (0 %ile)_____ UBW: _NA_______

IBW: __per growth chart (aiming to catch up to the 3%ile) % IBW: ____Na___ BMI: _NA______

Amputations: __None____ Adjustment for spinal cord injury: __None________

Weight History:

|Date/Time |Weight |Ln and OFC |Weight |

|10/6 8:00 |1276 gm |Avg wt 10 g/kg/d x 1wk. Ln and | |

| | |OFC trending below the 3rd %ile | |

|9/29 12:54 |1185 gm |Avg wt gain up 9 g/kg/d x1 wk. | |

| | |Ln not trending. OFC still | |

| | |trending. | |

|9/22 15:07 |1110 gm |Ht 37.5 cm (0%ile), OFC 27.25 cm| |

| | |(4%ile) | |

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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: _Weight gain was overall good but more is still needed for catch-up growth since LK is IUGR. Gain was assisted by NICU staff. Expected 18-20 g/kg/day gain to continue for optimal growth.___

4. Estimated Energy Needs (1): __Based off of McKay Dee standards____

My calculated recommendations for this patient at _McKay Dee (facility) were formulated using the following standard estimates of _110-120 kcals/kg/day_ energy needs, _3.5-4.5g/kg/day protein needs, and _150-160 ml_ fluid needs.

Justification for my calculated recommendations: _These are the numbers they use at McKay Dee based on clinical practice as well as published research/ASPEN standards to develop their own facility feeding protocols. Since the infants are supposed to be gaining every day their weight changes enough for the calories to change over time and the recommendations are put in “per kg per day” and continually reassessed as the baby grows, or doesn’t grow. The calculations are done based on these numbers. The above two ways of calculating needs are not appropriate for infants. These estimated needs are appropriate for premature catch-up growth of at least 15-20 g/kg/day.

Kcal/day: _140-153________ Grams of protein/day: _4.5-5.7______

Fluid needs/day: _191-204 ml______ Nitrogen needs/day: _0.912_______

NPC:N ratio: _142.8____________

5. Biochemical:

Laboratory Information

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Interpret glycemic control and give possible explanations for variation in blood glucose levels. Include in your explanation interventions taken to normalize blood glucose levels: ________________________________________________________________________

_________NA___________________________________________________________________________________________________________________________________________________________________________________________________________

Insulin/kg: ______________

Assessment of insulin resistance: _____________________________________________________________________________________________________________________________________________________________NA_______________________________________________________________________________________________________________________________

6. Medications:

|Medication |Use |Diet-related side |Signs/symptoms experiences by |

|(include dose) | |effects/restrictions |patient |

|Caffeine 10 mg q24 |CNS breathing stim |Some increased needs |Not sure |

|Sucrose 1 ml prn |For calming |Adds kcals |NA |

|MVT with Fe 0.5 ml |Supplement |Toxicity |None |

|Rash Cream | | | |

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|Self-prescribed medications and | | | |

|nutrition supplements | | | |

7. Clinical Evaluation:

Circle observed signs of nutrient deficiency:

Hair: Loss Mouth: Stomatitis

Thin, sparse Cheilosis

Nails: Spoon shape Glossitis

Transverse ridging Gingivitis

Tongue Tie

Skin: Dry, scaling Teeth: Missing

Jaundice Poorly fit dentures

Dermatosis Muscles: Edema

Petechiae Muscle wasting

DQ ulcer: Stage _____ Eyes: Icteric

Identify observed signs of nutrient deficiencies and list possible nutrition-related causes:

_None related to nutrition deficiency. _______________________________________________________________

Describe any physical handicaps that affect intake. Determine patient’s ability to perform activities of daily living: __Infant is still newborn and must be completely cared for. At less than 34 weeks PMA he is barely acquiring the reflexes needed to feed. SLP says that they are not worried about the tongue tie issue but will continue to monitor. ________________________________________________________________________

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8. Dietary:

|Date & time |Diet order |PO % |Assess tolerance to diet |Is diet adequate to meet patient’s|

| | | | |needs? |

|9/22/15 |EN + TPN |Npo |Tolerating |Optimized but no |

|9/29/15 |EN |Introduced bottle |Tolerating |Needs more pro for metabolic |

| | |1% nippling | |growth |

|10/6/15 |EN |Nippling 3% |Tolerating with some diaper rash |Needs more pro for metabolic |

| | | | |growth |

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Identify and evaluate any chewing/swallowing problems. Include in your explanation interventions taken to modify diet: _Was slightly tongue tied but seems to be handling the bottle well enough and is advancing slowly on EN via bottle/nipple. ________________________________________________________________________________________________________________________________________________

Obtain a diet history when needed for diet instructions or to discern patient’s nutritional status when appropriate:

|Meal & time |Food & preparation method |

|9/22/15 |PHM 22 kcal with Prolacta 10 ml q3, D10% TPN with 20% IL @ 0.7 |

| |for IV+PO total of 7 ml/hr provides per kg: 151 ml, 112 kcal, |

| |2.9 gm PRO, 76 mg Ca, 51 mg P, 0.1 mg Fe, and 90 units vit D. |

|9/29/15 |PHM 24 w/ Prolacta 23 ml q3, MVT w/ Fe 0.5 ml. Provides per |

| |kg: 155 ml, 123 kcals, 3.4 g PRO, 165 mg Ca, 86 mg P, 4.5 mg |

| |Fe, 242 units Vit D. |

|10/6/15 |PHM 22 kcals with liquid sim HMF HP @ 25 ml q3 + 0.5 ml MVT w/ |

| |Fe. Provides per kg: 157 ml, 117 kcals, 2.9 g PRO, 125 mg Ca, |

| |69 mg P, 4.3 mg Fe, 331 units vit D. |

Evaluate diet history by using dietary software. Interpret findings: _Not applicable______________________________________________________________

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Determine if food security influences diet. List possible interventions available to improve food procurement:

_Does not currently influence diet, receiving food in hospital since birth. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Education:

List all nutrition education given to the patient. Determine if there are any social, emotional, or physical factors that affect adherence to the education. Assess patient’s understanding, compliance, and receptivity:

_Mother has been receiving education on caring for her premature child from hospital staff. Pt mother will require education on appropriate feeding/fortification and what formula that will be require upon discharge from NICU. Good compliance expected by the mother and pt tolerance to home formula will be assessed before discharge. __________________________________________________________________

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10. Coordination of Nutrition Care:

Determine if any referrals need to be made to other programs or services and explain why:

_WIC was considered but mother does not qualify. Social work has been following up regularly with mother to make sure she is doing well and that home life for the pt will be stable enough to be discharged to. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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11. Nutrition Screening:

Currently patient is assessed at _HIGH______ nutrition risk based on the nutritional standards at _McKay Dee NICU_ (facility).

Justification for degree of nutrition risk assessed: _The pt is still not eating fully by bottle, will need continued enteral feedings. Pt is still not receiving enough protein and growth is under the 3rd %ile in OFC, Ln, and Wt.__

Nutrition Note:

Nutrition Assessment(s) and Follow-Up Note(s) based on _McKay Dee (facility) format:

9/22/15

ADIME

A: Baby boy was admitted @ 31 6/7 weeks d/t prematurity and IUGR from maternal PIH; delivered via c-section. Current anthros: Wt 1110 gm (0%ile), Ht 37.5 cm (0%ile), OFC 27.25 cm (4%ile). APGARS 8/9. Currently 7 days old and 32+ weeks PMA. Stable VT respiratory support. On TPN via peripheral line. GIR = 9/6 mg/kg/min, IL @ 3 g/kg/d, and protein @ 3.5 g/kg/d. EN @ 50% volumes. Advancing per feeding guidelines. Receiving PHM fortified to 22 kcal/oz using Prolacta. Mom not planning to provide MM. 102% BW, IUGR on all parameters per Fenton growth chart. Labs show hyponatremia and hypophosphatemia. Treating hyperbilirubinemia with PRN photo tx. Current diet order of EN+TPN. Infant IUGR status places baby @ increased risk of nutrient defecits. Estimated needs for acute state: 90-110 kcals/kg, 3.5-4 g/kg PRO, 150-160 ml/kg. TPN optimized, but cannot meet needs for growing infant. Wt trend appropriate, but growth not expected to meet expectations d/t constraints of TPN and suboptimal EN volumes and fortification. Will continue to monitor TPN provision of Na and P to normalize labs as able.

Enteral nutrition order (FH-2.1.1.3) and Parenteral nutrition order (FH-2.1.1.4), Height/length AD-1.1.1, Weight AD-1.1.2, Growth pattern indices/percentile ranks AD-1.1.6

D: Increased nutrient needs (NI-5.1) r/t Physiological causes increasing nutrient needs d/t accelerated growth or anabolism AEB prematurity.

I: EN (ND-2.1) + TPN (ND-2.2)

PHM 22 kcal with Prolacta 10 ml q3, D10% TPN with 20% IL @ 0.7 for IV+PO total of 7 ml/hr provides per kg: 151 ml, 112 kcal, 2.9 gm PRO, 76 mg Ca, 51 mg P, 0.1 mg Fe, and 90 units vit D.

Recommendations:

1- Maintain volumes @ 150-160 ml/kg/d

2- Contin ue to optimize TPN as able; special consideration for P and Na

3- Continue to advance EN as able

• Goal Fortification @ 24+ kcals/oz

• Consider using Similac liquid HMF HP

Goals: Wt gain of 18-20 g/kg/d, Optimal trends in Ln and OFC, Nutrition related labs WNL.

M/E: Enteral nutrition order (FH-2.1.1.3) and Parenteral nutrition order (FH-2.1.1.4). Will continue to assess and monitor TPN provision, advancement of EN volumes and fortification, and normalization of labs. RD to do full reassessment in 1 wk, including weight, ln, and OFC check.

Height/length AD-1.1.1, Weight AD-1.1.2, Growth pattern indices/percentile ranks AD-1.1.6

9/29/15

Follow up ADIME

A: Baby Boy is now 14 days old and 33+ wks PMA. Transition from VT to RA. Transitioned from TPN/EN to full EN on 9/25, increased to 24 kcals/oz using Prolacta fortifier on 9/28. Continue to use PHM as mom not providing milk Feeds gavaged via NG over 45 min d/t s/s GER. Good feeding cues, introduced bottle today. Wt gain = 9 g/kg/d x 7 days, OFC trending, length unchanged. Wt trend inadequate likely influenced by suboptimal nutrition x 1 wk. Expect some improvement of trends but prolacta does not meet goal micronutrient needs. Pt will require more PRO to feacilitate metabolic growth, AEB low BUN. Labs show normalizing Na, stable Ca, P, ALP. Noted low BUN. Tbil remains slightly elevated not currently requiring photo tx.

Enteral nutrition order (FH-2.1.1.3), Height/length AD-1.1.1, Weight AD-1.1.2, Growth pattern indices/percentile ranks AD-1.1.6

D: Inadequate oral intake (NI-2.1) r/t decreased ability to consume sufficient energy, nutrients AEB less than 24 wks GA.

Increased nutrient needs (NI-5.1) r/t physiological causes increasing nutrient needs d/t accelerated growth or anabolism AEB prematurity.

I: EN (Enteral Nutrition (ND-2.1))

PHM 24 w/ Prolacta 23 ml q3, MVT w/ Fe 0.5 ml. Provides per kg: 155 ml, 123 kcals, 3.4 g PRO, 165 mg Ca, 86 mg P, 4.5 mg Fe, 242 units Vit D.

Recommendations:

1- Consider transition to Sim liquid HMF HP to better meet PRO and micronutrient needs.

2- Maintain volumes @ 150-160 ml/kg/d.

Goals are: Wt gain of 18-20 g/kg/d, Optimal trends in Ln and OFC, Nutrition related labs WNL.

M/E: Enteral nutrition order (FH-2.1.1.3). Will continue to assess advancement of EN volumes and fortification, and continued normalization of labs. RD to do full reassessment in 1 wk, including weight, ln, and OFC check.

Height/length AD-1.1.1, Weight AD-1.1.2, Growth pattern indices/percentile ranks AD-1.1.6

10/6/15

F/u note

A: Baby Boy is now 21 days old and 34+ wks PMA. Doing well on RA. Transitioned to PHM 22 with liquid Sim HP 25 ml q3 on 10/3. Good Feeding cues, bottle quality scores have been 2-3 since 10/2, nippling 3% of feed on 10/4. Wt gain averaging up 10 g/kg/d x 1wk. Wt remains well under the 3rd, not trending, with Ln and OFC trending below the 3rd. Tbil slightly elevated not requiring photo tx, BUN slightly low, other labs reassuring. Infant on MVT with Fe 0.5 ml/day.

D: Inadequate oral intake (NI-2.1) r/t decreased ability to consume sufficient energy, nutrients AEB less than 24 wks GA.

Increased nutrient needs (NI-5.1) r/t physiological causes increasing nutrient needs d/t accelerated growth or anabolism AEB prematurity.

I: EN (Enteral Nutrition (ND-2.1)

PHM 22 kcals with liquid sim HMF HP @ 25 ml q3 + 0.5 ml MVT w/ Fe. Provides per kg: 157 ml, 117 kcals, 2.9 g PRO, 125 mg Ca, 69 mg P, 4.3 mg Fe, 331 units vit D.

Recommendations:

1- Advance to 24 kcals as tolerated.

2- Maintain volumes @ 150-160 ml/kg/day

Goals: Wt gain of 18-20 g/kg/d, Optimal trends in Ln and OFC, Nutrition related labs WNL.

M/E: Enteral nutrition order (FH-2.1.1.3). Will continue to assess advancement of EN volumes and fortification, and continued normalization of labs. RD to do full reassessment in 1 wk, including weight, ln, and OFC check.

Height/length AD-1.1.1, Weight AD-1.1.2, Growth pattern indices/percentile ranks AD-1.1.6

Literature Review

Brief explanation of disease

• Intrauterine growth restriction (IUGR) is the poor growth of an infant in the womb during pregnancy1. It can affect nutrition, brain development, and the rate of growth of the infant during the course of their childhood and life2.

• LK was IUGR related to maternal Pregnancy Induced Hypertension (PIH) and was delivered at 31 and 6/7 weeks via cesarean section.

Cause, incidence and risk factors

• The fetus may not be getting enough oxygen or nutrition during pregnancy due to high altitude, multiple pregnancy, preeclampsia/eclampsia, or placental problems1.

• IUGR can be caused by infections during pregnancy, congenital abnormalities or chromosome problems1.

• IUGR can occur if the mother smokes, abuses alcohol or drugs, has a clotting disorder, high blood pressure or heart disease, kidney disease, or has poor nutrition1.

• IUGR increases the risk of a miscarriage or stillbirth1.

• Baby Boy’s mother had PIH which was likely the cause of the early delivery and IUGR.

Signs, symptoms and tests

• The doctor following the pregnancy can measure the uterine fundal height, which is from the mother’s pubic bone to the top of the uterus and see if is smaller than expected for the baby’s gestational age1,2.

• The mother may feel that the baby is smaller than it should be and can be confirmed by ultrasound3.

• Infection and genetic tests may be indicated if IUGR is suspected3.

• Nonstress testing can be done to determine if the baby should be delivered earlier than the due date2.

• Baby Boy’s mother had a nonstress test and it was determined the infant should be delivered at 31+ weeks.

Medical treatment

• Monitoring the growing fetus closely with the patient’s OB is recommended to catch problems early2.

• Early delivery may be indicated by the testing of infant movement, blood flow, fluid around the baby, membrane status, or nonstress test results2,3.

• Once the infant is born, oxygen therapy can be initiated, due to importance in the metabolic process4.

• Baby Boy’s mother was receiving prenatal care; the OB was able to monitor LK’s growth.

• Baby Boy was delivered at 31+ weeks d/t PIH indications.

• Baby Boy was on VapoTherm oxygen until he was able to be weaned off to room air.

Nutrition treatment

• Preterm infants have higher energy, protein, and fluid needs that better reflect the nutrition they would be getting in the womb5.

• Preterm estimated needs are6,7:

| |Parenteral Nutrition |Enteral Nutrition |Mixed Feeds |

|Energy (kcals/kg/d) |90-120 (90-110) |105-130 (110-120) |100-110 |

|Fluid (mL/kg/d) |150-160 |150-160 |150-160 |

|Protein (g/kg/d) |3-4 |3.5-4.5 (depending on current |3-4.5 |

| | |wt) | |

• Infant growth will help assess nutrition status. A premature infant should grow 15-20 g/kg/d with length up 0.8-1.1 cm/wk and Head circumference up 0.5-1 cm/wk5,8.

• Baby Boy was trending under the 3rd%ile in weight, length, and OFC.

• Baby Boy was on Enteral nutrition to meet nutrition needs; due to some constraints and slow advancement of EN, LK had suboptimal protein intake, which resulted in inadequate wt, ln, and OFC growth.

Complications

• IUGR infants can become stressed during labor and are often born via C-section delivery1.

• IUGR infants are usually preterm and have greater nutrient needs than a normal term infant. They can be at greater risk for energy deficits which can effect overall growth and brain development9.

• Baby Boy was born via C-section.

• Baby Boy had protein and calorie deficits which negatively affected proper weight gain and length trends.

Disease management and prevention

• Do not drink alcohol, smoke, or use drugs during pregnancy1,3.

• Eat a healthy diet before conception and during pregnancy3.

• When the patient finds out about pregnancy, get consistent prenatal care to help prevent potential problems1.

• The patient should ask their health care provider about any medications they take regularly or how any chronic medical conditions will affect their pregnancy1,3.

• Baby Boy’s mother did not drink alcohol, smoke, or use drugs during pregnancy and she got prenatal care.

• Baby Boy’s mother had PIH followed closely.

Any other conditions that contributed to NCP

• Baby Boy had inflamed, irritated buttocks contributed because the doctor was slow to advance higher protein feedings in case of further irritation to the bowels and resulting irritant dermatitis of the buttocks.

References

1- White CD, American F, Obstetricians, et al. Intrauterine growth restriction: MedlinePlus Medical Encyclopedia. 2014. . Accessed September 30, 2015

2- Figueras F, Gardosi J. Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management.Am J Obstet Gynecol

3- Baschat AA, Galan HL, Ross MG, Gabbe SG. Intrauterine growth restriction. In: Gabbe SG, Niebyl JR, Simpson JL, eds.Obstetrics: Normal and Problem Pregnancies

4- Hay WW. Strategies for feeding the preterm infant. Neonatology. 2008;94(4):245-54.

5- Uauy R, Koletzko B. Defining the nutritional needs of preterm infants. World Rev Nutr Diet. 2014;110:4-10

6- Corkins MR. Pediatric Nutrition Support Handbook. American Society for Parenteral & Enteral Nutrition; 2011.

7- Koletzko B, Poindexter B, Uauy R. Recommended nutrient intake levels for stable, fully enterally fed very low birth weight infants. World Rev Nutr Diet. 2014;110:297-9.

8- Koletzko B. Nutritional Care of Preterm Infants, Scientific Basis and Practical Guidelines. S Karger Ag; 2014.

9- Hulst JM, Goudoever JBV, Zimmermann LJI, HOP WCJ, Albers MJIJ, Tibboel D, Joosten KFM. The Effect of Cumulative Energy and Protein Deficiency on Anthropometric Parameters in a Pediatric ICU Population. Clinical Nutrition. 2004:23;1381-1389

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