Nutrition Database

Intern Name Angela Misko

Patient Initials SR DOB 5/17/50 Age 63 Sex Female Unit/Room# 936
Admit Date 10/20/13 Admitting Diagnosis Intractable emesis in pt with metastatic ca
Prior Medical History Dyslipidemia, Ovary Ca, Signet Ring Cell Carcinoma, Hysterectomy, Appendectomy, Intestinal
resection with ileostomy.
Diet Order Full Liquids/TF Osmolite 1.2 @ 20ml/hr/TPN Supplements None
If applicable, describe food intake since admission or past 5 days Poor po intake. Not tolerating TF.
Any Food Allergies / Intolerances? No known.

Height (in inches and cm) 50 Weight (in pounds and kg) 95lbs (43kg) Weight History Loss Gain
if weight , how much in what time frame? Was loss/gain intentional or unintentional? Unintentional wt. loss in less
than 6 months per pt and pts husband due to getting sick.
Usual Body Weight (UBW) 138 Ideal Body Weight (IBW) 100 % IBW 95 % BMI 18.5

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)
Retired. Religion unknown. Lives with husband at home who is support system.
No alcohol or drug use. Husband prepares meals.

Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)
Drug name(s) Indication Nutritional Implication
Reglan GERD N/V/D
Protonix GERD N/V/D
Zofran Prevent nausea and
vomiting caused by
cancer chemotherapy,
radiation therapy, and
surgery
Diarrhea, Constipation
Pain Meds Pain N/V/D/C, Loss of
appetite, Wt. Loss
Phenergan Relieve the symptoms of

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allergic reactions







Nutrition related laboratory values
Lab Test
Lab value indicate if
abnormal
high or low ( or )
Nutritional significance if abnormal
Can a nutrition intervention help to correct this abnormal lab value? How?

Na
141
K
3.8
BUN
22
CREAT
1.25 Could indicate Impaired renal function or
dehydration. Intervention includes increased
protein needs and supplementation.

Albumin
2.9 Could indicate malnutrition, chronic
inflammation/infection, liver or kidney failure,
and protein loss. Intervention includes
increased protein and calorie needs and
supplementation.
Prealb
10 Could indicate malnutrition, liver damage, or
inflammation. Intervention includes increased
protein needs and supplementation.

Glucose
109
HgbA1C


H/H

MCV

MCH

Iron (Fe)

Transferrin Sat (%)

Ferritin


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Vitamin B
12
Folate


Ca
9.4
Phos
3.1
Mg
1.8


Is Patients Skin Intact? Yes No
If no, Surgical Wound Decubitus Ulcer
If decubitus ulcer, list stage (I-IV) and site(s) Stage 1 Sacral Pressure Ulcer
Is decubitus ulcer Improving? Getting worse?
Is any of the following present? Nausea Vomiting Diarrhea Constipation
Difficulty Chewing Difficulty Swallowing
Unable to feed self Malabsorption Early Satiety Taste Changes

Reminder.for calculations, what was the patients height (cm) and weight (kg) again? 152 cm 43 kg
Male Female Age 63
Any stress factors, activity factors to consider? Catabolic Illness, Ambulatory


Calculate Energy Needs using
1) Harris-Benedict ------------------------------------ 1,532 kcal
2) Mifflin St. Jeor -------------------------------------- 1,300 kcal
3) kcal/kg ----------------------------------------------- 1,500 kcal
4) Ireton Jones (only use in critically ill) ------- kcal
5) Penn State 2010 equation ---------------------- kcal

What formula did you ultimately use for the Pt & why? Kcal/kg gives an appropriate range and is hospital protocol.
Show your work for three of the five methods above used:




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1. Harris Benedict
RMR= 655 + 9.6 (43kg) + 1.8 (152cm) 4.7 (63yrs)
RMR= 655 + 413 + 274 296
RMR= 1,046 RANGE: 1,500-1,700kcal
AF=Ambulatory (1.2) SF= Catabolic Illness (1.2)
RMR= 1,064 X 1.2 X 1.2
RMR=1,532kcal

2. Mifflin St. Jeor
RMR= 10 (43kg) + 6.25 (152cm) 5(63yrs) -161
RMR= 430 + 950 -315 161 RANGE: 1,300-1,500kcal
RMR= 904 x 1.2 x 1.2
RMR= 1,300kcal

3. Kcal/kg
43kg x 35kcal = 1,505kcal
43kg x 40kcal = 1,720kcal RANGE: 1,500-1,700kcal



Calculate Protein Needs
How many g/kg would you use & why? 1.5-2.0g/kg because this pt has increased protein needs due to catabolic
illness (metastatic cancer).
Show your work:

43kg x 1.5g = 65gm Pro
43kg x 2.0g = 86gm Pro

65-86 g/day





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Calculate Fluid Needs using
1) ml/kg depending on age ----------------- 1,290 ml/day
2) Holliday-Segar method ------------------- ml/day
3) RDA method --------------------------------- 1,700 ml/day
4) urine output (urine out +500ml/day)- ml/day
What formula did you ultimately use for the Pt & why?? ~1,700ml because the range is higher and more
appropriate. Increased creatinine labs could indicate dehydration. Pt c/o extreme thirst.
Show your work for two of the four methods above used:
1. Ml/kg
63 years use: 30ml/kg
43kg x 30ml= 1,290ml/kg

2. RDA method
~1700kcal based on 40kcal/kg



Parenteral Calculations: What is the macronutrient composition of the TPN recommended by the physician?

Rate? ____75____mL/hr for how long? 24hr 12hr/day ______hr/day
Any PO intake? No Yes , explain ___Full Liquids______________________________________________
Total volume/24hr ____1800______ mL 2-in-1 Solution 3-in-1 Solution

Carbohydrate Concentration? D___8%_____ Amount of Dextrose (in grams) in 1000mL___144_____ g
kcal from Dextrose in 1000mL (grams * 3.4 kcal/g) ________ kcal
Total kcal from Dextrose provided / 24hr? ________ kcal (did you check total volume/24hr?)

Protein Concentration? ________ % Solution Amount of AA (in grams) in 1000mL__60____ g

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kcal from AA in 1000mL (grams * 4 kcal/g) ________ kcal
Total kcal from AA provided / 24hr? ________ kcal (did you check total volume/24hr?)

Lipids 10% (1.1kcal/mL) 20% (2kcal/mL)
mL of lipid solution provided in 24 hr (if hung separately) ________ mL
Amount of lipids infused in g/day ________ g
kcal from lipids infused per day ________ kcal (did you check total volume/24hr?)

Does the prescription meet the calculated nutrition needs?
PN provides: ____852____ Kcal ____60____ g Pro ___1800_____ mL Fluid per day. Compare to
Est. Needs: ____1500____ Kcal _____65___ g Pro __1700_____ mL Fluid
PN meets how much of calculated needs in %? ____57__% kcal __92____ % Pro ___106___ % Fluid
Do you have any recommendations? Pt is also receiving nutrition from TF, so no recommendation for TPN at this
time.



Enteral Calculations: What is the macronutrient composition of the Enteral Feedings recommended by the physician?

Formula__Osmolite 1.2 _________ Bolus? How frequent? ____________ Continuous?
NG PEG Other ____PEJ_____________
Any PO intake? No Yes , explain _Full Liquids_______________________________________________
Rate? ____20_mL/hr for how long? 24hr 12hr/day ______hr/day
Total volume (per day) of formula as ordered __________ mL/day

Per 1000mL this formula provides: __________ kcal
__________ g Pro
__________ mL free water


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As 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)
Total fluid provided (total free water plus additional flushes) __________ mL/day (_______ mL/kcal)
Does the prescription meet the calculated nutrition needs?
TF provides: ____576____ Kcal ___27_____ g Pro ____394____ mL Fluid per day. Compare to
Est. Needs: ____1500____ Kcal ____65____ g Pro ____1700____ mL Fluid
TF meets how much of calculated needs in %? ________% kcal ________ % Pro ________ % Fluid
Do 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 care
Describe interactions with or referrals made to any of these
health care team professionals:
Nursing (RN)

Check shift assessment for skin integrity and any significant GI issues. Spoke
with nurse about TF regimen, tolerance to TF, and any residuals.
Physician (MD)

Checked MD chart for any pertinent information regarding patients
nutritional status. For example, the following information was pulled from
the MDs note: Metastatic cancer. s/p intestinal resection with ileostomy,
s/p endoscopic gastrostomy tube placement now with percutaneous
endoscopic gastrostomy site open. Tube feeding was replaced to PEJ on
11/13. Receiving relistor 8mg to improve GI motility. TF well tolerated but is
leaking. Increased gastric residuals despite decreased TF rate. Drainage
around tube, pt can only tolerate low doses of TF. There are TF issues and
minimal stoma output on 11/18. Pt refusing hospice. Difficult situation.
Social Worker (SW)

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Speech Therapist (ST/SLP)


Physical Therapist (PT)


Occupational Therapist (OT)


Respiratory Therapist (RRT)


Woundcare / Ostomy Nurse

Checked wound specialist assessment for inquiry on wounds. Found stage 1
sacral wound.
Physicians Assistant (PA)


Other



Nutrition Diagnosis (P-E-S) Statement (write 2)
Problem: Inadequate Suboptimal enteral nutrition infusion

related to (Etiology): tube malfunction

as evidenced by Signs and Symptoms: leaking from peg tube, increased gastric residuals, and TF currently meeting
38% estimated kcal and 42% estimated protein needs.

Problem: Increased nutrient needs (protein/kcal)

related to (Etiology): Catabolic illness and severe wt. loss

as evidenced by Signs and Symptoms: metastatic cancer and >10% wt loss within 6 months.

One more possible: Inadequate oral intake related to poor appetite as evidenced by patient report.

Interventions (your recommendation as a dietetic intern)
TPN goal rate when feasible at 90gm protein, dextrose 225gm as well as daily lipids to provide 1625kcal.


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TF goal rate if medically feasible osmolite 1.2 @ 55ml/hr to provide 1584kcal, 73gm protein, and 1082 ml free
h20.

Do not d/c TPN or TF unless diet is advanced, well tolerated, and is meeting over 75% of pt needs.

Consider combination of TPN and TF to provide nutritional needs. Consider TPN as above with TF at goal rate
of 30ml/hr to provide 864kcal, 40gm protein, and 590ml of free h2o.

To follow


Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)
Monitor po intake goal >75% and tolerance

Monitor tolerance to TF and TPN regimen

Monitor skin integrity/wound healing

Prealbumin >18

All labs (cmp) wnl as able

Monitor MD orders and future family decisions


Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not
familiar with)?