Nutrition Database

Intern Name Jessica Grilliot

Patient Initials TT DOB 1/24/1956 Age 57 Sex M Unit/Room# 4118
Admit Date 10/14/13 Admitting Diagnosis SBO
Prior Medical Histor Colon Cancer, Colon Surgery, Shoulder Surgery, Dilation Esophagus
Diet Order TPN 5/D15 Solution with standard electrolytes Supplements N/A
If applicable, describe food intake since admission or past 5 days NPO except ice chips, popsicles, sips with meds
Any Food Allergies / Intolerances? No

Height (in inches and cm) 72, 183 cm Weight (in pounds and kg) 192 lb, 87.36 kg Weight History
Loss Gain
if weight , how much in what time frame? Was loss/gain intentional or unintentional? 25 lb time not specified
Usual Body Weight (UBW) 217 Ideal Body Weight (IBW) 80.9 kg % IBW 108 % BMI26.347

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)
Never smoked, drinks 3-4 cans beer 2x/wk, married, white


Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)
Drug name(s) Indication Nutritional Implication
Enoxaparin Anticoagulant Not with pork allergy
Fentanyl Analgesic Anorexia
Zofran Antiemetic N/A
Magnesium Hydroxide Laxative, Antacid 15-30% Mg is absorbed
Morphine Analgesic Anorexia, decreased wt,
increased thirst,
dehydration





Nutrition Database


Nutrition related laboratory values LAB VALUES NORMAL
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
136 N
K
3.9 N
BUN
18 N
CREAT
.9 N

Albumin
4.1 N
Prealb
N/A

Glucose
89 N
HgbA1C
N/A

H/H
12.1 L 36.3 L No
MCV
88.5 N
MCH
29.4 N
Iron (Fe)
N/A
Transferrin Sat (%)
N/A
Ferritin
N/A
Vitamin B
12 N/A
Folate
N/A

Ca
N/A
Phos
N/A
Mg
N/A


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 ulcer Improving? Getting worse?
Is any of the following present? Nausea X Vomiting X Diarrhea Constipation
Difficulty Chewing Difficulty Swallowing
Unable to feed self Malabsorption Early Satiety Taste Changes


Nutrition Database


Reminder.for calculations, what was the patients height (cm) and weight (kg) again? 182 cm 87.36 kg
Male X Female Age 57
Any stress factors, activity factors to consider? Yes, cancer pt confined to bed. 1.1 and 1.2



Calculate Energy Needs using
1) Harris-Benedict ------------------------------------ 2362 kcal
2) Mifflin St. Jeor -------------------------------------- 2278 kcal
3) kcal/kg ----------------------------------------------- 2184 kcal
4) Penn State 2010 equation ---------------------- 2364 kcal
What formula did you ultimately use for the Pt & why? 25 kcal/kg BW. I dont want him to lose weight because
of increased needs with cancer. He has already lost weight and is likely to lose more, so I will get what I can in him
within reason.
Show your work for three of the five methods above used:
Kcal/kg: 25*87.36 = 2184
Harris Benedict: 66 + 13.76 (87.36) + 5 (182) 6.8 (57) = 1789*1.1*1.2 = 2362
Mifflin St. Jeor: 10 (87.36) + 6.25 (182) 5 (57) = 1726*1.1*1.2 = 2278












Nutrition Database





Calculate Protein Needs
How many g/kg would you use & why? 1.5 to prevent further muscle wasting because of stress from cancer

Show your work: 80.9 x 1.5 = 121 g pro



121 g/day



Calculate Fluid Needs using
1) ml/kg depending on age ----------------- 2427 ml/day
2) Holliday-Segar method ------------------- 2318 ml/day
3) RDA method --------------------------------- 2148 ml/day
4) urine output (urine out +500ml/day)- n/a ml/day
What formula did you ultimately use for the Pt & why?? RDA method From the EAL: In addition, there was
no evidence found to establish or validate the [fluid] equations. These three equations have however been cited
extensively in many well respected documents and widely used in clinical practice.
http://andevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250894
Show your work for two of the four methods above used:
Ml/kg depending on age: 30 x 80.9 = 2427 ml/day
RDA Method: 25 x 80.9 = 2148 ml/day




Nutrition Database






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

Rate? __42______mL/hr for how long? 24hr X 12hr/day ______hr/day
Any PO intake? No X Yes , explain ______________________________________________________________
Total volume/24hr _____1008_____ mL 2-in-1 Solution 3-in-1 Solution

Carbohydrate Concentration? D____15%____ Amount of Dextrose (in grams) in 1000mL___302_____ g
kcal from Dextrose in 1000mL (grams * 3.4 kcal/g) ____1026____ kcal
Total kcal from Dextrose provided / 24hr? ___1037_____ kcal (did you check total volume/24hr?)

Protein Concentration? ____5____ % Solution Amount of AA (in grams) in 1000mL____50____ g
kcal from AA in 1000mL (grams * 4 kcal/g) ____200____ kcal
Total kcal from AA provided / 24hr? ___202_____ kcal (did you check total volume/24hr?)

Lipids 10% (1.1kcal/mL) 20% (2kcal/mL) X
mL of lipid solution provided in 24 hr (if hung separately) ___107_____ mL
Amount of lipids infused in g/day ____21____ g
kcal from lipids infused per day ____212____ kcal (did you check total volume/24hr?)

Does the prescription meet the calculated nutrition needs?
PN provides: ___1451_____ Kcal ____50____ g Pro ____1115____ mL Fluid per day.
Compare to
Est. Needs: __2184______ Kcal __121______ g Pro ____2148____ mL Fluid

Nutrition Database


PN meets how much of calculated needs in %? ___66__% kcal __41____ % Pro __52____ % Fluid
Do you have any recommendations? Keep formula, but increase rate to 84 ml/hr to provide 76% and 86%
estimated kcal and pro needs respectively. It would also provide 99% estimated fluid needs. This, unfortunately, is
the highest TPN rate the physicians at my facility are willing to go, but it would meet our goal of 75% of kcal and pro
needs during the pts LOS.



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)


Physician (MD)

Wrote sticky note on pt summary page with recommendation to increase
TPN ratet o 84 ml/hr.
Social Worker (SW)


Speech Therapist (ST/SLP)


Physical Therapist (PT)


Occupational Therapist (OT)


Respiratory Therapist (RRT)


Woundcare / Ostomy Nurse


Physicians Assistant (PA)


Other

No direct interaction with healthcare team for this pt.

Nutrition Diagnosis (P-E-S) Statement (write 2)
Problem: Altered GI function

related to (Etiology): colon cancer, admitted with SBO

as evidenced by Signs and Symptoms: anorexia, wt loss of 25 lbs, NPO status with orders to start TPN


Nutrition Database


Problem: Increased nutrient needs

related to (Etiology): Colon cancer, SBO, NPO with orders to start TPN

as evidenced by Signs and Symptoms: Increased pro needs for optimal healing and to maintain muscle mass and
immune support


Interventions (your recommendation as a dietetic intern)
Nutrition support with any PO intake as appropriate will provide 75% of estimated needs during LOS

Will consider supplement as diet is advanced with regard to recent weight loss

Recommend continuing TPN, but with change in formula to better meet estimated needs. Recommend 5% aa
+ D15 with standard lipids 3x/wk.
o This will provide 1660 kcal and 102 g pro, which represents 76% and 86% estimated kcal and pro
needs respectively. It would also provide 99% estimated fluid needs


Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)
Monitor nutrition related labs

Follow up per clinical protocol

Monitor tolerance to TPN