Nutrition Database

This assignment is intended to collect information and apply Medical Nutrition Therapy related knowledge
to a disease condition. All data will be kept confidential and anonymous, no patient names, initials,
room numbers, birth dates, or other personal identifiers will be collected.
Intern Name

Margaret Merlie

Patient Age

63_____

Admitting Diagnosis

Clinical Core Rotations: Basic / Intermediate / Advanced

Sex Male Female Your Assessment Date 11/9/15

Admit date 11/7/15

altered mental status readmission since D/C 11/4 from colostomy

Prior Medical History recent dx stage 3 colorectal cancer, colostomy, hx: htn, appe, cholecystectomy, bl benign
lumpectomy, cervical cyst removed, hysterectomy, hep c, osteoarthritis
Diet Order

cardiac

Supplements N/A

If applicable, describe food intake since admission or past 5 days (use percentages, expressed as a range or an average,
describe other pertinent issues or if common in facility mark checkbox on right to specify)
Good Fair Poor
Current PO intake good (51-75%). Previous admission one week ago on CL following colostomy

Any Food Allergies / Intolerances?

Height and Weight:

no

HT (in inches and cm)64 in, 163 cm Current WT (in pounds and kg)53.9 kg, 118# BMI 20.4

How was height obtained?

stated

Ideal Body Weight (IBW)120#

% IBW 98%

How was weight obtained? Built in bed scale

Usual Body Weight (UBW)

130#

% UBW91%

If the patient had a weight change, indicate this in pound and kg and % gained/lost and the timeframe. Was this
unintentional or intentional? Give the reason(s). Using the cutoff-percentages was this loss/gain significant?
12# (5.5 kg) significant loss in one month (9% loss) unintentional. Colostomy and rectal cancer dx
if applicable Dry Weight (in pounds and kg)
if applicable in your facility: What is the patients adjusted weight (in pounds and kg)

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)
Pt is married and has support at home, no alcohol use, smokes off and on, family hx of various cancers

Advance Directive: Yes No

Nutrition related implications? Qualified for malnutrition

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Skin Integrity / Chewing and Swallowing Ability / Misc. Info

Is Patients Skin Intact?

Yes

No

If no, what is present?

Surgical Wound

Does the patient have

Edema

Braden Score

13

PUSH Score

Decubitus Ulcer
+2, lower extremity Ascites

if pitting, state stage and site

If decubitus ulcer, list stage (I-IV) and site(s) stage 2 pressure ulcer on sacrum

If decubitus ulcer, is it

Improving?

Incontinent of urine?

Yes

No

Urinary catheter?

Yes

No

Getting worse?

Date of last BM & consistency 11/8 large, loose

Vomiting

Difficulty Chewing
Own teeth

Yes

No

Is patient on a ventilator? Yes

No

Most recent blood pressure

99/68

Most recent temperature

36.1F

Is patient receiving IV Fluids?

Yes

No

No

Constipation

Fit well? Yes

No

Malabsorption

Taste Changes

if yes, what type

is BP stable? Yes

No

mL

Difficulty Swallowing

Unable to feed self

Early Satiety

Diarrhea

2150

Edentulous

Dentures? Yes

Is patient on dialysis?

Yes

Bathroom privileges

Nausea

Are any of the following present?

output in mL over past 24 hours

Schedule

No

if yes, what type / rate / total volume in past 24 hours

Potassium phosphate (255 mL @65 mL/hr), ceftriaxone (100 mL @100 mL/hr)

If applicable, how many g Dextrose and kcal does this provide?

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Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)
Drug name(s)

Indication

Ceftriaxone
lovenox

antibiotic
Blood thinner

atenolol
lorazepam

Beta-blocker
anxiety

oxycodone

Pain relief

Nutritional Implication / food

Interaction

Diarrhea, nausea
Interacts with vit K, may
need to limit vit E and
alcohol consumption
due to increased risk of
bleeding
D/c/n/v, hypoglycemia
Constipation, change in
appetite
May interact with
diuretics and muscle
relaxants, may cause
respiratory distress

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Nutrition related laboratory values

Lab Test

Na

Lab values list all that

are available
indicate if abnormal
high or low ( or )
and if applicable,
state if they are
trending up or down.

139
2.9 trending

K
BUN
CREAT
GFR

17
0.9
>60
2.5

Albumin
Prealb
CRP
Glucose
HgbA1C

9.2/28.4

Decreased value may signify malnutrition, dehydration,

inflammation. If due to malnutrition or dehydration, patient
can be given additional nutrients or water to help correct
abnormal value.

Decreased values may signify anemia, cirrhosis, renal disease,

leukemias, or lymphomas. Increasing iron consumption may
improve anemia.

89.2
28.9

9.0 trending
Ca

Decreased value may signify deficient intake, surgery,

diarrhea, vomiting, or diuretics. May be improved by
increasing amount of potassium consumed.

87

H/H
MCV
MCH
Iron (Fe)
Transferrin Sat (%)
Ferritin
Vitamin B12
Folate

Nutritional significance if abnormal

Can a nutrition intervention help to correct this abnormal lab value? How?

Increased levels may indicate hyperparathyroidism, cancer

with parathyroid hormone-producing tumors, and excessive
intake of vitamin D or milk. Patient can reduce consumption of

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milk or vitamin D to see if levels will decrease
Phos
Mg
Total Cholesterol
LDL
HDL
TG
ALT
AST
Alkaline Phos
Total Bilirubin
Amylase
Lipase
BNP
Troponin or CK

3.0
1.6

Other relevant labs (e.g. ammonia, blood gases, AIDS/HIV related, etc.)

Nutritional Needs
What weight will you be using to calculate needs and why?
Any stress factors wound (x1.2)

Ideal body weight for pt to gain weight

, activity factors to consider?

no

Note: Understand the difference between resting energy expenditure and total energy expenditure. If you have a stressed
patient, you are likely to use a stress factor. If your patient is in bed moving around and alert, you will likely have to pick an
activity factor for Harris Benedict and Mifflin St.Jeor .

Calculate Total Energy needs using three of the five methods below. Show your work.
1) Harris-Benedict -----------------------------------
1430 kcal [655.1+ 9.6 (54.5) + 1.9(163) -4.7(63)]x1.2
stress factor
2) Mifflin St. Jeor -------------------------------------
1305 kcal [10(54.5) + 6.25(163) 5(63) 161] x 1.2
stress factor
3) kcal/kg ----------------------------------------------1363-1635 kcal (25-30 kcal/kg; 54.5kg wt)
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 based on hospital standards

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Calculate Protein needs
How many g/kg would you use & why?

1.0 1.2 gm/kg for increased needs for wound healing

Show your work:

1gm x 54.5 kg = 55 gm pro
1.2 gm x 54.5kg = 65 gm pro
55-65

g/day

Calculate Fluid needs using two of the four methods below. Show your work.
1) ml/kg depending on age -----------------
1636 ml/day 30ml/kg (54.5 kg)
2) Holliday-Segar method -------------------
ml/day
3) RDA method --------------------------------- 1363-1636 ml/day 25-30 ml/kg
4) urine output (urine out +500ml/day)-
ml/day

What formula did you ultimately use for the Pt & why?

RDA method per hospital standards

Enteral Calculations:
Formula
NGT

Total volume per day ordered

PEG

Continuous

mL

Other
ml/hr

Bolus (provide schedule and volume)

Cyclic (provide schedule and volume)

Any PO / Parenteral intake? Yes

Per 1000mL this formula provides:

No if yes, PO Diet Order

kcal

As per total volume (per day) this formula provides:

cardiac

estimated kcal intake 1000-1500 kcal

g Pro

mL free water

kcal

kcal/kg

g Pro

g Pro/kg

mL Free H2O

mL/kcal

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Did the patient receive the total volume ordered in the past 24 hours? Yes No if no, how much did the patient
receive
(% or mL) If tube feeding was stopped, why & for how long?

Additional water flushes per day. Amount and frequency

mL
(include fluids with meds, ask nursing for amount typically given and estimate total daily intake)

Does the prescription meet the calculated nutrition needs?

Enteral Nutrition provides:

Kcal

g Pro

mL Fluid per day.

Compare to Estimated Needs:

Kcal

g Pro

mL Fluid

EN meets how much of calculated needs in %?

Kcal

g Pro

mL Fluid

Do you have any recommendations?

Parenteral Calculations: Rate

Total volume/24hr

mL/hr
mL

Any PO or Enteral intake? Yes

Continuous

Cyclic

2-in-1 Solution 3-in-1 Solution

hr/day
is formula PPN or TPN

No if yes, estimated kcals from oral intake

Carbohydrate % Concentration

Grams of dextrose in 1L

g Total kcals from dextrose

Protein % Concentration

Grams of AA in 1L

g Total kcals from AA

Lipids 10% (1.1kcal/mL)

20% (2kcal/mL)

Grams of lipids infused/day

Volume of lipid solution provided in 24 hr (if hung separately)

mL

Total kcals from lipids

Is patient receiving Propofol? If yes, list dosage and kcals from Propofol
Total calories in parenteral nutrition

If done in your facility by the RDNs - if patient is on PPN, calculate osmolarity. Refer to textbook or ask preceptors for
resources to calculate this. Show your calculations:

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Does the prescription meet the calculated nutrition needs? If not, compare amount of kcals, protein and fluids
provided verses patient estimated needs:

Does the prescription meet the calculated nutrition needs?

Parenteral Nutrition provides:

kcal

kcal/kg

g Pro

g Pro/kg

mL Fluids

mL/kcal

Compare to Estimated Needs:

Kcal

g Pro

mL Fluid

PN meets how much of calculated needs in %?

Kcal

g Pro

mL 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
Nursing (RN)
Physician (MD)
Social Worker (SW)
Speech Therapist (ST/SLP)
Physical Therapist (PT)
Occupational Therapist (OT)
Respiratory Therapist (RRT)
Woundcare / Ostomy Nurse

Describe interactions with or referrals made to any of these

health care team professionals:

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Physicians Assistant (PA)
Other

Nutrition Diagnosis (P-E-S) Statement (write 2)

Problem: Unintended weight loss

related to (Etiology): decreased appetite

as evidenced by Signs and Symptoms: pt reports of decreased appetite and 12# (9%) wt loss x1 month

Problem: Increased nutrient needs (pro/vit/min)

related to (Etiology): increased nutrient demands

as evidenced by Signs and Symptoms: stage 2 pressure ulcer on sacrum.

Interventions (your recommendation as a dietetic intern)

Recommend cardiac diet, GI soft, offer supplements if PO intake <50%

Monitor, encourage, and record PO intake

Monitor and record weight weekly due to hx of weight loss

Education provided regarding recent colostomy

Nutrition Prescription

Recommend low fiber soft foods until GI tract healed. Then gradually increase fiber intake as tolerated.

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Nutrition Goals

Patient will consistently consume >75% of meals and not lose any more weight at follow up in 5-7 days.

Patients will name 3 ways to improve her diet to aid in the healing of her GI tract at follow up in 5-7 days.

Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)

Patient will restate information regarding diet following a colostomy.

Monitor food records in the hospital to ensure patient is consuming adequate nutrition

Monitor GI function

Record weight weekly to monitor any further weight loss

Discharge Planning (if applicable): List your recommendations / interventions / plan if your patient is being
discharged back home to live alone or with family or if transferred to an assisted living / long-term care facility.
Take weekly weights, consume 4-5 small meals each day to reduce stress on GI tract and promote food intake with
loss of appetite, encourage supplements if PO intake remains poor.

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