ADIME Form Inpatient

Date: 2/18/2016 Time: 10:00 AM Age: 29 Sex: Male

NUTRITION ASSESSMENT
Adm. Diagnosis: Wt loss, dehydration, high ostomy output

PMH: Chrons Disease s/p colectomy 3 months ago

Current Labs (with assessment): Na 142, K+ 3.3, BUN 18, Cr 0.9, Glucose 80, Alb 2.9, H/H 10.0/30.0, CRP 4.2. Level of CRP is high
indicating inflammation present. Alb level is low also indicating inflammation. The levels of K+ and H/H are due to malnutrition.
Medications (with assessment): Pt is currently on Solumedrol for treatment of inflammation, Inflixamab to treat pt Chrons Disease,
Zofran to prevent nausea and vomiting, Omeprazole give to prevent complications will colectomy, and Loperamide to decrease the pt
ostomy output.
ANTHROPOMETRICS
Ht: 69 (175.26 cm) IBW: 160# % IBW: 85.0%
Admit Wt: 136# (61.8 kg) UBW: 145# (65.9 kg) % UBW: 93.8%
Current Wt: 136# (61.8 kg) AIBW (for obesity): BMI: 20.1 BMI Classification: Normal
Est. Dry Wt: - Recent Wt. Hx: Pt. is continuously losing wt
Patient interview Notes: Until 2 weeks ago, pt has been able to tolerate low residue, high protein, low fat diet fairly well. Pt states he
has decreased appetite and is very tired making him unable to work (on medical leave).

Intake/Digestive Problems Physical & Mental Status Metabolic Stressors Access

NPO ______days ETOH/Drugs PO
Hearing Impaired Post-op/Surgery
Diarrhea Anorexia NGT NJT
Limited Vision Fever/Infection
Constipation Chewing Problem OGT GT
Dementia Wounds
Nausea Poor Dentition JT GJT
Language Barrier Trauma/Fracture
Vomiting Swallowing Problem PEG HICKMAN
Mental Status Changes Sepsis
Food Allergy/Intol: Aspiration Precautions CVL PORTACATH
N/A Other_______________
__________________ Assist w/ Meals PIV PICC

PHYSICAL ASSESSMENT
Notes on Physical Assessment: n/a

Adequately Nourished Obese At risk for malnutrition Malnourished

ESTIMATED NUTRITON NEEDS & INTAKE ASSESSMENT

Intake PTA (Usual Intake, Calorie Count, and/or results from Intake Analysis): ~60% of normal intake x 10 days, a bit more prior; nl
intake 2 wks ago -> average of ~72% est needs x 1 month.

Diet PTA: Current Diet Order:

Calorie Count/Intake % Goal Met by

Calculation Wt: 61.8 kg Est Needs
Assessment Results Current Intake
Energy
2045-2202 kcals
BMR __1573___ n/a n/a
(factor: 1.3-1.4)
Using _MSJ____
 74.2-80g
Protein n/a n/a
(factor: 1.2-1.3)

Fluid (Holiday Segar) 2336 mL n/a n/a

NUTRITION DIAGNOSTIC STATEMENTS (PES)

1. Chronic severe disease related malnutrition r/t colectomy 3 months AEB pt interview noting decreased appetite, 6.2% wt loss x 1
month, meeting ~60% of need x 10 days and meeting ~72% of estimated needs x 1 month (2 weeks prior).
2. Altered GI function r/t Chrons disease and colectomy AEB inability to consume nutrients PO and Alb and CRP lab values indicating
inflammation.
3. Inadequate mineral intake of potassium r/t colectomy AEB decrease lab value reading of 3.3 and GI loss through high ostomy
output.
GOALS
1. Metabolic tolerance of PN
2. Pt receive 100% of estimated caloric needs from PN regimen w/in 2-3 days.
3. Supplement Zinc daily
4. Monitor Labs
5. Progress to CL diet
INTERVENTIONS/RECOMMENDATIONS
1. Rec PN regimen: 100ml/hr of 15.2% D, 3.2% AA + 12ml/hr of 20% IL. This regimen gives 2124 kcals, 77g PRO, 2400 mL/d fluid with
a GIR of 4.1 mg/kg/min.
a. This regimen gives 58.4% kcal from CHO, 14.5% kcal PRO, and 27.1% kcal from fat.
2. Rec add 4 mg of supplemental zinc to PN daily for 1 week
3. Rec check daily CMP, Phos, Mg, Tg, and adjust PN PRN. Once CRP less than 2, rec check iron panel (Fe, TIBC, % Sat, Ferritin) and
Zinc.
4. Once appropriate, start CL diet. Start with chicken broth and limit sugary beverages.
5. RD to F/U with pt in 3-5 days.
6. RD discussed with team, will continue to follow on round.
MONITORING AND EVALUATION:
I&0 sheet Labs:_CMP, Phos, Mg, Tg, CRP, Iron panel, zinc._________________________ _________________________
Calorie Count X ______ days Patient Meal Rounds RD participation in Patient Care Team Rounds
Review changes in clinical status & discuss pt progress with team including: _____________________________________________
Other: _____________________________________________________________________________________________________
Follow-Up: RD f/u in __3-5 day_____to further evaluate ____tolerance of PN and lab values_____________________________

Signature and Credentials:

Date: 2/18/2016
Emily Glass, Nutrition Student
 PN Support Worksheet
To complete the worksheet below, you will need to have calculated your patients fluid needs (in mL/d),
total kcals/d, g of protein/d, and you will need to have an idea of what % of calories will come from fat.

Fluid:
1. Determine your actual fluid provision by dividing your fluid goal by 24 hrs (since your PN will run
for 24 hrs at a time). Round the result to the nearest mL. This result x 24 hrs/d will be your new
total fluid needs for the rest of your calculations.

2400 mL of fluid/day / 24 hrs= 100 mL of PN/hr

100 mL of PN/hr (rounded) x 24 hrs= 2400 mL of PN/day

Fat (Intralipid):
2. Determine fat calories by multiplying total kcals x % of kcals from fat. % kcals from fat are
usually about 20-30%. Round to the nearest kcal.

2124 kcal/d X 27 % kcals from fat= 575 kcal from fat

3. Determine the mLs/d of intralipid (IL) by dividing the kcals from fat by the kcals/mL of the IL
solution. 1.1kcal/mL for 10%, 2kcal/mL for 20%, 3kcal/mL for 30%. Round to the nearest mL.

575 kcal from fat/ 2 kcal/mL= 287.5 mL of IL/day

4. Determine the hourly rate of your IL by dividing your mL of IL/d by 24 hours. Round to the
nearest whole number.

287.5 mL of IL/day / 24 hrs= 12 mL of IL/hr

5. Calculate the exact kcals being provided from IL by multiplying your hourly rate of IL x 24 hrs x
kcal/mL of the IL solution.

12 mL/hr x 24hrs x 2 kcal/mL= 576 kcals from fat/day

Protein (Amino Acids):

6. Determine the protein percentage for PN by the dividing the g of protein/d by the total volume
of PN you plan to give. Round the result to one decimal place.

77.1 g pro/d/ 2400 total PN (mL)= 3.2 % AA for the solution

7. Determine the exact number of g of protein you will give by multiplying your %AA by your PN
volume.

3.2 %AA x 2400 total PN (mL)= 77 g protein/d

8. Determine the exact kcals from protein by multiplying the g/d by 4kcal/g.

77 g pro/d x 4kcal/g = 308 kcals from protein/day.

Carbohydrate (Dextrose):
9. Determine the kcals needed from dextrose by subtracting the kcals from fat and the kcals from
protein from your total kcal goal. Round to the nearest whole number.

2124 total kcals 576 IL kcals 308 pro kcals= 1239 kcals from
dextrose/d

10. Determine the number of g of dextrose per day by dividing the kcals from dextrose by 3.4 kcal/g.
Round to the nearest whole number.

1239 kcals from dex/ 3.4kcal/g = 364.4 g of dex/day

11. Determine % dextrose needed in the solution by dividing the g of dextrose by the solution
volume. Round to the nearest one decimal place.

364.4 g dex/d / 2400 total PN (mL) = 15.2 % dex for the solution

12. Determine the actual g of dex provided in the solution by multiplying the % dex by the total
volume. Round to the nearest one decimal place.

15.2 % dex x 2400 total PN (mL) = 364.8 g of dex/day

13. Determine the exact kcals from dextrose by multiplying g/d by 3.4kcal/g.

364.8 g dex/d x 3.4kcal/g = 1240 kcal from dex/day

Glucose Infusion Rate:

14. Determine the GIR by dividing the g of dex by the patients weight in kg then dividing by 1.44
(this is a short cut). Round to the nearest 2 decimals.

364.8 g dex/d / 68.1 pt wt in kg/1.44= 4.1 GIR in mg/kg/min

Total Calories:
15. Add the kcals from IL, pro, and dex to determine total kcals.

16. Determine the macronutrient distribution by dividing kcals from IL by total kcals (and following
the same process for kcals from pro and kcals from dex).

Total Regimen:
17. Your completed PN regimen should be written as follows:

100 mL/hr of 15.2 %D 3.2 %AA + 12 mL/hr of 27 % IL.

This regimen gives 2400 kcal/d, 77 g pro/d, 2400 ml/d fluid with a GIR of
4.1 mg/kg/min.

The above regimen gives 58.4 % of kcals from CHO, 14.5 % kcals from pro, and
27.1 % of kcals from fat.