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Overview Information: Patient admitted to the hospital after falling in the bathtub. Was found to
be unresponsive. Suffered trauma to the head. Has PEG tube in place. Recent weight loss since
hospitalization.
Medications:
1. Zantac 150 mg per PEG tube twice daily
2. Ritalin 5 mg at 0700 and 1300 per PEG tube
3. Trazodone 50 mg per PEG tube at bedtime
4. Tylenol per rectum or per tube 650 mg every 4 hours PRN
From day of discharge: WBC 13,500(ref 4,500 10,000); hemoglobin 10.4 (ref 13.5-16.5);
hematocrit 30.3; platelets 285,000; MCV 91.2; sodium 138; potassium 4.1; chloride 102; CO2
24; BUN 13; urobilirubin 0.4 (ref 0.5-1); creatinine 0.7; glucose 108; calcium 8.4; magnesium
1.7; phosphorus 2.8.
1
Appetite: abnormal as indicated on general vital assessment.
High risk for malnutrition
High braden scale score indicating high risk for ulcer
GI problems occasional constipation, last BM yesterday
Food and Nutrient Intake: the patient is at high risk for malnutrition. Has PEG tube in place.
Does not drink alcohol.
Infuse Replete via PEG tube at 80 ml/hr. 250 ml of water bolus every 6 hours
Check gastric residuals every 8 hours. Hold tube feeding if residual greater is than or equal to
400 ml.
Nutrition Diagnosis:
P: swallowing difficulty
E: related to: post stroke complications
S: as evidenced by: results of swallowing tests
Nutrition Intervention:
Prescription: meet daily energy and protein needs
Recommend: enteral nutrition daily (1,546 kcal per day and 98 g protein per day via PEG
tube until patient is able to eat comfortably) Replete via PEG tube at 80ml/hr nutrition
education and counseling centered around post stroke nutrition and dysphasia once a
month
Goals: to be able to meet calorie and protein requirements
Type of food/meals
Patient will receive nutrition therapy to fully be able to eat PO on own within 1 month