RD Assessment

Natalie, Lois, Cindy, Chris

& Yours truly
03/08- Day 2

Nutrition
Screening
<BMI/age (19) I
>70 yo (84) II
Ventilator III
Braden & Intake I
Level 1: High Nutrition
Risk (VII)
03/08- Day 2

Diet & Weight History

Pt: vented, sedated, Alzheimer's
H&P: Poor intake
Braden: 12
BMI: 19 Penn State for Vented Pt.
Wt. Hx: Energy: 1250
UBW: 69.7kg (2013) Protein: 68-78
Current: 56.7kg (2017) Fluids: 1250
Wt. loss: 13kg or 18.6%
http://www.houstonpress.com/
Per H&P, previous encounters, nurses assessment
 03/08- Day 2

Assessment: RD Screen
BM: yes, PTA diarrhea w/ Hx constipation per H&P
N/V: no per ER notes
Chewing/Swallow: vented
Labs
Appetite: poor per H&P BG: 185
Wt. loss yes per PMH Lytes: Na+ 134, K+ 4.1
Diet Recall TBD BM: 3/7- diarrhea
HD stable, pH WNL

Per H&P, Surgical Cx via Horizon

 Assessment: NFPA 2,9,18

SubQ fat Muscle Wasting Edema

 Nutrition Dx: Malnutrition
Chronic, severe, protein-calorie malnutrition related to
inadequate intake as evidenced by
moderate to severe orbital sub-cutaneous fat loss
moderate to severe muscles wasting of the temporalis, clavicle, deltoid, and scapula muscles
mild edema of the extremities.
 MNT Recommendations & Intervention
Malnutrition protocol ASPEN
New ileostomy s/p subtotal colectomy AND NCM
Initiating nutrition support ASPEN (Nutrition Support Core Curriculum)
Fluid & electrolyte status ASPEN but umm Pharmacy please

Clinical judgement + Lierature = Initate PN

Nutrition Goals Throughout Stay
Meet nutrition needs
maintain/gain weight, transition/ increase PO intake
Appropriate ileostomy output
Fluid/ lyte balance
BG control
Heal wounds
 Monitoring/ Evaluating

Fluid Status & Labs Intake & Nutrition Needs

I/O: Free water, ileostomy output TPN rate
Electrolytes: Na+, K+, Cl-, Mg+ EN rate
Phosphate & glucose PO rate
Calorie count
Supplements & meals ordered
TPN: Day 1

Day 3

Assess
Monitor/ Evaluate
Na+ 131, Mg 1.4, K+ WNL, Cl- WNL
Fluids
BG 167
TPN labs
nutrition needs
Intervention
TPN: 1 Liter Clinimex 4.25/ 10 @ 40mL/hr
Lipids MWF (today) +kcals from Propofol
TPN: Day 2
EN: Day 1

Day 4
Assess
Na+ Mg+ K+ Cl- all WNL!
BG: 128, WBC: high
Advanced TPN: 1 Liter Clinimex 5/ 15 @ goal (60mL/hr) Meets needs
Intervention Monitor & Evaluate
No need for bolus electrolytes Lytes: check BNP, Mg, Phos
Initiate trickle TF EN tolerance
Promote 1.0 via OGT @ 10mL/22hr (220mL) Nutrient needs via EN & TPN
TPN: Day 3-5
EN: Day 2-4

Day 5- 7

TPN & EN Interventions

3/11: TPN @ goal, EN @ trickle. Needs met!
3/12: TF on hold adjust TPN rate to 75mL. Needs met!
3/13: Continue TPN @ goal, resume EN @ trickle. Needs Met!
Meanwhile
BG running high 120-160 insulin
Phos, Mg, dropping bolus Kphos, Mg So4
TPN: Day 6
EN: Day 5
Day 8-9

Assessment Intervention
BG+, Na+, Cl- high Weaning off TPN

Phos still low Added AF 25mL

Work with Pharm- bolus
Bowel sounds present, HD stable,
pH WNL, no residuals Rec. EN Promote 50/22hr. Start at 30mL
adv 20mL q6 to goal. Via Corpak
1275 kcal
69g pro
 TPN
EN: Day 7

Day 10

Assessing Intervention
Labs: BG, Na, Cl- high Phos low Diet Advanced
Mg- WNL Ensure compact w/ meals
EN: TF @ goal w/ AF @ 25mL. Regular wait what?
I/O Ileostomy >1.5L from watery green Low residue + oatmeal (tolerated),
to liquid brown mechanical soft
Wt: 66kg (up 10 kg hmm) Start calorie count
EN: Day 8

Day 11

Assessment
Labs:
BG & Na+ increase
K & Phos dropped even more
I/O: high output >1L
Intake: meeting needs
EN: 1.1L Promote @ goal
PO: Kcal: 50% Pro: 25%
Intervention
Labs:
Increased AF to 40mL for hypernatremia
providing K+ IV and PO
TF: Change
Vital AF* meets 66% needs
PO: decrease TF to 55mL/14 hr noc feeding - per
MD
EN: Day 9

Day 12

Assessment Intervention
Labs: Pharm: managing w/ bolus and PO
BG & Na+ still high but decreasing supplements
K & Phos still low
Intake: add ground meats, changed
I/O: high output >1.5L (brown green)
supplements to Ensure Enlive
Intake : meeting needs
EN: 700mL Vital AF @ goal 50mL/14hr,
AF 40
PO: attempt 3 meals. Kcal: 55% Pro: 43%
 EN: Day 10- 13

Pt pulls of Corpac
Day 13
Day 16
Assessment Intervention
Labs: Labs:
BG & Na+ , Cl- still high but decreasing Continue K+, added Ca+ & Phos PO
K & Phos still low I/O
I/O: high output 2.1-2.5 L (yellow liquid) Reduce AF to 20mL/ 10 hr per MD
Intake : meeting needs New ileostomy nutr. ed 1/ son
EN: at goal Check C-diff
PO: attempt 3 meals + supplements. Kcal: 95% Pro: 60% Recommend loperamide
Braden: high risk (12) PO: encourage
Wounds on sacrum
PO: Mechanical
Soft, low fiber

Day 17

Evaluate Medical Course

Labs: BG, Na, Mg, K = WNL
Phos still low
I/O: Output 1.6L
PO: low (15% kcal, 9% pro) s/p TF
pull out
Wt: 60.9kg (+4.2kg since admin)
C-Diff neg
Moves to surgical unit
Develops wound right leg
Changes code: DNR, DNI
PO: Mechanical
Soft, low fiber

Day 18- 22

Evaluate Medical Course

Labs: BG back up, Mg back down Wound heal delay, wound vac
I/O: ileostomy 2x >1.5L, 2x<1L Palliative Care Cx s/p Stage 4 CA
PO: meeting needs kind of Pushing loperamide
~2 meals/day (81% kcal, 86% protein)
Supplement changes Ensure compact
TID
 Day 23-28 Last Days
Assess Intervention
Needs: MSJ x AF 1.3 ~1400kcal, 60-90g pro D/C cal ct. ?
Labs: WNL Except Ca+, WBC! Changed supplement: Enlive w/ B& D
Braden: Moderate Compact AML, PML
PO: likely not meeting needs Discharge: Ensure or equivalent TID until
I/O: good (<1L) & bad days (>2L) wt is stable
Wt: maintained
Monitor/Evaluate
Labs: K+ trending down again
Discharge: 4/2 @ 3pm clinical barrier-
wounds PO, Output, Wt, wounds, malnutrition
 Evaluation
Well
Impact of patient care?
Maintain weight, Nutrition needs
Goals Met ? (kind of), increase PO, heal wounds
Goals not met ? Malnutrition, high output
Effectiveness as Medical Team / RD? Well enough. But many
uncertainties
 Questions?
Vocab
Practices
Laboratory results/ interpretations
Interventions
Diagnostic testing results
Medications
Discharge plans
 Sources
1. Charitable Organization. ConcordHospital.org. Updated 2017 http://www.concordhospital.org Accessed: March 20,2017
2. American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics. Consensus statement of the Academy of Nutrition and
Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition
(undernutrition). J Acad Nutr Diet. 2012;112:730-738. doi: 10.1016/j.jand.2012.03.012
3. Septic Shock. Concord Hospital acute care protocol poster. Updated February 2017
4. Shahedi, K. Diverticulitus. Medscape.com. Updated Jan 16, 2017 http://emedicine.medscape.com/article/173388-
overview?pa=ulhXuAra2W1EMrs0GvDz%2BbdOZMHw%2FBg%2FNhex1LxIgHXgn3m5BnptkNSWYMtBVMX7BLeh%2Fm8UD4FqqTPeQeekXGJ661RRkmlqEd
RCHFh3%2B6Y%3D Accessed: April 21, 2017.
5. Lal, SK. Gastrointestinal Perforation. Medlineplus.org. Updated May 11, 2016. https://medlineplus.gov/ency/article/000235.htm Accessed April 21, 2017.
6. Phillip, N., Rogers, G. Gastrointestinal Perforation. Healthline.com. Published February 12, 2016. http://www.healthline.com/health/gastrointestinal-
perforation#symptoms2. Accessed: April 21, 2017.
7. Azar, SA., Anad, BS. Diverticulitis Empiric Therapy. Emedicine.medscape.com. Updated June 11, 2016. http://emedicine.medscape.com/article/2060097-overview.
Accessed: April 21, 2017.
8. Malhotra, A., Mathur, AK. Early enteral nutrition in cases of perforation of the gut with peritonitis.
JPostgradMed; https://staticweb.bmj.com/clinmed/original/2003040004v1/Main_Page.htm Accessed April 24, 2017.
9. Gossum, A.V., et al. ESPEN guidelines on parenteral nutrition: gastroenterology. Published by: European Society for Clinical Nutrition and Metabolism. Clinical Nutrition
2009;28:415427 doi:10.1016/j.clnu.2009.04.022
10. 2013 Canadian clinical practice guidelines: 2.0 early vs. delayed nutrient intake. Critical Care Nutrition website.
http://www.criticalcarenutrition.com/docs/cpgs2012/2.0.pdf. March 2013. Accessed October 30, 2013. Accessed: April 30, 2017.
 Sources
11. Haudungan A. Bowel obstruction- causes and pathophysiology. Youtube.com. Published April 5, 2016.
https://www.youtube.com/watch?v=sBm12CkNtAo Accessed: April 25, 2017
12. http://www.sepsis.org/sepsis-and/perforated-bowel/
13. Wooley, JA. Role of nutrition during the metabolic response to sepsis. Support Line 2003:25(4); 3-7.
14. Gordon, PH,. Nivatvongs, S. Principles & Practices of Surgery: Colon, Rectum, Anus. 3rd ed. 2006. Informa Healthcare New York, NY.
15. Concord Hospital. ICU/Critical Care Nutritional AssessmentArticle. N.D. 17.
16. Academy of Nutrititon and Dietetics. IDNT Terminology 3rd edition
18. Malhotra A, Mathur AK, Gupta S. Early enteral nutrition after surgical treatment of gut perforations: A prospective randomised study.
JPostgradMed; 2004:50(2) http://www.bioline.org.br/pdf ?jp04032
19. McClave SA, Martindale RG, Vanek WV, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill
patients. JPEN J Parenter Enteral Nutr. 2009;33(3):277-316.
20. Makola, D., Parrish, CR. Elemental and Semi-Elemental Formulas: Are They Superior to Polymeric Formulas? Practi Gastro. 2005:34;59-72
https://www.google.com/?client=safari&channel=mac_bm