Patient Initials SR DOB 5/17/50 Age 63 Sex Female Unit/Room# 936 Admit Date 10/20/13 Admitting Diagnosis Intractable emesis in pt with metastatic ca Prior Medical History Dyslipidemia, Ovary Ca, Signet Ring Cell Carcinoma, Hysterectomy, Appendectomy, Intestinal resection with ileostomy. Diet Order Full Liquids/TF Osmolite 1.2 @ 20ml/hr/TPN Supplements None If applicable, describe food intake since admission or past 5 days Poor po intake. Not tolerating TF. Any Food Allergies / Intolerances? No known.
Height (in inches and cm) 50 Weight (in pounds and kg) 95lbs (43kg) Weight History Loss Gain if weight , how much in what time frame? Was loss/gain intentional or unintentional? Unintentional wt. loss in less than 6 months per pt and pts husband due to getting sick. Usual Body Weight (UBW) 138 Ideal Body Weight (IBW) 100 % IBW 95 % BMI 18.5
Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.) Retired. Religion unknown. Lives with husband at home who is support system. No alcohol or drug use. Husband prepares meals.
Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications) Drug name(s) Indication Nutritional Implication Reglan GERD N/V/D Protonix GERD N/V/D Zofran Prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery Diarrhea, Constipation Pain Meds Pain N/V/D/C, Loss of appetite, Wt. Loss Phenergan Relieve the symptoms of
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allergic reactions
Nutrition related laboratory values 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 141 K 3.8 BUN 22 CREAT 1.25 Could indicate Impaired renal function or dehydration. Intervention includes increased protein needs and supplementation.
Albumin 2.9 Could indicate malnutrition, chronic inflammation/infection, liver or kidney failure, and protein loss. Intervention includes increased protein and calorie needs and supplementation. Prealb 10 Could indicate malnutrition, liver damage, or inflammation. Intervention includes increased protein needs and supplementation.
Glucose 109 HgbA1C
H/H
MCV
MCH
Iron (Fe)
Transferrin Sat (%)
Ferritin
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Vitamin B 12 Folate
Ca 9.4 Phos 3.1 Mg 1.8
Is Patients Skin Intact? Yes No If no, Surgical Wound Decubitus Ulcer If decubitus ulcer, list stage (I-IV) and site(s) Stage 1 Sacral Pressure Ulcer Is decubitus ulcer Improving? Getting worse? Is any of the following present? Nausea Vomiting Diarrhea Constipation Difficulty Chewing Difficulty Swallowing Unable to feed self Malabsorption Early Satiety Taste Changes
Reminder.for calculations, what was the patients height (cm) and weight (kg) again? 152 cm 43 kg Male Female Age 63 Any stress factors, activity factors to consider? Catabolic Illness, Ambulatory
Calculate Energy Needs using 1) Harris-Benedict ------------------------------------ 1,532 kcal 2) Mifflin St. Jeor -------------------------------------- 1,300 kcal 3) kcal/kg ----------------------------------------------- 1,500 kcal 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 gives an appropriate range and is hospital protocol. Show your work for three of the five methods above used:
2. Mifflin St. Jeor RMR= 10 (43kg) + 6.25 (152cm) 5(63yrs) -161 RMR= 430 + 950 -315 161 RANGE: 1,300-1,500kcal RMR= 904 x 1.2 x 1.2 RMR= 1,300kcal
3. Kcal/kg 43kg x 35kcal = 1,505kcal 43kg x 40kcal = 1,720kcal RANGE: 1,500-1,700kcal
Calculate Protein Needs How many g/kg would you use & why? 1.5-2.0g/kg because this pt has increased protein needs due to catabolic illness (metastatic cancer). Show your work:
43kg x 1.5g = 65gm Pro 43kg x 2.0g = 86gm Pro
65-86 g/day
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Calculate Fluid Needs using 1) ml/kg depending on age ----------------- 1,290 ml/day 2) Holliday-Segar method ------------------- ml/day 3) RDA method --------------------------------- 1,700 ml/day 4) urine output (urine out +500ml/day)- ml/day What formula did you ultimately use for the Pt & why?? ~1,700ml because the range is higher and more appropriate. Increased creatinine labs could indicate dehydration. Pt c/o extreme thirst. Show your work for two of the four methods above used: 1. Ml/kg 63 years use: 30ml/kg 43kg x 30ml= 1,290ml/kg
2. RDA method ~1700kcal based on 40kcal/kg
Parenteral Calculations: What is the macronutrient composition of the TPN recommended by the physician?
Rate? ____75____mL/hr for how long? 24hr 12hr/day ______hr/day Any PO intake? No Yes , explain ___Full Liquids______________________________________________ Total volume/24hr ____1800______ mL 2-in-1 Solution 3-in-1 Solution
Carbohydrate Concentration? D___8%_____ Amount of Dextrose (in grams) in 1000mL___144_____ g kcal from Dextrose in 1000mL (grams * 3.4 kcal/g) ________ kcal Total kcal from Dextrose provided / 24hr? ________ kcal (did you check total volume/24hr?)
Protein Concentration? ________ % Solution Amount of AA (in grams) in 1000mL__60____ g
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kcal from AA in 1000mL (grams * 4 kcal/g) ________ kcal Total kcal from AA provided / 24hr? ________ kcal (did you check total volume/24hr?)
Lipids 10% (1.1kcal/mL) 20% (2kcal/mL) mL of lipid solution provided in 24 hr (if hung separately) ________ mL Amount of lipids infused in g/day ________ g kcal from lipids infused per day ________ kcal (did you check total volume/24hr?)
Does the prescription meet the calculated nutrition needs? PN provides: ____852____ Kcal ____60____ g Pro ___1800_____ mL Fluid per day. Compare to Est. Needs: ____1500____ Kcal _____65___ g Pro __1700_____ mL Fluid PN meets how much of calculated needs in %? ____57__% kcal __92____ % Pro ___106___ % Fluid Do you have any recommendations? Pt is also receiving nutrition from TF, so no recommendation for TPN at this time.
Enteral Calculations: What is the macronutrient composition of the Enteral Feedings recommended by the physician?
Formula__Osmolite 1.2 _________ Bolus? How frequent? ____________ Continuous? NG PEG Other ____PEJ_____________ Any PO intake? No Yes , explain _Full Liquids_______________________________________________ Rate? ____20_mL/hr for how long? 24hr 12hr/day ______hr/day Total volume (per day) of formula as ordered __________ mL/day
Per 1000mL this formula provides: __________ kcal __________ g Pro __________ mL free water
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As per total volume (per day) this formula provides: __________ kcal ( ________ kcal/kg) __________ g Pro (________ g Pro/kg) __________ mL free water
Any stoppage time to the feedings? yes why? / how long? ___________ no If you answered yes above, for how long did the TF run, and what percentage of formula was infused versus what was ordered for the day? ________________________ % Additional water flushes per day - __________ mL / day (also ask nursing how much water is given with medication and try to add to get an idea of fluid given) Total fluid provided (total free water plus additional flushes) __________ mL/day (_______ mL/kcal) Does the prescription meet the calculated nutrition needs? TF provides: ____576____ Kcal ___27_____ g Pro ____394____ mL Fluid per day. Compare to Est. Needs: ____1500____ Kcal ____65____ g Pro ____1700____ mL Fluid TF meets how much of calculated needs in %? ________% kcal ________ % Pro ________ % 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 Describe interactions with or referrals made to any of these health care team professionals: Nursing (RN)
Check shift assessment for skin integrity and any significant GI issues. Spoke with nurse about TF regimen, tolerance to TF, and any residuals. Physician (MD)
Checked MD chart for any pertinent information regarding patients nutritional status. For example, the following information was pulled from the MDs note: Metastatic cancer. s/p intestinal resection with ileostomy, s/p endoscopic gastrostomy tube placement now with percutaneous endoscopic gastrostomy site open. Tube feeding was replaced to PEJ on 11/13. Receiving relistor 8mg to improve GI motility. TF well tolerated but is leaking. Increased gastric residuals despite decreased TF rate. Drainage around tube, pt can only tolerate low doses of TF. There are TF issues and minimal stoma output on 11/18. Pt refusing hospice. Difficult situation. Social Worker (SW)
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Speech Therapist (ST/SLP)
Physical Therapist (PT)
Occupational Therapist (OT)
Respiratory Therapist (RRT)
Woundcare / Ostomy Nurse
Checked wound specialist assessment for inquiry on wounds. Found stage 1 sacral wound. Physicians Assistant (PA)
as evidenced by Signs and Symptoms: leaking from peg tube, increased gastric residuals, and TF currently meeting 38% estimated kcal and 42% estimated protein needs.
Problem: Increased nutrient needs (protein/kcal)
related to (Etiology): Catabolic illness and severe wt. loss
as evidenced by Signs and Symptoms: metastatic cancer and >10% wt loss within 6 months.
One more possible: Inadequate oral intake related to poor appetite as evidenced by patient report.
Interventions (your recommendation as a dietetic intern) TPN goal rate when feasible at 90gm protein, dextrose 225gm as well as daily lipids to provide 1625kcal.
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TF goal rate if medically feasible osmolite 1.2 @ 55ml/hr to provide 1584kcal, 73gm protein, and 1082 ml free h20.
Do not d/c TPN or TF unless diet is advanced, well tolerated, and is meeting over 75% of pt needs.
Consider combination of TPN and TF to provide nutritional needs. Consider TPN as above with TF at goal rate of 30ml/hr to provide 864kcal, 40gm protein, and 590ml of free h2o.
To follow
Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?) Monitor po intake goal >75% and tolerance
Monitor tolerance to TF and TPN regimen
Monitor skin integrity/wound healing
Prealbumin >18
All labs (cmp) wnl as able
Monitor MD orders and future family decisions
Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not familiar with)?