Clinical

Case Study Nutrition Care Process Worksheet

1. Please outline the steps of the Nutrition Care Process for your case study patient. Not all
sites use this language but will use much of the process. In some cases the clinical staff may
have provided some of the care without you or before you were involved, but you must be
involved in some aspects of care.

Completed
NCP How did you or other clinical staff achieve this step:
by: I, CS, B
Abby, the RD for the Bone Marrow Transplant floor,
Assessment
initially assessed the patient while doing rounds with
Summarize the
the BMT team. The patient was started on a regular
patients nutrition CS
diet, but fairly quickly started to experience nausea and
status and risk level.
diarrhea. Due to low PO intake, Abby providing the

patient with Ensure, ProMod, and Magic Cup.
Altered GI function (NC-1.4) RT chemotherapy,
Diagnosis PES and
ulcerative colitis AEB nausea and frequent episodes of
explanation. You may
diarrhea over the course of 27 days.
include more than one
- Patient had numerous episodes of diarrhea, to the
if appropriate but I
point where her electrolytes were becoming
indicate which is the
unbalanced and she
primary PES.
could not keep anything down. Chemo was likely the

trigger, worsened by UC.
Intervention Include
and prioritize the
1. Control nausea and diarrhea.
objectives of the
2. Rehydrate and renourish.
treatment. These B
3. Balance electrolytes.
should correspond to
4. Ensure appropriate PO intake.
your PES.

- We monitored number of BMs/day because this was
the patients biggest issue and biggest complaint.
Though her diarrhea was likely not due to nutrition,
knowing if the number of BMs decreased or not would
Monitoring What did tell us if she was tolerating the type of nutrition support
you monitor for we provided her or if it was worsening her symptoms.
improvement? Why? - We also monitored PO intake. This was easier to do
How did you measure when she was on EN and TPN since we knew exactly B
the effectiveness of how many calories and macronutrients she was
the intervention? receiving. It was harder to know exactly how much food
she took PO because the patient was not the best
historian and often emotional.
- We measured the effectiveness of the intervention by
whether or not her BMs/nausea decreased, how she
said she was feeling, and how her labs looked,
 specifically her electrolytes.
1. Goals were eventually met after trying out Vital 1.5
Evaluation Were TFs, then TPN for bowel rest. While on TPN, the patient
goals met? Did you was allowed pleasure feeds PO, though she was not
need to reassess due able to eat much initially.The patients status improved
to changes in patient significantly while on TPN and she was more B
status? Is there a new comfortable with eating PO toward the end of her stay.
PES? 2. We had to reassess after PO intake did not provide
adequate nutrition and again after it was evident EN
was not helping her GI issues either.
I = intern, CS = clinical staff, B = both clinical staff and intern

2. Explain the evidence-based guidelines for MNT for this patients condition(s). Reference the
source of the evidence. If, after identifying evidence-based MNT, you would propose a
different plan of care, what would it be and why? (No judgment here, hindsight generally
easier than foresight.)

. Enteral nutrition should be used in patients with a functioning gastrointestinal tract in whom
oral intake is inadequate to meet nutrition requirements.
- Pharmacologic doses of parenteral glutamine may benefit patients undergoing hematopoietic
cell transplantation.
- Patients should receive dietary counseling regarding foods which may pose infectious risks
and safe food handling during the period of neutropenia.
- Nutrition support therapy is appropriate for patients undergoing hematopoietic cell
transplantation who develop moderate to severe graft-vs-host disease accompanied by poor
oral intake and/or significant malabsorption.
- Nutrition support therapy is appropriate in patients undergoing hematopoietic cell
transplantation who are malnourished and who are anticipated to be unable to ingest and/or
absorb adequate nutrients for a prolonged period of time. When parenteral nutrition is used, it
should be discontinued as soon as toxicities have resolved after stem cell engraftment.
(http://www.sbnpe.com.br/wp-content/uploads/2016/07/JPEN-J-Parenter-Enteral-Nutr-2009-
August-472-500.pdf)

- After knowing the evidence-based MNT, I believe I would still suggest the same nutrition
support that we gave, though I might consider suggesting glutamine supplementation.
- ULH is leaning away from the neutropenic diet because there is not strong enough evidence to
support that cutting out those foods prevents infection. So, while in the hospital, the doctors
support continuation of the neutropenic diet, but tell patients they dont have to follow it at
home. Two of the RDs, one inpatient and one oncology outpatient, are working with the
doctors to discontinue the inpatient neutropenic diet entirely.


3. Discuss the documentation / charting requirement of your clinical site. If applicable,
comment on variation in charting styles between RDs. Which works best for you?
- The documentation is through Cerner, a type of electronic medical record. Charting must be
completed after each assessment or follow up. It is in ADIME format. One of the dietitians is
extremely fast and concise with her charting, while another is very slow but thorough. I prefer
to be somewhere in between, as I am definitely thorough (being new at charting, I dont want
to miss anything), but have gotten faster at finding and documenting the most pertinent
information.