Nutrition Database

Intern Name Angela Misko

Patient Initials H, P DOB 10/18/40 Age 73 Sex F Unit/Room# 1029
Admit Date 11/09/13 Admitting Diagnosis Vomiting X 4hrs, Gassy
Prior Medical History Colon caner with colon resection, HTN
Diet Order Low Fat Supplements None
If applicable, describe food intake since admission or past 5 days Poor PO intake. Not having any protein foods.
Any Food Allergies / Intolerances? None.

Height (in inches and cm) 56 Weight (in pounds and kg) 151lbs. (68kg) Weight History Loss
Gain
if weight , how much in what time frame? Was loss/gain intentional or unintentional? Unintentional
Usual Body Weight (UBW) Ideal Body Weight (IBW) 130 % IBW 116 % BMI 24.3

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)
Retired, Buddhist.


Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)
Drug name(s) Indication Nutritional Implication
Morphine Sulfate
(Pain meds)
Pain. Take with food. May cause taste
changes and constipation.
Famotidine
(Pepcid)
Stomach ulcers, GERD, over-
production of stomach acid
Bland diet may be
recommended. Limit caffeine.
Loperamide + Simethicone
(Maalox)
Diarrhea +
Gas
Diarrhea may increase fluid and
electrolyte needs. +
Avoid carbonated beverages
and gas-forming foods to
prevent flatulence.
IVFs Dehydration Fluid requirements may be
slightly decreased since they are
receiving IV fluids on top of diet.
Fe Sucrose
Ondansetron
(Zofran)
Prevent nausea and vomiting

Nutrition Database








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
138

K
3.6

BUN
106

CREAT
0.81


Albumin
2.7 low
Additional protein supplement to aid in wound healing.
Prealb
--


Glucose
97

HgbA1C


H/H

MCV

MCH

Iron (Fe)

Transferrin Sat (%)

Ferritin

Vitamin B
12
Folate


Ca

Phos

Mg



Is Patients Skin Intact? Yes No
If no, Surgical Wound Decubitus Ulcer
If decubitus ulcer, list stage (I-IV) and site(s)
Is decubitus ulcer Improving? Getting worse?

Nutrition Database


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? 168 cm 68 kg
Male Female Age 73
Any stress factors, activity factors to consider? Colon Cancer and Colon Resection


Calculate Energy Needs using
1) Harris-Benedict ------------------------------------ 2100-2300 kcal
2) Mifflin St. Jeor -------------------------------------- 1200-1400 kcal
3) kcal/kg ----------------------------------------------- 1700-2000 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 per hospital protocol
Show your work for three of the five methods above used:

1) Harris-Benedict
BMR= 655.1 + 9.56(68kg) + 1.7(168cm) 4.7(73y.o)
BMR= 655.1 + 650 + 285.6 343.1
BMR= 1247.6
Activity Factor= 1.2 (ambulatory)
Stress Factor= 1.5 (s/p surgery)
BMR= 1247.6 x 1.2 x 1.5
BMR= 2244 Range: 2100-2300 kcal

2) Mifflin St. Jeor

RMR= (9.99 x 68kg) + (6.25 x 168cm) (4.92 x 73) 161
RMR= (679) + (1050) (359) (161)
RMR= 1209 Range: 1200-1400 kcal




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3) Kcal/kg

68kg x (25kcal) = 1700kcal
68kg x (30kcal) = 2040kcal
Range: 1700-2000kcal






Calculate Protein Needs
How many g/kg would you use & why? 1.3-1.7 is a good range due to the increased needs from the patients colon
resection.
Show your work:

68kg x 1.3g = 88.4g
68kg x 1.7g = 115.6g
88-115 g/day



Calculate Fluid Needs using
1) ml/kg depending on age ----------------- 1700 ml/day
2) Holliday-Segar method ------------------- ml/day
3) RDA method --------------------------------- 1700-2000 ml/day
4) urine output (urine out +500ml/day)- ml/day
What formula did you ultimately use for the Pt & why?? RDA gives an appropriate range. Both values very similar
Show your work for two of the four methods above used:


Nutrition Database


1) mL/Kg Depending on age:
25mL/kg 25ml(68kg) = 1700ml H2O
2) RDA Method

Choose 1700-2000kcal needs 1700-2000ml H2O




Parenteral Calculations: What is the macronutrient composition of the TPN recommended by the physician?

Rate? ________mL/hr for how long? 24hr 12hr/day ______hr/day
Any PO intake? No Yes , explain ______________________________________________________________
Total volume/24hr __________ mL 2-in-1 Solution 3-in-1 Solution

Carbohydrate Concentration? D________ Amount of Dextrose (in grams) in 1000mL________ 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________ g
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?)

Nutrition Database



Does the prescription meet the calculated nutrition needs?
PN provides: ________ Kcal ________ g Pro ________ mL Fluid per day. Compare to
Est. Needs: ________ Kcal ________ g Pro ________ mL Fluid
PN meets how much of calculated needs in %? ________% kcal ________ % Pro ________ % Fluid
Do you have any recommendations?



Enteral Calculations: What is the macronutrient composition of the Enteral Feedings recommended by the physician?

Formula____________________ Bolus? How frequent? ____________ Continuous?
NG PEG Other _________________
Any PO intake? No Yes , explain ______________________________________________________________
Rate? ________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

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)

Nutrition Database


Total fluid provided (total free water plus additional flushes) __________ mL/day (_______ mL/kcal)
Does the prescription meet the calculated nutrition needs?
TF provides: ________ Kcal ________ g Pro ________ mL Fluid per day. Compare to
Est. Needs: ________ Kcal ________ g Pro ________ 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)

Spoke to RN about pts plan of care from a nutrition standpoint.
Physician (MD)

Reviewed MDs progress note for any nutrition related issues and
recommendations.
Social Worker (SW)


Speech Therapist (ST/SLP)


Physical Therapist (PT)


Occupational Therapist (OT)


Respiratory Therapist (RRT)


Woundcare / Ostomy Nurse

No noted wounds per chart.
Physicians Assistant (PA)


Other



Nutrition Diagnosis (P-E-S) Statement (write 2)
Problem: Inadequate oral intake


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related to (Etiology): poor appetite and altered GI functions

as evidenced by Signs and Symptoms: patient report.

Problem: Increased nutrient needs (pro/kcal)

related to (Etiology): increased demands

as evidenced by Signs and Symptoms: colon cancer and colon resection.


Interventions (your recommendation as a dietetic intern)
Encouraged PO intake and hydration

Recommend ensure clear QID

Recommend prostat x 1 packet BID

Consider probiotics (if diarrhea continues)

Provided patient with outpatient referral (per patient request)

Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)
PO intake goal >75% at most meals

Labs wnl as able

Maintain skin integrity

Avoid further wt. loss

GI fxns wnl as able


Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not
familiar with)?

Nutrition Database



Colon resection- bland low residue diet was appropriate. Patients with colon resections do not absorb adequate
amounts of fluid. Hydration encouraged. Because of her colon CA, this patient has increased calorie and protein
needs. This patient mentioned she had three hernias in the abdominal area that could be the cause of her nausea
and vomiting.