Carley Bedell

Backus Hospital
Date: 2/15/19

ADIME #1

A : Assessment:
Age: 34 Gender: M Admit Date: 2/12/19 Date Seen: 2/14/19

Admitting Dx: Patient J.S. is a 34 year old male who was readmitted to Backus Hospital on
February 13, 2019 for difficulty breathing (moderate), lethargy and cough occurring over the past
2-3 days before admission. Patient is nonverbal, mother provided medical information. Primary
medical diagnosis for hospitalization is gram-negative pneumonia.

Treatments/Therapies: Upon admission, a chest x-ray was performed to assess the patient’s
condition. The chest x-ray showed signs of pneumonia; low lung volume and right midlung zone
infiltrates and/or atelectasis was present with sharp demarcation with minor fissure. Receiving
sodium chloride 0.9% (NS) infusion 75mL/hour continuously for electrolyte replenishment. J.S.
is also receiving oxygen (2L n/c).

PMHx: On January 24-January 28, 2019 J.S. was admitted for sepsis (SIRS) secondary
to aspiration pneumonia and was transferred to Yale Hospital January 28-February 6, 2019 for
continuous electroencephalogram (EEG) monitoring due to severe frequent seizures. Since home
from Yale no seizures have occurred.

 Gram-Negative Pneumonia: The colonization of gram-negative bacilli in the lungs

resulting in an infection causing inflammation and fluid accumulation in the air sacs in one
or both lungs. Notably, individuals with respiratory complications are at a high risk of
developing pneumonia. 1
 Acute respiratory failure with hypoxia: A condition with low oxygen in the tissues of the
body due to damage or narrowing of the airways.2 Nutritional considerations include; fluid
balance, adequate magnesium, calcium, vitamin D and K, and macronutrient
recommendations such as increasing calories, 15-20% calories from protein, 30-45%
calories from fat, and 40-55% calories from carbohydrates.3
 Dysphagia (with G/J tube): A swallowing dysfunction causing disruption in an individual’s
ability to safely swallow food textures and liquids. Diet textures are assigned a diet texture
level based on severity of swallowing difficulties ranging from soft regular foods to
ground, and in severe cases puree foods. Enteral tube feeding is prescribed or patients with
high risk of aspiration from oral intake and prevent pneumonia and sepsis from occurring.3
 Seizure Disorder: When there is a frequent disturbance of the brain’s electrical activity that
allow the brain to communicate with the spinal cord, nerves and muscles. This condition
is caused by brain damage, head injuries, genetic factors, infection, low blood sugars,
dehydration and tumors. 4 A ketogenic diet has been shown to reduce the severity and
frequency of seizure occurrences. 5
 Cerebral Palsy (CP): The inability of the brain to control and/or coordinate muscles due
to damage to the brain during early development. The various types of CP are according to
neurological signs with muscle tone and abnormal motor patterns.3 Those with CP are
prone to seizures and respiratory complications such as aspiration, pneumonia, and
Carley Bedell
Backus Hospital
Date: 2/15/19

respiratory distress syndrome.5 High caloric needs are recommended for clients with CP,
those with mild CP would be recommended to have fourteen kcal per centimeter height.3

 Aspiration pneumonia (reoccurring): When food, drink, vomit or saliva is inhaled into the
lungs. Commonly caused by a disturbance in the normal gag reflex from a brain injury or
swallowing problem resulting in aspiration. 1

Height: Weight: BMI: UBW: % UBW:

5’ 50.8kg 22 119 94%

(152.4cm)

**Weight changes in hospital: Weight has been maintained since 5-6# weight loss from previous
admission, January 24, 2019- January 28, 2019.

Nutrition Requirements:
kcal: Mifflin St Jeor X (AF) X (IF) = (9.99 X 50.8 kg) + (6.25 X 152.4 cm) – (4.92 X 34 y/o) + 5 = 1293
kcal

1293 kcal X 1.3 (IF) = 1680 kcal

kcal/kg = 34 kcal/kg x 50.8kg = 1727 kcal (30-35kcal/kg range used)--- using 1727kcal due to
severity of condition

Protein gm/kg = 1.2 – 1.5 gm/kg = 61- 76 g PRO= using 76g protein due to severity of condition

Fluid = 1cc/kcal or 30 cc/kg: 2305 cc or 2427 cc

Method 4: (kg body wt- 20) x 15 + 1500=(50.8-20) x 15 + 1500=1,962

Method 1: 35ml/kg (patients with infections)=35ml/kg x 50.8kg=1778 (rounding to nearest 100)=1800ml

free water

**Method 1 was used, followed hospital recommendation. 1962ml is too high, don’t want to over hydrate
patient since he is additionally on IV and receives numerous medications through the G-tube.

Diet Order:
Current Order: Diet NPO

 Receiving Ketogenic tube feed formula (Ketocal) with Prosource TF, 60ml continuous
 Continuous IV fluid, Sodium Chloride 0.9% Infusion 75ml/hr
Assessment of Appropriateness of current diet order:

The current diet is appropriate, J.S. cannot eat solid food or drinks due to severe swallowing difficulty due
to dysphagia, CP and respiratory failure with hypoxia. J.S. is unable to feed himself and is on aspiration
 Carley Bedell
Backus Hospital
Date: 2/15/19

precaution. Due to diarrhea, TF formula will be changed to Ketogenic formula with no insoluble fiber
(Ketovie Peptide) upon discharge due to inaccessibility.

Labs: Source: Nutrition Care Manual

Date Lab Name Patient’s Normal Significance

Result Range

2/14/2019 Glucose 84 mg/dL 70 - 100 WNL

mg/dL

2/14/2019 Blood Urea 11 mg/dL 10 - 20 WNL

Nitrogen (BUN) mg/dL

4/10/2014 Creatinine 0.3 mg/dL 0.5 – 1.1

mg/dL

2/14/2019 Sodium (Na) 144 mmol/L 136 – 145 WNL- Well hydrated due to fluids from tube feed,
mmol/L sodium chloride continuous IV fluid

2/14/2019 Potassium (K) 4 mol/L 3.5 – 5.0

mol/L

2/14/2019 Chloride (Cl) 106 mEq/L 98 – 106

mEq/L

2/14/2019 Carbon Dioxide 28 23 – 29 WNL, receiving oxygen (2L)

(CO2) mEq/L mEq/L

2/13/2019 White Blood Cell 9.1 k/cmm 5 – 10 WNL

(WBC) k/cmm

2/14/2019 Red Blood Cell 3.95 4.7 – 6.1 Low decreased from 4.24 from 2/13/19, may have
(RBC) cells/mcL cells/mcL decreased due to pneumonia

4/10/2014 Hemoglobin (Hb) 13.9 g/dL 14 - 18 Low value, may have decreased due to pneumonia
g/dL

2/14/2019 Hematocrit (Hct) 38.9 % 42 – 52 % Low value, decreased from 2/13/19, may have
decreased due to pneumonia

** Blood culture testing pending (for pneumonia)

Meds: Source: WebMD

Name Purpose Side Effects Nutritional Concerns
CloBAZam Control Seizures Drowsiness, tiredness, Avoid Alcohol
(CONFI) headache, constipated, weight
(per G tube) gain, fever, cough, drooling,
trouble sleeping, or nausea
 Carley Bedell
Backus Hospital
Date: 2/15/19

CloazePAM Control seizures Drowsiness, dizziness, Avoid Alcohol

(klonoPIN) tiredness, loss of coordination,
(per G tube) or increased saliva production
Diphenoxylate Diarrhea Stomach/abdominal pain or Avoid Alcohol
(Atropine) swelling, severe nausea,
(per G tube) vomiting, mental/mood
changes
Felbamate Treat Severe Seizures Drowsiness, dizziness, Avoid Alcohol
(FelBATOL) tiredness, loss of coordination,
(per G tube) headache, blurred/double
vision, hiccups, or loss of
appetite
Gabapentin Control Seizures Drowsiness, dizziness, Avoid Alcohol
(Neurontin) tiredness, loss of coordination,
(per G tube) unusual eye movement, or
shaking (tremor)
Lacosamide Control Seizures Dizziness, drowsiness, Avoid Alcohol
(VIMPATl) blurred/double vision, nausea,
(per G tube) vomiting, tiredness, loss of
balance, difficulty walking,
shakiness (tremor), or
memory problems
LevETIRAcetam Control Seizures Drowsiness, dizziness, Avoid Alcohol
(Keppra) unusual tiredness, or
(per G tube) weakness
LevOCARNitine Diet Supplement Upset stomach, nausea, N/A
(Carnitor) preventing/treat low vomiting, diarrhea, headache,
(per G tube) blood levels of muscle pain/weakness,
carnitine swelling of hands/lower
legs/feet, tingling skin, or
body odor

Side effect can be seizure

Topiramate Control Seizures Tiredness, drowsiness, Avoid Alcohol
(TOPAMAX) dizziness, loss of
coordination, tingling of the
hands/feet, loss of appetite,
bad taste in your mouth,
diarrhea, and weight loss
Valproate Control Seizures Diarrhea, dizziness, Avoid Alcohol
(DEPAKENE) drowsiness, hair loss,
blurred/double vision, ringing
in ears, shakiness (tremor),
unsteadiness
Vanocomycin Antibiotic, for Pain, redness, and tenderness Avoid/limit alcohol
(VANCOCIN) bacterial infections
IV
Carley Bedell
Backus Hospital
Date: 2/15/19

Physical Assessment:
Was unable to be see patient due to inability to verbalize and intellectual disability. It was necessary to wait
for mother to be present for conversation and therefore, was unable to meet with patient since mother wasn’t
at the hospital. J.S. is bed ridden but recent reports state he is awake, alert and has no acute distress. He is
receiving oxygen (2L n/c). No wheezing, rale or rhonchi. No seizures since released from Yale in the
beginning of February.

Pertinent Social Hx:

Patient lives at home with his mom he is not ambulatory and receives full care from mother. Mother
prepares all TF formula using a blender. J.S. is bed ridden and unable to communicate.

Nutrition Hx, Diet PTA:

Patient J.S. has been on NPO and on a tube feed for quite some time. After his recent hospital admission,
he was prescribed a ketogenic formula from Yale hospitals seizure unit due to high frequency of seizure
occurrences. J.S. receives the Ketocal (ketogenic formula) with Prosource for optimal nourishment for
health conditions (seizures and pneumonia) but will be transitioning to a ketogenic formula with soluble
fiber (Ketovie Peptide).

Summary of Current Intake:

The patient is NPO on a permanent TF getting Ketocal 60ml/hr and Prosource (1.5 oz) TID to increase
protein consumption for compromised pulmonary status due to pneumonia and acute respiratory failure.
Daily total intake is 1438, meeting 80% of goal. Patient is getting 400ml over 1800cc fluid goal from
Ketocal. Notably, J.S. is receiving 8 seizure medications and 1 medication for diarrhea through G-tube that
can be contributing to excess fluid consumption. Upon discharge patient will switch to Ketovie Peptide to
reduce excessive diarrhea.

D (Diagnosis) PES:
Enteral Nutrition Composition Inconsistent with Needs (NI-2.5) related to deficient fiber intake as
evidenced by excessive diarrhea.

I (Intervention):
Organized into 4 categories:

Food and/or Nutrient
Delivery
Nutrition Education
Nutrition Counseling
Coordination of
Nutrition Care
Implement ketogenic formula with soluble fiber, Ketovie Peptide
(providing 1.5kcal/ml; 2.6g fiber; 6g MCT/serving) in place of current
formula, Ketokal formula. Switch 60ml/hr to 48ml/hr to meet calorie
requirements.
Educate mom on preparation and administration of Ketovie Peptide formula
N/A
Yale Dietitian Adrianna involved in monitoring patient, doctor assigned to
patient, and nursing staff administering TF
Carley Bedell
Backus Hospital
Date: 2/15/19

M/E Monitoring and Evaluation:

Organized into 5 categories:

Food/Nutrition Related Monitor patients tolerance of EN and EN intake

Outcomes
Anthropometric
Measurement Outcomes
Biochemical Data, Medical
Tests, and Procedure
Nutrition-Focused Physical
Findings Outcomes
Nutrition Education
Outcomes
Pt will meet at least 75-100% nutrient needs from EN by F/U
Monitor sodium chloride IV supplement intake
Pt will continue to maintain weight
Monitor weight
Maintain and monitor serum electrolytes
Monitor H/H
Evaluate blood culture results upon release
Monitor bowel movements (frequency and consistency)
Monitor respiratory status/rate
Monitor seizure occurrence
Patients mother will be able to prepare G-tube formula and follow
nutrition prescription

Meal Plan:
1. For current Dx explain- Foods Allowed, Foods Not Allowed, Diet Instruction Materials if appropriate.
Describe in your own words the rationale for diet restrictions/modifications
Foods Allowed NPO
Foods Not Allowed N/A

Diet Instruction If diarrhea continues evaluate EN composition and assess other contributing factors
Materials if appropriate such as medication.

2. Menu Plan or Nutrition Support Regimen for Discharge “Diet “ If Appropriate

Tube Feed Calculation:

Nutrient Needs: 1727kcal; 76g P; 1800ml

Prosource TF: 1.5oz (1pkg) 11g; 40kcal (TID)

1.5oz=44ml x 3= 132ml= 130ml total
11g x 3 = 33g protein
40kcal x 3 = 120 kcal total

1727kcal-120kcal=1607kcal left
1800ml-130ml=1670ml left

Ketovie Peptide: 1.5kcal/ml; 2.6g fiber; 6g MCT/serving

1607kcal/kcal/ml TF=1607kcal/1.5kcal/ml=1,071ml=1,070ml volume to give

1070ml/24h=47.9=45mls/hr
45ml x 24h x 1.5kcal/ml= 1620kcal
(1070ml x 32g protein)/1000=34g protein
45ml/hr x 24 x 0.76=820ml free water
1670ml-820lm=850ml water flushes
Carley Bedell
Backus Hospital
Date: 2/15/19

850ml/6=142ml=140ml flush every 4 hours or 6x/day

****45ml/hr was used instead of 60ml/hr as currently prescribed due to possible error. 60ml/hr when
calculated was resulting in significantly higher kcal than recommended. No ml free water was listed on
formula composition, 1.5kcal/ml typically provides 76% water which was used to calculate free water.

Macronutrient/Micronutrient Calculations:

(1070ml x 32g )/1000=34g protein

(1070ml x 14g )/1000=15g carbohydrate
(1070ml x 148g)/1000=158g fat
(1070ml x 10g)/1000=11g fiber
(1070ml x 900mcg)/1000=963mcg vitamin A |DRI: 900mcg|
(1070ml x 20mcg)/1000=21.4mcg vitamin D |DRI: 180mcg|
(1070ml x 8mg)/1000=8.6mg vitamin E |DRI: 15mg|
(1070ml x 60mcg)/1000=64.2mcg vitamin K |DRI: 90mcg|
(1070ml x 2mg)/1000=2.14mg Thiamin |DRI: 1.2mg|
(1070ml x 2mcg)/1000=2.14mcg vitamin B12 |DRI: 2.4mcg|
(1070ml x 2mg)/1000=2.14mg vitamin B6 |DRI: 1.2mg|
(1070ml x 180mg)/1000=193mg vitamin C |DRI: 90mg|
(1070ml x 600mg)/1000=642mg Choline |DRI: 425mg|
(1070ml x 1820mg)/1000=1947mg Calcium |DRI: 1000 mg|
(1070ml x 1290mg)/1000=1380mg Phosphorus |DRI: 700mg|
(1070ml x 230mg)/1000=246mg Magnesium |DRI: 420mg|
(1070ml x 18mg)/1000=19.26mg Iron |DRI: 8mg|
(1070ml x 1530mg)/1000=1637mg Sodium |DRI: 1500mg|
(1070ml x 2430mg)/1000=2600mg Potassium |DRI: 4700mg|
(1070ml x 1870mg)/1000=2000mg Chloride |DRI: 2300mg|

Macronutrient DRI’s:
Adults above 18y= 2403kcal
Fat (20-35%)= 53-67g
2403x.2=481kcalx 1g/9kcal=53g| 2403x.25=600.75kcalx 1g/9kcal=67g

CHO 45-65= 270g-390.5g

2403x.45=1081kcalx 1g/4kcal=270g| 2403x.65=1562kcalx 1g/4kcal=390.5g

Protein 10-35= 40g-140g

2403x.10=240kcalx 1g/6kcal=40g| 2403x.35=871kcalx 1g/6kcal=140g

Patient J.S. nutrient consumption from EN formula had significantly higher fat (148g) than DRI
(53-67g), protein (67g) is within DRI recommendations (40-140g) and carbohydrates (15g) are
significantly below DRI’s (270-390.5g). The calories of the formula (1727kcal) was much lower than DRI’s
for an active adult male (2403kcal). This is because of the patients compromised health conditions that
require a ketogenic diet (low carbohydrate, high fat). His lack of mobility, but compromised health require
fewer calories than the DRI. Most of the patients micronutrient consumption is around the DRI amount
except potassium and vitamin D were lower and vitamin C, Phosphorus, Iron, Calcium were higher. The
formula varies in the nutrients due to the nutrient needs required to control/reduce seizure occurrences and
severity.
Notably, since 60ml/hr was not calculating properly EN formula prescription should be reassessed.
Carley Bedell
Backus Hospital
Date: 2/15/19

Calculations:
BMI calculation: kg/ m2
278 lbs/ 2.2 (kg/ lb) = 126kg
5 feet 8 inches = 68 inches* 2.54 (cm/ in) = 173 cm = 1.73m
50.8 kg / 1.524 m2
BMI = 22→ Normal

𝐶𝑢𝑟𝑟𝑒𝑛𝑡 𝑊𝑒𝑖𝑔ℎ𝑡
Usual Weight %: ∗ 100
𝑈𝑠𝑢𝑎𝑙 𝑊𝑒𝑖𝑔ℎ𝑡
112
= 119 ∗ 100 = 94%

References:

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conditions/pneumonia/symptoms-causes/syc-20354204
2. Kahn, April; Marcin, Judith, MD. Chronic Respiratory Failure, 2018. Healthline Website.
https://www.healthline.com/health/chronic-respiratory-failure#complications
3. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's
Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier/Saunders, 2012.
4. Adamolekun, Bola MD. (2019). Seizure Disorders. Merck Manual Consumer Version.
https://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/seizure-
disorders/seizure-disorders
5. Cerebral Palsy and Seizures. (2019). Cerebral Palsy Guidance.
https://www.cerebralpalsyguidance.com/cerebral-palsy/associated-disorders/seizures/
6. Respiratory Health. (2019). My Child at CerebralPalsy.org
https://www.cerebralpalsy.org/information/respiratory-health
7. Academy of Nutrition and Dietetics. (2013). Nutrition Care Manual. Retrieved from Academy of
Nutrition and Dietetics Web Site: http://nutritioncaremanual.org/auth.cfm?p=%2Find
8. Medications and Drugs. (2005-2019). WebMD. https://www.webmd.org/drugs