Dietetics Case Study: DNI Pharmacotherapy (Activity)

Questions
1. Why is Violeta being seen by an outpatient MD?

- She reports not feeling herself, is taking medication for depression and has
reported more drinking lately.

2. Who is Violeta’s Doctor?

- Her doctor is Dr. Kerry West

3. How tall is Violeta?

- She is 66 inches tall

4. How much does Violeta weigh?

- She weighs 185lbs

5. Calculate and assess her BMI.

- 185 / 2.2 = 84 / 66 x .0254 = 1.676 x 1.676 = 2.81

- 82/2.81 = 29.89
- Violeta is considered overweight or almost obese

6. After reviewing her problem list, what concerns do you have?

- I am concerned about her mental health, if she is eating enough, if she is drinking
too much, and if she is capable of utilizing the nutrients she consumes. I am also
concerned with her unintentional weight loss and would like to help figure out
why it is occurring.

7.​ W
​ hy did her doctor order a Dietitian Consult?

- Her doctor was concerned about her unintentional weight loss so she ordered a
dietitian consult

8.​ U
​ sing Standardized Language, list at least 3 possible Nutrition Problems.

- Inadequate oral intake

- Unintended weight loss
 - Undesirable food choices

9.​ W
​ hy do you need to provide DNI education for people taking MAOIs?

- MAOIs are commonly prescribed antidepressants that interact with various foods
such as processed meats, pickled or fermented foods, and some soy products. It
is important to educate those taking this medication on what foods interact with it
because it can counteract its ability to perform properly, thus defeating the
purpose of the drug.

10. List three things you will mention to this patient:

1) Eating is important and if weight loss is intentional, there are other ways to lose
weight that are healthy.
2) There are many options for mental help, including therapists who can help you
through whatever t is going on in your life right now. It is also important to note
your support system and utilize them as best you can.
3) Poor eating habits and alcohol consumption may be disrupting your sleep.
Altering these aspects of your life may greatly improve your sleep quality.

11. What foods will you suggest as best choices for Violeta? Which foods will you
encourage her to limit or avoid?

- I would suggest nutrient dense foods and suggest more consistent eating habits.
She would benefit from consuming more fruits and vegetables, along with healthy
fats as well.
- I would have her avoid smoked or processed meats, such as hot dogs, bologna,
bacon, corned beef or smoked fish, pickled or fermented foods, such as
sauerkraut, kimchi, caviar, tofu or pickles, sauces, such as soy sauce, shrimp
sauce, fish sauce, miso and teriyaki sauce, soybeans and soybean products

12. What will you tell this patient about herbal supplements?

- I would tell her that all herbal supplements are not regulated by the FDA and
should be used with caution. Each one she ingests should also be discussed with
a physician to ensure safe / proper usage, especially while she's on other
medication.

13. What other healthcare providers would you talk to about Violeta? What
information/recommendations would you convey?
- Doctor - to monitor her labs and ensure her organs are functioning properly
- Social worker - to discuss a care plan in the event that the patient is no longer
able to take care of herself. A social worker will be able to check up on the
 patient to ensure her needs are being met, if not by herself, by her family
members.
- Counselor / therapist - to discuss her depression and alcohol consumption. Once
that is under control, it will be easier to work on her eating habits to get her at a
stable and healthy weight
- Psychiatrist - to ensure she is getting the proper medication prescribed to her for
her depression, etc

Tina Rickard (TPN Case Study)

Client history: 

- None were recorded 

- Tina is a 44 year old female with a history of multiple bowel obstructions over the past 
six years, adding multiple bowel diagnosis. She is now hospitalized. You came to work 
and received a notice that the Hospitalist started TPN upon admission and had 
consulted the Nutrition Support Team for nutrition support recommendations a few 
days ago, but the nurse forgot to enter those orders. It's now Friday at 14:30 and you 
need to go assess Tina's nutrition status and determine if the TPN is appropriate for her 
nutrition & hydration needs before the clinical pharmacist leaves at 16:30.  

Biochemical data, medical tests and procedures: 

- Complete bowel obstruction, feeding tube placement, most other information is missing 
from file  

Anthropometric measurements: 

- 139lbs, 66inches, BMI = 22.4 

Physical exam finding (nutrition focused): 

- None - but nurses reported adult failure to thrive  

Food and nutrition history: 

- History of GI issues that may be altering her nutritional status. Bowels should rest, 
nutritional status should be assessed regularly.  

Comparative standards: 

- Doctor - to monitor progress and healing of tube placement  

- Pharmacist - to ensure the medication she is on is accurate and not taken with anything 
that would alter it  
- Nurse - to administer tube feeds and monitor the patient’s wellbeing and ability to 
adjust to the nutrition support  
- Gastroenterologist - to discuss tube placement and to evaluate its effectiveness and 
stability as well  

Total energy estimated needs: 

- 139lbs, 44yo, 66inches 

- (10 × ​weight​ in kg) + (6.25 × ​height​ in cm) - (5 × age in years) - 161 
- (10 x 63kg) + (6.25 x 167.6) - (220) - 161 
- 630 + 1,047.8 - 220 - 161 = 1,297 (1,300) x 1.375 = 1,788 + 500 calories for stress 
= 2,297 (​2,300) calories  
- Current Energy Provided: 
- Solution:SOL00096 TPN IV 
- Solution Volume:1440 
- Solution Rate:60 cc/hr 
- # of Bags:1 
- Additive 1: 
- 500 cc daily Intralipid 20 % Fat Emulsion Injectable Suspension 
- Additive 2: 
- 1 Clinimix E 5/25 (5 % amino acids with electrolytes in dextrose 25 % ) Injectable 
Solution 
- n​1000cc 5% AA = 1000 x .05 = 50 grams protein x 4 cals/g = ​200 cals
- n​1000cc 25% Dex = 1000 x .25 = 250 grams carb x 3.4cals/g = ​850 cals
- n​500cc 20% Fat = 2 cals/cc x 500 = ​1,000 cals
- Totals: ​2050 calories
 -  

Total protein estimated needs: 

- Short Bowel: 1-1.5g/kg = 63 x 1.5, 63 x 2 = 7

​ 8.8 - 126​ grams of protein  

Total fluid estimated needs: 

- 35mL/kg = 2,205mL or 2.2L fluid 

Other: ** The current nutrition support order provides about 250 calories less than what 
is recommended for the patient to consume. I would increase protein to at least 80 
grams and decrease fat accordingly.  

Nutrition Diagnosis 

(P) Problem: 

- Altered gastrointestinal function  

(E) Etiology (r/t): 

- Related to decreased functional length of the GI tract 

(S) S/S (aeb): 

- As evidenced by failure to thrive (on the basis of a 5% weight decreases and 

dehydration)  

Nutrition Intervention 
Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

- total calorie needs (2300 kcals/day)

- total protein needs (provide 20% of total calories from solution as protein)
- (Using a 10% AA solution 100 gm AA per L)
- 2300 x .2 = 460 kcals of protein / 4 kcal/g = 115 gm protein = 1150 mL
- total fat needs (provide 20-30% of total calories as fat)
- (Using a 20% lipid emulsion provides 2 kcal/mL)
- 2300 x .25 = 575 kcals of fat / 2 mL per kcal = 287.5 mL
- 575 kcals / 9 g/kcal = 64 g
- Balance kcals with carbohydrate (dextrose)
- 1265 kcals needed / 2380 kcal * 1000mL = 513 mL
- 2380 is derived from 70% dextrose = 700g/1000mL * 3.4kcal/g
- Add mL together for total formula needs
- 10% AA 1150 mL, 20% Lipid 287.5 mL, 70% Dex + 513 mL Total 1950.5 mL at 80mL
per hour continuous TPN.

Intervention: 

- Modify composition of TPN solution to meet patient’s needs adequately.  

Goal:  

- Maintain weight and improve hydration and overall health status.  

Nutrition Monitoring and Evaluation 

Indicator: 
 - Follow up with RDN in 2 days to see improvement in health status from TPN alterations. 
Perform a nutrition focused physical exam and view pertinent labs to evaluate 
nutritional status.  

Criteria: 

- Adequate hydration status and stabilized weight from time of TPN start to time of 
re-evaluation.  

Nutrition Post CVA

Questions
1. Using any of the resources located under #1, list the side effects, or the residual
effects, of a cerebrovascular accident.
- Possible muscle and joint pain, difficulty swallowing, speaking, and
understanding speech, decreased motor control, memory problems, and
emotional disturbances.

2. Homer has an order for a Dietician Consult. Review his History and Physical note
and list what problems or assessment items that may interfere with Homer’s ability to
consume and metabolize proper nutrition.

- Homer has osteoporosis and T2DM which may interfere with his nutrient
utilization if untreated. He is also on plenty of medications that could interact with
nutrient utilization as well. Lately, his dysphagia that was brought on by his stroke
will really interfere with his ability to ingest nutrients

3. How will you evaluate Homer’s nutritional status?

- I would evaluate his status through labs and through a nutrition focused physical
exam. I will do so by calculating his individual protein, energy, and fluid needs
and compare them to what his nutrition support is providing him currently. I will
also monitor how well his needs are being met through nutrition support and
adjust it as needed.

4. What would you assess and/or evaluate in your physical exam of Homer to assist
you in determining his nutritional status?
 - I would assess his BMI, his ability to move (motor control)

5. Calculate Homer’s IBW and ABW using pounds and inches. Use pounds for your
answer.
- He is 5’9 or 69 inches tall
- 6 x 9 = 54 +106 = 160lbs IBW
- ABW = ​145lbs 
- 160 + (.4 x 145 - 160) 
- 160 - (-)6 = 154lbs 
- IdealBW+(0.4∗(ActualBW−IdealBW)) 

6. What is Homer’s IBW and ABW in kilograms?

- 160 / 2.2 = 72.7kg IBW 

- ABW = 70kg 

7. What is Homer’s percentage of IBW?

- 145 / 160 = 90.6% or 91% of his IBW

8. What is Homer’s BMI and what does it mean?

- His BMI is 21.4 and this means he is at a healthy weight

9. Calculate Homer’s calorie needs per day using the Mifflin-St. Jeor equation.
What are the results?

- Using homer’s ABW* 

- (10 × ​weight​ in kg) + (6.25 × ​height​ in cm) - (5 × age in years) + 5. 
- 700 + 1,095.4 - 425 + 5 = 1,375 calories or 1,400 calories x 1.2AF =​ ​1,680 or 1
​ ,700 
calories  

10. Below is a photo of the cans that the LTC facility has in stock. Based on your
calculations in #9, is the current order of 80mL/hour correct? If not, what hourly rate
would you recommend for the formula?

- 237ml / 250 calories = 1.05cal x 80mL per hour = 84.4 x 24 hours continuous
feeding =​ 2,025​ calories
- His current order is too high for his calorie needs. Based on a calorie
recommendation of 1,700 calories, he should be given 70mL per hour
continuous.
11. Based on Homer’s weight, is the order for 250 mL of free water every 6 hours
adequate? If not, what would you recommend?

- This is an adequate amount of free fluid. His total fluid needs are around
1,650mL and this fulfills about 1,500mL.

12. What signs and symptoms would you be observing for that would indicate Homer is
no longer tolerating his tube feedings?

- Nausea, diarrhea, high volume of gastric residuals, vomiting

13. Explain what the advantages and disadvantages are to administering enteral
feedings continuously. As opposed to ordering the enteral feeding on an intermittent or
bolus schedule. List the reference(s) used to explain your answer.

- Advantages: continuous is ensured to be given to a patient, bolus may be

forgotten or not enough may be given to the patient to meet their needs (by
mistake). It is more easily tolerated by most patients, especially those with
aspiration risk. It also has the ability to be feeding the patient overnight so more
nutrients can be delivered and the patient can more heal quickly.
- Disadvantages: it decreases mobility and it may be difficult to set up inside the
home if that is what the patient wishes to do once discharged.
- Stawicki, S., Evans, D., Forbes, R., Jones, C., Cotterman, R., Njoku, C., . . .
Papadimos, T. (2016). Continuous versus bolus tube feeds: Does the modality
affect glycemic variability, tube feeding volume, caloric intake, or insulin
utilization? ​International Journal of Critical Illness and Injury Science,​ ​6​(1), 9.