Russell Sage College - NCP Documentation Form

Name:
Patient ID: EW Reason for Nutrition Consult: Assessment of PEG and trach sites, and orders
implemented
Admit Date: 2/12/24 Current Date: 2/12/24 Admit Medical Diagnosis: Tracheostomy and percutaneous endoscopic
gastrostomy placement secondary to pneumonia
NUTRITION ASSESSMENT
Food and Nutrition Related History:

Current Inpatient Diet Order: Feeding Ability Oral Problems

□ Independent X Chewing Problem
Jevity 1.5 cal @ 45mL/hr □ Limited Assistance X Swallowing Problem
Flush with 60 mL of room
temperature water before and after X Extensive/Total Assistance □ Mouth Pain
each feeding. Plus, flush with 200 ml □ N/A □ None of the Above
room temperature water every 8
hours. Explain: Explain:
Currently has tracheostomy and PEG tube Currently has tracheostomy and PEG tube

Physical Assessment:
Abdomen: Soft. Tender in the upper left quadrant where PEG tube is present. No masses or organomegaly. Bowel sounds normoactive in all four
quadrants.
Exttremities: Weakness bilateral lower extremities
Mouth: Buccal mucosal intact; dry and pale
Neck and Axilla: Tracheostomy present
Skin: Joints and muscles symmetric, mild weakness present

Anthropometric Measurements
Age: Gender Ht: Current Wt: 70kg/154lb BMI:
54yo Male 72in Admit Wt: 21
IBW: 80kg/178lb (Hamwi)
Wt Hx (specify time frame):
1/14/24- 81.8kg, lost BMI Classification:
% Wt change: Normal
14% wt change
Biomedical Data (list only pertinent nutrition-related labs)
Labs →
Date ↓ Glucose Creatinine Calcium Albumin AST Hemoglobin Hematocrit
(SGOT)
High, High, 1.2 Low, Low, 3.0 High, 70 Low, 12 Low, 35
150 8.4
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
Tracheostomy placement 24 days ago, PEG placed 23 days ago, Chest Xray (PA?LAT) waiting on results

PMH:
Hypertension treated and controlled with Metoprolol 25 mg daily and Hydrochlorothiazide 12.5 mg oral daily.

Pertinent Medications & Dosage

3 ML Sodium Chloride 0.9% Prefilled Syringe
Metroprolol Tartrate 25MG Oral Tablet
Alprazolam 1MG/ML Concentrate for Oral solution
Skin status: X Intact □ Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): _No risk________
Comments:

Estimated Nutritional Needs based on ___70 kg

 Calories (kcal/kg & total kcal/day) Protein (g/kg & total g/day) Fluid (ml/kg & total ml/day)
1569kcal/day (MST) 2500mL/day
22kcal.kg 36mL/kg
Holliday-Segar
NUTRITION DIAGNOSIS (include IDNT codes)
P (problem)___________________________ E (Etiology)____________________________ S (Signs & Symptoms)
____________________________related to: ________________________as evidenced
by:
P (problem)___________________________ E (Etiology)____________________________ S (Signs & Symptoms)
____________________________related to: ________________________as evidenced
by:
INTERVENTION

MONITORING & EVALUATION

Indicators (marker): Criteria (SMART Goal specific to marker):

_______________________________________________________________________________________________
Intern’s Signature Date Preceptor’s Signature Date

Answer all assigned Case Questions and the following. Use your notes and textbook to help with answering
the questions. Cite your sources if you use outside material.

1. Assess your PES Statement:

P: Can YOU resolve or improve the nutrition diagnosis?

E: Is the etiology the "root" cause? Will YOUR intervention resolve the problem by addressing the
etiology? If not, can YOUR intervention at least lessen the signs and symptoms?

S: Will measuring the signs and symptoms indicate if the problem is resolved or improved? Are the
signs and symptoms specific enough?

Overall: Does your nutrition assessment data support the nutrition diagnosis, etiology, and signs &
symptoms?

2. What is a percutaneous endoscopic gastrostomy? Briefly describe the procedure for its placement.

3. What is a tracheostomy? What is a trach collar?

4. Describe the uses for the following medication: Alprazolam, Metoprolol, Xopenex, Hydrochlorothiazide.
5. If Mr. Watson were to be transitioned from the tube feeding to an oral diet, describe how that may be
accomplished?