Dietetic Internship - Major Case Study Presentation

Major Case Study
Presentation
Brandi Curtis, Dietetic Intern
Patient's initials:
• DB
Age, Height, Weight:

• 69 y/o, 5’3” or 63”, 137.7 kg (303 lbs), 53.78 BMI
General
Occupation:
• Retired
Informat
Family responsibility:
• Divorced
Date of Admission:
ion • 3/10/21
Attending Physician:
• Pranav Tayal, MD
Unit:
• Med/Surg and ICU
Congestive heart failure (HCC)
[I50.9]
Cellulitis and abscess of lower
Past extremity [L03.119, L02.419]
Hypertension [I10]
Medica Diabetes mellitus type 2 with
complications (HCC) [E11.8]
l Neuropathy [G62.9]
History Hyperlipidemia [E78.5]
Asthma [J45.909]
Hysterectomy
Past [SHX81]
Surgica
Cardiac
l Catheterization
History [CATH01]
Dialysis catheter
insertion
[PRO303]
• acetaminophen (TYLENOL EXTRA STRENGTH) 500 MG
tablet
• albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulizer
solution
• albuterol 90 mcg/actuation inhaler
• amLODIPine (NORVASC) 5 MG tablet (Start: 3/24/2021; End:
4/23/2021)
• apixaban (ELIQUIS) 5 mg Tab (Start: 3/24/2021; End: 4/23/2021)
• carvedilol (COREG) 25 MG tablet (Start: 10/9/2017)
• cholecalciferol, vitamin D3, 1,000 unit
Medicati
tablet
• cyanocobalamin (vitamin B-12) 1000 MCG
tablet
• furosemide (LASIX) 40 MG tablet (Start: 2/5/2021)
ons
• gabapentin (NEURONTIN) 600 MG tablet (Start: 11/20/2020)

• glipiZIDE (GLUCOTROL) 5 MG tablet (Start: 3/10/2021)
• insulin glargine (LANTUS) 100 unit/mL (3 mL) InPn (Start:
3/24/2021; End: 4/23/2021)
• insulin lispro (HumaLOG) 100 unit/mL injection (Start: 3/24/2021;
End: 4/23/2021)
• metFORMIN (GLUCOPHAGE-XR) 500 MG 24 hr tablet (Start:
3/16/2021)
• multivitamin (multivitamin) per
tablet
• nystatin (MYCOSTATIN) powder (Start: 3/24/2021; End:
3/24/2022)
• ramipriL (ALTACE) 10 MG capsule (Start: 2/7/2021)
• vitamin E 1,000 unit cap
• warfarin (COUMADIN) 5 MG tablet (Start: 2/7/2021)
Present Admission 3/10/21
• Initial ED triage note:
• "Patient to ED via EMS c/o shortness of breath beginning 20 min to EMS arrival. Per EMS, BP
240/P accucheck 380. Per EMS, duoneb given en route to hospital patient has not taken
any home medications today. Patient denies any pain at this time."
• Clinical Impression from ED physician:

• Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present
(HCC)
• Pneumonia of both lower lobes due to infectious organism
Day 1 Admission Progress 3/11/21
• Chief Complaint
•Patient presents with
• Shortness of Breath
• Anxiety
• INTERVAL HISTORY/SUBJECTIVE
•Patient seen and examined at bedside. Reports
feeling better today. No acute overnight events
noted. Afebrile at this time.
Day 1 Admission Impression & Plan
(Brief)
2. Respiratory failure 3. Bilateral lower extremity
1. Severe sepsis -Likely secondary to chronic
secondary to community- sepsis. Currently requiring lymphedema/cellulitis -
acquired pneumonia/E. coli minimal supplemental Continue
UTI/LE cellulitis oxygen via nasal cannula 2 antibiotics. Podiatry
L/min. Wean as able. consulted awaited.
5. Diabetes mellitus type 2

6. History of pulmonary
-Continue Lantus/insulin
4. Chronic debility -PT/OT embolism -Continue
sliding scale. Hold
eval Coumadin. Check INR
Metformin/glipizide.
daily.
Diabetic diet.
Code Status: Full Code

Diet: Diet Special; Diabetic; • Disposition: To be determined
7. Hypertension -Continue pending
Carbohydrate Consistent
amlodipine 5 mg p.o. daily.
60g/meal (1500-2000 kCal
Titrate up as needed.
equivalent)
Day 1 Labs
Ref. Range 3/11/2021 08:54
SODIUM Latest Ref Range: 135 - 145 mmol/L 133 (L)

POTASSIUM Latest Ref Range: 3.5 - 5.1 mmol/L 3.6
CHLORIDE Latest Ref Range: 98 - 108 mmol/L 95 (L)
Bicarbonate Latest Ref Range: 21 - 32 mmol/L 29
Anion Gap Latest Ref Range: 10 - 20 mmol/L 13
GLUCOSE Latest Ref Range: 65 - 99 mg/dL 214 (H)
BUN Latest Ref Range: 8 - 25 mg/dL 8
CREATININE Latest Ref Range: 0.60 - 1.20 mg/dL 0.49 (L)
eGFR Latest Ref Range: >=60 mL/min/1.73 m2 100
BUN/Creatinine Ratio Latest Ref Range: 10.0 - 20.0 16.3
Total Protein Latest Ref Range: 6.0 - 8.0 g/dL 6.4
ALBUMIN Latest Ref Range: 3.2 - 5.2 g/dL 3.6
CALCIUM Latest Ref Range: 8.4 - 10.2 mg/dL 8.8
ALK PHOS Latest Ref Range: 40 - 150 U/L 71
AST Latest Ref Range: 0 - 45 U/L 16
ALT Latest Ref Range: 0 - 40 U/L 12
Total Bilirubin Latest Ref Range: 0.0 - 1.3 mg/dL 0.7
MAGNESIUM Latest Ref Range: 1.6 - 2.4 mg/dL 1.4 (L)
Lactic Acid Latest Ref Range: 0.6 - 2.0 mmol/L 1.2
WBC Latest Ref Range: 4.50 - 11.00 K/mcL 14.90 (H)
RBCs Latest Ref Range: 4.00 - 5.20 M/mcL 4.14
HGB Latest Ref Range: 12.0 - 16.0 g/dL 11.8 (L)
HCT Latest Ref Range: 36.0 - 46.0 % 36.9
MCV Latest Ref Range: 80.0 - 100.0 fL 89.1
MCH Latest Ref Range: 26.0 - 34.0 pg 28.5
MCHC Latest Ref Range: 31.0 - 37.0 g/dL 32.0
RDW Latest Ref Range: 11.6 - 14.8 % 15.3 (H)
Platelets Latest Ref Range: 150 - 400 K/mcL 225
MPV Latest Ref Range: 9.4 - 12.4 fL 9.6
Nucleated RBC Latest Units: % 0.0
Nucleated RBC Abs Latest Ref Range: 0.00 - 0.00 K/mcL 0.00
•Patient seen and examined at bedside. Reports
feeling anxious. No acute overnight events noted.
Afebrile at this time.
• No changes to impression & plan.
Day 2 Labs
Ref. Range 3/12/2021 05:19
SODIUM Latest Ref Range: 135 - 145 mmol/L 136
CREATININE Latest Ref Range: 0.60 - 1.20 mg/dL 0.49 (L)
MAGNESIUM Latest Ref Range: 1.6 - 2.4 mg/dL 2.1
RBCs Latest Ref Range: 4.00 - 5.20 M/mcL 4.08
HCT Latest Ref Range: 36.0 - 46.0 % 36.9
MCHC Latest Ref Range: 31.0 - 37.0 g/dL 30.6 (L)
PROTIME Latest Ref Range: 11.8 - 14.3 seconds 18.2 (H)
INR Latest Ref Range: 0.8 - 1.1 1.6 (H)
Day 3 Discharge Order 3/13/21
Patient is currently being discharged in stable

condition.
Discharge diagnosis:
• Acute hypoxic/hypercarbic respiratory failure

• Acute diastolic CHF exacerbation/right heart failure
• AKI with oliguria
• Severe Sepsis secondary to pneumonia/UTI/lower extremity cellulitis
• Diabetes mellitus type 2
• History of pulmonary embolism
• Severe sepsis secondary to community-acquired pneumonia/E. coli
UTI/bilateral lower extremity cellulitis
• Bilateral lower extremity chronic lymphedema
• Chronic debility
•Patient seen and examined at bedside this morning and again in the
afternoon. She did report of some anxiety otherwise no other acute
concerns were noted this morning. Patient feels better after receiving Ativan
0.5 mg p.o. x 2, 4-5 hours apart. Later in the afternoon, was noted to be
drowsy and difficult to arouse. She was also tachypneic with increased
work of breathing. From oxygen requirement of 2 L/min, patient went on to
requiring nonrebreather mask, stat ABG showed respiratory acidosis with
pH of 7.20 and PCO2 of 89.8. Patient was transferred to ICU and intubated.
Patient was planned for discharge this morning, discharge was canceled.
•No Significant labs obtained for nutrition.
Day 3 Admission Impression
& plan
2. Respiratory failure -Likely
secondary to acute diastolic CHF
exacerbation. S/p intubation.
Continue mechanical ventilation. 3. Severe sepsis secondary to
1. X-ray chest 3/13/2021 -
Start Lasix 40 mg IV every 12 community-acquired pneumonia/E.
Pulmonary edema
hourly. Strict INO's, daily weight. coli UTI/LE cellulitis
Cardiology consult /critical care
consult. Currently on
Versed/fentanyl drips.
6. Diabetes mellitus type 2 -

4. Bilateral lower extremity chronic
Continue Lantus/insulin sliding
lymphedema/cellulitis - Continue 5. Chronic debility -PT/OT eval
scale. Hold
antibiotics.
Metformin/glipizide. Diabetic diet.
Code Status: Full Code

• Disposition: To be determined pending
8. Hypertension -Stable.
7. History of pulmonary embolism -
Discontinue amlodipine. Continue
Continue Coumadin. Check INR
Coreg 25 mg twice daily. Titrate up
daily
as needed.
Day 4 Admission Progress,
Impression, & Plan 3/14/21
•Patient seen and examined at bedside. Intubated and
sedated. Low urine output reported.
• Impression & Plan: mostly the same as day 3.
• Changes:
• Awaiting ECHO
• Oliguria - Nephrology consulted
Day 4 Labs
Ref. Range 3/14/2021 04:09

CHLORIDE Latest Ref Range: 98 - 108 mmol/L 101
CREATININE Latest Ref Range: 0.60 - 1.20 mg/dL 0.80
Total Protein Latest Ref Range: 6.0 - 8.0 g/dL 5.6 (L)
ALBUMIN Latest Ref Range: 3.2 - 5.2 g/dL 2.3 (L)
WBC Latest Ref Range: 4.50 - 11.00 K/mcL 9.26
RBCs Latest Ref Range: 4.00 - 5.20 M/mcL 3.70 (L)
HCT Latest Ref Range: 36.0 - 46.0 % 33.6 (L)
Acute Kidney Injury –
Definition and
Pathophysiology
• Formerly, acute renal failure.
• Is characterized by a sudden reduction in
glomerular filtration rate (GFR).
• GFR – the amount of filtrate per unit in
the nephrons and altered ability of the
kidney to excrete the daily production of
metabolic waste.
• Elevated Blood Urea Nitrogen (BUN)
• Can occur in association with oliguria or
without, but typically occurs in previously
healthy kidneys.
Decreased urine output, although occasionally urine output remains normal
Fluid retention, causing swelling in your legs, ankles or feet
Acute
Shortness of breath
Fatigue
Kidney Confusion
injury - Nausea
Weakness
Sympto Irregular heartbeat
ms Chest pain or pressure
Seizures or coma in severe cases
Acute kidney failure. (2020, July 23). Retrieved March 31, 2021, from
https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-caus
es/syc-20369048
Acute Kidney Injury –
Causes/Etiology
1. Inadequate renal perfusion (prerenal).
• Dehydration
• Circulatory collapse
2. Diseases within the renal parenchyma (intrinsic).

• Trauma, surgery
• Septicemia
• Nephrotoxicity
• Vascular disorders
• Acute glomerulonephritis
3. Urinary tract obstruction (postrenal).

• Benign prostatic hypertrophy with urinary retention
• Carcinoma
• Rhabdomyolyses
• Ureteral stones and obstruction
Acute kidney Injury – Definition of
New Words
For me:
• Oliguria – decreased output of urine.
For other practitioners:
• New form of classification: RIFLE (Risk, Injury,

Failure, Loss, and ESRD)
• Indicates the likelihood of a patient recovering or
progressing of acute renal failure.
• Helps dietitians know whether to increase protein
intake goals or be more moderate to preserve
kidney function.
Protein:
Acute
• Increased protein needs d/t
Kidney physiological stress.
Injury – • Ranges:
• .5 to .8 g/kg for nondialysis
Nutrition patients
• 1 to 2 g/kg for dialysis patients
Treatmen • 1.5 to 2.5 g/kg for continuous
renal replacement therapy
t • .8 to 1 g/kg during stabilized
Significa medical status
nt Energy:
Research • If indirect calorimetry is not

available, 25-40 g/kg of IBW.
Acute Kidney Injury – Nutrition
Treatment Significant Research Cont.
• Fluid & Sodium:
• Sodium is restricted d/t decreased urinary production
– intake should be restricted as well to as low as 20-
40 mEq/day.
• Can be tricky d/t requirement for IV solutions.
Administration of these solutions in an electrolyte free
water in oliguria leads to water intoxication.
• All fluid above the daily calculated water loss should
be given in a balanced salt solution.
• Replace output from the previous day PLUS 500 mL.
Acute Kidney Injury – Nutrition
Treatment Significant Research Cont.
• Potassium:
• K+ levels can shift abruptly and need to be
monitored.
• Intake should be individualized based on serum
levels.
• Dialysis is the mechanism for K+ removal.
• Recommendation: 30-50 mEq/day in oliguric
phase but depends on the individual; replace losses
in diuretic phase.
Acute Kidney Injury – Medical
Treatment Significant Research
• Clinical course and outcome depends on the cause.
• Some can be treated with medical management. Others need renal
replacement therapy to reduce the acidosis, correct the uremia, and
control hyperkalemia.
• Hemodialysis
• Peritoneal dialysis
• Continuous renal replacement therapy
• Continuous venovenous hemofiltration
• Continuous venovenous hemodialysis
Acute Kidney injury –
Complications
• Fluid buildup in the lungs which can cause shortness of breath.
• Chest pain if the pericardium becomes inflamed.
• Muscle weakness d/t possible fluid and electrolyte imbalance.
• Permanent kidney damage that will require either permanent dialysis or a kidney
transplant in order to survive.
• Death d/t loss of kidney function.
Acute kidney failure. (2020, July 23). Retrieved March 31, 2021,
from https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-
causes/syc-20369048
• Acute problems Being Managed In Hospital

• Acute hypoxic hypercarbic respiratory failure: Likely secondary to acute diastolic CHF exacerbation / RHF. S/p intubation
on 3/13/21. Blood gas this morning showed improvement. Pulmonology was consulted. Planning for CPAP trial, possible
extubation today. Continue supportive care.
• Acute exacerbation of chronic diastolic CHF, with pulmonary edema: Patient was given IV torsemide, however patient was
not responding due to acute kidney injury. Cardiology input appreciated. 2D echocardiogram showed a normal ejection
fraction. Possible hemodialysis today per nephrology.
• Sepsis secondary to pneumonia, UTI, lower extremity cellulitis: Patient was treated with IV vancomycin and Zosyn. Her
Vanco level is above 70 due to acute kidney injury. We will switch Zosyn to Rocephin based on urine culture sensitivity.
Will monitor Vanco level if patient go on hemodialysis today.
• Acute kidney injury with oligouria: Likely combination of underline diabetic nephropathy, sepsis, and the vancomycin
toxicity. Nephrology input appreciated. Patient still not making urine. Surgery was consulted for hemodialysis temporary
catheter placement. Planning for inpatient hemodialysis.
• Bilateral lower extremity chronic lymphedema and cellulitis: Continue Rocephin. Patient's vancomycin level is
supratherapeutic.
• Assessment:
Day 5
• Height: 5' 3"
• Current weight: (!) 156.8 kg (345 lb 11.2 oz)
• Body mass index is 61.24 kg/m².
• Wt Readings from Last 5 Encounters:
Nutritio
• 03/15/21 (!) 156.8 kg (345 lb 11.2 oz)
• 02/23/21 130.2 kg (287 lb)
• 03/06/18 130.2 kg (287 lb)
• 12/06/17 132 kg (291 lb)
n
• 11/09/17 132.5 kg (292 lb)
• Wt hx: CBW vs. Adm wt indicates pt has gained 58 lbs. Likely d/t
innacuracy of bed scale measurement.
Assess
• Current diet order: No diet orders on file
• Recent intake: Prior to intubation, pt has consumed 50-75% x 1

meal and 75-100% x 3 meals per nursing documentation. Current
intake likely meets estimated needs.
ment
• Skin Integrity: Intact
• GI Function: Last BM Date: (unknown)
• Nutrition Focus Physical Exam Type: Not performed.
• Estimated Needs:
• Total Energy Estimated Needs: 1572-1834
• Method for Estimating Needs: 30-35 kcal/kg IBW
• Total Protein Estimated Needs: 52-79 g
• Method for Estimating Needs: 1-1.5 g/kg IBW
• CKD: Dietary Protein Intake,
Maintenance Hemodialysis
and Peritoneal Dialysis,
Evidence
Diabetic Analysis
• In adults with CKD 5D and who
have diabetes, it is reasonable Library –
to prescribe a dietary protein
intake of 1.0 -1.2 g /kg body Implementat
weight per day to maintain a
stable nutritional status. For
patients at risk of hyper and/or
ion of
hypoglycemia, higher levels of
dietary protein intake may need
Significant
to be considered to maintain
glycemic control (OPINION). research
• Consensus Conditional
• CKD: Statement on Energy
Intake in CKD 1-5D Evidence Ana
• In adults with CKD 1-5D (1C)
and who are metabolically lysis
stable, we recommend
prescribing an energy intake of Library –
25-35 kcal/kg body weight per
day based on age, gender, Implementati
level of physical activity, body
composition, weight status on of
goals, CKD stage, and
concurrent illness or presence Significant re
of inflammation to maintain
normal nutritional status. search
• Fair Imperative
Nutrition Care Initial Assessment
• Reason for visit: Physician Consult for Tube Feed Recs
• Nutrition Diagnosis: Inadequate oral intake related to
mechanical ventilation as evidenced by pt requiring intubation
and unable to consume nutrition PO.
• Nutrition Intervention: Initiate Enteral Nutrition
• Nutrition Prescription: Initiate Diabetasource AC at 10 ml/ hr,
Day 5
advance as tolerated by 10 ml every 6 hours to goal rate of 70
ml/ hr. Include 100 ml free water flushes q 4 hours to meet fluid
Nutrition
intervention/
needs. Diabetasource AC at goal rate of 70 ml/ hr to provide
1848 kcals (35 kcals/ kg IBW), 92.4 g protein (1.8 g/ kg IBW),
and 100 ml free water, assuming 22/24 hour infusion.
• Nutrition Goals: Pt will receive 80% of prescribed tube feeding
volume
Plan of Care
• Start Date:3/15/2021 Expected End Date:3/19/2021
• Nutrition Education: No needs at this time.
Day 5 Labs
Ref. Range 3/15/2021 02:05

GLUCOSE Latest Ref Range: 65 - 99 mg/dL 94
CREATININE Latest Ref Range: 0.60 - 1.20 mg/dL 1.96 (H)
eGFR Latest Ref Range: >=60 mL/min/1.73 m2 26 (L)
BUN/Creatinine Ratio Latest Ref Range: 10.0 - 20.0 8.2 (L)
Total Protein Latest Ref Range: 6.0 - 8.0 g/dL 5.4 (L)
ALBUMIN Latest Ref Range: 3.2 - 5.2 g/dL 2.5 (L)
Vancomycin Trough Latest Ref Range: 5.0 - 20.0 mcg/mL 71.6 (CH)
Day 6 Admission Progress
changes 3/16/21

• Acute exacerbation of chronic diastolic CHF, with pulmonary
edema: Patient was dialyzed on 3/16/21, 4 L fluid removed.
Continue follow-up. Continue Lasix.
• Sepsis: Vancomycin still supratherapeutic. Discontinue

vancomycin.
• Acute kidney injury with oliguria: Inpatient hemodialysis was

started on 3/14/21.
Day 6 Labs
Ref. Range 3/16/2021 02:08
CALCIUM Latest Ref Range: 8.4 - 10.2 mg/dL 8.3 (L)
Glucose Latest Ref Range: 65 - 99 mg/dL 116 (H)
Changes 3/17/21

• Acute hypoxic hypercarbic respiratory failure: Blood gas this morning showed
improvement but not weaning. C/w daily SBTs. Continue supportive care.
Pul and critical care following.
• Bilateral lower extremity chronic lymphedema and cellulitis: improving
• Morbid obesity, Body mass index is 60.19 kg/m².
• Will need counseling on weight loss towards goal BMI under 25 prior to
discharge
• No Significant labs obtained for nutrition.
Changes 3/18/21

• Acute hypoxic hypercarbic respiratory failure: Patient is off sedation for 24 h.
CPAP daily.
• Sepsis secondary to pneumonia, UTI, lower extremity cellulitis: Finished

antibiotics Rocephin.
• Acute kidney injury with oliguria: Renal following, likely will need scheduled
dialysis at discharge. Social service consult on board.
• Bilateral lower extremity chronic lymphedema and cellulitis: improving with

dialysis
Day 8 Labs
Ref. Range 3/18/2021 03:26
Day 9 Admission progress
Changes 3/19/21

• Acute hypoxic hypercarbic respiratory failure:
Unable to wean yesterday due to mental status.
Patient was off sedation. More waking up today.
CPAP trial today, possible extubation.
• Monitoring and Evaluation: Pt did not receive >80% of prescribed tube
feeding volume
Day 9
• Nutrition Diagnosis: Inadequate oral intake related to mechanical
ventilation as evidenced by pt requiring intubation and unable to
consume nutrition PO. Resolving
Admission •
•
Nutrition Intervention: Continue Enteral Nutrition
Nutrition Prescription: Tube Feeding: continue with previous
Nutrition •
recommendations.
Nutrition Goals: Pt will receive 80% of prescribed tube feeding volume
Follow up • Start Date:3/19/2021 Expected End Date:3/23/2021
3/19/21
• Nutrition Education: No needs at this time
• Assessment:
• Current weight: (!) 142.6 kg (314 lb 6.4 oz) Body mass
index is 55.69 kg/m².
• Weight: CBW vs previous assessment indicates pt has lost 31
lbs (9%). Most likely d/t fluid loss of -11,101.4 mL.
• Current diet order: tube feed
• Recent intake: Pt TF currently running at 50 mL/hour. TF on
hold multiple times d/t multiple extubation trials. Current intake
does not meet estimated needs.
• Difficulty Chewing/Swallowing: Intubated-UTA
• Skin Integrity: Stg 2 pressure ulcer to coccyx
• GI Function: WNL
• Physical Appearance: UTA
Day 9 Labs
Ref. Range 3/19/2021 04:36 3/19/2021 04:37




• Acute hypoxic hypercarbic respiratory failure:
Tolerated extubation on 3/19/21. Now stable on 2
Liter nasal cannular. Overnight, patient had a
several episodes of stridor, was getting epi
treatment. She still n.p.o., awaiting speech eval.
Day 10 Labs
Ref. Range 3/20/2021 04:18
BUN Latest Ref Range: 8 - 25 mg/dL 27 (H)
RDW Latest Ref Range: 11.6 - 14.8 % 14.3
Changes 3/21/21

• Acute hypoxic hypercarbic respiratory failure: Now
stable on 2 Liter nasal cannular, BiPAP at night.
She still n.p.o., awaiting speech eval.
• Acute exacerbation of chronic diastolic CHF, with
pulmonary edema: Patient will need outpatient
dialysis set up before discharge.
Day 11 Labs Ref. Range 3/21/2021 04:10

Nucleated RBC Abs Latest Ref Range: 0.00 - 0.00 K/mcL 0.04 (H)
Changes 3/22/21

• Acute kidney injury with oliguria: Patient only has a
temporary dialysis catheter placed. Will consult
surgery to change to a PermCath before discharge.
Day 12 Labs
Ref. Range 3/22/2021 04:48
MPV Latest Ref Range: 9.4 - 12.4 fL 9.3 (L)
Day 13 Admission progress 3/23/21
• Patient seen and examined at bedside. Sitting at
the edge of the bed working with PT/OT. No acute
overnight events noted. Continue to use BiPAP as
needed
Day 13 Admission 3/23/21
Impression & Plan Changes
1. Acute hypoxic/hypercarbic
2. AKI with oliguria-Patient to
respiratory failure - Continue
undergo permanent HD cath
supplemental oxygen via
placement today. Patient will
nasal cannula/BiPAP support.
get hemodialysis after the
Cardiology evaluation
cath placement.
appreciated.
5. History of pulmonary
4. Diabetes mellitus type 2-
embolism-Patient on chronic
Continue to hold oral
anticoagulation with
hypoglycemics. Continue
Coumadin. Will switch to
insulin sliding scale. Diabetic
Eliquis 2.5 mg p.o. twice
diet.
daily.
6. Diet: Diet NPO

• Oral nutrition supplements
Novasource Renal 3 times daily with 7. Code Status: Full
meals
Code; Disposition: To be
determined pending
• Monitoring and Evaluation: PO intake was between 50-75% at most meals since
extubation.
Day 13
• Nutrition Diagnosis: Inadequate energy intake related to increased physiological
needs as evidenced by meal percents and tray ticket history. Resolving
• Nutrition Intervention: Initiate Medical Food Supplement
Admission • Nutrition Prescription: Diet: Diet NPO, Oral nutrition supplement: Nepro with

Carbsteady TID
Nutrition
• Nutrition Goals: PO intake > 75% most meals
• Start Date:3/23/2021 Expected End Date:3/27/2021
Follow • Assessment:
• Pertinent clinical information: pt extubated on 3/19. Diet advanced on 3/21.
Up 3/23/21 •
•
Current weight: (!) 137.7 kg (303 lb 9.6 oz)
Body mass index is 53.78 kg/m².
• Weight:
• 3/22/21 138.1 kg actual
• 3/21/21 135.9 kg actual
• 3/21/21 140.3 kg method not known
• CBW vs previous LOS indicates pt's wt has fluctuated between 137.7-
140.3.
• Current diet order: NPO Diet
• Recent intake: Pt ordering small to adequate sized trays per CBORD. Pt
consuming 75-100% x 3 meals and 25-50% x 2 meals per nursing
documentation. Current intake likely does not meet estimated needs.
• Patient/family comments: Pt reports good appetite. Pt reports normally
consuming 3 meals per day a home.
• Difficulty Chewing/Swallowing: No
• GI Function: Diarrhea
• Physical Appearance: no change from initial assessment
Day 13 Labs
Ref. Range 3/23/2021 04:14
Day 14 Admission progress 3/24/21
• Patient seen and examined at bedside.s/p permanent
HD cath placement 3/23/2021. No acute overnight
events noted. Continue to use BiPAP as needed
• Awaiting discharge
• No changes to impression & plan.

Day 14 Labs
Ref. Range 3/24/2021 02:46
changes 3/25/21

• Acute hypoxic hypercarbic respiratory failure: Patient
needs BiPAP for night on discharge
• Acute kidney injury with oliguria: We will continue

scheduled hemodialysis after discharge.
• Lower back decubitus ulcer: Wound consult.

Day 15 Labs
Ref. Range 3/25/2021 04:14
Day 16 Admission progress
Changes 3/26/21

• Acute lower back pressure ulcer, stage II: Wound
consult appreciated. Continue with daily dressing
change. Follow-up of a wound clinic.
Day 16
Admission • Nutrition Care Initial Assessment
• Reason for visit: LOS
Nutrition • Nutrition Diagnosis: No nutrition diagnosis at this
Follow Up time.
• Nutrition Intervention/ Prescription: Not applicable at
3/26/21 this time.
• Nutrition Goals: PO intake > 75% most meals
• Start Date:3/26/2021 Expected End
Date:4/2/2021
• Assessment:
• Pertinent clinical information:
• Height: 5' 3"
Day 16 •
•
Current weight: (!) 137.7 kg (303 lb 9.6 oz) Body mass index is
53.78 kg/m².
Wt Readings from Last 5 Encounters:
Admission Nutrit •
•
03/23/21 (!) 137.7 kg (303 lb 9.6 oz)
02/23/21 130.2 kg (287 lb)
ion Follow Up •
•
03/06/18 130.2 kg (287 lb)
12/06/17 132 kg (291 lb)
3/26/21
• 11/09/17 132.5 kg (292 lb)
• Wt hx: CBW vs. Adm wt indicates pt has gained 16 lbs (5%).
• Diet Special; Renal; 1000 mL (600 mL Nutrition / 400 mL Nursing); Oral
nutrition supplements Novasource Renal 3 times daily with meals
• Recent intake: 75-100% x 5 meals. Pt ordered adequate breakfast tray
(494 kcal, 21 g protein) this date per CBORD. Current intake meets
estimated needs.
• Patient/family comments: Pt reports appetite has improved. Pt reports
Nepro gave her diarrhea. Pt reports liking it and wanting to purchase a
nutrition supplement at home. Pt reports it being expensive. Coupon
for Boost given to pt.
• Difficulty Chewing/Swallowing: No
• GI Function: Last BM Date: 03/24/21
• Physical Appearance: no signs or symptoms of malnutrition
• Nutrition Focus Physical Exam Type: Visual
Day 16 Labs
Ref. Range 3/26/2021 08:09




MPV Latest Ref Range: 9.4 - 12.4 fL 9.3 (L)


Patient is currently being
discharged in stable condition.
Discharge diagnosis
• Acute hypoxic/hypercarbic respiratory
Day 16 failure
• Acute diastolic CHF exacerbation/right
heart failure
Discharg • AKI with oliguria
• Severe Sepsis secondary to
e Order pneumonia/UTI/lower extremity cellulitis
• Diabetes mellitus type 2
3/26/21 • History of pulmonary embolism

• Severe sepsis secondary to community-
acquired pneumonia/E. coli
• UTI/bilateral lower extremity cellulitis
• Bilateral lower extremity chronic
lymphedema
• Chronic debility
What would I
have done
differently?
• Would have loved to have gotten an
NFPE but was unable to.
• Wish I would have followed up with
her about Nepro because I had no
idea that it gave her diarrhea. That is
something I should know or be aware
of and intervene.
• Granted, it wasn't documented
anywhere. Just stated "loose;
soft" for bowel assessment.
• Wish I would have seen her more.
References
• Acute kidney failure. (2020, July 23). Retrieved
March 31, 2021, from
https://www.mayoclinic.org/diseases-
conditions/kidney-failure/symptoms-causes/syc-
20369048
• Mahan, L. K., & Raymond, J. L. (2017). Krause's
food & the nutrition care process. St. Louis, MO:
Elsevier.
• EAL
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Major Case Study

Age, Height, Weight:

History Hyperlipidemia [E78.5]

• Clinical Impression from ED physician:

5. Diabetes mellitus type 2

Code Status: Full Code

SODIUM Latest Ref Range: 135 - 145 mmol/L 133 (L)

Patient is currently being discharged in stable

• Acute hypoxic/hypercarbic respiratory failure

6. Diabetes mellitus type 2 -

Code Status: Full Code

SODIUM Latest Ref Range: 135 - 145 mmol/L 138

Fluid retention, causing swelling in your legs, ankles or feet

Sympto Irregular heartbeat

ms Chest pain or pressure

Seizures or coma in severe cases

2. Diseases within the renal parenchyma (intrinsic).

3. Urinary tract obstruction (postrenal).

• Oliguria – decreased output of urine.

For other practitioners:

• New form of classification: RIFLE (Risk, Injury,

Research • If indirect calorimetry is not

• Acute problems Being Managed In Hospital

• Wt Readings from Last 5 Encounters:

• Recent intake: Prior to intubation, pt has consumed 50-75% x 1

• GI Function: Last BM Date: (unknown)

• Nutrition Focus Physical Exam Type: Not performed.

SODIUM Latest Ref Range: 135 - 145 mmol/L 138

• Acute problems Being Managed In Hospital

• Sepsis: Vancomycin still supratherapeutic. Discontinue

• Acute kidney injury with oliguria: Inpatient hemodialysis was

• Acute problems Being Managed In Hospital

• Bilateral lower extremity chronic lymphedema and cellulitis: improving

• Morbid obesity, Body mass index is 60.19 kg/m².

• Acute problems Being Managed In Hospital

• Sepsis secondary to pneumonia, UTI, lower extremity cellulitis: Finished

• Bilateral lower extremity chronic lymphedema and cellulitis: improving with

• Acute problems Being Managed In Hospital

Nutrition Prescription: Tube Feeding: continue with previous

Nutrition Goals: Pt will receive 80% of prescribed tube feeding volume

Follow up • Start Date:3/19/2021 Expected End Date:3/23/2021

BUN/Creatinine Ratio Latest Ref Range: 10.0 - 20.0 5.1 (L)

RBCs Latest Ref Range: 4.00 - 5.20 M/mcL 3.10 (L)

HGB Latest Ref Range: 12.0 - 16.0 g/dL 8.5 (L)

INR Latest Ref Range: 0.8 - 1.1 2.0 (H)

• Acute problems Being Managed In Hospital

• Acute problems Being Managed In Hospital

SODIUM Latest Ref Range: 135 - 145 mmol/L 136

• Acute problems Being Managed In Hospital

6. Diet: Diet NPO

Admission • Nutrition Prescription: Diet: Diet NPO, Oral nutrition supplement: Nepro with

• No changes to impression & plan.

• Acute problems Being Managed In Hospital

• Acute kidney injury with oliguria: We will continue

• Lower back decubitus ulcer: Wound consult.

• Acute problems Being Managed In Hospital

POTASSIUM Latest Ref Range: 3.5 - 5.1 mmol/L 4.2