Nutrition Database

Intern Name Angela Misko

Patient Initials IL DOB 04/01/28 Age 85 Sex F Unit/Room# 626
Admit Date 11/04/13 Admitting Diagnosis Encephalopathy
Prior Medical History ESRD-HD, DM, HTN, ANEMIA
Diet Order Mechanical Soft Supplements None
If applicable, describe food intake since admission or past 5 days Well per RN
Any Food Allergies / Intolerances? No Known

Height (in inches and cm) 50 Weight (in pounds and kg) 137lbs (62kg) Weight History Loss Gain
if weight , how much in what time frame? Was loss/gain intentional or unintentional? N/A
Usual Body Weight (UBW) Ideal Body Weight (IBW) 100 % IBW 138 % BMI 26.9

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)
Occupation and alcohol use unknown. Nonverbal.


Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)
Drug name(s) Indication Nutritional Implication
Atrovastatin Hyperlipidemia; To prevent or
decrease risk of cardiovascular
events or slow progression of
atherosclerosis.
Caution with grapefruit and
related citrus fruits.
Pantoprazole Na AntiGERD; Antisecretory May cause N/D
Piperacillin ABX Anorexia
Insulin Aspartate Diabetic Caution with hepatic or
decreased renal function.









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
140
K
4.8
BUN
85 H
This patient is on hemodialysis with ESRD which correlates
with an expected increased BUN level. A protein allowance of
1.2-1.3g/kg per dat will often minimize the accumulation of
excessive nitrogenous wastes, maintain a positive nitrogen
balance, and replace the amino acids lost during hemodialysis.
CREAT
4.78 H
Indicates impaired renal function. Significance: Meet pts KCAL
and PRO needs. Increase protein.



Albumin
2.9 L
Indicative in renal disease and protein loss. Meet the needs.
Increase protein.
Prealb


Glucose
88
HgbA1C


H/H

MCV

MCH

Iron (Fe)

Transferrin Sat (%)

Ferritin

Vitamin B
12
Folate


Ca
9.1
Phos

Mg








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Is Patients Skin Intact? Yes check. No
If no, Surgical Wound Decubitus Ulcer
If decubitus ulcer, list stage (I-IV) and site(s)
Is decubitus ulcer Improving? Getting worse?
Is any of the following present? Nausea Vomiting Diarrhea Constipation
None. 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? 152.4 cm 62 kg
Male Female check. Age 85
Any stress factors, activity factors to consider? ESRD-HD


Calculate Energy Needs using
1) Harris-Benedict ------------------------------------ kcal
2) Mifflin St. Jeor -------------------------------------- kcal
3) kcal/kg ----------------------------------------------- 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 because patients needs are increased due to chronic
illness


Show your work for three of the five methods above used:





Nutrition Database


Harris Benedict:
BMR= 655.1 + 9.56(62kg) + 1.7(152.4cm) 4.7(85y.o)
BMR= 655.1 + 592.7 + 259 399.5
BMR= 1506.8-399.5
BMR= 1107 x FACTOR(1.2)
BMR= 1328 Range: 1300-1500

Mifflin St. Jeor:
BMR= (9.99x62kg) + (6.25x152.4cm) (4.92x85) 161
BMR= 619 + 952.5 418.2 161
BMR= 992 Range: 1000-1200

Kcal/Kg:
Choose: 25-30kcal/kg
25kcal(62kg) =1550kcal/kg 30kcal(62kg)=1860kcal/kg
1550kcal-1860kcal Range: 1500-1800












Nutrition Database



Calculate Protein Needs
How many g/kg would you use & why? 1.2-1.5 is recommended because patients in HD have elevated protein needs.
Show your work:

Choose: 1.2-1.5 g/kg (dialysis pt)
1.2g x 62kg=74.4g PRO
1.5g x 62kg=93g PRO
Range: 74-93g 74-93 g/day



Calculate Fluid Needs using
1) ml/kg depending on age ----------------- ml/day
2) Holliday-Segar method ------------------- ml/day
3) RDA method --------------------------------- ml/day
4) urine output (urine out +500ml/day)- ml/day
What formula did you ultimately use for the Pt & why?? Ml/kg because it is lower and fluid allowance for a renal pt is
1000ml/day plus the amount of urine output. Want to be careful not to consume too much. Used ABW.
Show your work for two of the four methods above used:
Ml/kg Method:
25ml/kg x 45kg = 1125ml H2O Range: 1200-1350 (used ABW)
30ml/kg x 45kg = 1350ml H20
RDA Method:
If choose 1500-1800 kcal Range: 1500-1800ml H2O




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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?)

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

Nutrition Database


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)
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

Nutrition Database


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 with nurse regarding patients appetite, PO intake. Inquire about
nausea, vomiting, constipation, or diarrhea.
Physician (MD)

Checked notes for any pertinent information regarding patients status and
GI issues.
Social Worker (SW)


Speech Therapist (ST/SLP)

Checked notes for swallow evaluation result. This patient was seen for false
tubefeeding trigger.
Physical Therapist (PT)


Occupational Therapist (OT)


Respiratory Therapist (RRT)


Woundcare / Ostomy Nurse

Checked skin integrity in wound reports.
Physicians Assistant (PA)


Other



Nutrition Diagnosis (P-E-S) Statement (write 2)
Problem: Increased nutrient needs (kcal/protein)

related to (Etiology): related to chronic illness (ESRD on HD)

as evidenced by Signs and Symptoms: as evidenced by past medical history per chart and HD.

Problem: Excessive Nutrient Utilization


Nutrition Database


related to (Etiology): related to impaired nutrient utilization

as evidenced by Signs and Symptoms: as evidenced by ESRD on HD per MD chart.


Interventions (your recommendation as a dietetic intern)
Recommend 1800 ADA and renal addition to soft mechanical

Request nepro one can daily

Encourage PO intake

Upgrade soft mechanical diet when tolerance accepted



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

Monitor tolerance

Meet estimated needs

No skin breakdown

Monitor visceral proteins


Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not
familiar with)?
I learned that Piperacillin is an ABX and is a pertinent medication to the dietitian. I also learned that pantoprazole is
an antiGERD medication.