Nutrition Prescription (The patients/clients individualized recommended dietary intake of energy and/or selected foods or nutrients based on current

reference standards and dietary guidelines and the patients/clients health

condition and nutrition diagnosis): Nutrient Needs: Kcals: 1,375-1,680 kcals/d, Fluids: 1,375-1,680 ml/d, Protein: 66-72 g/d (Kcals: 25-30 kcals/kg of upper IBW of 55 kg.), (Fluids: 1 ml/kcal/d), (Protein: 1.2-1.3 g/kg
(hypermetabolic state & pt. is ventilated) of upper IBW of 55 kg).

Assess Priority Diagnosis (PES Statement) Intervention Monitoring Evaluation

Interpret data needed to identify nutrition related
problems, their causes, and significance
Client Information: WF is a 74 y.o. Caucasian
female. WF was admitted to ICU 2/2 opioid
overdose. Active dx of uterine and thyroid cancer and
UTI.
Subjective Assessment: Patient ventilated and not
alert at visit. Per ICU nurse, patients tube feedings
were stopped a few hours prior to assessment visit
because patient was to be extubated that afternoon.
Dx: Opioid overdose, cancer (uterine and thyroid),
and UTI
PMH: Opioid use, epilepsy, seizures, acute heart
failure, anemia, CKD stage 4, COPD, depression,
osteoporosis, and thyroid disorder
______RT______ AEB_______
1 Increased nutrient needs (energy &
protein) RT increased needs for
hypermetabolic state and pt.s
inability to breathe on her own
AEB active dx of cancer (uterine &
thyroid), temperature of 99.4 in
last 24 hrs., and pt. currently
ventilated.
2 Inadequate enteral nutrition
infusion RT insufficient energy and
protein provided by current rate
AEB TF of Jevity 1.2 @ 40 ml/hr
provides patient with < 80% of
recommended kcals and protein.
What are you going to do to fix the problem?
Meals and Snacks: Upon extubation and Speech
Therapy approval to advance diet, initiate PO
intake via renal diet order within 24 hours.
Enteral Nutrition: If unable to be extubate
within 24 hours, increase goal rate of TF of Jevity
1.2 by 15 ml/hr to meet kcal and pro needs.
What data do you need to assess
your intervention?
Nutrient Intake: PO intake of
energy and protein via calorie
count to be completed by ICU
nurse.
Nutrient Administration:
Infusion of energy and protein via
TF rate.
Quantifiable goal(s)
By next review in 2-3 days:
Calorie count records indicating
intake of 75% of renal diet to
provide patient with 1,465 kcals
and 71 g pro.
By next review in 2-3 days:
Infusion of Jevity 1.2 to meet goal
rate of 55 ml/hr to provide patient
with 1,584 kcals (29 kcals/kg of
upper IBW of 55 kg), 73 g pro (1.3
g/kg), and 1,065 ml fluid (19
ml/kg).

Objective/Assessment:
Anthropometrics:
Ht: 158 cm/5 ft. 2 in., Wt: 75 kg/165.4#., BMI: 30
(Obese), IBW: 50.5 kg/110# and 149% IBW, UBW/
%UBW: unable to determine at time of visit, pt. not
alert and no family present at bedside.

Biochemical:
Labs 2/7/17: BUN 43 (H), Cr 1.76 (H), GFR 28 (L),
Gluc 128 (H), Ca 7.2 (L), Alb 1.8 (L), Phos 5.4 (L)

Clinical:
General Appearance: Patient appears frail and has
mild temporal wasting.
Physical Findings: Unable to determine d/t patient
not alert at assessment visit, will check back in 2-3
days to obtain information.
Social History: Patient has history of opioid use.
Family found patient unresponsive at home prior to
admit to hospital.
Current Meds:
Insulin apart, soln. SubQ injection q6h & prn
hyperglycemia
Levothyroxine via I.V.
Coreg 12.5 mg BID, tablet
Protonix 40 mg BID, powder IV
Solu-Medrol 40 mg, powder-injection, IV push q6h
Morphine 0.5 mg, soln. injection, IV push q4h
Ativan, PRN for seizures

Previous Meds:
Propofol @ 2.29 ml/hr & Dilantin 400 mg, 8 ml via
I.V.
Note: Meds. stopped at time of assessment visit.

Dietary:
Intake: Patient currently NPO and on tube feedings.
Per ICU nurse, feedings stopped prior to assessment
visit 2/2 patient was to be extubated later in the day.
Also, patient was tolerating PO diet well prior to
extubation and will most likely begin PO diet post-
extubation per nurse.

Current Diet Order: Jevity 1.2 @ 40 ml/hr to

provide 1,152 kcal (21 kcal/kg of upper IBW of 55
kg), 53 g of pro (0.96 g/kg), and 774 ml fluids (14
ml/kg).

Note: Patient currently receiving NS @ 50 ml/hr.