clinical worksheet #1 cancer and...
TRANSCRIPT
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Name: Danielle Reschke BRIGHAM YOUNG UNIVERSITY
NDFS 466
Clinical Worksheet #1
CLINICAL WORKSHEET #1 Cancer and Trauma
Purpose(s) 1. To complete nutrition assessment, diagnosis, and intervention for a case patient.
2. To practice the application of clinical judgment. Note: When using “Clinical Judgment”
there may be no “one” right answer to most of the questions asked, therefore it is
important to explain or justify your answers.
General Guidelines
1. Complete both case studies in the worksheet
2. Worksheets must be completed electronically
3. Upload the cases in Learning Suite in the assignment section.
a. The worksheets must be uploaded as a Word document (.doc or .docx an .rtf file
is also acceptable)
b. Name file LastName_FirstName_Worksheet_1 For example if my name was John
Doe the file would be names Doe_John_Worksheet_1
4. Graded assignments will be returned, with comments, via Learning Suite
Sources for completing worksheet.
Assume these are the sources available:
Nutrition Care Manual -- Adult and Pediatric (online). This should be your first source;
use other sources only if needed.
IDNT Manual
Any textbooks from NDFS courses
ADA Evidence Analysis Library (online) and noted journal articles
Class Lecture Notes from any NDFS course
ASPEN nutrition support guidelines
Websites for formula companies (e.g. Nestle, Mead Johnson, Abbot)
Citations. List sources used at the end of the case and cite sources as appropriate throughout worksheet.
Cite works as indicated in the student handbook.
Points Each case is worth 12.5 points a total of 25 points for the full worksheet.
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Case #1: Esophageal Cancer and Enteral Feedings
Doctor’s Office Workup JQ is a 69-year old retired military officer. He sought medical attention after several months of
increased difficulty swallowing, lethargy, paleness, and unintentional weight loss. JQ’s physician
ordered blood lab work and did an upper GI series. The upper GI revealed an esophageal lesion
which when biopsied, was positive for squamous cell carcinoma. A chest x-ray was negative.
Available lab results from the doctor’s office visit follow:
Glucose 98 mg/dl Albumin 3.0 g/dl
Hospital Admission JQ was admitted to the hospital for further work up and surgery. Information from his Doctor’s
Office workup was available in the hospital chart. His admitting diagnoses were:
1. Esophageal squamous cell CA
2. Dysphagia 2° to #1
3. Anemia
4. Malnutrition
Labs from the hospital after surgery include
Hgb 11 g/dl Prealbumin 20 mg/dl
Hct 32% Glucose 105 mg/dl
Albumin 2.7 g/dl Calcium 7.6 mg/dl
JQ has never had any previous medical problems; however, he has a long standing history of
smoking (1 pack per day) and moderate social drinking. He is happily married with three grown
children. He has adequate medical insurance and a substantial retirement pension.
Additional radiographic studies indicated the carcinoma was quite extensive and radical surgery
was necessary. JQ was NPO for surgery. He tolerated the surgery fairly well, but would not be
able to take an oral po for several weeks. The physician ordered a diet consult for nutrition
support.
As JQ had difficulty speaking, the dietitian spoke with his wife regarding his diet history. Mrs. Q
stated that JQ’s height was 5'10" and he weighed 170 lbs three months ago, which was his usual
weight. He ate three meals a day and enjoyed a dish of ice cream in the evenings. Although he
followed no special diet, lately he preferred soft, moist foods such as casseroles or meat loaf with
lots of gravy and seemed to be eating smaller portions. The last two weeks he had barely eaten
anything. He drank water with his meals as large amounts of milk gave him gas and cramping.
He had no food allergies.
The nurse weighed JQ using the bed scale and recorded his hospital admit weight at 151 lbs.
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Section 1: Nutrition Assessment Complete a Nutrition Assessment by working through the following
Food/Nutrition Related History (AKA Dietary)
1. Are JQ’s nutritional needs being met? Explain. (Type text in box below)
No, because he has not been eating for around 2 weeks and he has been NPO for the surgery.
This shows that he is losing weight because he does not have enough calories. Also, if he has
been eating, he’s most likely not getting enough protein, which is important for him especially as
he is recovering from surgery.
Anthropometric Measurements 1. List JQ’s
Ht (in & cm) 70 inches; 177.8 cm
Wt (lb & kg) 151 lbs; 68.6 kg
Usual Wt (lb
& kg)
170 lbs; 77.3 kg
%IBW IBW=5 ft=106 #
10 in x 6 lbs per in= 60
106 + 60= 166 lbs
151/166= 91% IBW
BMI 68.6 kg/(1.778)2= 21.7
2. Evaluate JQ’s current wt and any significant wt changes. (Type text box below)
JQ has a healthy current weight, he is within 10% of his IBW and his BMI is 21.7, which is
in a healthy range
[(170-151=19)/170= 0.11 x 100= 11.2% weight loss in 3 months, which is classified severe
weight loss for that amount of time.
(1)
Biochemical Data, Medical Tests and Procedures
1. List abnormal lab values and explain possible causes for each. The causes should be related
to the case, not just any cause. e.g. what is causing JQs abnormal levels.
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Lab and Value Possible Causes
Albumin 2.7 Malnutrition—JQ has seems to have acute malnutrition caused by
squamous cell carcinoma and 2o
dysphagia that have caused him to
be unable to eat and have affected his nutrition. (2)
Hgb 11 Anemia—One of JQ’s diagnoses was anemia. Anemia can decrease
hemoglobin levels. (2)
Hct 32% Anemia— One of JQ’s diagnoses was anemia. Anemia can decrease
hematocrit levels. (2)
Ca2+ 7.6 Hypoalbumineamia—JQ has low albumin blood levels. Low albumin
levels in the blood can decrease calcium levels in the blood. (2)
Nutrition-Focused Physical Findings (AKA Clinical)
1. List and explain any pertinent nutrition-related physical characteristics found in the nutrition-
focused physical exam, interview, or medical record. (Type text in box below.)
Difficulty swallowing—indicative of dysphagia
Paleness and lethargy—indicative of anemia
Unintentional weight loss—indicative of malnutrition
Milk intolerance—his cramping and bloating after drinking milk may indicate lactose
intolerance.
Client History
1. List and explain any pertinent nutrition-related concerns found in the client history
Smoking—can affect vitamin and mineral absorption; cause weight loss; can cause lung, throat,
and mouth cancer.
Comparative Standards
1. Determine JQ’s needs for energy, protein, and fluid. (Type needs in chart below.) Indicate wt
used for calculations, formula used (e.g. HBE, Penn, Kcal/Kg, etc.) write out name of
formula and equation as appropriate, and any activity/stress factors.
Needs Equation Used Activity/Stress
Factors
Energy (Kcals) 2600 kcal Unintended Weight Loss in
Healthy Older Adults (3)
1.25
Protein (g/d) 103 g/day 1.5 g/kg/day (3)
Fluid (ml/d) 2100 mL/day 30 mL/kg for average adults (3)
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Weight Used (lb
and Kg)
151 lbs
68.6 kg
Use the box below to show your calculations
Weight: 68.6 kg x 30 kcal/kg= 2058 kcal x 1.25 activity factor= 2573 (I rounded up to 2600
kcal)
Protein: 68.6 x 1.5 g/kg=102.9 (I rounded up to 103 g/day)
Fluid: 68.6 kg x 30 mL/kg=2058 mL (I rounded up to 2100 mL)
2. Justify the following:
Equation used for energy needs and any activity/stress factors used.
Protein need calculation
Weight used
Remember to cite sources used for justification; sources should be listed at end of case. (Type
text in box below.)
Weight: I used the Unintentional Weight loss for Healthy Older Adults, because JQ had severe
unintentional weight loss in the past 3 months. He had a healthy body weight before his
admission to the hospital and his UBW is close to his IBW. He also currently has a healthy BMI
with his current weight, so I thought that using the unintentional weight loss equation for healthy
adults made sense. (3)
I used JQ’s admit weight, because he has been losing weight for several months, so his admit
weight is going to be more indicative of his current nutritional status as compared to his usual
body weight.
Protein: I used the guidelines for underweight individuals in the “weight management” category
of the NCM. These guidelines said that 1-2 g/kg/day of protein was needed for weight regain. I
chose 1.5 g/kg. (3)
Fluid: I used the 30 mL/kg, because that was what the needs were stated as for average adults,
and I thought that because JQ was healthy before his admission, it made sense for him to have
the average amount of fluids that adults need. (3)
IDNT Nutrition Assessment Terms and Statements
Using the case and assessment information you discussed above, complete the following table.
Enter a one or more assessment terms for each assessment category along with
terminology number. The term used should be at least in the second level, but can be
third or fourth level as appropriate for the case. For example
o First level Food and Nutrient Intake (1)
Second level Energy Intake (1.1.)
Third level Food intake (1.2.2)
o Fourth level Amount of food (FH-1.2.2.1).
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o See pages 77-81 of IDNT 4th
edition for a quick look. In-depth pages 83-221.
Write a brief assessment statement for each term chosen. You can combine terms into
one state if it seems logical. For example anthropometrics would logically go together in
one statement. Others may as well.
o Example: Ht: XX (in/cm); wt: XX (lbs/kg); BMI XX, usual wt XX. Weight loss
XX% mild loss.
Note: only enter information if it applies to this case. Add additional rows as needed.
Assessment Category
Assessment term and number (4)
Assessment Statement
Food/Nutrition-Related History
Energy Intake: FH-
1.1.1
Unintentional weight loss % of 11.2% in 3
months; states that he has been eating smaller
portions,
Diet Experience: FH-
2.1.2.6
Has gas and cramping when drinks milk. This
indicates that he may have a dairy intolerance
Anthropometric Measurements
Weight Change: AD-
1.1.4
11.2% weight loss in 3 months.
Height/length: AD-
1.1.1
70 inches, 177.8 cm
Weight: AD-1.1.2 158 lbs, 68.6 kg
Biochemical Data, Medical Tests, and Procedures
Calcium, serum: BD-
1.2.9
Serum calcium levels are low at 7.6 mg/dL
Swallow study: BS-
1.4.23
JQ reported having a hard time swallowing and
has dysphagia 2o at 1#
Hemoglobin: BS-
1.10.1
Hemoglobin value is low at 11 g/dL
Hematocrit: BS-1.10.2 Hematocrit value is low at 32%
Albumin: BD-1.11.1 Albumin levels are low at 2.7 g/dL
Nutrition-Focused Physical Findings
Overall Appearance:
PD-1.1.1
Overall Appearance of JQ shows muscle wasting
and paleness
Extremities, muscles
and bones: PD-1.1.4
Muscle wasting due to malnutrition and weight
loss.
Client History
Personal Data: 1.1 Age: 67, Gender: Male, Tobacco Use: Positive
Patient chief nutrition
complaint: CH: 2.1.1
JQ’s chief complaint was unintentional weight
loss, difficulty swallowing, lethargy, and
paleness.
Gastrointestinal: CH-
2.1.5
Mrs. Q reports that JQ has gas and cramping
when he drinks milk which indicates possible
lactose intolerance.
Hematology/Oncology:
CH 2.1.7
Esophageal squamous cell carcinoma
Surgical Treatment:
CH-2.2.2
Upper GI surgery to remove squamous cell
carcinoma.
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Section 2. Nutrition Diagnosis
Determine Nutrition Diagnosis/Problem (4)
1. Use the IDNT book to list problems (nutrition diagnosis) JQ has. Add rows if necessary.
Diagnosis term
number Diagnosis Term
Domain (Intake, Clinical,
Behavioral/Environmental) NI-1.1 Inadequate Energy Intake Intake
NI-2.1 Inadequate Oral Intake Intake
NI-5.2 Malnutrition Intake
NC-1.1 Swallowing difficulty Clinical
NC-3.2 Unintended weight loss Clinical
Write a Nutrition Diagnosis PES Statement (4) Write a Diagnosis Statement using PES format for two of JQ’s problems:
Diagnosis Term/ Problem
Etiology Signs and/or
Symptoms
Unintended Weight
Loss
Related
to Decreased ability to
consume sufficient
energy
As
evidenced by Weight loss of >7.5% in
90 days
Swallowing Difficulty Related
to An esophageal tumor As
evidenced by An abnormal swallow
study
Section 3. Nutrition Intervention
Analyze Potential Nutrition Interventions
1. Is TPN appropriate for JQ? Explain. (Type text in box below.)
No, because JQ’s GI tract is working properly and it is important to use the digestive system if
it’s working. TPN is also invasive and JQ is not in a situation where TPN is necessary to receive
all needed nutrients. (5)
2. Is PPN appropriate? Explain. (Type text in box below.)
No, because JQ’s GI tract is working and it is best to use the digestive system if it’s working.
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Also even though PPN is not as invasive as TPN, it is still invasive and shouldn’t be used if it’s
not necessary. In this case, he can receive all the nutrients he needs from enteral feeding, so PPN
is not appropriate. (5)
3. Is enteral feeding appropriate? Explain. (Type text in box below.)
Yes, because he has trouble swallowing, so enteral feeding will help him to be able to get all of
the nutrients that he needs to heal. Also, enteral feeding will allow him to use his GI tract, which
is indicative of better mortality and morbidity outcomes when assisting patients with feeding. (5)
4. List two enteral formulas which would be appropriate for JQ. Justify why the formula is
appropriate.
Formula Name Justification for Use
Jevity 1.0 (6) I used Jevity because a standard solution is better to use in situations
where there is not a specific disease state, such as this situation,
where the main problem is unintentional weight loss. Jevity has the
kcal, the protein, and the fluid that JQ needs to gain weight and
recover. Jevity is also less expensive than formulas for specific
disease states.
Osmolite 1.0 (6) I used osmolite for the same reasons as I used Jevity.
5. Calculate the following information to meet JQ’s current nutritional needs which you
determined in the comparative standards section above. TF must closely meet JQ’s
estimated energy and protein needs for credit.
List energy, pro, fluid needs from above: 2600 kcal, 103 g protein, 2100 mL/day
Formula #1 (6) Formula #2 (6)
Formula Name Jevity 1.0 Osmolite 1.0 (1.64)
Goal rate ml/hr 102.5 mL/hr 102.5 mL/hr
Total ml/day 2460 ml 2460 mL
Total Kcals 2460 kcal 2608 kcal
Non-Pro Kcal 2049 kcal 2172 kcal
Pro g and Kcals 109 g; 411 kcal 109 g; 436 kcal
CHO g and Kcals 380 g; 1336 kcal 354 g; 1416 kcal
Fat g and Kcals 109 g; 713 kcal 85 g; 756 kcal
Osmolality 492 mOsm/kg H2O 492 mOsm/kg H2O
Total Fluid 2040 mL 2066 mL
Free fluid (ml) 1703 mL 1740 mL
Additional fluid need (ml) 397 mL 360 mL
Comment on adequacy of your formula recommendation(s) in meeting estimated nutrient
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needs: These formulas meet the recommendations for JQ in calorie needs, protein needs, and fluid needs. Both of these would be good for enteral nutrition for him.
6. Where the tube should be placed? Why? (Type text in box below.)
The tube should be placed nasogastrically, because the enteral feeding will not be long term, fust
for the amount of time for JQ to meet recover from his surgery and gain back the weight he lost.
A jejunostomy or a gastronomy will be too invasive for a short term enteral feeding.
(5).
7. What tube lumen is appropriate? (Type text in box below.)
8-12 French (5)
8. What are the general guidelines regarding the use of the feeding tube for medications.
(Type text in box below.)
Using feeding tubes for medications can result in metabolic complications, due to nutrient
interactions. They can also cause osmolality abnormalities and crystal or gel formations.
If medications need to be put down the tube, the tube can be flushed with water, then crushed
medications can be put down the tube, and then the tube needs to be flushed with water after
the medication has been given.
Also liquid forms of medications can be given down the feeding tube.
No enteric coated or sublingual medications can be given with a feeding tube.
(5)
9. How can you increase the fiber in a tube feeding? Evaluate the practice of adding
Metamucil to a feeding tube. (Type text in box below.)
You can increase fiber during a tube feeding by using a formula that has fiber added into it
already.
Adding Metamucil into a feeding tube is not recommended, because it will cause gel formation
(5)
10. Complete the following table regarding common nutrition-related problems in the tube-
fed patient. Fill in 3-4 causes and corrective measures for each problem area (Type text in
box below.)
Problem Possible Causes Suggested Corrective Measures
Nausea Surgery (5) Keep the patient comfortable
Pain Medications (5) Ask the doctor about different pain
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Vomiting medications or give tube feeding at
times when he has not had pain meds.
Rapid infusion (5) Infuse the solution slower
Infusing cold formula (5) Let the formula warm up before
infusing
Diarrhea Bacterial overgrowth (5) Treat infection
Contaminated tube feed (5) Flush the tube with water and stop
contamination
Fat malabsorption (5) Infuse the solution slower or try a
different solution that has lower
amounts of fat.
Constipation Milk based formula (5) Find a dairy free formula
Decreased fiber (5) Give patient more fiber
Decreased fluid (5) Give patient more fluid.
Determine Appropriate Nutrition Interventions
1. Complete the following table
a. Fill in the nutrition prescription
b. Fill in one or two interventions. Make sure the interventions are different from
each other. Formula solution (ND 2.1.1.) and Insert enteral feeding tube (ND
2.1.2) are the same ultimate intervention – starting a TF.
i. The intervention should be at least a second level term. Example:
1. First level “Food and/or nutrient delivery” (ND)
a. Second level “ Meal and Snacks (ND 1)
i. Third level Specific foods/beverages or groups (ND
1.3)
c. Use the IDNT manual nutrition intervention terminology. Be sure that the
interventions match your PES statements. That means the interventions should be
directed at fixing the nutrition problem/diagnosis.
d. Remember these interventions should be things done at the initial overall nutrition
assessment, not interventions that will come later at f/u encounters or future
outpatient visit.
Nutrition Prescription:
It is important to consume more calories than are expended for unintentional
weight loss and underweight individuals. A high calorie diet with adequate
NPC is important to help with weight loss.
Intervention Goal(s)/Expected Outcome
Intervention # 1
ND-2.1: begin enteral feeding of
Jevity 1.0 through a NG tube at
102.5 mL/hr.
Weight regain back to 170 # or 77
kg.
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(4)
Intervention # 2
RC-1.4: collaboration with speech
pathologist to prevent dysphagia
(4)
Prevention of dysphagia and
increased ability to eat comfortably
with a decreased risk of aspiration.
Section 4. Nutrition Monitoring and Evaluation
1. What signs and symptoms should the dietitian look for when monitoring JQ’s tolerance
to the tube feeding. (Type text in box below.)
Abdominal distention and discomfort
Fluid intake and ouput
Edema and dehydration
Wegiht
Stool output and consistency
Serum electrolytes, BUN, creatinine, glucose, calcium, magnesium, phosphorous.
(1)
2. What tools can the dietitian use to monitor the nutritional adequacy of the enteral
feeding? Include recommended lab tests. (Type text in box below.)
Tube position
Weight trends
Fluid intake output—urinalysis
Lab data: glucose levels, albumin and prealbumin, electrolyte levels.
Medications
Changes in GI function
(3)
3. Is JQ at risk for refeeding syndrome? Explain. (Type text in box below.)
Yes, because he has not eaten in an extended period of time
(3)
4. What indicators of refeeding syndrome will you watch for? (Type text in box below.)
Electrolyte abnormalities, edema, heart arrhythmias.
(3)
5. How can refeeding syndrome be avoided? (Type text in box below.)
Through monitoring JQ’s serum potassium, magnesium, and phosphorous levels and normalized
through replacement therapy prior to starting enteral nutrition. Also through starting enteral
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nutrition slowly.
(3)
6. Complete the following table for the two interventions and goals you indicated above.
Define the following
a. The indicators you will use to measure change. The indicators should measure
progress towards goal. Example: If your goal is weight gain, possible indicators
would be weight, BMI, skin-folds, calorie count.
b. The criteria for evaluation (be specific.) What criteria will you use to assess if
the indicators show you are meeting goals? In the above example criteria would
be weight increase, BMI between 18.5 and 24.9 Kg/m2, skin-folds within normal
range, calorie intake XXXX/day.
c. Note: the IDNT manual has listed indicators and criteria in the Assessment,
Monitoring, and Evaluation, and Diagnosis section. Remember your interventions
are aimed at resolving a nutrition problem/diagnosis.
Intervention (Copy from above)
Goal/Expected Outcome (Copy form above)
Indicator(s)
Criteria for evaluation
ND-2.1: begin
enteral feeding
of Jevity 1.0
through a NG
tube at 102.5
mL/hr.
(4)
Weight regain back to 170
# or 77 kg
Weight, calorie count. 2600 kcal/day
given to JQ.
Weight regain of
2 lbs per week
until weight is
regained.
RC-1.4:
collaboration
with speech
pathologist to
prevent
dysphagia
(4)
Prevention of dysphagia
and increased ability to eat
comfortably with a
decreased risk of
aspiration.
Swallow studies. Ability to
eat/drink all
thicknesses of
foods and liquids
in a barium
swallow study
without
aspirating.
Section 5. Complete your initial chart note
1. Write your Initial Assessment chart note in the box below. The note should contain all
steps of the nutrition care process, assessment (include all areas), diagnosis,
intervention (include nutrition prescription), monitoring and evaluation (include
goals and indicators). Use the information you’ve written about above to create your
note.
A: 69 year old male
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Height: 70”; 177.8 cm
Weight: 151 lbs; 68.6 kg
IBW: 166 lbs
% IBW: 91%
BMI: 21.7
Pertinent Labs: Albumin: 2.7
Hgb: 11
Hct: 32%
Ca2+: 7.6
D: Unintended weight loss related to decreased ability to consume sufficient energy as evidenced
by weight loss of >7.5% in 90 days.
I: Begin enteral feeding of Jevity 1.0 through a NG tube at 102.5 mL/hr to help JQ regain weight
back. Enteral feeding will give 2600 kcal/day to JQ. A goal of regaining 2 lbs per week.
M/E: Follow up daily to see how the tube feed is being tolerated. Follow up weekly to evaluate
weight gain in JQ compared to the goal of 2 lbs/week.
Section 6. Hospital Follow-Up
The physician ordered the TF protocol you recommended and JQ is tolerating the tube feed well.
He has been on the TF for several weeks and has been progressing and recovering from his
medical illness. A new swallow study indicated JQ could start trying po.
1. Outline your plans for advancement from TF to oral feedings. How will you progress
from TF to oral feeds? Include how you would advance the oral feedings, and what kind
of diet you would want him on orally. How will you know when to d/c the TF? (Type
text in box below.)
I will start JQ on spoon-thickened and pureed foods and start with him eating 1 meal/day orally
and receiving the rest of his kcal from enteral nutrition. After a week of this, if he is tolerating
the oral diet well, I will transition him from eating 1 meal/day orally to having 2 meal/day orally.
If he tolerates this diet well for a week, then I will take him off of the tube feed entirely and let
him eat 3 meals orally per day. After he can eat 3 meals orally, I will introduce some
mechanically altered foods and honey-thickened liquids into his diet. As I introduce less-soft
foods into his diet, I will continue to check for aspiration and monitor his tolerance for these
foods. As he can eat less-soft foods and thinner liquids, I will continue to introduce more foods
into his diet gradually. The hope is that he will be able to eat all thickness of foods eventually.
2. During the transition period, what information would you monitor and why? (Type text in
box below.)
Information Monitored Why Weight To see if he is receiving nutrients from the food that is being
given to him and if he is tolerating an oral diet.
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Swallowing Abilities To ensure that he is not aspirating.
3. List at least one potential nutrition related problem JQ might encounter during this
transition phase and provide a realistic solution. (Type text in boxes below.)
Problem: Constipation (1)
.
Solution: Providing more fluid and fiber with meals. (1)
Section 7. Outpatient Follow-Up
JQ has advanced to full oral feedings and has been discharged. He has scheduled a follow up
with you in one month in the outpatient clinic.
1. During JQ’s outpatient visit, identify which parameters would you monitor to assess his
current nutritional status and indicate why. (Hint – use assessment, monitoring, and
evaluation terms from IDNT.) (Type text in box below.)
I would evaluate his weight, because the primary goal that I set for JQ was weight gain back to
170 lbs. I would also give him a 24 hour recall or a food diary to evaluate and to monitor his
caloric intake. A 24 hour recall or a food diary would also give me an idea of his dysphagia,
because I will be able to see what kinds of foods he is eating (i.e. soft casseroles that may be
more indicative of dysphagia or a regular diet).
References for Case Study #1 (Use the format indicated in the Student Handbook)
1. Mahan KL, Escott-Stump S, Raymond JL. Krause’s Food & the Nutrition Care Process.
13th
ed. St. Louis, MS: Elsevier Saunders; 2012
2. Pagana KD, Pagana TJ. Mosby’s Maunal of Diagnostic and Laboratory Tests.4th
ed. St.
Louis, MS: Mosby Inc; 2010.
3. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/index.cfm. Accessed February 10, 2015.
4. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology
(IDNT) Reference Manual. 4th
ed. Chicago, IL; 2013
5. Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, Feb.
10, 2015
6. Abbott Nutrition. Our Products. Available at: http://abbottnutrition.com/brands/abbott-
brands. Accessed February 9, 2015.
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Case #2 Trauma TPN and the Metabolic Effects of Injury
Hospital Admission JJ is a 23-year old male admitted to the hospital unconscious after being trampled by a bull in a
local rodeo contest. In addition to multiple fractures, an exploratory laparoscopy identified
massive internal injuries to the GI system.
Physician’s Orders Dietitian to consult for TPN and make recommendations
The dietitian was able to obtain the following information from the medical record and
observation.
Previous medical history unremarkable with minor injuries in the past resulting from
other rodeo accidents.
Large framed, approximately 6'1" tall and weighed 210# on the bed scale.
Family members live out of state and have not been able to visit JJ yet.
Admit labs
Alb 2.1 g/dl Hct 31% Prealbumin 7.0 mg/dl
Trigs 170 mg/dl Hgb 10 g/dl CRP 21.4 mg/dl
Gluc 200 mg/dl Na 133 mmol/L
.
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Section 1. Nutrition Assessment
Food/Nutrition Related History (AKA Dietary)
1. Do you need a diet history on this patient? Why or why not? No, because JJ is in acute response phase, so what he has been eating previously is not as
important and making sure that he has enough kcal and protein to support his metabolic
processes.
Anthropometric Measurements 1. List JQ’s
Ht (in & cm) 73”; 185 cm
Wt (lb and Kg) 210 #; 95.5 kg
IBW (lb and Kg) 184 #; 83.6 kg
%IBW 114%
BMI (kg/m2) 28
2. How accurate are JJ’s current anthropometrics?
I would say that they are probably pretty accurate. JJ was not malnourished before coming into
the hospital, so his weight and BMI are most likely accurate.
Biochemical Data, Medical Tests and Procedures
1. List abnormal lab values explain possible causes for each. (pagana)
Lab and Value Possible Causes
Albumin; 2.1 g/dl
Inflammation—because albumin is a negative phase reactant, during
inflammation albumin levels decrease. (2)
Triglyercides; 170
mg/dl
Because JJ’s triglycerides are a little bit over the normal ranges, I
think that it could be because of the acute stress response causing
lipolysis. (2)
Glucose; 200 g/dl Acute stress response—Severe stress stimulates catabolism which
secretes glucagon secretion. Glucagon secretion causes
hyperglycemia. (2)
Hct; 31% Hemorrhage—because JJ has broken bones, bruises, and undergone
internal injuries with his GI tract, there may be some internal
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bleeding which could cause a low hematocrit (2)
Hgb; 10 g/dl Hemorrhage—because JJ has broken bones, bruises, and undergone
internal injuries with his GI tract, there may be some internal
bleeding which could cause a low hemoglobin (2)
Na 133 mEq/L JJ’s sodium is just under the normal values, so I think that it could be
because of his injuries, but there is nothing drastic that is causing the
low sodium values. (2)
Prealbumin: 7 mg/dl Inflammation—because prealbumin is a negative phase reactant,
during inflammation prealbumin levels decrease. (2)
CRP; 21 mg/dl Inflammation—because CRP is a positive phase reactant, during
inflammation CRP levels increase. (2)
2. Are these lab values accurate tools to use to determine JJ’s nutritional status? Explain
No because due to the acute response phase and inflammation, these lab values do not show
JJ’s actual biochemical values or his biochemical nutrition status.
Nutrition-Focused Physical Findings (AKA Clinical)
1. What clinical signs would you look for to help complete your nutritional assessment?
Edema and muscle wasting.
(1)
2. What clinical signs are typical in trauma patients?
Edema, muscle wasting, confusion.
(1)
Comparative Standards
1. Determine JJ’s needs for energy, protein, and fluid. (Type needs in chart below.) Indicate
wt used for calculations, formula used (e.e. HBE, Penn, Kcal/Kg, etc.) write out name of
formula and equation as appropriate, and any activity/stress factors.
Needs Equation Used Stress Factors
Energy (Kcals) 2600 25-30 kcal/g (1) None
Protein (g/d) 115 g 1.2-2.0 g/kg (3)
Fluid (ml/d) 2400 mL per day 25-30 ml/kg (3)
Weight Used (lb
& kg)
210 lbs
95.5 kg
Use the box below to show your calculations
18
Kcal: 25 kcal x 95.5= 2400 kcal; 30 kcal x 95.5= 2900 kcal
Protein: 1.2 g/kg x 95.5= 115 g/day; 2.0 g/kg x 95.5= 191 g/day
Fluid: 25 ml/kg x 95.5= 2400 ml/day; 30 kcal x 95.5= 2900 mL/day
2. Justify the following:
Equation used for energy needs and any activity/stress factors used.
Protein need calculation
Weight used
Remember to cite sources used for justification; sources should be listed at end of case. (Type
text in box below.)
Energy: Krause said that a range of 25-30 kcal/kg could be used in critical care. I calculated this
range and then chose a number in the middle, which was 2600 kcal. (1)
Protein: The nutrition care manual said to use 1.2-2.0 g/kg of protein for critical care patients, I
chose 1.2, because I didn’t want to give him too much protein, as giving too much protein can
cause hyperglycemia in the acute response phase. (3)
Weight: I used his admit weight, because no other weight was given and it is unlikely that he has
lost much weight in the short amount of time between getting injured and arriving at the hospital.
IDNT Nutrition Assessment Terms and Statements
Using the case and assessment information you discussed above, complete the following table.
Enter a one or more assessment terms for each assessment category along with
terminology number. The term used should be at least in the second level, but can be
third or fourth level as appropriate for the case. For example
o First level Food and Nutrient Intake (1)
Second level Energy Intake (1.1.)
Third level Food intake (1.2.2)
o Fourth level Amount of food (FH-1.2.2.1).
o See pages 77-81 of IDNT 4th
edition for a quick look. In-depth pages 83-221.
Write a brief assessment statement for each term chosen. You can combine terms into
one state if it seems logical. For example anthropometrics would logically go together in
one statement. Others may as well.
o Example: Ht: XX (in/cm); wt: XX (lbs/kg); BMI XX, usual wt XX. Weight loss
XX% mild loss.
Note: only enter information if it applies to this case. Add additional rows as needed.
Assessment Category
Assessment term and number
Assessment Statement
Food/Nutrition-Related History
N/A N/A
N/A N/A
N/A N/A
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Anthropometric Measurements
Body
composition/growth/weight
history AD-1.1
(4)
Height: 73”, 185 cm
Weight: 210 lbs; 95.5 kg
IBW: 184 lbs; 83.6 kg
% IBW: 114%
BMI: 28.0
Biochemical Data, Medical Tests, and Procedures
Sodium BD-1.2.5
(4)
Sodium levels are low at 133
Glucose, casual- BD-1.5.2
(4)
Glucose levels are high at 200
C-reactive protein BD-
1.6.1
(4)
CRP is high at 21
Triglycerides, serum BD-
1.7.7
(4)
Triglycerides are high at 170
Nutritional Anemia Profile
BD-1.10
(4)
Hgb is low at 10
Hct is low at 31%
Protein Profile BD-1.11
(4)
Albumin is low at 2.1
Prealbumin is low at 7
Nutrition-Focused Physical Findings
Overall Appearance PD-
1.1.1
(4)
Unconscious,
Extremities muscles and
bones PD-1.1.4
(4)
Bruises and broken bones
Digestive System PD-1.1.5
(4)
Internal damage of GI tract
Client History Personal Data CH-1.1
(4)
23 years old, male.
Section 2. Nutrition Diagnosis
Determine Nutrition Diagnosis/Problem
1. Use the IDNT book to list problems (nutrition diagnosis) JQ has. Add rows if necessary.
Diagnosis term
number Diagnosis Term
Domain (Intake, Clinical,
Behavioral/Environmental) NI-1.1 (4) Increased energy expenditure Intake
NC-1.4 (4) Altered GI function Clinical
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Write a Nutrition Diagnosis PES Statement (4) Write a Diagnosis Statement using PES format for two of JJ’s problems:
Diagnosis Term/ Problem
Etiology Signs and/or
Symptoms
Increased energy
expenditure
Related
to Acute phase stress
response
As
evidenced by Fractures and internal
injuries
Altered GI Function Related
to Internal injuries to
the GI tract
As
evidenced by Exploratory laporascopy
results.
Section 3. Nutrition Intervention
Analyze Potential Nutrition Interventions
1. From your nutrition assessment do you think JJ is at nutrition risk? Explain.
Yes, because he is in the acute response phase of metabolic stress, his body is most likely
catabolic. This means that his protein, calorie, and fluid needs will increase. If these increased
needs are not met, he could become malnourished and his risk of mortality will increase.
2. What will be the main challenges in providing sufficient nutrition?
Giving JJ increased calories and protein but not over feeding him. Over feeding a patient in
critical care increases mortality and morbidity risks. I think another challenge will be assessing
his nutrient absorption to JJ, because he has internal injuries to his GI tract. (3)
3. Is enteral feeding appropriate? Explain.
No, because we are not sure if he will aspirate or if he can swallow. Also, because he has many
internal injuries to his GI tract, his GI tract may not work. In addition, we want to start feeding
him within 24 hours, and we will not be able to receive the information we need to evaluate if he
is at risk for aspiration or if his GI tract will be efficient at absorbing nutrients, so it will be best
to start him on TPN. (3)
Complete the physician’s order to consult for TPN.
The hospital has a standard TPN formula of 500 cc D50 and 500cc 8.5% AA (per 1000 cc) and
the availability of both 10% and 20% lipids.
4. Calculate a TPN solution to meet JJ’s current nutrition needs as calculated above. Fill in
the following table with the TPN calculations. If you cannot determine a TPN that will
adequately meet both energy and pro needs, discuss that in the last part of #5 below.
List energy, pro, fluid needs from above: Energy: 2600 kcal; Protein: 116 g; Fluid: 2400 mL
21
Total volume of standard solution (ml/24 hr)
2400 mL
Rate of standard solution (ml/hr) 100 mL/hr
Type of lipids used and frequency
10% 2x per week
Carbohydrate grams and Kcals 600 g; 2040 kcal
Protein grams and Kcals 102 g; 408 kcal
Fat grams and Kcals 14 g/day; 157 kcal per day
Total Kcals 2605
Non-pro Kcals 2197
Non-pro Kcals (NPC):N ratio (Goal ~150:1)
137:1
% NPC Calories from lipid (Goal <30%)
7%
% NPC from CHO (goal 70-80%) 93%
Fat Load (goal ≤ 1 gm/kg) 0.15
CHO Load (mg/kg/min) 4.36
Show calculations below.
1200 mL protein: 1200 x .085= 102 g x 4= 408 kcal
1200 mL CHO: 1200 x .5= 600 g x 3.4= 2040 kcal
Fat: 1000 mL x 1.1 kcal/ml= 1100 kcal/7= 157 kcal/day
1100 kcal/11 kcal per g= 100 g/7= 14 g/day
5. Assess the above TPN recommendation for JJ’s needs. Current TPN provides:
% Protein needs 88%
% NPC needs 103%
% total Kcal needs
100%
% free fluid needs 100%
Appropriate NPC:N ratio? Explain.
Yes, because it is around 150:1, which was the guideline for this ratio.
Having a NPC:N ratio around 150:1 will help promote muscle
building instead of muscle catabolism while still giving the patient the
energy that he/she needs.
Appropriate fat load? Explain.
I think that this fat load is a little bit low, but the fat low is within the
guideline of <1.0, so this fat load is appropriate.
Appropriate CHO load? Explain.
This carb load is lower than the guideline of 5-7, so I do not think that
it is appropriate.
Is there I could add in modules, such as extra carbohydrate or extra protein.
22
something you can do to more closely meet pt needs when only standard TPN is available?
(5)
6. List the advantages and disadvantages of using standard TPN solutions.
Advantages Disadvantages -Already made
-less expensive
-Reduce the risk of infection
-less waste
(5)
-Doesn’t cater to special needs
-Is difficult to customize
-Can be harder to calculate
(5)
7. List the advantages and disadvantages of using individualized TPN (3-in-one solutions).
Advantages Disadvantages -You can get the exact grams and calorie
amounts that you need
-Easier to meet the special needs of patients
-Fat goes in at a slower rate so fat clearance
improves
-Saves time for the nurses
(5)
-Takes more time
-Can be harder to calculate
-More expensive
-Increased risk of contamination
-There can be solution issues with mixing
things in the custom solution
-Risk of occluding the TPN catheter.
(5)
8. List the general complications of TPN.
Some complications of TPN include hyperglycemia, hypoglycemia, EFA deficiencies,
hypertriglyceridemia, azotemia, high BUN and high creatinine. It can also cause fatty liver
and biliary obstructions. Also hemothoraxes, infections, and blood clots are important to
watch out for. (5)
9. List the indications for use of TPN. (e.g. when is TPN appropriate)
Peripheral: If they will have TPN for <2 weeks and don’t need full nutrition.
Central: If TPN is a long-term solution (>1 week), if a feeding tube isn’t working or the
patient can’t eat, and if the client is clinically stable and hemodynamically stable.
(5)
Determine Appropriate Nutrition Interventions
10. Complete the following table
a. Fill in the nutrition prescription
b. Fill in one or two interventions. Make sure the interventions are different from
23
each other. Formula solution (ND 2.1.1.) and Insert enteral feeding tube (ND
2.1.2) are the same ultimate intervention – starting a TF.
i. The intervention should be at least a second level term. Example:
1. First level “Food and/or nutrient delivery” (ND)
a. Second level “ Meal and Snacks )(ND 1)
i. Third level Specific foods/beverages or groups (ND
1.3)
c. Use the IDNT manual nutrition intervention terminology. Be sure that the
interventions match your PES statements. That means the interventions should be
directed at fixing the nutrition problem/diagnosis.
d. Remember these interventions should be things done at the initial overall nutrition
assessment, not interventions that will come later at f/u encounters or future
outpatient visit. Note: you may have one goals that the two interventions will
address or you may have two separate goals.
Nutrition Prescription:
During critical care and the acute stress response, it is important to support
the metabolic system through giving patients adequate calories, protein, and
fluid.
Intervention Goal(s)/Expected Outcome
Intervention # 1
ND-2.2:
Begin 2400 mL of parenteral
nutrition each day with 2 bags of
10% lipids twice a week.
(4)
That the calorie and protein amounts
will provide JJ nutrition that he needs
while his body goes through the
acute stress response.
Intervention # 2
RC-1.3:
Work with medical team to ensure
that JJ’s GI tract can heal and that he
can transition to an oral diet as soon
as possible.
(4)
That JJ’s gut will heal and that with
time and counseling with other
health professionals, he will be able
to transition from TPN to an oral
diet.
Section 4. Nutrition Monitoring and Evaluation
1. What should you use to monitor TPN effectiveness and recommendation?
-Blood glucose levels to watch for hyperglycemia and to adjust protein and carbohydrate recommendations -BUN so that protein breakdown and kidney function can be assessed and accounted for. -Serum osmolality to ensure that he is getting enough free fluid and that there aren’t too many aspects to the TPN that is changing the osmolality. -Electrolytes to watch for hyponatremia and hypernatremia. (3)
24
2. What complications could result if excessive carbohydrate is given in TPN?
Hyperglycemia (5)
3. What are your best monitors to check CHO tolerance?
Blood glucose levels and insulin levels (5)
4. What complications could result if excessive fat is given in TPN?
Hyperlipidemia, fatty liver and spleen, impaired liver, anemia, and clotting insufficiencies. (5)
5. What are your best monitors to check for lipid tolerance?
Blood lipid levels
6. Complete the following table for the two interventions and goals you indicated above.
Define the following
a. The indicators you will use to measure change. The indicators should measure
progress towards goal. Example: If your goal is weight gain, possible indicators
would be weight, BMI, skin-folds, calorie count.
b. The criteria for evaluation (be specific.) What criteria will you use to assess if
the indicators show you are meeting goals? In the above example criteria would
be weight increase, BMI between 18.5 and 24.9 Kg/m2, skin-folds within normal
range, calories at XXXX kcal/day.
c. Note: the IDNT manual has listed indicators and criteria in the Assessment,
Monitoring, and Evaluation, and Diagnosis section. Remember your interventions
are aimed at resolving a nutrition problem/diagnosis.
Intervention (Copy from above)
Goal/Expected Outcome (Copy form above)
Indicator(s)
Criteria for evaluation
ND-2.2:
Begin 2400 mL
of parenteral
nutrition each
day with 2 bags
of 10% lipids
twice a week.
That the calorie and protein
amounts will provide JJ
nutrition that he needs
while his body goes
through the acute stress
response.
Weight fluctuations, hyper-
or hypo- glycemia, blood
lipid levels outside of the
normal ranges, and muscle
anabolism.
Weight stability,
blood glucose
levels within
normal ranges,
blood lipid levels
within normal
ranges, and
nitrogen
excretion
through the stool.
RC-1.3:
Work with
medical team to
ensure that JJ’s
That JJ’s gut will heal and
that with time and
counseling with other
health professionals, he
Fewer visible internal GI
tract injuries, normal
swallow studies.
Ability to eat
without
aspirating, and
tolerance of a
25
GI tract can heal
and that he can
transition to an
oral diet as soon
as possible.
will be able to transition
from TPN to an oral diet.
tube feed.
Section 5. Complete your initial chart note
1. Write your Initial Assessment chart note in the box below. The note should contain all
steps of the nutrition care process, assessment (include all areas), diagnosis,
intervention (include nutrition prescription), monitoring and evaluation (include
goals and indicators). Use the information you’ve written about above to create your
note.
A: 23 year old male
Height: 73”; 185 cm
Weight: 210 lbs; 95.5 kg
IBW: 184 lbs; 83.6 kg
% IBW: 114%
BMI: 28
Pertinent Labs: Albumin: 2.1
Triglycerides: 170
Glucose: 200
Hgb: 10
Hct: 31%
Na: 133
Prealbumin: 7
CRP: 21
D: Increased energy expenditure related to acute phase stress response as evidenced by
fractures and internal injuries.
I: Begin 2400 mL of parenteral nutrition each day with 2 bags of 10% lipids twice a week.
M/E: Follow up daily to see if TPN is being tolerated and to adjust TPN order. Follow up
once a week to check for weight fluctuations and protein excretion.
Section 6. Hospital Follow-Up The physician ordered the TPN you recommended. You are assessing JJ 3-days later and want to
determine if the TPN is meeting JJ’s needs. A UUN was ordered.
1. If the UUN was 32 gm/24 hr, how many grams of protein are being lost in one day? (hint
1 gm N= 6.25 g pro OR protein is 16% N)? Show work
32 g N/.16 N= 200 g protein (5)
2. Using the UUN above calculate the N balance. Show work
(32 g lost each day + 4= 36 g N) (5)
26
(102 g ingesting x .16= 16 g N)
16-32= -16
(5)
3. How would you modify your nutrition support (in general) based on the N balance
calculated above?
I would give JJ 100 more grams of protein in the TPN.
4. Would indirect calorimetry be of benefit in assessing this patient?
Yes, indirect calorimetry would be beneficial (3)
5. What can indirect calorimetry tell you?
It can tell us how many calories he is burning, which can help us adjust the TPN order. It will
also tell us the RQ, which can tell us if he is burning more CHO, protein, or fat.
(3)
After a week, you met as part of the interprofessional team in rounds to discuss JJ’s case. The
team decided JJ was ready to try po feeds.
6. How would you (the dietitian) modify the TPN as JJ is advanced to po feedings?
I would taper him off of TPN so that he is receiving 33%-50% of his nutrient needs from a tube
feed or from an oral diet. I would then watch and see when JJ is meeting 50% of his needs from a
tube feed or an oral diet, and then take him off of TPN completely.
(5)
7. How would you monitor tolerance to his oral feedings?
I would look for diarrhea, distention, and his biochemical lab values.
(3)
References for Case Study #2 (Use the format indicated in the Student Handbook)
1. Mahan KL, Escott-Stump S, Raymond JL. Krause’s Food & the Nutrition Care Process.
13th
ed. St. Louis, MS: Elsevier Saunders; 2012
2. Pagana KD, Pagana TJ. Mosby’s Maunal of Diagnostic and Laboratory Tests.4th
ed. St.
Louis, MS: Mosby Inc; 2010.
3. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/index.cfm. Accessed February 10, 2015.
4. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology
(IDNT) Reference Manual. 4th
ed. Chicago, IL; 2013
27
5. Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, Feb.
10, 2015