Name: Melanie Dueck BRIGHAM YOUNG UNIVERSITY

NDFS 466

Clinical Worksheet #1

CLINICAL WORKSHEET #1 Hypermetabolism and Nutrition Support in Critical Care

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 Gradebook 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 Gradebook

Sources for completing worksheet.

Assume these are the sources available:

Nutrition Care Manual -- Adult and Pediatric (online)

IDNT Manual

Any textbooks from NDFS courses

ADA Evidence Analysis Library (online) and noted journal articles

Class Lecture Notes from any NDFS course

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.

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 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:

Hgb 11 mg/dl 11 mg/dl Prealbumin 20 mg/dl

Hct 32% 32% Glucose 105 mg/dl

Albumin 2.9 g/dl Calcium 7.6 mg/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

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.

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)

JQ’s nutritional needs are not being met. He has experienced severe weight loss by losing 19

pounds within 3 months. His ideal body weight is 166 lb. He used to be 102% of his IBW but is

is now 91% of his IBW. It was reported that within the last 2 weeks he hasn’t really eaten

anything so his nutritional needs would not be met since he isn’t consuming anything.

2. What other information regarding his diet history would help in your assessment and why?

Hint: Use the IDNT book for other possible Food/Nutrition Related History terms. (Type text

in box below)

I would like to know a more about what exactly he has been eating so I can know his total energy

intake. I would also like to know what he was eating before to have an idea of what his total

energy intake was before so I have an idea of how many calories he should be consuming now as

he is on an NPO diet.

Anthropometric Measurements 1. List JQ’s

Ht 5’10” (177.8cm)

Wt 151lb (68.6kg)

Usual Wt 170

%IBW 166lb

BMI 22 (current); 24.5 (usual)

2. Evaluate JQ’s current wt and any significant wt changes. (Type text box below)

JQ is has a healthy BMI but he has experienced severe weight loss of 19 lbs within the last 3

months. He was at 102% IBW and is now at 90% IBW.

Biochemical Data, Medical Tests and Procedures

1. List abnormal lab values and explain possible causes for each.

Lab and Value Possible Causes

2.9g/dL Albumin

(low)

Malnutrition, protein-losing enteropathies (malabsorption

syndromes), inflammatory disease (1)

32% Hematocrit

(low)

Anemia, hemorrhage, dietary deficiency (iron, folate, B-12) (1)

11g/dL Hemoglobin

(low)

Anemia, hemolytic anemia, hemorrhage, dietary deficiency (1)

7.6mg/dL Calcium Hypoparathyroidism, vitamin D deficiency, hypoalbuminemia,

malabsorption (1)

2. What other lab tests would help in your nutritional assessment and why? (Type text box

below)

BUN- when elevated this can indicate GI bleeding, dehydration, starvation, sepsis, renal fal

failure; low levels could signify negative nitrogen balance (1)

Gastric residual volume- this will help evaluate food toleration of the gut(1)

Serum B12, Serum folate, Serum iron- this will help to assess what the anemia is being

caused by and the function of the absorption gut (1)

CRP- inflammatory illness (1)

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.)

Squamous cell carcinoma in the GI are of particular concern due to the alterations in nutrient

absorption. It was not indicated what was removed in the surgery but any removal of the

intestine alters and decreases nutrient absorption. Difficulty of swallowing due to the cancer not

only causes decreased food intake, but also fluid intake due to the pain it causes. The 19 pound

weight loss is a manifestation of JQ’s lack of nutrition caused by not eating or drinking.

Client History

1. List and explain any pertinent nutrition-related concerns found in the client history

JQ’s history of smoking is of particular concern. Smoking typically decreases appetite and

increases the need for nutrients such as vitamin C. The contamination of smoking and the

decreases appetite are not beneficial to JQ’s healing and regaining weight.

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.e. HBE, Penn, Kcal/Kg, etc.) write out name of

formula and equation as appropriate, and any activity/stress factors.

Needs Formula Used Activity/Stress

Factors

Energy (Kcals) 2059kcal/d 30kcal/kg --

Protein (g/d) 117 g/d 1.7g/kg --

Fluid (ml/d) 2059 ml/d 1ml/kcal --

Weight Used (lb) 151

Use the box below to show your calculations

Energy: 151/2.2= 68.64kg *30kcal/kg= 2059kcal

Protein: 68.6 x 1.7= 117g/d

Fluid: 1ml/kcal* 2059kcal= 2059ml/d

2. Justify the following:

Formula used for energy needs and any activity/stress factors used.

Protein need calculation

Remember to cite sources used for justification; sources should be listed at end of case. (Type

text in box below.)

The recommendation for energy requirements are 20-35kcal/kg. I chose 30kcal/kg for JQ

because he needs more calories than the Harris benedict equation predicts but he since he has lost

weight and has less tissue to support I did not use 35kcal/kg. (2)

I used 1.7g/kg to determine protein needs because JQ recently had surgery and has lost a lot of

weight. The recommendation for critically ill patients is 1.5g/kg and 1.9g/kg who are critically

ill and underweight. JQ isn’t underweight but he has had sever weight loss and is critically ill.

This high protein recommendation will help his body to heal and to regain lost body tissue. (2)

Document Nutrition Assessment

From your assessment of this patient, 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 73-75 of IDNT.

Write a brief assessment statement for each term chosen.

o Hint: Sample nutrition assessment documentation statements can be found in the

IDNT (pg 87-198.)

Note: only enter information if it applies to this case. Add additional rows as needed.

Assessment Category

Assessment term and number (3)

Assessment Statement

Food/Nutrition-Related History

Amount of food FH-

1.2.2

Based on the patient food history as reported by his

wife, the patient is consuming hardly any food and

is therefore not meeting calorie needs. Will

evaluate calorie needs and recommend liquid

formulas.

Anthropometric Measurements

Weight AD-1.1.2 JQ has 11% severe weight loss within three months.

Will monitor weight gain at next assessment.

Biochemical Data, Medical Tests, and Procedures

Calcium, serum BD-

1.2.9

JQ’s calcium serum level is 7.6mg/dl which is

below expected range. Will monitor change in

serum level at next assessment.

Hemoglobin BD-

1.10.1

JQ’s hemoglobin level is 11mg/dl which is below

the expected range for adult males. Will monitor

change in hemoglobin level at next assessment.

Hematocrit BD

1.10.2

JQ’s hematocrit level is 32% which is below the

expected range for adult males. Will monitor

change in hematocrit percent at next assessment.

Albumin BD-1.11.1 JQ’s albumin is 2.9g/dl which is below the expected

level. Will monitor change of albumin at next

assessment.

Nutrition-Focused Physical Findings

Overall Appearance

PD 1.1.1

Patient/client has difficulty communicating vocally.

Will monitor ability to speak at next assessment.

Digestive system PD

1.1.5

Patient/client has experienced pain swallowing.

Will monitor ability to swallow at next visit.

Client History

Patient/client chief

nutrition complaint

CH-2.1.1

Patient/client recent complaint of only eating soft

foods.

Surgical treatment

CH 2.2.2

Patient/client had surgery to remove esophageal

lesion. Ordered by doctor not ot take oral po for

several weeks.

Section 2. Nutrition Diagnosis

Determine Nutrition Diagnosis/Problem

1. List the problems JQ has in the Intake Domain (if any)

Diagnosis term number

(3) Diagnosis Term

NI-1.4 Inadequate energy intake

NI-2.1 Inadequate oral intake

NI 5.2 malnutrition

NI 5.3 Inadequate protein-energy intake

2. List the problems JQ has in the Clinical Domain (if any)

Diagnosis term number

(3) Diagnosis Term

NC 1.1 Swallowing difficulty

NC 1.4 Altered GI function

3. List the problems JQ has in the Behavioral-Environmental Domain (if any)

Diagnosis term number

(3) Diagnosis Term

NB 1.1 Food and nutrition-related knowledge deficit

Write a Nutrition Diagnosis PES Statement Write a Diagnosis Statement using PES format for two of JQ’s problems:

Diagnosis Term/ Problem

Etiology Signs and/or

Symptoms

Inadequate energy

intake

Related

to Inadequate food

intake

As

evidenced by Weight loss

Anemia Related

to Inadequate food

intake

As

evidenced by Low hemoglobin and

hematocrit levels

Section 3. Nutrition Intervention

Analyze Potential Nutrition Interventions

1. Is TPN appropriate for JQ? Explain. (Type text in box below.)

No. The inability to eat and swallow is due to the surgery that took place in the esophagus. The

rest of the GI tract is intact and should be used due to its immunologic benefits and health of the

digestive tract itself. JQ would benefit from enteral feeding.

2. Is PPN appropriate? Explain. (Type text in box below.)

This would be appropriate for a short-term use since JQ is malnourished. This however should

be discontinued as soon as >60% of energy requirements can be met enterally. (4)

3. Is enteral feeding appropriate? Explain. (Type text in box below.)

Enteral feeding is appropriate because the GI tract is intact past the esophagus. The use of the GI

tract is beneficial for the health of the GI tract and provides many immunological benefits to the

client/patient. Oral feeding is not appropriate because the esophagus is not intact.

4. List two enteral formulas which would be appropriate for JQ. Justify why the formula is

appropriate.

Formula Name Justification for Use

Crucial (Nestle) This formula promotes absorption and tolerance in critically ill

patients with GI impairment and those who have had major elective

upper GI surgery. This is a 1.5kcal/ml formula so it will help provide

JQ with adequate calories. (5)

Impact 1.5 (Nestle) This 1.5kca./ml formula is for surgical and trauma patients. It

supports the immune system and prevents infection for those at risk

such as those who have undergone major elective surgery of the GI

tract. (5)

5. Calculate the following information to meet JQ’s current nutritional needs which you

determined in the comparative standards section above.

Formula #1 (5) Formula #2 (5)

Formula Name Crucial Impact 1.5

Goal rate: 86ml/hr 86ml/hr

Total Kcals 2060kcal 2060kcal

Non-Pro Kcal 1545kcal 1607kcal

Pro (g) 129g 115g

CHO (g) 184g 192g

Fat (g) 92.8g 94.7g

Osmolality 490 550

Free fluid (ml) 1057ml 1071ml

Additional fluid need (ml) 1002ml 988ml

6. Where the tube should be placed? Why? (Type text in box below.)

The tube should be placed in the stomach and end in the duodenum. Placing the tube in the

stomach could lead to risk of gastric fluids and food coming up the esophagus and agitating or

infecting the surgical wound. JQ is also at risk of aspiration due to his swallowing difficulty

7. What tube lumen is appropriate? (Type text in box below.)

An 8-12 french tube is appropriate for enteral placement in the duodenum. (2)

8. The nurse is crushing an enteric-coated pain med and flushing it through the feeding tube.

Evaluate this practice. (Type text in box below.)

There is no point in having an enteric-coated pill if it is going to be crushed because it will no

longer be coated. It is also not necessary to have the coated pain med because it is entering into

the duodenum and enteric coated medications are only needed if it enters the stomach. (4)

9. What are the general guidelines regarding the use of the feeding tube for medications.

(Type text in box below.)

It is preferred to not use the tube for medications. If the tube is used for medications they

should be crushed and the tube should be flushed before and after. Enteric coated or

sublingual tabs are not to be flushed down a tube. (4)

10. 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.)

Yes. You can add both soluble and insoluble fiber by choosing a high fiber formula. (2)

Metamucil add more bulk to the stool and is similar to adding medications through the feeding

tube.

11. Complete the following table regarding common nutrition-related problems in the tube-

fed patient. Fill in as many causes as indicated in the table (i.e. nausea would have three

possible causes listed, diarrhea five.) (Type text in box below.)

Problem (2) Possible Causes Suggested Corrective Measures

Nausea 1.delayed gastric emptying 1. erythromycin (antibiotic)

2. cold formula 2. room temperature formula

3. medications 3. get off narcotic pain medications

Vomiting 1. high fat 1. switch to lower fat formula

2. rapid formula infusion 2. decrease infusion rate

Diarrhea 1.Medications 1. get off medications

2.antibiotics 2. get off antibiotics

3.infection 3. antibiotics

4.formula intolerance 4. switch formula

5.lactose intolerance 5. change formula

Constipation 1. pain medications 1. enemas

2. Impaction 2. sorbitol

3. low fluid intake 3. increase fluid

4. low fiber intake 4. increase fiber

Determine Appropriate Nutrition Interventions

12. Complete the following table

a. Fill in the nutrition prescription

b. Fill in at least two interventions. 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.

Nutrition Prescription:

Recommend enteral nutrition order Impact 1.5 86ml/hr.

Intervention Goal(s)/Expected Outcome

Intervention # 1 (3)

ND 2.1.2 Insert enteral feeding tube Meet energy intake needs

Intervention # 2 (3)

ND 3.2.1 Multivitamin/mineral Achieve normal mineral and vitamin

serum levels and correct anemia

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.)

Gastric residuals

Feelings of nausea/vomiting

Diarrhea/constipation evaluation

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.)

Albumin and iron lab tests

Vitamin/mineral serum levels

Weight gain

3. Is JQ at risk for refeeding syndrome? Explain. (Type text in box below.)

Due to JQ’s lack of food intake in the last two weeks he is at risk for refeeding syndrome. The

rapid infusion of CHO increases insulin release and reduces salt and water excretion. Since JQ

will be fed enterally he is less likely to have refeeding syndrome because the digestive and

absorptive processes mediate the rapid impact from refeeding. Nutrient intake should be

moderate in CHO and include phosphorus, potassium, and magnesium supplements. (6)

4. What indicators of refeeding syndrome will you watch for? (Type text in box below.)

Low serum levels of potassium, phosphorus, and magnesium. (6)

5. How can refeeding syndrome be avoided? (Type text in box below.)

Refeeding syndrome can be avoided by enteral feeding and administering conservative amounts

of CHO and give adequate amounts of intracellular electrolytes (phosphorus, potassium,

magnesium). (6)

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.

6. 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. (Type text in box below.)

I will begin to transfer to oral feedings by moving from continuous feeding to a 12 and then 8

hour continuous feeding during the night. This will help to stimulate hunger and satiety cues. I

will continue to have him tube feed until oral feeding is well tolerated. I will recommend a level

1 dysphagia pureed diet so that the food is easy to swallow and won’t have high risks of

aspiration. I will slowly advance him to level 2 dysphagia mechanically altered diet, level 3

dysphagia advanced, diet, and back to a normal diet. (6)

7. What information would you monitor and why? (Type text in box below.)

Information Monitored Why Aspiration JQ has not eaten much in weeks and he is recovering from

surgery on his esophagus. As he begins to drink and eat

again it is very possible that he could aspirate which would

lead to infection.

Dysphagia The surgery should have removed all of the cancer making it

possible to swallow without pain one JQ heals. If dysphagia

continues the cancer may still be present.

Weight JQ had sever weight loss due to the cancer and inability to

eat. As JQ begins to eat again he should gain weight. If he

doesn’t the cancer may still be present and he could still have

difficulty eating.

8. 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: Aspiration

.

Solution: To prevent aspiration a dysphagia diet is recommended. Eating pureed food and

thickening liquid drinks will prevent aspiration.

9. 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.

b. The criteria for evaluation (be specific)

c. Note: the IDNT manual has listed indicators and criteria in the Assessment,

monitoring, and evaluation 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 2.1.2 Insert

enteral feeding tube

(3)

Meet energy intake needs Enteral G-tube ending

in duodenum

JQ will consume

2060kcal/day

enterally meeting

his energy needs

ND 3.2.1

Multivitamin/mineral

(3)

Achieve normal mineral

and vitamin serum levels

and correct anemia

Normal albumin,

hematocrit, and

hemoglobin levels

3.5-5g/dl albumin

42-52% hematocrit

14-18g/dl

hemoglobin

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.) (3)

FH 1.2.2.1 amount of food- this will help me evaluate if JQ is meeting his energy requirements

FH 1.2.2.2 types of food- this will help me know his ability to swallow various textures of food

FH 5.1.3 ability to recall nutritional goals- this will help me know if he understood and was

following the dysphagia diet recommended

AD 1.1.2 weight- this indicate JQ’s energy intake since we last met

BD 1.10.1, BD 1.10.2 Hemoglobin and Hematocrit- this will identify nutritional anemia

PD 1.1.1- Overall appearance (ability to communicate)- JQ had difficulty speaking before. His

ability to speak will indicate healing of the esophagus

References for Case Study #1 (Use the format indicated in the Student Handbook)

(1) Pagana KD, Pagana TJ. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th

ed. St.

Louis, MO: Mosby Inc; 2010.

(2) Williams P. Lecture notes. Advance dietetics practice, Brigham Young University,

January 2012.

(3) The American Dietetic Association. International Dietetics and Nutrition Terminology

Reference Manual. 3rd

ed. Chicago, IL: American Dietetic Association; 2011.

(4) American Society for Parenteral and Enteral Nutrition. Aspen Guidelines & Standards.

Available at: www.nutritioncare.org. Accessed February 22, 2012.

(5) Nestle Nutrition. 2010 HealthCare Products Pocket Guide. Nestle HealthCare Nutrition

Inc; 2010.

(6) Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th

ed. St. Louis, MO:

Saunders Inc; 2008.

Case #2 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

.

Section 1. Nutrition Assessment

Food/Nutrition Related History (AKA Dietary)

1. Do you need a diet history on this patient? Why or why not? A diet history would be useful but is not needed. JJ was a healthy young adult before the accident so dietary recommendations are based on the extent of the injury.

2. How can you make a judgment regarding his dietary intake prior to admission? I would make a judgment regarding his dietary intake based on his percent ideal body weight.

Anthropometric Measurements 1. List JQ’s

Ht 185.42cm

Wt 95.5kg

IBW 184lb

%IBW 1.14%

BMI 27.8 overweight

2. How accurate are JJ’s current anthropometrics?

His height was only approximated, not measured so it is not accurate. He was weighed using a

bed scale which is one of the least accurate scales.

Biochemical Data, Medical Tests and Procedures

1. List abnormal lab values if significant explain possible causes for each. If labs are not

significant for cause, put a NA in the possible causes box.

Lab and Value Possible Causes

2.1g/dl Alb Low- inflammation (1)

200mg/dl Glucose High- acute stress response; pheochromocytoma (catecholamine

causes hypeblycemia); acute pancreatitis(1)

31% Hct Low- hemolytic anemia, hemorrhage(1)

10g/dl Hgb Low- hemolytic anemia, hemorrhage(1)

7.0mg/dl prealbumin Low- inflammation(1)

21.4mg/dl CRP High- inflammatory response, tissue necrosis, bacterial infection(1)

133mmol/L Na Low- Hyperglycemia, edema(1)

170mg/dl Trigs High- uncontrolled diabetes(1)

2. Are these lab values accurate tools to use for JJ’s nutritional assessment? Explain

These lab values are accurate tools for assessing JJ’s nutritional assessment because he has

suffered traumatic injury. These values signify that JJ is experiencing metabolic stress and is

in the flow phase. During this phase it is necessary that JJ receive the nutrients to replete his

stores due to the increase in energy expenditure and catabolism. (2)

Nutrition-Focused Physical Findings (AKA Clinical)

1. What clinical signs would you look for to help complete your nutritional assessment?

I would check for edema to assess if JJ’s weight is altered by it. I would also check to see if GI

function was altered.

2. What clinical signs are typical in trauma patients?

Metabolic response (increase in hormones, glucose, fatty acids, insulin, cardiac output, oxygen

consumption, body temperature, catabolism, hypermetabolism), state of stress, edema, fever,

injury, & inflammation. (3)

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 Formula Used Stress Factors

Energy (Kcals) 3003kcal Harris Benedict 1.4

Protein (g/d) 143g/d 1.5g/kg/d

Fluid (ml/d) 3003ml/d 1ml/kcal/d

Weight Used (lb) 210lb (95.5kg)

Use the box below to show your calculations

Energy: 66+ (13.7 * 95.5kg) + (5*185.42cm)- (6.8 *23)= 2145kcal * 1.5 stress factor= 3003kcal

Protein: 95.5kg * 1.5g/kg/d= 143g/d

Fluid: 1ml/kcal * 3003kcal= 3003ml/d

2. Justify the following:

Formula used for energy needs and any activity/stress factors used.

Protein need calculation

Remember to cite sources used for justification; sources should be listed at end of case. (Type

text in box below.)

To estimate calorie needs I used the Harris Benedict equation and multiplied it by a stress factor

of 1.4 because the recommendation for trauma patients is a stress factor from 1.3-1.5. I used

1.7g/kg/d to estimate protein needs because the ASPEN guidelines recommend 1.5-2.0g/kg/d for

trauma patients. I used 1ml/kcal/d to estimate fluid needs as recommended. (4)

Document Nutrition Assessment

From your assessment of this patient, 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 73-75 of IDNT.

Write a brief assessment statement for each term chosen.

o Hint: Sample nutrition assessment documentation statements can be found in the

IDNT (pg 87-198.)

Note: only enter information if it applies to this case. Add additional rows as needed.

Assessment Category

Assessment term and number (5)

Assessment Statement

Food/Nutrition-Related History

Diet order FH 2.1.1 Patient/client prescribed TPN diet.

Anthropometric Measurements

Weight AD 1.1.2 Patient/clinet is 1.14% of IBW. Will reweigh and

check for edema to assess that weight is accurate.

Biochemical Data, Medical Tests, and Procedures

Albumin BD-1.11.1 Patient/client’s albumin is 2.1g/dl which is below

the expected range (3.5-5g/dl) for adults. Will

monitor change at next encounter.

Prealbumin BD-

1.11.2

Patient/client’s prealbumin is 7.0mg/dl which is

below the expected range (15-36mg/dl) for adults.

Will monitor change at next encounter.

CRP BD-1.6.1 Patient/client’s CRP is 21.4mg/dl which is above

the expected range (<1.0mg/dl) for adults. Will

monitor change at next encounter.

Glucose, casual BD

1.5.2

Patient/client’s glucose is 200mg/dl which is above

the expected range (<200mg/dl) for adults. Will

monitor change at next encounter.

Hemoglobin BD

1.10.1

Patient/client’s hemoglobin is 10g/dl which is

below the expected range (14-18g/dl) for adult

males. Will monitor change at next encounter.

Hematocrit BD

1.10.2

Patient/client’s hematocrit is 31% which is below

the expected range (42-52%) for adult males. Will

monitor change at next encounter.

Triglycerides, serum

B 1.7.7

Patient/client’s triglyceride level is 170mg/dl which

is above the expected range 40-160mg/dl) for adult

males. Will monitor change at next encounter.

Nutrition-Focused Physical Findings

Extremities, muscles

and bones PD 1.1.4

Patient/client has multiple fractures and internal

injuries to the GI system.

Client History

Musculoskeletal CH

2.1.10

Patient/client history of minor injuries from other

rodeo accidents.

Occupation CH

3.1.6

Patient/client is a rodeo contestant and has suffered

from minor injuries before.

Section 2. Nutrition Diagnosis

Determine Nutrition Diagnosis/Problem

1. List the problems JJ has in the Intake Domain (if any)

Diagnosis term number (5)

Diagnosis Term

NI 1.2 Increased energy expenditure

NI 5.1 Increased nutrient needs of zinc, vitamin A, vitamin C, and Protein for

healing.

2. List the problems JJ has in the Clinical Domain (if any)

Diagnosis term number (5)

Diagnosis Term

NC 1.4 Altered GI function

NC 1.1 Swallowing difficulty

NC 2.1 Impaired nutrient utilization

3. List the problems JJ has in the Behavioral-Environmental Domain (if any)

Diagnosis term number (5)

Diagnosis Term

NB 2.6 Self-feeding difficulty

Write a Nutrition Diagnosis PES Statement Write a Diagnosis Statement using PES format for two of JJ’s problems:

Diagnosis Term/ Problem

Etiology Signs and/or

Symptoms

Inadequate protein

intake

Related

to Hypermetaolic state

and inflammatory

response

As

evidenced by Low albumin level of

2.1g/dl and nigh CRP

level of 21.4mg/dl

Inability/inadequate

food intake

Related

to Altered

gastrointestinal tract

function

As

evidenced by Exploratory laparoscopy

identifying trauma to GI

tract

Section 3. Nutrition Intervention

Analyze Potential Nutrition Interventions 1. From your nutrition assessment do you think JJ is at nutrition risk? Explain.

JJ is at nutritional risk. He has massive internal injury to his GI tract, preventing him from oral

or enteral feeding. This presents a problem because the gut has beneficial immune factors and

allows him to eat to obtain the nutrients his body needs. JJ will need a TPN which carries risk of

infection. It is not known how extensive the damage to the gut is but JJ will be at an even greater

nutritional risk if parts of the gut cannot be saved.

2. What will be the main challenges in providing nutrition support?

TPN will first be given but infection is a risk. Enteral feeding maybe possible but it may not be

if the gut is damaged past the ileum. The problem with only feeding him TPN is that omega-3 is

not present presenting a risk for essential fatty acid deficiency and not getting the anti-

inflammatory benefits.

3. Is enteral feeding appropriate? Explain.

Enteral feeding is not appropriate because there is extensive injury to the GI system. The GI

system should only be used if it is working and in good condition. Once it heals it can be used

again.

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

Total volume of standard solution (ml/24 hr) 2682ml/24hr

Rate of standard solution (ml/hr) 112ml/hr

Type of lipids used and frequency 10% 2x/wk

Grams Carbohydrate 670.5g

Grams protein 114g

Total Kcals 2893kcal

Non-pro Kcals 2437kcal

Non-pro Kcals (NPC):N ratio (Goal ~150:1) 134:1

% NPC from lipid (Goal <30%) 6.4%

% NPC from CHO 93.6%

Fat Load (goal ≤ 1 gm/kg) .15g/kg

CHO Load (mg/kg/min) 4.9 mg/kg/min

5. Assess the above TPN recommendation for JJ’s needs. Current TPN provides:

% Protein needs 80%

% NPC needs 100%

% total Kcal needs

96%

% free fluid needs 89%

Appropriate NPC:N ratio? Explain.

The closer the ratio is to 150:1, the less stress is caused on the body.

134:1 is fairly close to the standard.

Appropriate fat load? Explain.

Critically ill patients are to have a maximum of 1gm/kg/average per

day and the fat load is below that. ASPEN requires at least 2 500ml

10% lipids a week to prevent essential fatty acid deficiency. (6)

Approprite CHO load? Explain.

CHO load can be from 3-7mg/kg/min but it is best to have it below

5mg/kg/min due to the rate at which glucose oxidizes in the

metabolically stressed. (2, 3)

6. List the advantages and disadvantages of using standard TPN solutions.

Advantages Disadvantages Easy, cheaper, always have on hand at the

hospital

The standard TPN solution makes it hard to

meet both the estimated protein and calorie

needs because the percent of dextrose and

amino acids cannot be changed.

7. List the advantages and disadvantages of using individualized TPN (3-in-one solutions).

Advantages Disadvantages Tailored to the patient; can change the

percent of CHO and protein; don’t have

separate lipids

Must calculate/figure out formula; expensive;

takes time to make

8. List the general complications of TPN.

Mechanical complications, infection and sepsis, metabolic complication, gastrointestinal

complications. (3)

9. List the indications for use of TPN.

Nonfunctional or severely diminished small bowel due to surgery, obstruction, or infarction.

(3)

2-3 feet of functioning small bowel.(3)

Those who are or will become malnourished and don’t have sufficient gastrointestinal

function to restore or maintain optimal nutritional status. (3)

Determine Appropriate Nutrition Interventions

1. Complete the following table

a. Fill in the nutrition prescription

b. Fill in at least two interventions. 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.

Nutrition Prescription:

Dietary recommendation of 112ml/hr standard TPN and two 10% lipids

weekly.

Intervention Goal(s)/Expected Outcome

Intervention # 1 (5)

ND 2.2.1 formula solution (parental

nutrition)

Meet adequate energy needs to

support healing.

Intervention # 2 (5)

ND 3.2.3 (1,2) & ND 3.2.4 (8) Vitamin A &C and zinc will aid in

wound healing to get the GI tract

functioning again.

Section 4. Nutrition Monitoring and Evaluation

1. What lab values and/or other parameters should you use to monitor TPN and indicate

how often you would check them.

Labs or other parameter (3) Frequency of checking (3)

Weight

Serum electrolytes

BUN

Serum calcium

serum glucose

Serum triglycerides

Liver function enzymes

Hemoglobin, hematocrit

Platelets

WBC count

Clinical status

Catheter site

Temperature

I & O

Daily

Daily

3/wk

3/wk

Daily

Weekly

3/wk

Weekly

Weekly

As indicated

Daily

Daily

Daily

Daily

2. What complications could result if excessive carbohydrate is given in TPN?

Excessive carbohydrate can lead to hyperglycemia, hepatic abnormalities, and increased

ventilation need. (3)

3. What are your best monitors to check CHO tolerance?

The best way to check CHO tolerance is to calculate the osmolarity of the parental solution.

Blood glucose levels are another way to monitor CHO tolerance. If CHO is too high and the

patient isn’t producing enough insulin to bring the glucose into the cells blood glucose levels will

be elevated. (3)

4. What complications could result if excessive fat is given in TPN?

High amounts of fat alter prostaglandin metabolism causing proinflammatory and

immunosuppressive effects. (3)

5. What are your best monitors to check for lipid tolerance?

The best way to check for lipid tolerance is by looking at blood triglyceride levels. If excessive

fat is given then inflammation will increase but this can be monitored by looking at CRP levels.

6. 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)?

32g N* 6.25g protein= 200g

7. Using the UUN above calculate the N balance.

(114g/6.25) – (32gm+4g)= -17.76 (2)

8. How would you modify your nutrition support (in general) based on the N balance

calculated above?

I would increase the protein recommendation because JJ is in negative nitrogen balance. I order

a 3 in 1 TPN to make a solution with a higher percent amino acid solution.

9. Would indirect calorimetry be of benefit in assessing this patient?

Indirect calorimetry would be very useful in assessing this patient’s calorie needs. Equations are

only an estimate and may be pretty off since the height is only an approximation and the weight

was taken using a bed scale. (3)

10. What can indirect calorimetry tell you?

Indirect calorimetry tells me the REE by estimating energy production measuring oxygen

consumption and carbon dioxide production. (3)

11. How would you (the dietitian) modify the TPN as JJ is advanced to po feedings?

I would monitor the oral intake and decrease the TPN infusion rate until JJ is receiving at least

75% of his nutrient needs orally. At this point I would recommend TPN be discontinued. When

monitoring JJ’s oral intake I will note his appetite and motivation to eat orally. Once TPN is

discontinued I will continue to monitor JJ’s intake to make sure that his GI tract are functioning

properly and that he is receiving his nutrient needs. (3)

12. How would you monitor tolerance to his oral feedings?

I will monitor his oral tolerance by monitoring how much he eats, measuring gastric residuals,

and asking him how he feels.

13. When would you recommend fully discontinuing a TPN feeding once an oral diet was

established?

TPN should be discontinued one 75% of nutrient needs are met orally. (3)

14. 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.

b. The criteria for evaluation (be specific)

c. Note: the IDNT manual has listed indicators and criteria in the Assessment,

monitoring, and evaluation 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 2.2.1

formula solution

(parental

nutrition)

Meet adequate energy

needs to support healing

Peripheral parental

access

JJ will consume

approximately

2900kcal, 96% of

the recommended

level 3000kcal.

ND 3.2.3 (1,2) &

ND 3.2.4 (8)

Vitamin A & C and zinc

will aid in wound healing

to get the GI tract

functioning again.

900mg/d vitamin A

90mg/d vitamin C

11mg/d zinc

900mg/d vitamin A,

90mg/d vitamin C,

and

11mg/d zinc intake.

References for Case Study #2 (Use the format indicated in the Student Handbook)

(1) Pagana KD, Pagana TJ. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th

ed. St.

Louis, MO: Mosby Inc; 2010.

(2) Williams P. Lecture notes. Advance dietetics practice, Brigham Young University,

January 2012.

(3) Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th

ed. St. Louis, MO:

Saunders Inc; 2008.

(4) Intermountain Health Care. Intermountain Urban Southern Region Adult Patient Care

Nutrition Guidelines. March 2010.

(5) The American Dietetic Association. International Dietetics and Nutrition Terminology

Reference Manual. 3rd

ed. Chicago, IL: American Dietetic Association; 2011.

(6) American Society for Parenteral and Enteral Nutrition. Aspen Guidelines & Standards.

Available at: www.nutritioncare.org. Accessed February 22, 2012.