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.