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Name: Toni Brown 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.

• eNCPT (aka IDNT) Manual • Any textbooks from NDFS courses • Academy Evidence Analysis Library (online) • Academy Practice and Position papers • 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 has no food allergies.

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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) No, he has low food and beverage intake

Anthropometric Measurements 1. List JQ’s Ht (in & cm) 70 in, 177.8 cm

Wt (lb & kg) 151 lb, 68.6 kg

Usual Wt (lb & kg) 170 lb, 77.3 kg

%IBW 91%

BMI 21.2 (current) or 23.9 (usual)

2. Evaluate JQ’s current wt and any significant wt changes. (Type text box below) JQ’s current weight is not significantly alarming. He is still 91% of his ideal body weight. What is concerning is that he has had 11% wt loss in the last 3 months and with his recent surgery and NPO diet order, he is unlikely to maintain good nutrition status.

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.

Lab and Value Possible Causes (1) Hct 32% (42-52) d.t. recent surgery

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Hgb 11g/dl (13.5-17.5)

d.t. recent surgery

Albumin 2.7 g/dl (3.5-5)

d.t. recent surgery and low protein intake in last month

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.) Cancerous mass in esophagus removed by surgery. Before his surgery he was NPO and is not able to take oral po for several weeks. His surgery prevents him from eating now and damage to the esophagus may hinder future feedings.

Client History 1. List and explain any pertinent nutrition-related concerns found in the client history He had difficulty swallowing, lethargy, unintentional weight loss, and paleness. This is related to the 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) 2176 Harris-Benedict (2) 1.4 (2) Protein (g/d) 100.5 g 1.3 g/kg (3) Fluid (ml/d) 2173 1 ml/kcal (3)

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Weight Used (lb and Kg)

170 lb, 77.3 kg

Use the box below to show your calculations Resting metabolic -ate (RMR) = 66.47 + 13.75(W) + 5(H) – 6.76(A) = 66.47 + 13.75(77.3) + 5(177.8) – 6.76(69) = 1552 kcals x 1.4 = 2173 I estimated 1.4 g/kg protein to provide protein due to stress from surgery (2)

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.)

I used the Harris-Benedict equation because it was recommended for patients with head-neck cancer (2). The Harris-Benedict equation may underpredict energy needs for this population, so I used his usuaal weight to increase the calories given and included the stress factor of 1.4 to increase the amount of calories given. He will need additional protein to accommodate stress, but his protein needs will probably not be extremely high. I estimated 1.4 g/kg protein because of stress. Increasing protein to 2 g/kg/day causes dehydration in older adults, so I didn’t estimate high.

eNCPT (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).

• 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.

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Assessment Category

Assessment term and number (4) Assessment Statement (4)

Food/Nutrition-Related History

Energy Intake FH1.1.1 Decreased energy intake

Anthropometric Measurements

Weight Change AD 1.1.4 11% wt. loss in last 3 mo.

Biochemical Data, Medical Tests, and Procedures

Hemoglobin BD 1.10.1 Hemoglobin 11 g/dl (low) Hematocrt BD1.10.2 Hematocrit 32% (low) Albumin BD 1.11.1 2.7 g/dl (low)

Nutrition-Focused Physical Findings

Digestive System P.D 1.1.5 Difficulty swallowing due to tumor/surgery

Client History Hematology/Oncology CH 2.1.7 Tumor in esophagus Surgical Treatment CH 2.2.2 Surgery to remove esophageal tumor

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 (4) Domain

(Intake, Clinical, Behavioral/Environmental) (4)

NI 2.1 Inadequate Oral Intake Intake NI 5.2 Malnutrition Intake NC 1.1 Difficulty Swallowing Clinical NC 1.4 Altered GI Function Clinical NC 3.2 Unintended Weight Loss Clinical

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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 oral intake Related to

Inability to consume sufficient energy

As evidenced by

Weight loss

Difficulty swallowing Related to

Esophageal surgery As evidenced by

Avoidance of foods

Section 3. Nutrition Intervention Analyze Potential Nutrition Interventions

1. Is TPN appropriate for JQ? Explain. (Type text in box below.) Yes because he will not be able to take anything oral po for several weeks (longer than 7 days w/o food) (1)

2. Is PPN appropriate? Explain. (Type text in box below.) Yes if TPN is not tolerated (2)

3. Is enteral feeding appropriate? Explain. (Type text in box below.) Yes because his gut still works. (3)

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

appropriate.

Formula Name Justification for Use TwoCal HN (Abbott) 2 kcal/ml for low-volume feedings, protein to support wound

healing, suitable for lactose intolerance Pivot 1.5 Cal (Abbott) High-calorie, very high protein for stressed surgical, head and neck

cancer patients, suitable for lactose intolerance

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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: 2173 kcals, 100.5 g protein, 2173 ml fluid

Formula #1 Formula #2 Formula Name TwoCal HN Pivot 1.5 Cal Goal rate ml/hr 45 ml/hr 60 ml/hr Total ml/day 1087 ml/day 1449 ml/day Total Kcals 2173 kcals 2173 kcals Non-Pro Kcal 1837 NPC 1661 NPC Pro g and Kcals 90.8 g, 363 kcals 135.9 g, 544 kcals CHO g and Kcals 237.5 g, 951 kcals 249.8 g, 999 kcals Fat g and Kcals 98.4 g, 886 kcals 73.6 g, 662 kcals Osmolality 725 mOsm/kg H2O 595 mOsm/kg H20 Total Fluid 1087 ml 1449 ml Free fluid (ml) 760.9 g 1099.8 g Additional fluid need (ml) 1087 ml 724 ml Comment on adequacy of your formula recommendation(s) in meeting estimated nutrient needs: Both solutions provide adequate calories, but Pivot 1.5 Cal requires more formula which decreases acceptability. Also, Pivot provides a lot more protein than his calculated needs. TwoCal HN fits JQ’s needs better.

6. Where the tube should be placed? Why? (Type text in box below.) Percutaneously in the stomach (PEG). This method is non-surgical with minimum wound complications. It gives easy access, and will avoid the irritated esophagus. JQ is predicted to not eat for several weeks, so it would be appropriate to insert a PEG (5).

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

Gastrostomy tube (5). 18-28 F (3)

8. What are the general guidelines regarding the use of the feeding tube for medications. (Type text in box below.)

Generally, feeding tubes should not be used for medications (3)

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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.) Soluble and insoluble fiber can be administered with the tube feed. Usually adding Metamucil to a feeding tube is unnecessary and expensive. However, it may be beneficial if the patient is experiences diarrhea. (3)

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 (3) Suggested Corrective Measures (3) Nausea Vomiting

Tube feed cold Keep at room temperature EN administered too quickly Slow down/antibiotics High fat in tube feed Decrease fat Look/smell tube feed Covered container

Diarrhea Antibiotics Probiotics Bacteria overgrowth TPN Steatorrhea Change osmolality

Constipation Milk-base Change formula Low fiber Increase fiber Low water Increase water

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 eNCPT (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.

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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:

TwoCal HN at 45 ml/hr to provide 2173 kcals, 98 g protein, 237.5 g CHO, 98.4 g fat, 187 ml fluid

Intervention (4) Goal(s)/Expected Outcome (4) Intervention # 1

Insert Enteral feeding tube ND 2.1.7 Adequate kcals to promote healings

Intervention # 2

Collaboration with other nutrition professionals RC 1.3

Determine method of enteral feeding

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.) N/V, coughing, aspirating, sneezing, signs of overfeeding (3)

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.)

Monitor weight gain, fluids in/out, nutrient deficiencies. Evaluate Hct, Hgb, Alb to see if they’ve changed. (3)

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3. Is JQ at risk for refeeding syndrome? Explain. (Type text in box below.) Yes because he had a significant decrease in intake for a brief time. Administering a high calorie diet quickly could cause intolerance. (2)

4. What indicators of refeeding syndrome will you watch for? (Type text in box below.) Edema, low electrolytes, aspirations (2)

5. How can refeeding syndrome be avoided? (Type text in box below.) Feeding slowly. Start with low-calorie formula and work up (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 from above)

Indicator(s)

Criteria for evaluation

Insert Enteral feeding tube ND 2.1.7

Start enteral nutrition Adequate calories 2173 kcals

Collaboration with other nutrition professionals RC 1.3

Determine method of enteral feeding

Results of discussion Chosen method of feeding

Section 5. Complete your initial chart note

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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.

History: 69 yr-old male, military, married, three kids Assessment: Food/Nutrition-Related History Outcomes: Swallowing difficulties, eating three meals/d with soft moist foods but poor intake past 2 wks, unable to take po post surgery Anthropometric Measurement Outcomes: Ht. 70 in, 177.8 cm; Wt. 170 lbs, 77.3 kg; BMI 21.2 kg/m2; 91% IBW Biochemical Data, Medical Tests, and Procedure Outcomes: Hgb. low at 11 g/dl, Hct. low at 32%; Alb. low at 2.7 g/dl; Ca low at 7.6 mg/dl Nutrition-Focused Physical Finding Outcomes: damage to esophagus due to surgery to remove tumor Comparative Standards: 2173 kcals, 100.5 g protein, 2173 ml fluid Diagnosis: Inadequate oral intake related to inability to consume sufficient energy, as evidenced by 11% weight loss Difficulty swallowing related to esophageal surgery, as evidenced by avoidance of foods Intervention: Insert Enteral feeding tube ND 2.1.7 Collaboration with other nutrition professionals RC 1.3 Monitor and Evaluate:

1) Start enteral nutrition: evaluate adequate calories 2) Determine method of enteral feeding: Results of discussion

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.)

JQ can start supplementing tube feed when he thinks he can tolerate it. He will continue eating

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orally and receiving tube feed until 75% of intake comes orally. Then he can discontinue tube feed. He could eat a little at each meal. The tube feed could be shut off a few hours before breakfast to stimulate hunger. He should eat soft/pureed foods until he can tolerate solid foods (3,5).

2. During the transition period, what information would you monitor and why? (Type text in box below.)

Information Monitored (3) Why (3) Weight gain/loss Monitor adequacy of diet Nutrient deficiencies Prevent malnutrition Fluid balance Electrolyte balance

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: aspiration . Solution: pureed foods, elevated bed (2)

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.)

Total energy intake FH 1.1.1.1 Food intake FH 1.2.2 Weight change AD 1.1.4 Nutritional anemia profile BD 1.10 Protein profile BD 1.11 Digestive system (esophagus) PD 1.1.5 (4)

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

1. Pagana KB, Pagan TJ. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th ed. St. Louis, MO: Elsevier; 2010.

2. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at https://www.nutritioncaremanual.org/. Accessed February 9, 2016.

3. Williams P. Lecture notes. Advanced Dietetics Practice, Brigham Young University, January 6, 2016.

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4. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago; 2013.

5. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012.

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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. He was healthy prior to his accident. He is unlikely to have significant deficiencies. Nutrition will relate to the current injuries to the GI. (1)

Anthropometric Measurements 1. List JQ’s Ht (in & cm) 73 in, 185.4 cm

Wt (lb and Kg) 210 lbs, 95.5 kg

IBW (lb and Kg) 184 lbs, 83.6 kg

%IBW 114%

BMI (kg/m2) 27.8 kg/m2

2. How accurate are JJ’s current anthropometrics? They are not accurate. The height was approximated (not even measured from laying down) and the weight was taken from the bed scale. Additionally, he may be experiencing edema from stress (1).

Biochemical Data, Medical Tests and Procedures

1. List abnormal lab values explain possible causes for each. Lab and Value Possible Causes (2) Alb 2.1 g/dl Stress response causing low albumin

Glucose 200 mg/dl High due to stress response

Hct 31% Low due to edema and pooling in injuries

Hgb 10 g/dl Low due to edema and blood in injuries

Prealb 7 mg/dl Low

CRP 21.4 mg/dl High due to stress response

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Triglycerides 170 mg/dl High due to broken bones

2. Are these lab values accurate tools to use to determine JJ’s nutritional status? Explain No. During stress, albumin and prealbumin do not give an accurate picture of the nutritional status of the client. Glucose levels, however, is indicative of a problem (hyperglycemia—probably from stress) (1).

Nutrition-Focused Physical Findings (AKA Clinical)

1. What clinical signs would you look for to help complete your nutritional assessment? Edema, digestive system (lower GI), extremities, muscles and bones (3)

2. What clinical signs are typical in trauma patients? Edema, hyperglycemia, low protein, dehydration (1,4)

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) 2506 kcals Mifflin-St Jeor (5) 1.25 (5) Protein (g/d) 1.6 g/kg 152.8 g 1.2-2 g/kg/day (4) Fluid (ml/d) 2506 ml 1 ml/kg (1) Weight Used (lb & kg)

210 lbs, 95.5 kg

Use the box below to show your calculations RMR = (9.99 x wt) + (6.25 x ht) – (4.92 x age) + 5 = (9.99 x 95.5) + (6.25 x 185.4) – (4.92 x 23) + 5 = 2005 x 1.25 = 2506

2. Justify the following: • Equation used for energy needs and any activity/stress factors used. • Protein need calculation

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• Weight used Remember to cite sources used for justification; sources should be listed at end of case. (Type text in box below.)

Mifflin-St Jeor is a fairly accurate prediction of calorie needs for critically ill, non-obese patients. The stress factor was designated by the NCM. Protein needs were based on the range 1.2-2 g/kg (4). Since he is stressed and larger build, we estimated on the higher end of protein needs. We used the bed-scale weight because he is unconscious and cannot give a better estimate.

eNCPT (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).

• 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

Amount of Food FH 1.2.2.1 Adequate before admit General, Healthful Diet FH 2.1.1.1 Adequate before admit

Anthropometric Measurements

Frame Size AD 1.1.3 Large frame size Body Mass Index AD 1.1.5 BMI overweight status

Biochemical Data, Medical Tests, and Procedures

Hct BD 1.10.2, Hgb BD 1.10.1 Low: 31%, 10 g/dl Alb BD 1.11.1, Prealb BD 1.11.2 Low: 2.1 g/dl, 7 mg/dl Trigs, serum BD 1.7.7, Gluc, casual BD 1.5.2

High: 170 mg/dl, 200 mg/dl

C-Reactive Protein BD 1.6.1 High: 21.4 mg/dl

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Nutrition-Focused Physical Findings

Extremities, muscles, and bones PD1.1.4 Injured, fractures Digestive System PD 1.1.5 Lower GI injuries

Client History Occupation CH 3.1.6 Bull-riding History of recent crisis CH 3.1.8 Bull-riding accident

Section 2. Nutrition Diagnosis

Determine Nutrition Diagnosis/Problem

1. Use the eNCPT book to list problems (nutrition diagnosis) JQ has. Add rows if necessary. Diagnosis

term number

Diagnosis Term Domain

(Intake, Clinical, Behavioral/Environmental)

NI 2.1 Inadequate Oral Intake Intake NI 3.1 Inadequate Fluid Intake Intake NI 5.1 Increased Nutrient Needs Intake NC 1.4 Altered GI Function Clinical NC 3.3 Overweight/Obesity Clinical NB1.4 Self-monitoring Deficit Behavioral/Environmental

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 oral intake Related to

Damaged GI tract d/t trauma

As evidenced by

DI damage show by laproscopy

Increased nutrient needs

Related to

Hypermetabolism d/t trauma

As evidenced by

Internal injuries

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Section 3. Nutrition Intervention

Analyze Potential Nutrition Interventions

1. From your nutrition assessment do you think JJ is at nutrition risk? Explain. Yes. Although, subsequent to admit he was eating a healthful diet, his current status puts him at risk for future deficiencies.

2. What will be the main challenges in providing sufficient nutrition? We don’t know the extent of the damage in the GI, so it is difficult to place a tube. We also don’t have accurate measurements so the calculations will be approximate. (4)

3. Is enteral feeding appropriate? Explain. No because we don’t know how well the GI functions. (4)

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: 2506 kcals, 152.8 g, 2506 ml Total volume of standard solution (ml/24 hr)

1800 ml

Rate of standard solution (ml/hr)

75 ml/hr

Type of lipids used and frequency

10% 4x/wk

Carbohydrate grams and Kcals 450 g, 1530 kcals Protein grams and Kcals 153 g, 612 kcals Fat grams and Kcals 50 g, 550 kcals Total Kcals 2456 kcals Non-pro Kcals 1844 kcals Non-pro Kcals (NPC):N ratio (Goal ~150:1)

% NPC Calories from lipid (Goal <30%)

17%

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% NPC from CHO (goal 70-80%) 82% Fat Load (goal ≤ 1 gm/kg) 0.52 CHO Load (mg/kg/min) 3.3

Show calculations below. 153/0.085 = 1800 ml 153 g x 4 kcal/g = 612 kcals 900 ml x .5 = 450 g CHO 450 g x 3.4 kcals/g = 1530 kcals CHO 612 + 1530 = 2142 kcals 2506 – 2142 = 364 kcals from fat 10% 550 kcals 364 x 7 = 2548/550 = 4.6 bags 4 bags (4 bags x 550 kcals)/7 = 314 kcals/day 1530 + 314 = 1844 NPC 314/1844 = 17% lipid 450/1844 = 82% 50/95.5 = 0.52 fat load (450 x 1000)/95.5/1440 = 3.3 CHO load

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

% Protein needs 100% % NPC needs 97% % total Kcal needs

98%

% free fluid needs 72% Appropriate NPC:N ratio? Explain.

Appropriate fat load? Explain.

Yes because it is below 1 g/kg

Appropriate CHO load? Explain.

Yes because it is between 3-7 mg/g/min

Is there something you can do to more closely meet pt needs when only standard TPN is available?

You could use different concentrations of the standard formula (D40, D30, 10% protein)

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6. List the advantages and disadvantages of using standard TPN solutions. Advantages (1) Disadvantages (1)

Cheaper Prepared for immediate use Simple calculations

Inflexible

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

Advantages (1) Disadvantages (1) Flexible Less contamination Continuous lipid

Waste Expensive Calculations

8. List the general complications of TPN. Contamination, calculations, patient tolerance (1)

9. List the indications for use of TPN. (e.g. when is TPN appropriate) Pt won’t be fed for 7 days, can’t tolerate tube feed, GI doesn’t work (1)

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

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 eNCPT (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 goal that the two interventions will address or you may have two separate goals.

Nutrition Prescription:

Standard solution of TPN (50% Dextrose, 8.5% protein) for 1844 kcals and 153 g protein, 10% lipid solution 4 times/wk for 314 kcals/day, for a total of 2456 kcals/day

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Intervention (3) Goal(s)/Expected Outcome (3) Intervention # 1

Collaboration with other nutrition professionals RC 1.3

Determine method of TPN

Intervention # 2

TPN composition ND 2.2.1 Calculate composition

Section 4. Nutrition Monitoring and Evaluation

1. What should you use to monitor TPN effectiveness and recommendation?

TPN follows calculations, weight maintenance, nutrient deficiencies (5)

2. What complications could result if excessive carbohydrate is given in TPN? Added stress to body, hyperglycemia (1)

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

Respiratory Quotient is the best monitor (RQ = 1) (1)

4. What complications could result if excessive fat is given in TPN? High triglycerides which leads to liver problems (1)

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

Lipid profiles are the best indicators (1)

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 eNCPT (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

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Collaboration with other nutrition professionals RC 1.3

Determine method of TPN Results of discussion Chosen method

TPN composition ND 2.2.1

Calculate composition Results of calculations 2506 kcals, 153 g protein

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.

History: 23 year-old male, no medical history Assessment: Food/Nutrition-Related History Outcomes: Anthropometric Measurement Outcomes: Ht. 73 in, 185.4 cm; Wt. 210 lbs, 95.5 kg; BMI 27; 114% IBW Biochemical Data, Medical Tests, and Procedure Outcomes: Hgb. low at 10 g/dl, Hct. low at 31%; Alb. low at 2.1 g/dl; CRP high at 21 mg/dl; glucose high at 200 mg/dl Nutrition-Focused Physical Finding Outcomes: internal bleeding, possible fractures Comparative Standards: 2506 kcals, 153 g protein, 2506 ml fluid Diagnosis: Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by no food intake Increased nutrient needs related to compromise of organs related to GI function as evidenced by internal injuries Intervention: Collaboration with other nutrition professionals RC 1.3 TPN composition ND 2.2.1 Monitor and Evaluate: Goals:

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1) Determine method of TPN 2) Calculate composition

Indicators: 1) Results of discussion 2) Results of calculations

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

N loss = UUN + 4 = 32 + 4 = 36 g N 36 g N x 6.25 g pro = 225 g protein (1)

2. Using the UUN above calculate the N balance. Show work

N balance = pro intake/6.25 – (UUN + 4 ) = 153/6.25 – (36) = -12 (1)

3. How would you modify your nutrition support (in general) based on the N balance calculated above?

He needs a greater amount of protein. The standard solution could have a greater concentration of protein or he needs supplemental protein. (4)

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

Yes because we don’t know his RMR. His height/weight is inadequate (1)

5. What can indirect calorimetry tell you? RMR, determines energy needs (1)

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?

Turn off TPN early in the morning so he feels hungry (Don’t decrease until JJ is getting 1/3 kcals po.) (1)

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

Nausea/vomiting, pain, diarrhea, constipation, GI distress, aspirations (4)

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

1. Williams P. Lecture notes. Advanced Dietetics Practice, Brigham Young University,

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January 6, 2016. 2. Pagana KB, Pagan TJ. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th ed. St.

Louis, MO: Elsevier; 2010. 3. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology

(IDNT) Reference Manual. 4th ed. Chicago; 2013. 4. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care

Process. 13th ed. St. Louis, MO: Elsevier; 2012. 5. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at

https://www.nutritioncaremanual.org/. Accessed February 9, 2016.