Medical Nutrition Therapy Clinical Experience Kathleen Dorsch FND

Medical Nutrition Therapy Clinical Experience Kathleen Dorsch FND 431 -900 Spring 2011

Patient Information Patient PD is a 53 YO female admitted with hypoxia, respiratory failure, septic shock, and community-acquired pneumonia Patient sedated and intubated NPO diet order initiated nutrition assessment

Nutrition Assessment Ht: 165 cm; Wt: 95 kg; IBW: 56. 7 kg; BMI: 35 Labs: WBC 3. 2, Na 134, K 3. 5, Glu 133, albumin 2. 9, prealbumin 8. 3 Meds: Propofol, Bactrim, Levaquine, Zosyn, Lovenox, sliding scale insulin EEN: 25 kcal x 56. 7 kg IBW=1, 417 kcal Protein: 2 g/kg x 56. 7 IBW=113 g

Nutrition Diagnosis Inadequate oral food/beverage intake related to intubation and ventilator as evidenced by NPO diet order.

Nutrition Intervention Nasogastric tube for enteral feeding PD needs ~1, 500 kcal/day Propofol is lipid-soluble and contributes 1. 1 kcal/ml. PD was given 40 ml/day, which contributed 1, 056 kcal Patient received 500 ml of 1. 0 kcal high protein formula and 2 Beneprotein packets/5 times a day Total kcal=1, 556; total protein=91. 25 Goal rate: 25 ml/hr; tube flushed with 30 ml of water every 6 hrs

Nutrition Monitoring Patient tolerance and s/s of nausea, vomiting, diarrhea (daily) Gastric residual volume every 6 hours (if >300 ml w/o n/v/d, return residuals to stomach and reduce flow to lower rate) Serum electrolytes, BUN, creatinine twice weekly Glucose checked 2 times a day Monitor Propofol use and adjust tube feeding order as needed

Nutrition Monitoring/Evaluation After several days, PD was able to be extubated and Propofol discontinued Needs recalculated to 1, 700 ml of high protein enteral formula and Beneprotein discontinued Total kcal=1, 700; total protein=106 g Labs recorded after extubation: BUN 20 mg/dl Creatinine 0. 5 mg/dl Glu 121 mg/dl Na 143 m. Eq/L K 3. 8 m. Eq/L Albumin 2. 6 g/dl Phos 3. 8 mg/dl

Nutrition Evaluation PD was evaluated by the speech therapist after being extubated Oral feedings resumed Patient released on February 1, 2011

ADIME Chart Note Nutrition Assessment Pt is 53 YO female admitted w/ hypoxia, respiratory failure, septic shock, communityacquired pnuemonia Ht: 165 cm; Wt: 95 kg; IBW: 57 kg; BMI: 35 Labs noted: WBC 3. 2, Na 134, K 3. 5, Glu 133, albumin 2. 9, prealbumin 8. 3 Medications: Propofol, Bactrim, Levaquine, Zosyn, Lovenox, sliding-scale insulin EEN: 25 kcal x 56. 7 kg IBW=1, 417 calories and 2 g/kg x 56. 7 kg IBW=113 g protein Current diet is NPO, intubation and ventilator Nutrition Diagnosis Inadequate oral food/beverage intake related to intubation and ventilator as evidenced by NPO diet order Nutrition Intervention Tube feeding initiated Goal rate: 500 ml Promote high protein formula without fiber Delivered 25 ml/hr over 20 hours; flush tube with 30 ml every 6 hours 2 packets Beneprotein 5 times/day Total kcal= 1, 056 kcal/day from Propofol + 500 kcal enteral formula=1, 556 kcal total Nutrition Monitoring Monitor pt tolerance & s/s nausea, vomiting, distention Monitor gastric residual volume every 6 hours Monitor serum electrolytes, BUN, creatinine, glucose Monitor Propofol use and adjust TF as needed to provide adequate calories and protein