Nutrition Rounds Enteral Nutrition Rotation By Hannah Griswold

Transcription

1 Rounds Enteral Rotation By Hannah Griswold Introduction RJ is a 57 year old male with history of seizure disorder and adenocarcinoma of the duodenal bulb complicated by duodenal perforation status post 4/16/15 exploratory laparoscopy, pancreaticoduodenectomy, and feeding Jtube placement for duodenal bulb adenocarcinoma admitted to the SICU for post-operation monitoring. Hospital day 4/17-4/19 1. Baseline anthropometrics Ht: 5 11 (180 cm) Wt: 205 lb (93 kg) IBW: 78 kg IBW%: 121% ABW: 82 kg Weight History: Per chart review, lost 14 pounds in the past year (not significant) Physical assessment & SGA score: No fat or muscle wasting or edema evident and skin integrity was intact with no pressure wounds SGA score A 2. Home Medications & Meds on admit: HOME Meds: - Seizure medications: KEPPRA, VIMPAT, and TEGRETOL ADMIT Meds: - dextrose 5 % and 0.45% NS IV - morphine 30 mg/30 ml, IV - ketorolac (TORADOL), Q6H o Na 141 o K 4.2 o CL 111 o CO2 24 o BUN 9 o CREAT 0.70 o GLU 129 o CA 7.7 o PO4 2.9 o MG 1.8 1

2 1. Baseline anthropometrics Ht: 5 11 (180 cm) Wt: 205 lb (93 kg) IBW: 78 kg IBW%: 121% ABW: 82 kg Weight History: Per chart review, lost 14 pounds in the past year (not significant) Physical assessment & SGA score: No fat or muscle wasting or edema evident and skin integrity was intact with no pressure wounds SGA score A 2. Home Medications & Meds on admit: HOME Meds: - Seizure medications: KEPPRA, VIMPAT, and TEGRETOL ADMIT Meds: - dextrose 5 % and 0.45% NS IV - morphine 30 mg/30 ml, IV - ketorolac (TORADOL), Q6H o Na 141 o K 4.2 o CL 111 o CO2 24 o BUN 9 o CREAT 0.70 o GLU 129 o CA 7.7 o PO4 2.9 o MG Food/ History o General diet prior to admission, no diet recall collected o No known food intolerances/allergies o Diet Order: NPO 5. Social history o Has social support (from significant other and son), lives at home with family, no functional status change, and is independent in food procurement 2

3 Monitoring and Evaluation Impression Patient to tolerate trickle tube feeding within 24 hours. Patient is at increased nutrition risk secondary to need for TF to provide nutrition support and anticipate will consume adequate needs when advanced to PO diet. Hospital Day 4/20 1. History: Current Diet Order: NPO Current Enteral Order: 60 ml/hr x 24 hours [On hold for Upper GI this morning] 2. Current Meds - dextrose 5 % and 0.45% NS IV - morphine 30 mg/30 ml, IV - ketorolac (TORADOL), Q6H Diagnosis/PES o Na 139 o K 3.5 o CL 108 o CO2 24 o BUN 6 o CREAT 0.62 o GLU 109 o CA 8.2 o PO4 3.0 o MG 1.8 o Upper GI Altered GI function related to recent GI surgery as evidenced by pancreaticoduodenectomy. 3

4 Intervention Oral : NPO Enteral : Recommend starting feeds of 60 ml/hr over 24 hours via Jtube - if continue Promote, goal =85 ml/hr Electrolytes: Monitor lab daily and replete K, Mg, Phos as needed WNL Hydration: Recommend change D5.45 saline solution to nondextrose containing solution Monitoring and Evaluation Impression GI: Monitor BM for potential constipation with narcotic use, and/or post-op ileus (no signs of) Monitor tolerance to nutrition, GI status, intake/output, labs Goal: Patient will tolerate goal tube feeding infusion within 24 hours At nutritional risk secondary to need for TF to provide nutrition support post-operatively. Anticipate will tolerate goal feeds, eventually meet needs without TF once cleared for diet advancement. Hospital Day 4/21 1. History: Current Diet Order: Clear Liquid Diet + ensure berry supplements Current Enteral Order: 60 ml/hr x 24 hours [Stopped TF due to suspected chyle leak with milk and TG output in JP drain] 2. Current Meds - ketorolac (TORADOL), Q6H o Na 140 o K 3.6 o CL 107 o CO2 25 o BUN 8 o CREAT 0.67 o GLU 122 4

5 o CA 8.4 o PO4 3.6 o MG 2.0 o TG 279 JP output with milky, cloudy appearance Altered GI function related to recent GI surgery as evidenced by Diagnosis/PES pancreaticoduodenectomy. Intervention Oral and Enteral : o Monitor JP triglyceride output and milky appearance o Monitor ability to tolerate tube feedings or advance diet -- if cleared for Jtube advancement, would start portagen to ensure adequate protein delivery Electrolytes: Monitor lab daily and replete K, Mg, Phos as needed WNL Hydration: Receiving through clear liquid diet and ensure supplements, no IVFs infusing GI: Monitor BM and initiate bowel regimen PRN Monitoring and Evaluation Impression Monitor tolerance to nutrition, GI status, intake/output, labs Goal: Patient will tolerate goal tube feeding infusion or diet advancement within 48 hours Tolerating clears, though not meeting needs. Anticipate will tolerate goal feeds or eventually meet needs without TF once cleared for diet advancement. Hospital Day 4/22 1. History: Current Diet Order: Clear Liquid Diet + ensure berry supplements Current Enteral Order: 85 ml/hr x 24 hours 1. Current Meds 2. Biochemical Data, Medical Tests and Procedures o Na 139 o K 3.9 o CL 107 o CO2 25 5

6 1. History: Current Diet Order: Clear Liquid Diet + ensure berry supplements Current Enteral Order: 85 ml/hr x 24 hours 1. Current Meds 2. Biochemical Data, Medical Tests and Procedures o Na 139 o K 3.9 o CL 107 o CO2 25 o BUN 7 o CREAT 0.67 o GLU 106 o CA 8.8 o PO4 4.3 o MG 1.9 o TG 908 JP output: serosanguinous (clear, watery appearance) Diagnosis/PES Altered GI function related to recent GI surgery as evidenced by pancreaticoduodenectomy. Intervention Oral : Continue to offer clear liquid diet, encouraged ensure clear intake --- possible diet advancement tomorrow (fat free foods) in addition to TFs Enteral : Start 20 ml/hr and advance by 20 ml/hr every 4 hours until reach goal rate of 85 ml/hr o Goal Tube Feeds Provide: Total kcal: 2052 kcal Kcal/kg: 25 kcal/kg Total Protein (gms): 73 gm gm Protein/kg: 0.9 gm ml Free Water From Formula: 1714 ml o Monitor JP triglyceride output and milky appearance and ability to tolerate tube feedings Electrolytes: Monitor lab daily and replete K, Mg, Phos as needed WNL 6

7 Hospital Day 4/23 1. History: Current Diet Order: Clear Liquid Diet + ensure berry supplements Current Enteral Order: 85 ml/hr x 24 hours 2. Current Meds o Na 139 o K 3.5 o CL 105 o CO2 24 o BUN 9 o CREAT 0.72 o GLU 140 o CA 8.9 o PO4 4.0 o MG 2.1 Altered GI function related to recent GI surgery as evidenced by Diagnosis/PES pancreaticoduodenectomy. Intervention Oral : Continue to offer clear liquid diet, encouraged ensure clear intake --- possible diet advancement (fat free foods) in addition to TFs - though unlikely to meet needs orally with this diet secondary to limited options Enteral : o Monitor JP triglyceride output and appearance - improving without milky output o Continue 85 ml/hr x 24 hours Electrolytes: Monitor lab daily and replete K, Mg, Phos as needed WNL Hydration: Receiving through clear liquid diet and ensure supplements, no IVFs infusing GI: Monitor BM and initiate bowel regimen PRN 7

8 Monitoring and Evaluation Impression Monitor tolerance to nutrition, GI status, intake/output, labs Goal: Patient will tolerate goal tube feeding infusion or diet advancement Tolerating clear liquids, however TF supplementation needed to meet nutritional needs. Anticipate will eventually meet needs without TF once cleared for diet full advancement upon resolution of chyle leak. 8