CLINICAL WORKSHEET #2 Nutrition Support In: Extended Care Facilities, HIV Disease, and Thermal Injury

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1 Name: Danielle Reschke BRIGHAM YOUNG UNIVERSITY NDFS 466 Clinical Worksheet #2 CLINICAL WORKSHEET #2 Nutrition Support In: Extended Care Facilities, HIV Disease, and Thermal Injury 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. 3. To advance assessment and diagnosis skills. General Guidelines 1. Complete two of the 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) b. Name file LastName_FirstName_Worksheet_2 For example if my name was John Doe the file would be names Doe_John_Worksheet_2 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) IDNT Manual Any textbooks from NDFS courses ADA Evidence Analysis Library (online) and noted journal articles 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. Choose TWO (2) of the three case studies to complete 1

2 Case #1: Enteral Feedings at an Extended Care Facility with Decubitus Ulcers Hospital Admission Social: DH; 86 year old female resides at Shady Oaks ECF ECF Feeds: Intermittent tube feeding; 1 can Osmolite (237 ml) QID (4 X day) through a PEG. Admitting diagnosis: fever of unknown origin and acute unresponsiveness. Other: Stage III decubitus ulcers in the sacral area aggravated by bouts of diarrhea and fecal incontinence. Ht: 5'0" Wt: 89 lb Labs: Albumin of 2.8 gm/dl. Section 1: Nutrition Assessment Complete a Nutrition Assessment using the information available. Use the IDNT book as a guide for indicators to assess and document. While the first worksheet prompted you on areas to assess, you are to now use your judgment in making a Nutrition Assessment. You will be scored on the appropriateness of assessment areas and your assessment of those areas. To help you get the assessment started completed the following few questions 1. Calculate DH s tube feeding prescription per day: TF Order Kcals Protein g Free fluid ml or cc Vitamin and mineral intake in general. i.e. what percent of vitamin/minerals ~100% of most; 50-60% of most etc. 948 ml/day 1000 kcal 42 g 796 ml % of most 2. Calculate comparative standards. Show equation calculations and justify equations, weights, and factors used to calculate comparative standards. e.g. did you use HBE, Kcals/Kg, or another equation and why. What weight did you use IBW, Actual Wt, etc. Cite sources as appropriate. (Add rows or columns as needed) Nutrient Needs Equation used, Source and/or justification Kcal 1420 kcal-1620 kcal kcal/kg for adults with pressure ulcers who are underweight or losing 2

3 weight (1). She is at 89% of her IBW, so more calories are needed, but she does not need to gain major amounts of weight. Protein 41 g-61 g g/kg for elderly adults with pressure uclers. (1) Fluid 1500 ml 1 ml per kcal with a minimum of 1500 ml (1). 3. Indicate information in addition to the two items above you will use in your assessment. Underweight BMI of 17.4 (40.5 kg/2.32 m2) 89% of IBW (IBW= 100 #. 89/100=89%) Stage III pressure ulcer Diarrhea Fever Albumin levels of 2.8 mg/dl Section 2. Nutrition Diagnosis Determine Nutrition Diagnosis/Problem 1. List the problems DH has in the any of the diagnosis domains (2) Diagnosis term number Diagnosis Term NI-1.2 Inadequate Energy Intake Intake NI-2.3 Inadequate enteral nutrition infusion Intake NI-3.1 Inadequate fluid intake Intake NC-3.1 Underweight Clinical Domain (Intake, Clinical, Behavioral- Environmental) Write a Nutrition Diagnosis PES Statement Write Two Diagnosis Statements using PES format for two of DH s problems. Be sure to use the appropriate format as indicated in the IDNT book. (2) Inadequate enteral nutrition infusion related to increased caloric needs evidenced by a stage III decubitus ulcer. Inadequate fluid intake related to increased fluid needs as evidenced by diarrhea. 3

4 Section 3. Nutrition Intervention Analyze Potential Nutrition Interventions 1. Is DH s diet order appropriate for her current condition? Explain. (Type text in box below.) No, it is not giving her enough calories or protein, especially for a stage III pressure ulcer and for a fever. She is in need of higher calories, protein, fluid, and other nutrients such as vitamins and minerals that will help her with wound healing and metabolic stress. 2. What would be an appropriate formula and rate based on DH s needs? Fill in the table below Osmolite x per day to give her extra calories and the extra protein that she needs. List your estimated nutrient needs from above: Kcal: kcal Protein: g Fluid: 1500 ml Formula Name Osmolite 1.5 Rate/Administration 237 ml can 4 x per day; 39.5 ml/hr Kcals 1420 kcal Protein 60 g Fiber 0 g Fluid 724 ml Osmolality 525 mosm/kg Show all work/calculations for formula in the box below. Rate/administration: 237 x 4= 948 ml/24 hr= 39.5 ml/hr. Kcal: 355 kcal x 4= 1420 kcal Protein: 15 g x 4=60 g Fiber: 0 x 4= 0 g Fluid: 181 ml x 4= 724 ml 3. What nutrients would enhance wound healing? (Type text in box below) Energy: People with pressure ulcers are in need of high energy to help facilitate wound healing and reduce weight loss. Diets should not be restricted (1) Protein: Enough protein is needed for patients to stay in positive nitrogen balance and to spare protein for energy. (1) Vitamins and minerals: A supplement for vitamins and minerals should be given if there is a 4

5 deficiency. A vitamin or mineral deficiency may have an effect in wound healing. (1) Zinc: Zinc may help with wound healing as long as it is given in amounts that are <40 mg per day. Supplementation in greater amounts than this may increase the patient s risk for pressure ulcers. (1) Arginine/Glutamine: These may be used for energy and can produce higher amounts of collagen in the wound site which can help facilitate wound healing. These may be helpful to supplement in patients with pressure sores. (1) 4. How is nutrition involved in the development of decubitus ulcers? (Type text in box below) Energy intake, protein intake, fluid intake, and vitamin and mineral intake are all involved in the development and prevention of pressure ulcers. (1) 5. What is a PEG? (Type text in box below) A PEG stands for Percutaneous Endoscopic Gastronomy, and it is a feeding tube that is placed in the stomach and ends in the stomach. (3) 6. Why would it be used instead of an NG tube? (Type text in box below) An NG tube is used for more short term tube feedings, while a PEG is used if the tube feeding will be over a longer period of time and tube feeding will become a more permanent part of the patient s life. (3) 7. What is an intermittent tube feeding? (Type text in box below) An intermittent tube feed is one where patients are fed multiple times throughout the day in short periods of time. For example, an intermittent feed could be a formula of 237 ml infused in 45 minutes, 4 times per day. (1) 8. What are the advantages of using an intermittent tube feeding in and ECF environment? (Type text in box below) An advantage that I can see of using an intermittent tube feeding in an ECF environment is that patients are hooked up to a pump all day, so they can move around more easily and exercise and interact with people more. Also, with an intermittent feed, patients can have an oral intake as well as a tube feed and receive some calories orally in addition to their tube feed. 5

6 9. When wouldn t you choose an intermittent schedule? (Type text in box below) If patients are critically ill, it is better to use a continuous feeding instead of an intermittent feeding. Also if patients are critically ill with hemodynamic instability, an intermittent schedule should not be used as that can alter mesenteric blood flow. Also patients that have low blood pressure and who are on one or more catecholamine pressor agents is not recommended. (1) 10. What is the best schedule of feeding for DH? Explain. (Type text in box below) I think that a continuous feeding will be best for DH while she is in the hospital. She is immobile and is under some metabolic stress, so currently; she will probably not have an adequate oral intake. She also has diarrhea, and giving her fluid over a larger amount of time may help to reduce her diarrhea due to her fluid being spread out instead of given in a bolus. Determine Appropriate Nutrition Interventions 11. 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 etiology of the nutrition problem/diagnosis. Nutrition Prescription: DH should be given osmolite 1.5 at 39 ml/hr for 24 hours. She needs 1500 kcal and 61 g of protein. Intervention # 1 Intervention # 2 Intervention Parenteral infusion with increased calories (2) Fluid-modified diet with increased fluid intake of 1500 ml given over a 24 hour period. (2) Goal(s)/Expected Outcome Weight gain of 11 lbs so that DH meets IBW. Decreased dehydration with better skin turgor and electrolyte balances. Section 4. Nutrition Monitoring and Evaluation 1. What will you watch for in monitoring this patient? (Hint: How will you know if your feeding approach is appropriate? Think both short and long term.) (Type text in box below.) 6

7 While monitoring DH, I will watch for increased diarrhea, hyperglycemia or hypoglycemia, micronutrient requirements and balances, and tube occlusions. (1) 2. What routine monitoring should be done for a long-term enteral feeding? (Type text in box below.) Monitoring of gastrointestinal function and feeding tolerance to assess if the patient is tolerating the increased enteral load. Laboratory data should also be monitored, especially hyperglycemia, renal function, and hydration status. (1) 3. Do you think this patient was appropriately monitored prior to hospital admit? Why? (Type text in box below.) No, because she is underweight, not receiving enough calories to maintain a healthy weight, and has a stage III ulcer that is aggravated by incontinence and diarrhea. If she was appropriately monitored, her weight would hopefully be higher, she would have disposable briefs changed frequently to combat her incontinence and her pressure sore would be less severe, because she would be moved more frequently. Another possibility is that she is monitored appropriately, but is refusing treatment. 4. 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. 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) Parenteral infusion with increased calories. Fluid-modified diet with increased fluid intake of 1500 Goal/Expected Outcome (Copy form above) Weight gain of 11 lbs so that DH reaches her IBW. Decreased dehydration with better skin turgor, decreased fluid output, and electrolyte balances. Indicator(s) Weight regain. Skin turgor, fluid output, and electrolyte balance. Criteria for evaluation 1500 kcal will be given to DH. Weight regain of 1 lbs per week until she is back to her IBW ml will be given to DH over 24 hr period. Improved skin 7

8 ml turgor will be evaluated as well as decreased fluid output until DH is at a normal fluid output. Electrolytes will be measured daily to make sure that electrolytes are in normal levels and that there aren t imbalances. 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. A: 86 year old female Height: 60 ; 144 cm Weight: 89 lbs; 40.5 kg IBW: 100 lbs % IBW: 89% BMI: 17.4 Albumin 2.8 mg/dl D: Inadequate enteral nutrition infusion related to increased caloric needs evidenced by a stage III decubitus ulcer. I: Begin enteral feeding of Osmolite 1.5 at 39.5 ml/hr to help DH regain weight of 11 lbs. and receive enough nutrients to help facilitate healing of the stage III pressure ulcer. M/E: Follow up daily to see how the tube feed is being tolerated. Follow up weekly to evaluate weight gain in DH. Evaluate wound healing of stage III pressure sore and fever and diarrhea daily. References (Use the format indicated in the Student Handbook) 1. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at: Accessed February 24,

9 2. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. 4 th ed. Chicago, IL; Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, Mar. 3,

10 Case #2: Thermal Injury and Enteral Feeding A nineteen year old boy was admitted with 3rd degree (full thickness) burns over 30% of his body, including his hands and face, when a gas fireplace exploded in front of him. He is 5'9" tall and usual weight is 163 lbs. No admit weight was taken. All medical information (labs, meds etc.) are unavailable as he was taken immediately to surgery and he has no known prior medical history. Post-surgery he was placed on mechanical ventilation. The physician has ordered a nutrition consult with nutrition support per dietitian to start as soon as the patient is out of surgery. Section 1: Nutrition Assessment Complete a Nutrition Assessment using the information available. Use the IDNT book as a guide for indicators to assess and document. While the first worksheet prompted you on areas to assess, you are to now use your judgment in making a Nutrition Assessment. You will be scored on the appropriateness of assessment areas and your assessment of those areas. Get the assessment started To help you get the assessment started completed the following few question. 1. Calculate approximately how much fluid this patient may need for both initial resuscitation and ongoing maintenance (basal + evaporative). Show your work. Equation used, Source, and/or justification Initial Resuscitation 8891 ml (1) Basal 119 ml/hr (1) Evaporative 102 ml/hr (1) Total Maintenance 221 ml/hr Given above Note: m2 = TBSA = ((wt (Kg) Ht (cm))/3600) wt in kg, ht in cm The square root is for the entire equation; Show your work for fluid calculations in the box below. Initial Resuscitation: (4 cc x 74.1 kg x 30% burn)=8891 ml; Basal: (1500cc x 1.86 m2)/24=119 ml/hr Evaporative: (25+30) x (1.86 m2)= 102 ml/hr Total maintenance: 119 ml/hr ml/hr= 221 ml/hr 10

11 2. Describe how much fluid would be given in the first 24 hours (per 8 hr increments) with the initial resuscitation. (1) Total ml ml/hr 1 st 8 hours 5870 ml 734 ml/hr 2 nd 8 hours 2935 ml 367 ml/hr 3 rd 8 hours 2935 ml 367 ml/hr 3. Calculate comparative standards. Show equation calculations and justify equations, weights, and factors used to calculate comparative standards. e.g. did you use HBE, Kcals/Kg, or another equation and why. What weight did you use IBW, Actual Wt, etc. Cite sources as appropriate. (Add rows or columns as needed). Nutrient Needs Equation used, Source and/or justification Energy kcal kcal/kg (2); the NCM explains that this range is appropriate for patients with >20% of their body surface area covered in burns. Protein 110 g-150 g 1.5g/kg-2.0 g/kg (2) Vitamin C 500 mg/day (2) this amount was given specifically in the NCM Vitamin A IU/day (2) this amount was given specifically in the NCM 4. Indicate information in addition to the items above you will use in your assessment. He has just had surgery, so that could affect is PO intake. He has burns on his hands and face, which could affect his ability to eat and his desire to eat. He is on a ventilator, which will affect his intake and his energy requirements. Section 2. Nutrition Diagnosis Determine Nutrition Diagnosis/Problem 1. List the problems DH has in the any of the diagnosis domains. Do NOT use fluid intake (3) as a diagnosis. (3) Diagnosis Domain (Intake, Clinical, Behavioral- Diagnosis Term term Environmental) 11

12 number NI-1.1 Increased energy expenditure Intake NI-5.1 Increased nutrient needs of protein Intake NI-5.1 Increased nutrient needs of Vitamin C Intake NI-5.1 Increased nutrient needs of Vitamin A Intake NB-2.6 Self-feeding difficulty Behavioral-environmental Write a Nutrition Diagnosis PES Statement Write Two Diagnosis Statements using PES format for two of DH s problems. Be sure to use the appropriate format as indicated in the IDNT book. (3) Increased energy expenditure related to hypermetabolism as evidenced by burns covering 30% of his body surface area that suggest increased protein catabolism and metabolic stress. Increased nutrient needs of Vitamins A and C related to increased demands caused by wound healing as evidenced by burns covering 30% of his body and recent surgical procedures. Section 3: Nutrition Intervention: Analyze Potential Nutrition Interventions 1. What type of nutrition support is appropriate for this patient? Explain. Enteral, because his gut is still working and it is important to use the GI tract if possible with nutrition support. Also, he doesn t have any contraindications of enteral support such as a bowel obstruction, SBS, or other GI tract problems (4) Assume you decided upon an enteral feeding: 2. To avoid complications, where would you want the tube to be placed? Why? I would place a PEJ to avoid the esophagus and to decrease risk of aspiration and because his healing will take a long amount of time, this feeding tube is going to be a more long-term solution. Also, due to his ventilator, placing an NG tube or a G tube would be more difficult. In addition to those, his face is heavily burned and placing a feeding tube on his face would be painful and uncomfortable and may decrease his desire to eat. (4) 3. Identify 2 possible formula brand names that would be appropriate for this patient and justify reason for appropriateness. 12

13 Formula #1 Formula #2 Formula Name Perative Pivot Justify reasons for choosing this formula It is calorically dense, high in protein, and has vitamin A and C. It also has glutamine and arginine which may help in wound healing. Pivot is very high calorie and has very high amounts of protein. It is designed for patients in metabolic stress and has high amounts of vitamin A and C and also has arginine, glutamine, and omega-3 fatty acids which may help in wound healing. 4. Choose one of the above formulas and calculate a feeding regime that would best meet this patient s needs. List your estimated nutrient needs from above: Energy: kcal Protein: g Vitamin C: 500 mg Vitamin A: IU Formula Name Pivot Final goal rate Total 1422 ml Final rate ml/hr 59 ml/hr Kcals Total 2130 kcal Kcals/Kg 29 kcal/kg Protein Total 132 g Pro g/kg 1.8 g/kg Carb Total g 245 g Carb Load mg/kg/min 2.30 mg/kg/min Fat 72 g % Total Kcal from fat 30% Free Fluid 1080 ml 5. Do you think this patient needs supplements of any vitamins or minerals? Justify your answer. Yes, the nutrition care manual explains that vitamin C and vitamin A are needed specifically in burn patients to help with wound healing. (2). Determine Appropriate Nutrition Interventions 6. Complete the following table 13

14 a. Fill in the nutrition prescription (i.e. nutrition order, etc.) 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 etiology of the nutrition problem/diagnosis. c. Do NOT use IV fluid as an intervention. Nutrition Prescription: Pivot will be given at 59 ml/hr over a 24 hour period. His energy needs are between 1850 and 2220 kcal. His protein requirements are between g. Intervention # 1 Intervention # 2 Intervention Enteral nutrition formula of Pivot given at 59 ml/hr. (3) Multivitamin supplement containing vitamin and C to provide 500 mg of vitamin C and 1000 IU of vitamin A per day. (3) Goal(s)/Expected Outcome Increased calories and protein to help facilitate wound healing and to decrease metabolic stress. Increased availability of vitamins A and C to help facilitate wound healing. Section 4. Nutrition Monitoring and Evaluation 1. Initially post burn what you expect to see in patient s weight and albumin levels? As time goes on, what changes would you expect to see in the patient s weight and albumin levels? I would expect to initially see albumin and prealbumin levels drop because they are acute phase proteins and in metabolic stress, acute phase protein levels drop. However, as time goes on, I would expect prealbumin to increase more quickly than albumin, because it has a shorter halflife, but prealbumin and albumin will increase over time. Over time, as acute stress phase slows down and the body decreases hypermetabolism, I would expect to see weight increase. I would also expect to see weight increase as fluid losses decrease and fluid retention increases. 2. Do the changes above reflect the patient s nutritional status? Why? No, because weight, albumin, and prealbumin can be skewed by hydration status and burn patients are overhydrated. This will cause weight to increase but prealbumin and albumin to be diluted, which will not give an accurate reading nor a good reflection of nutrition status. (2) 3. What will be your best long term monitors (indicators) to assess if your nutrition care is appropriate? Nitrogen balance and wound healing status. (2) 14

15 4. 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. 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 and its etiology. Intervention (Copy from above) Enteral nutrition formula of Pivot given at 59 ml/hr. Multivitamin supplement containing vitamin and C to provide 500 mg of vitamin C and 1000 IU of vitamin A per day. Goal/Expected Outcome (Copy form above) Increased calories and protein to help facilitate wound healing and to decrease metabolic stress. Increased availability of vitamins A and C to help facilitate wound healing. Indicator(s) Weight, albumin and prealbumin, wound healing. Wound healing. Criteria for evaluation Nitrogen balance, BUN, and UUN, because weight loss will be due to fluid and albumin and prealbumin will not be reliable, so measuring nitrogen balance will be a good way to assess growth. Wound healing and faster skin growth. 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 15

16 note. A: 19 year old male Height: 69 ; 175 cm Weight: 163 lbs; 74.1 kg D: Increased energy expenditure related to hypermetabolism as evidenced by burns covering 30% of his body surface area that suggests increased protein catabolism and metabolic stress. I: Begin enteral feeding of Pivot at 59 ml/hr through a PEG to give adequate calories and protein to meet increased calorie and protein needs. M/E: Follow up daily to see how the tube feed is being tolerated. Follow up daily to evaluate unintentional weight loss and to evaluate albumin and prealbumin levels. Evaluate wound healing daily. References (Use the format indicated in the Student Handbook) 1. Graves C. Lecture notes. Advanced Dietetics Practice, Brigham Young University, March 4, Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at: Accessed March 10, Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. 4 th ed. Chicago, IL; Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, March 6,