Care ConferenceCaryn MassiminoUConn Health Center

Introduction

Admission Date: 10/08/14 Assessed from 11/4/14 – 11/11/14

Age: 64 Gender: Male Diagnosis: Intestinal perforation,

hyperglycemia, MRSA, Sepsis Past Medical History: CHF, COPD,

Asthma, Afib, Gout, Seizures, Pneumonia, Sleep Apnea

Anthropometrics

Height: 5’5” Current Weight: 75.3kg (11/6)

Previous weights: Adm wt = 99kg, 88.9kg (10/23), 87.3kg (10/28), 85.4 (10/31), 77.8kg (11/5)

%Wt Change: -23.9% weight loss in 1 month

BMI: 27.6 (Overweight) IBW: 62kg %IBW: 121%

Physical Findings

Patient on Bi-pap ventilator Confused from heavy drugs in ICU NG tube for Tube Feeding Edema: LUE, RUE, LLE, RLE – pitting +1 Skin: abdominal wound, open area near

ileum; all other skin on body intact not surrounding surgical area

NGT for suctioning from ileostomy

Social History

History of chronic asthma from the age of 3

On corticosteroids since asthma diagnosis

Uses C-pap ventilator for sleep apnea PTA

Lives at home with wife Former Smoker

2 packs/day

Intestinal Perforation

Treated with temporary Ileostomy or Colostomy

Complications include wound failurePartial/total disruption of any layers of operative woundHigher risks with patients who use Corticosteroids, Sepsis, heavy coughing

Diet Orders During Hospitalization Current Diet Order: Peptamen AF TF

10cc/hr 24hr trickle c TPN D 20/AA 7.5 60cc/hr 24hr = 1699kcal, 126g pro

Previous Diet Orders: (11/6): Peptamen AF TF 50cc/hr 24hr trickle

c TPN D 14/AA 7.25 30cc/hr 24hr c 1 pro-source sup daily = 1702kcal, 158g pro

(10/30): Peptamen AF TF 10cc/hr 24hr trickle c TPN D 17.5/AA 8.75, 66cc/hr 24hr, 20% lipids 5x/wk = 2006kcal, 144g pro

(10/24): TPN D 17.5/AA 8.75, 66cc/hr 24hr, 20% lipids 5x/wk = 1718kcal, 126g pro

Nutritional Requirements

Mifflin St. Jeor = (99.9 x 75.3kg) + (6.25 x 165.1cm) + (4.92 – 64) + 161 (1.2 IF) (1.2 AF)= 2347kcal

Penn State 2010 = 1699kcal 30Kcal/kg = 2259kcal Protein = 2g/kg/day = 151g/day Fluid = 25cc/kg/day = 1833cc/day Other nutrients deemed necessary:

Vitamins A, C, K, D, thiamin, zinc, phosphorous, calcium Possibly arginine & glutamine for wound

healing

Diagnosis

Patient assessed with increased nutrient needs R/T intestinal perforation, MRSA, and Sepsis AEB unintentional weight loss of 52lbs in course of hospitalization, multiple infections, delayed wound healing, and low albumin levels.

Intervention Food/Nutrient Delivery:

Provide Peptamen AF TF at 30cc/hr 24hr c TPN D 20/AA 7.5 60cc/hr 24hr to provide 2275kcal, 160g pro

Decrease TPN c TF tolerance advancement to promote transitional feeding

Coordination of Care: Assess residuals/tolerance of tube feeding daily Assess wound healing and infection status daily Obtain daily weights Work with MD to change patient’s nutrition support

orders properly

Monitoring & Evaluation Food/Nutrition Related Outcomes:

Monitor residuals for TF and tolerance to advancement daily Anthropometric Measurements Outcomes:

Check weight daily to see if patient maintaining/gaining weight to promote healing and diet advancement 

Biochemical Data: FSG, TG to monitor tolerance to lipids and TF daily Monitor I/OS daily to test for edema Monitor intolerance to TF daily through residual levels Monitor protein labs weekly to assess for malnutrition/over-

nutrition Monitor electrolytes weekly to see if patient is tolerating

supplements and TF/TPN  Nutrition Focused Physical Outcomes:

Monitor physical appearance daily for wound healing, edema, weight loss/gain to assess diet advancement

Alterations To Diet Order

Peptamen AF TF: 30cc/hr 24hr TPN: D 20/AA 7.5 60cc/hr 24hr

Provides: 2275kcal and 160g protein to provide adequate nutrition for wound healing and weight maintenance for patient to start transitional feeding to be solely dependent on tube feed as tolerated.

Transitional Feeding Diet Order Peptamen AF TF: 50cc/hr 24hr TPN: D 20/AA 7.5 35cc/hr 24hr

Provides 2263kcal and 154g protein to provide adequate nutrition while advancing the tube feeding to promote GI usage if tolerated. This would provide advancement to wean the patient off of TPN nutrition and on to relying solely on tube feedings to provide complete nutrition.

References

Mahan, L. Kathleen, Sylvia Stump, Janice L. Raymond, and Marie V. Krause. Krause's food & the nutrition care process. 13th ed. St. Louis, Mo.: Elsevier/Saunders, 2012. Print.

Pronsky, Zaneta M., and Jeanne P. Crowe. Food medication interactions. 16th ed. Birchrunville, Penn.: Food-Medication Interactions, 2010. Print.

Stump, Sylvia. Nutrition and diagnosis-related care. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2012. Print.

"WebMD - Better information. Better health.." WebMD. WebMD, n.d. Web. 6 Feb. 2014. http://www.webmd.com/.

"Mayo Clinic - Mayo Clinic." Mayo Clinic - Mayo Clinic. N.p., n.d. Web. 8 Apr. 2014. http://www.mayoclinic.org/.

Questions?