clinical worksheet #2 nutrition support in: …...5 deficiency. a vitamin or mineral deficiency may...
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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
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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 948 mL/day
Kcals 1000 kcal
Protein g 42 g
Free fluid ml or cc 796 mL
Vitamin and mineral intake in
general. i.e. what percent of
vitamin/Minerals ~100% of
most; 50-60% of most etc.
80-100% 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 35-40 kcal/kg for adults
with pressure ulcers who
are underweight or losing
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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 1.0-1.5 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
Domain (Intake, Clinical, Behavioral-Environmental)
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
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.
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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 1.5 4 x per day to give her extra calories and the extra protein that she needs.
List your estimated nutrient needs from above:
Kcal: 1420-1620 kcal
Protein: 41-61 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
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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.
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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 Goal(s)/Expected Outcome
Intervention # 1
Parenteral infusion with increased
calories (2)
Weight gain of 11 lbs so that DH
meets IBW.
Intervention # 2
Fluid-modified diet with increased
fluid intake of 1500 mL given over a
24 hour period. (2)
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.)
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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)
Goal/Expected Outcome (Copy form above)
Indicator(s)
Criteria for evaluation
Parenteral
infusion with
increased
calories.
Weight gain of 11 lbs so
that DH reaches her IBW.
Weight regain. 1500 kcal will be
given to DH.
Weight regain of
1 lbs per week
until she is back
to her IBW.
Fluid-modified
diet with
increased fluid
intake of 1500
Decreased dehydration
with better skin turgor,
decreased fluid output, and
electrolyte balances.
Skin turgor, fluid output,
and electrolyte balance.
1500 ml will be
given to DH over
24 hr period.
Improved skin
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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:
https://www.nutritioncaremanual.org/index.cfm. Accessed February 24, 2015.
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2. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology
(IDNT) Reference Manual. 4th ed. Chicago, IL; 2013
3. Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University, Mar. 3,
2015
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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) The square root is for the entire equation;
wt in kg, ht in cm
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 + 102 ml/hr= 221 ml/hr
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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
1st 8 hours 5870 mL 734 mL/hr
2nd 8 hours 2935 mL 367 mL/hr
3rd 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 1850-2220 kcal 25-30 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 10000 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 term
Diagnosis Term Domain (Intake, Clinical, Behavioral-
Environmental)
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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.
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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: 1850-2220 kcal
Protein: 110-150 g
Vitamin C: 500 mg
Vitamin A: 10000 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
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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 110-150
g.
Intervention Goal(s)/Expected Outcome
Intervention # 1
Enteral nutrition formula of Pivot
given at 59 ml/hr. (3)
Increased calories and protein to help
facilitate wound healing and to
decrease metabolic stress.
Intervention # 2
Multivitamin supplement containing
vitamin and C to provide 500 mg of
vitamin C and 1000 IU of vitamin A
per day. (3)
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 half-
life, 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)
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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)
Goal/Expected Outcome (Copy form above)
Indicator(s)
Criteria for evaluation
Enteral nutrition
formula of Pivot
given at 59
ml/hr.
Increased calories and
protein to help facilitate
wound healing and to
decrease metabolic stress.
Weight, albumin and
prealbumin, wound
healing.
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.
Multivitamin
supplement
containing
vitamin and C to
provide 500 mg
of vitamin C and
1000 IU of
vitamin A per
day.
Increased availability of
vitamins A and C to help
facilitate wound healing.
Wound healing. 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
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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, 2015
2. Academy of Nutrition and Dietetics. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/index.cfm. Accessed March 10, 2015.
3. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology
(IDNT) Reference Manual. 4th ed. Chicago, IL; 2013
4. Willams P. Lecture notes. Advanced Dietetics Practice. Brigahm Young University,
March 6, 2015