Your Name and/or Name of Partner (if working with one):Kinsey Rohling and Dana Melink

University of Minnesota - Department of Food Science & NutritionFScN 4665 - Medical Nutrition Therapy I - Fall 2014

Case 2100 Points

Due Date: THURSDAY, NOVEMBER 6th Please be sure to do the following:

Show all calculations, and explain your rationale. Calculations do not have to be typed. Answer all questions directly on this form. Type all answers (except calculations).

Submit in hard copy in class on the due date. You will be deducted one point per day after the due date until the hard copy is turned in.

You may work ALONE or with ONE other person. Do not share your work with other individuals beyond your group. If you work with a partner, you should hand in only ONE case with your name and your partner’s name clearly listed at the top of the first page.

Some resources needed for solving the Case:1. Lecture notes on:

a. Metabolism in Disease and Injury-Induced Stressb. Nutrition Assessment I-History and Physical Examinationc. Nutrition Assessment II- Anthropometryd. Nutrition Assessment III-Biochemical/Laboratory

2. Module I: Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation

3. Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting4. Module III: An Introduction to the Exchange Lists for Meal Planning5. Module V: Metabolism in Disease and Injury-Induced Stress.6. ASPEN Adult Critical Care Nutrition Guidelines (link provided in the Moodle site)7. IDNT Reference Manual nutrition diagnoses pages8. Krause’s Food and the Nutrition Care Process, 13th edition.

a. Chapter 39: Medical Nutrition Therapy for Metabolic Stress: Sepsis, Trauma, Burns, and Surgery.

b. Chapter 41: Medical Nutrition Therapy for Neurologic Disorders (pg. 935; Head Trauma or Neurotauma)

9. Miller KR, Kiraly LN, Lowen CC, Martindale RG, and McClave SA. “CAN WE FEED?” A Mnemonic to Merge Nutrition and Intensive Care Assessment of the Critically Ill Patient. J Parenter Enteral Nutr 2011;35(5): 643 - 659.

Mr. Phillips is a 24 year-old male admitted to the surgical intensive care unit following a motorcycle accident. Mr. Phillips’ primary diagnosis is traumatic brain injury (TBI) and he is currently mechanically ventilated.

From the admitting physician’s note:Chief complaint: Patient is unable to provide any information upon admission.Patient Hx: Mr. Phillips is a 24 year-old male admitted following a motorcycle accident. The accident occurred while traveling approximately 40 miles per hour. He was thrown from his

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motorcycle and landed 20 feet away from the street. He was not wearing a helmet. Other motorists began CPR immediately. EMTs were on the scene within 5 minutes and Mr. Phillips was promptly transferred to a Level 1 Trauma Center. Initial Acute Physiology and ChronicHealth Evaluation (APACHE) II score was 10.

Type of treatment: PMH: Broken right femur- 10 years of ageMeds: None Allergies: NoneSmoker: Non-smoker Family Hx: Non-contributory. Both parents and siblings are healthy and living.Social Hx: Single, construction worker, occasional alcohol, no drug use

Physical Examination: General appearance: Abrasions to the face, forehead, and torso; 9 cm laceration to the scalp; facial bruising, broken right humerus and several broken ribs. Vitals: Temp 99.9, BP 105/70, HR 92, RR 32Skin: Pale, dry, multiple abrasions and bruisesHeight: 6’2”Weight: 203 lbsUsual Body Weight: 193 lbs (prior to weight training program started six months ago)

From the RD’s interview of Mr. Phillips’ mother and sister:Nutrition Hx:General: General: Appetite good. Typically eats three meals daily and snacks in the afternoon and late evening. Cooks most meals for self and eats at restaurants or fast food outlets 1-2 times weekly. According to his family members, he has gained approximately 10 lbs in the last six months after starting a weight-training program.

Typical dietary intake:Breakfast: 16 oz. coffee (black), two slices of wheat toast with 2 Tbsp peanut butter,

1 cup corn flakes, 1 cup 1% milk, ½ cup orange juice, 1 medium-sized banana (4 oz)

Lunch: 1 large apple, turkey sandwich (2 slices wheat bread, 1 Tbsp mayonnaise, 3 oz. turkey, 1 oz. cheddar cheese, 1 lettuce leaf, 1 slice tomato), ¾ oz. potato chips, 12 oz. Mountain Dew, 2 Oreo cookies

Dinner: 6 oz. chicken breast (no skin), 1 cup mashed potatoes, 1 cup steamed vegetables (non-starchy), 12 oz. 1% milk, 1 slice wheat bread, 1 T. margarine, 2” square brownie

HS Snack: 8 oz. orange juice, 1 slice wheat bread with 1 Tbsp peanut butter

Food allergies/intolerances/aversions: NonePrevious MNT? NoneFood purchase/preparation: Prepares own mealsVit/Min or other supplements: Standard multivitamin with minerals, creatine powderActivity: Weight lifting 4 days weekly, 45 minutes cardio training 5 days weekly (running, cycling, rollerblading), construction work 5 days weeklyTreatment Plan:

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Mr. Phillips is intubated and sedated. Intracranial pressure (ICP) monitoring is ongoing. He is receiving Dilantin to prevent seizure activity.Routine vitals Q 4 hours, NPOLabs: BMP, ABGs Q 8 hoursMeds: Dilantin, KCl, NaPO4, solumedrol, insulin drip, ativan, fentanylPRN Meds: Magnesium, Phosphorus, Potassium, Colace, Miralax IVF: D5 ½ NS + 20 mEq KCl at 150 ml/hrChest x-ray dailySputum cultures and Gram stain pending

Hospital course:On hospital day 2, Mr. Phillips’ APACHE II score remains 10 and his ICP readings have been normal. Cerebral perfusion pressures are adequate. Mechanical ventilation and sedation are unchanged. You are consulted to complete a nutrition assessment on hospital day 2, so nutrition support can be initiated.Laboratory data:

Lab Test Day 1 Day 2 Day 3 Normal Range Units

Glucose 179 165 132 70 - 110 mg/dL

Na+ 145 148 149 136 - 145 mEq/L

Cl- 98 96 97 95 - 107 mEq/L

K+ 3.4 3.7 3.6 3.5 - 5.0 mEq/L

BUN 15 12 11 8 - 25 mg/dL

Cr 0.9 0.8 0.7 0.6 - 1.5 mg/dL

Phosphorus 2.9 1.8 2.3 2.6 - 4.5 mEq/L

Mg++ 1.4 1.2 1.6 1.5 - 2.2 mEq/L

Calcium 7.8 8.2 8.8 8.5 – 10.5 mg/dL

Albumin 2.8 2.7 2.8 3.5 - 5.0 mg/dL

Prealbumin 3 4 6 – 8.5 g/dL

Alkaline Phosphatase 230 236 220 200 - 400 mg/dL

Transferrin 300 315 200 - 400

Lab Test Day 1 Day 2 Day 3 Normal Range Units

White Blood Cells (WBC) 5.1 9.8 10.8 25 - 160 U/L

Arterial Blood Gases:

pH 7.35 7.27 7.37 7.35 – 7.45

PCO2 37 39 43 35 - 45 mmHg

PO2 77.4 87 85.9 80 - 100 mmHg

HCO3 24.7 26.4 25.8 22 - 26 mEq/L

Laboratory information prior to admission:Annual CBC and lipid profile- WNLNUTRITION ASSESSMENT

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Dietary Intake Data

1. From Mr. Phillips’ typical dietary intake, calculate the total number of calories he consumed. Also calculate the energy distribution of calories for protein, carbohydrate, and fat. For this question, you must use the Exchange Lists for Meal Planning (Use Appendix 34 in the back of the Krause text: See pp. 1110-1121 (13th ed.) and Module III, “An Introduction to the Exchange Lists for Meal Planning”), and complete each of the steps outlined below, showing your calculations.

Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate that is designated as such under “Other Carbohydrate” or “Combination” lists as simply “Carbohydrate” rather than “Starch”, and then count these separately under “Other Carbohydrates” in the table for Step 2. Complete the table below. (10 points)

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Breakfast Counts As (Specify Exchanges)16 oz. coffee (black) Free

2 slices of wheat toast 2 Starch2 Tbsp peanut butter 2 High Fat

1 cup corn flakes 2 Starch1 cup 1% milk 1 Low Fat Milk

½ cup orange juice 1 Fruit1 medium size banana (8 oz) 2 Fruit

Lunch1 large apple 2 Fruit

2 slices wheat bread 2 Starch1 Tbsp regular mayonnaise 3 Fats

3 oz. turkey 3 Lean Meats1 oz cheddar cheese 1 High Fat Meat

1 leaf of lettuce Free1 thin slice of tomato Free

¾ oz potato chips 1 Starch12 oz Mountain Dew 2.5 Other CHO

2 Oreo cookies (original) 1 Other CHO & 1 FatDinner

6 oz. baked skinless chicken breast 6 Lean Meats1 cup mashed potatoes (nothing

added)2 Starch

1 cup steamed vegetables (mixed cauliflower/broccoli)

2 Non-Starchy Veg

12 oz. 1% milk 1.5 Fat-Free Milk1 slice wheat bread 1 Starch

1 Tbsp margarine (stick) 1 Fat~ 2” square brownie 2 Other CHO + 2 FatEvening (HS) Snack

8 oz. orange juice 2 Fruit1 slice wheat bread 1 Starch

1 Tbsp peanut butter 1 High Fat1 cup ice cream (regular) 2 Other CHO & 4 Fats

Step 2: Add the totals from the table in step 1. Count all items that were listed anywhere besides the “STARCH” list, that counted as carbohydrate exchanges, under the “Other carbohydrate” section in the table below. Count as starches ONLY those foods listed specifically on the STARCH list. (10 points)

Exchange GroupTotal

servings/day

CHO(g)

Protein(g)

Fat(g)

Starch 1115

1653

33Use 0

5

Non-Starchy Vegetables 25

102

40

Fruit 715

1050 0

Other Carbohydrates 7 ½ 15

112.50 0

Fat-Free Milk 012 8 0

Low-Fat Milk (1/2 - 1%) 2 ½ 12

308

200

Reduced-Fat Milk (2%) 012 8 5

Whole Milk 012 8 8

Lean Meats/Substitutes 90 7

63 3

27

Medium Fat Meats/Substitutes0 7 5

Exchange GroupTotal

servings/day

CHO(g)

Protein(g)

Fat(g)

High Fat Meats/Substitutes 40 7

288

32

Fats 11 0 0 5

55

TOTAL grams 422.5 148 114

Determine kcals by multiplying TOTAL grams X 4 = X 4 = X 9 =

TOTAL KCALS 1690 592 1026

GRAND TOTAL KCALS (CHO + protein + fat) 3308

Step 3: Determine the % kcals provided by CHO. (2 points)1690/3308 (100) = 51%Step 4: Determine the % kcals provided by protein. (2 points)592/3308 (100) = 18%Step 5: Determine the % kcals provided by fat. (2 points) 1026/3308 (100) = 31%

Anthropometric Data2. A. Calculate Mr. Phillips’ “ideal” weight using the Hamwi equation. (2 points)

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Ideal Body Weight: Men = 106 for the first 5’ and then 6 lbs for every inch after. 6’2” = 202 lbs for ideal body weight +/- 10% = 181.8 - 222.4lbsMr. Phillips actual body weight = 203lbs

B. Calculate the % “ideal” weight and % usual body weight he is at his current weight. (4 points)

% Ideal Body Weight: Actual weight/Ideal body weight (100)203 lbs/202 lbs (100) = 100.5%

Usual Body Weight: Actual Body Weight/Usual Body Weight (100)203 lbs/ 193 lbs (100) = 105%

His “normal” body weight was 193 lbs 6 months ago before he started weight training program

B. Calculate Mr. Phillips’ BMI. Into which category does he fall, based upon the National Institutes of Health, National Heart, Lung, and Blood Institute’s Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, which was provided in the “Nutrition Assessment II: Anthropometry” notes? (2 points)BMI: Weight (kg)/Height (m2)

203 lbs/ 2.2 kg = 92.27kg6’2” = 74 inches (0.0254m)= 1.88m2

BMI = 92.27 kg/ 1.88m2 = 26.1 kg/m2

BMI of 26.1 classifies Mr. Phillips as “Overweight”

C. Evaluate Mr. Phillips’ current weight in terms of change from usual body weight over time (be specific). If he has lost weight, is it clinically significant? Explain. (4 points)6 Months ago Mr.Phillips weighted 193lbs and has gained 10 lbs since starting weight training program; he now weighs 203lbs.He has not lost any weight within the last 6 months, so this would not be clinically significant.

3. Evaluate Mr. Phillips’ dietary intake, anthropometric, PE/clinical, and biochemical data pertinent to his diagnosis. When appropriate, compare his data to standard/normal values. Be as thorough and SPECIFIC as possible, and then clearly identify at least ONE piece of data that is of concern from a nutritional standpoint within each data category as you begin to prioritize the most prominent nutrition issues that need to be addressed. EXPLAIN your rationale for each issue that you mention.

A. Dietary intake data (Refer back to what you found in question #1 and evaluate Mr. Phillips’ intake in terms of major nutrients or food groups that appear to be lacking, and any obvious problems you think he is having with intake) (2 points):According to AMDR macronutrients should fall between:

CHO: 45-65% Daily Intake Mr. Phillips: 51%

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Protein: 10-35% Daily Intake Mr. Phillips: 18%

Fats: 20-35% Daily Intake Mr. Phillips: 31%

According to this, Mr. Phillips’ intake is adequate for macronutrient calories. However he only consumed 2 non-starchy vegetable on the recorded day, so he did not consume enough vegetable servings, which could indicate that he may be lacking some essential vitamins and minerals that can only be found in vegetables.

B. Anthropometric data (refer back to your answers in question #2) (2 points):According to his BMI, Mr. Phillips’ is “overweight”; however BMI does consider his activity level or muscles mass. This means we need more information to find out what his muscles mass and body fat percentages are, since he may have more muscle mass due to recent weight training. Knowing that would help conclude if he is “unhealthy overweight”.With the information here, we could presume that Mr. Phillips’ is at a healthy weight because he has started a weight training program and that his “overweight status” would not affect his health status in this case.

C. PE/clinical findings (2 points):General appearance: Abrasions to the face, forehead, and torso; 9 cm laceration to the scalp; facial

bruising, broken right humerus and several broken ribs.

Mr. Phillips’ has experienced multiple abrasions and bruises and has pale and dry skin. He also has several broken bones and his temp is slightly elevated.

Dry skin and elevated body temp could suggest that Mr. Phillips is dehydrated, but his BUN/Cr ratio is not greater than 20 and there are no other physical signs of dehydration. Mr. Phillips seemed to be very well nourished and healthy before the accident, so all physical and clinical findings should be related to the accident.

D. Biochemical data (2 points):

Mr. Phillips’ albumin and prealbumin levels are low, along with his overall white blood cell count. Hypoalbuminemia is usually a sign for malnutrition and can occur in critical illness states because of an excessive loss of protein.

4. A. Refer to your lecture notes on Metabolism in Disease and Injury-Induced Stress and the article by Miller et al (2011) “CAN WE FEED?” A Mnemonic to Merge Nutrition and Intensive Care Assessment of the Critically Ill Patient. Briefly explain how the APACHE II score is calculated, and for what purposes can it be used? What does Mr. Phillips’ APACHE II score of 10 suggest about the severity of his TBI? (4 points)

The APACHE II score is used to classify the severity of illness in an ICU setting. It can also be used to predict mortality. It factors in both acute and chronic conditions, and it’s

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calculated using the patient’s age, temperature, hemodynamics, arterial blood gas values, electrolytes, and renal function. The maximum APACHE score is 71 which corresponds with the highest severity of disease and risk of death. Mr. Phillips’ APACHE II score of 10 suggests that his TBI is not very serious because it is on the very low end of the scale.

B. Explain at least two factors placing patients with TBIs at increased nutritional risk. (Hint: think of the metabolic changes that occur with this condition). (4 points)

Patients with TBIs are hypermetabolic and hypercatabolic, so they are at risk of malnutrition if their increased if calorie needs are not met. Their measured REE could be 140-175% of the predicted REE. They also have increased protein requirements to assist in the healing process, and it is recommended for these patients to be given 1.5-2.0 g/kg, and >2.0 g/kg may be necessary to create positive nitrogen balance.

TBI patients may develop oropharyngeal swallowing disorders which would put them at risk for decreased oral intake. In these cases, a dysphagia diet would be necessary if not on enteral or parenteral nutrition support.

The patient is potentially at risk for overfeeding if the calories from Propofol are not accounted for when determining calorie requirements.

Patient is at risk of dehydration since patients with TBIs are on fluid restrictions to decrease cerebral edema.

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5. Identify the mechanism of action for each medication that Mr. Phillips is currently taking. Determine any food-medication interactions and nutrition recommendations for consumption. (6 points)

Medication Rationale for Use/Action Food-Medication Interactions

Nutrition Recommendations

Solumedrol

It is an anti-inflammatory glucocorticoid. It is commonly used to treat inflammation related to arthritis, bronchial inflammation and acute bronchitis, autoimmune diseases like lupus, and multiple sclerosis. It also decreases immune system's response to various diseases to reduce symptoms such as swelling, pain, and allergic-type reactions.

Can cause blood sugar levels to rise.Grapefruit in combination with drug can cause blood levels to rise.Drug can also cause fluid retention. Alcohol can cause unwanted side effects and impair.Decreases intestinal absorption of calcium, causes sodium retention, and promotes urinary loss of calcium, potassium, zinc, vitamin C, and nitrogen.

Check insulin levels while on drug.Limit consumption of grapefruit.Do not consume alcohol.Consume a diet high in calcium, vitamin D, protein, potassium, zinc, and vitamin C. Consume a diet low in sodium.

Dilantin

Used to control seizures (anticonvulsant drug). Can also be used to treat types of irregular heart beats.

Interferes with folic acid and Vit. D.Decreases serum levels of folic acid, calcium, vitamin D, biotin, and thiamin.pH changes in GIT associated with Phenytoin may cause decrease Folate uptake.

Absorption can be decreased with Enteral TF, so flush tubes before and after administration.Check Vit D and Folate levels.Do not consume alcohol.Avoid alcohol, grapefruits, and grapefruit juice.

Fentanyl

Treats moderate to severe chronic pain (narcotic pain reliever).

Alcohol can cause nervous system side effects such as drowsiness, dizziness, low blood pressure, fainting, coma, or even death.Grapefruit and grapefruit juice can increase the amount of fentanyl (with the use of transdermal fentanyl patches, specifically) that is absorbed into the body to dangerous levels

Do not consume alcohol.Avoid alcohol, grapefruits, and grapefruit juice.

Ativan

Oral medication that treats anxiety, depression and insomnia. Is a benzodiazepine, which produces a calming effect in the body.Can also be used to prevent nausea and vomiting

Alcohol can increase nervous system side effects such as drowsiness, dizziness, and difficulty concentration.Caffeine reduces its therapeutic effectiveness.

Do not consume alcohol.Avoid caffeine also.It is also recommended to use herbal and natural products with caution, especially if they cause CNS stimulation or sedation.

6. Look at Mr. Phillips’ arterial blood gas reports on hospital days 1-3. Why would arterial blood gases (ABGs) be drawn for this patient? (1 point)

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Mr Phillips was in an accident that resulted in physical abrasions to the head and neck that may be affecting his breathing (he is intubated). ABG tests will be used to check specific pH balance and Oxygen and CO2 levels to help understand how well the kidneys and lungs are functioning (if there is any kind of compensation happening). To confirm or refute a metabolic disease and/or head/neck injury that would affect breathing, an ABG test should be done.

Calculation of Nutrient Needs

7. Refer to the guidelines given in “Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting” and “ASPEN Adult Critical Care Nutrition Guidelines 2009” (link provided in the Moodle) to complete the following. Show your work and specify the source for your answers, and explain your reasoning for making the choices you made.

A. Using an appropriate prediction equation (with or without activity/stress or injury factor, as you deem appropriate), estimate Mr. Phillips’ total energy requirement. As always, explain your thinking and show your work. (4 points)TEE= RMR= 9.99(92.27) + 6.25(188) - 4.92(24) + 5= 1983.45 kcalTEE= RMR= 1983.45kcals

Penn State for non-obese critically ill: RMR= (1983.45) (0.96) + (50) (31) + (37.7) (167) -6212= 3538kcals

B. On hospital day 3, indirect calorimetry is performed and Mr. Phillips’ REE = 3703 and RQ = 0.79. Would you assess him to be hypometabolic, normometabolic, or hypermetabolic? Explain your rationale. (2 points)

Measured RMR/Predicted RMR = 3703/1983.45= 1.87- hypermetabolic

Mr. Phillips is hypermetabolic because his measured RMR/predicted RMR ratio is between above 1.1.

RQ less than 1.0 indicates that the patient is not being overfed.

C. Estimate Mr. Phillips’ protein requirement. Explain your thinking and show your work. (2 points)

92 kg X 1.5 g/kg= 138 g protein1.5 g/kg falls in the recommended range of 1.5-2.0 g/kg for TBI patients

Calculating NPC:N ratio to evaluate whether protein level is too high138 g protein X 4 kcal/g= 552 kcal from protein3538-552= 2986 non-protein kcal138/6.25= 22.08 g N2986/22.08= 135:1 NPC:N This falls within the range of reasonable non-protein kcal

to nitrogen ratios in a hospital setting (100:1-150:1) and confirms that 1.5 g/kg protein is a reasonable protein requirement.

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D. Using a goal kcal level of 3700 kcal/day, calculate a goal enteral tube feeding for Mr. Phillips. Use the Fairview Enteral Formulary. Provide the amount of energy, protein, and fluid provided by your nutrition prescription. (6 points)

Replete with Fiber3700 kcal/1.0 kcal/ml= 3700 ml Replete with Fiber3700 kcal/24 h/day= 154.17= 154 ml q h X 24 h (continuous feeding)3696 ml per dayENERGY: 3696 ml X 1.0 kcal/ml= 3696 kcalsPROTEIN: 3.7 Liters X 62 g protein/Liter= 229 g proteinFREE FLUID: 3696 ml X 84% free fluid= 3104.64 ml free fluid

E. Are any additional tube feeding water flushes needed? If so, what is an adequate water flush regimen, taking into account his fluid needs and amount of water being supplied by the tube feed formula? (2 points)

FREE FLUID: 3696 ml X 84% free fluid= 3104.64 ml free waterMinimum fluid requirement: 3700 ml (1.0 ml/kcal energy required)

3700 ml-3104.64 ml provided by formula= 595 ml water595ml /6= 99.17 ml… round up to 100 ml flush every 4 hours

8. A. Mr. Phillips does not have a past medical history of diabetes. Why are his blood glucose levels elevated? Explain your answer. (2 points)

Mr. Phillips’ blood glucose levels are elevated due to accelerated gluconeogenesis by the liver from lactate, pyruvate, alanine, and glycerol that occurs during the body’s reaction to trauma and stress. During stress, the body catabolizes glycogen, protein, and fat to provide glucose and fatty acids for energy, amino acids, and for the synthesis of positive acute phase proteins.

B. What is the typical method for managing elevated blood glucose levels in the intensive care unit? (1 point)

Monitor serum glucose every 6 hours and provide nutrition support therapy.

C. According to the ASPEN Adult Critical Care Nutrition Guidelines (2009), what are the recommendations for managing blood glucose in the ICU setting when providing nutrition support therapy? What is the range for blood glucose that was considered most appropriate by the Guidelines Committee? (2 points)

Keeping blood glucose in the range of 80-110 mg/dL has been shown to reduce sepsis, ICU length of stay, and hospital mortality much more so than when keeping blood glucose levels <200 mg/dL. However, more moderate control of 140-180 mg/dL has been shown to prevent hypoglycemia that might occur with more strict control of 80-110 mg/dL.

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The range for blood glucose that was deemed most appropriate in the ICU setting by the Guidelines Committee when providing nutrition support therapy is 110-150 mg/dL.

9. Over a period of weeks, Mr. Phillips’ neurological status improves and he is able to be weaned from the mechanical ventilator. Mr. Phillips still has a feeding tube in place. The Speech Language Pathologist recommends initiating a dysphagia level 1 diet (pureed), honey-thick liquids, and 1:1 supervision for all meals. Write your nutrition recommendations for transitioning to an oral diet. (3 points)

We would recommend that the patient stay on TF since we don’t know how he will react to the eating whole foods or if he will be able to sustain whole foods. First switch to a cyclic tube feeding regimen (at night) to begin the oral transition along with a 3 day calorie count to make sure he is getting proper amount of calories and protein during the day (50%-75% of needs). If he does not get enough calories and protein, Mr. Phillips will be in the hospital longer because he needs more calories and enough protein to heal his wounds from the accident. Continue tube feeding when beginning the oral diet to make up for any caloric deficit that might occur. The transition to oral feeding may be a slow, difficult process and patient may need supplementation via tube feedings to ensure he receives enough calories. Starting Mr. Phillips off on a honey thickened liquids diet only and depending how he reacts, increase levels after that.

Nutrition Diagnosis

10. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation and your IDNT Reference Manual diagnosis pages. Based on what you discovered in earlier questions, identify TWO of Mr. Phillips’ most prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS) using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE # from the IDNT Reference Manual nutrition diagnosis pages for each diagnosis you write.

A. Nutrition Diagnosis #1: (2 points)Increased energy expenditure (NI- 1.1)

B. Nutrition Diagnosis #2: (2 points)Increased protein needs (NI 5.1)

NUTRITION INTERVENTION, MONITORING AND EVALUATION

11. Now go back to your two nutrition diagnoses. For one diagnosis, write a complete nutrition diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling each section (P, E, and S) appropriately. Identify your short- and long-term goals, an appropriate intervention strategy to address the problem, and measurable outcomes you will monitor to evaluate the effectiveness of your intervention. You may want to use Module II and the “What is ADIME” document on the course web site under “Reference Materials and Resources for Clinical Cases” to help you with this question.

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A. PES: (3 points)

Increased energy expenditure related to traumatic brain injury and other trauma injuries (9 cm laceration on scalp, broken humerus, multiple broken ribs) as evidenced by hypermetabolic state determined by a measured RMR/predicted RMR ratio of 1.87.

B. Intervention Step 1: Planning (i.e. jointly establish goals with the patient)

State at least TWO short-term goals that you will establish collaboratively with Mr. Phillips. Remember that the goals should be clear, measureable, achievable, and time-defined. (4 points)

Two Short-term goals (i.e. between now and the next visit):1. Increase caloric intake to at least 3700 within 24 hours of arrival to meet extra

energy needs due to injuries caused by accident.2. Set up an entreal tube feeding within 24 hours of arrival to help meet needs for

increased energy expenditure by meeting his caloric needs (3700kcal) and protein needs (at least 138g).

3. Increase albumin levels into normal range (3.5-5.0mg/dL) by day 5 through increasing caloric intake (3700kcal) and protein intake (at least 138g).

C. Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of care with the patient)

State what nutrition-related action(s) you as the RD will take to address the problem identified in the PES statement. Be sure that the INTERVENTION will specifically address the nutrition-related diagnosis and/or its underlying etiology described in your PES statement. This information will be documented in the “Intervention” section of your ADIME chart note. (2 points)

Inform the patient to why he has increased caloric needs/increased energy expenditure (because of injuries and wounds from the accident).Educate the patient to how meeting caloric and protein needs helps heal wounds. Discuss how the patient’s calorie and protein requirements will be met while he is in the hospital (Replete with Fiber entreal tube feeding).Monitor patient’s calorie and protein intake to ensure they are getting an adequate amount.

D. Measurable Outcome: State what nutrition care indicator you will MONITOR in order to EVALUATE the progress of the patient resulting from your INTERVENTION described in part C. Nutrition care indicators are clearly defined markers that can be observed and measured and are used to quantify the changes that are the result of nutrition care. For example, food and nutrient intake data, laboratory values, etc. Keep in mind that you may also identify clinical/laboratory parameters that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is the intervention you identified for your PES. Be sure that the nutrition care indicator

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can be used specifically to evaluate the success of your nutrition intervention. This information will be documented in the “Monitoring/Evaluation” section of your ADIME chart note. (2 points)

To evaluate Mr. Phillips’ progress we will monitor calorie and protein intake to ensure it is meeting his increased energy expenditure. We can also do another indirect calorimetry to see if there are any changes in Mr. Phillips’ REE and adjust his diet accordingly. When Mr. Phillips’ neurological status improves and he can be weaned off mechanical ventilation, we can begin to initiate oral feeding. First switch to a cyclic tube feeding regimen (at night) to begin the oral transition along with a 3 day calorie count to make sure he is getting proper amount of calories and protein during the day (50%-75% of needs). We could put Mr. Phillips on a honey thickened liquids diet and observe how this transition is going for him and based on our observations, we can decide if he is ready for oral feeding. When doing this transition we would monitor Mr. Phillips nutrient intake (calories, protein, fat, carbs, vitamins, minerals, etc.), blood glucose levels, and albumin levels to ensure they fall within normal range. If they do not fall within normal range, we would adjust Mr. Phillips diet accordingly.We would also monitor and observe any changes in Mr. Phillips’ injuries that would indicate if our nutrition care is helping his wound healing. We could also monitor the patient’s white blood cell count to determine if his body is healing properly or if it is fighting an infection.

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