1. Medical Nutrition Therapy Clinical Experience Kathleen Dorsch FND 431-900 Spring 2011

2. Patient Information Patient PD is a 53 YO female admitted with hypoxia, respiratory failure, septic shock, and community-acquired pneumonia Patient sedated and intubated NPO diet order initiated nutrition assessment

3. Nutrition Assessment Ht: 165cm; Wt: 95kg; IBW: 56.7kg; BMI: 35 Labs: WBC 3.2, Na 134, K 3.5, Glu 133, albumin 2.9, prealbumin 8.3 Meds: Propofol, Bactrim, Levaquine, Zosyn, Lovenox, sliding scale insulin EEN: 25 kcal x 56.7kg IBW=1,417 kcal Protein: 2 g/kg x 56.7 IBW=113 g

4. Nutrition Diagnosis Inadequate oral food/beverage intake related to intubation and ventilator as evidenced by NPO diet order.

5. Nutrition Intervention Nasogastric tube for enteral feeding PD needs ~1,500 kcal/day Propofol is lipid-soluble and contributes 1.1kcal/ml. PD was given 40ml/day, which contributed 1,056 kcal Patient received 500ml of 1.0kcal high protein formula and 2 Beneprotein packets/5 times a day Total kcal=1,556; total protein=91.25 Goal rate: 25 ml/hr; tube flushed with 30ml of water every 6 hrs

6. Nutrition Monitoring Patient tolerance and s/s of nausea, vomiting, diarrhea (daily) Gastric residual volume every 6 hours (if >300 ml w/o n/v/d, return residuals to stomach and reduce flow to lower rate) Serum electrolytes, BUN, creatinine twice weekly Glucose checked 2 times a day Monitor Propofol use and adjust tube feeding order as needed

7. Nutrition Monitoring/Evaluation After several days, PD was able to be extubated and Propofol discontinued Needs recalculated to 1,700 ml of high protein enteral formula and Beneprotein discontinued Total kcal=1,700; total protein=106g Labs recorded after extubation:  BUN 20 mg/dl  Creatinine 0.5 mg/dl  Glu 121 mg/dl  Na 143 mEq/L  K 3.8 mEq/L  Albumin 2.6 g/dl  Phos 3.8 mg/dl

8. Nutrition Evaluation PD was evaluated by the speech therapist after being extubated Oral feedings resumed Patient released on February 1, 2011

9. ADIME Chart Note Nutrition Assessment Pt is 53YO female admitted w/ hypoxia, respiratory failure, septic shock, community- acquired pnuemonia Ht: 165cm; Wt: 95 kg; IBW: 57 kg; BMI: 35 Labs noted: WBC 3.2, Na 134, K 3.5, Glu 133, albumin 2.9, prealbumin 8.3 Medications: Propofol, Bactrim, Levaquine, Zosyn, Lovenox, sliding-scale insulin EEN: 25kcal x 56.7kg IBW=1,417 calories and 2g/kg x 56.7kg IBW=113 g protein Current diet is NPO, intubation and ventilator Nutrition Diagnosis Inadequate oral food/beverage intake related to intubation and ventilator as evidenced by NPO diet order Nutrition Intervention Tube feeding initiated Goal rate: 500 ml Promote high protein formula without fiber Delivered 25 ml/hr over 20 hours; flush tube with 30 ml every 6 hours 2 packets Beneprotein 5 times/day Total kcal= 1,056 kcal/day from Propofol + 500 kcal enteral formula=1,556 kcal total Nutrition Monitoring Monitor pt tolerance & s/s nausea, vomiting, distention Monitor gastric residual volume every 6 hours Monitor serum electrolytes, BUN, creatinine, glucose Monitor Propofol use and adjust TF as needed to provide adequate calories and protein