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Care Conference

Care Conference. Caryn Massimino U C onn 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

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Care Conference

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  1. Care Conference Caryn Massimino UConn Health Center

  2. 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

  3. 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%

  4. 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

  5. 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

  6. Intestinal Perforation • Treated with temporary Ileostomy or Colostomy • Complications include wound failure • Partial/total disruption of any layers of operative wound • Higher risks with patients who use Corticosteroids, Sepsis, heavy coughing

  7. 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): PeptamenAF 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

  8. 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

  9. 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.

  10. 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

  11. 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

  12. Alterations To Diet Order • Peptamen AF TF: 30cc/hr24hr • TPN: D 20/AA 7.5 60cc/hr24hr • 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.

  13. 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.

  14. 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/.

  15. Questions?

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