Complete the table below for all diagnoses and relevant disorders included in medical record. Diagnosis or Disorder with ICD-10 code Definition and Etiology Pathophysiology Current Medical Treatment Nutritional Treatment Hypoxic Respiratory Failure* ICD-10-CM J96.01 -Occurs when the respiratory system can no longer carry out normal functions.1 -Usually a direct result of chronic conditions such as COPD or acute injury to the respiratory system such as those associated with ARDS.1 -In the case of this Veteran, pulmonary and volume (fluid) overload likely caused an increase in pressure within the alveolar and capillary space. This pressure impairs gas exchange and -Ineffective gas exchange across the which results in any of the following: an abrupt cessation of respirations, confusion, or unresponsiveness.1 -The presence of hypoxia indicates either a specific body system or the body has been deprived of adequate oxygen.1, 2 -Oxygen therapy via cannula, face mask, CPAP, BiPAP, or mechanical ventilation. The Veteran received all of these forms of oxygen therapy plus oxymizer and high-flow nasal cannula. 1 -Additional treatments include pharmacological agents such as respiratory stimulants, bronchodilators, antibiotics, steroids, sedatives, narcotics, and paralytic agents.1 -Nutritional needs will vary from patient to patient; therefore treatment will be individualized. Thorough nutrition assessment is warranted. If mechanical ventilation is utilized, nutritional treatments need to be appropriate in order to promote successful ventilator weaning. 2 -Early and aggressive nutrition support has been found to greatly improve patient outcomes. Research has
Nutric Score of ≥5 which indicates high nutrition risk and was initially hemodynamically stable. Pulmonary Edema* ICD-10-CM J81.1 -An abnormal accumulation of fluid in the lungs. -Likely cause for this case would be the volume overload patient is experiencing due to ESRD. Other contributors to pulmonary edema include CHF, HTN, certain medications, and traumatic lung injury.3 -As fluid begins to accumulate within the lungs, the flow of oxygen is impaired. As a result shortness of breath is experienced.3 -Oxygen therapy via cannula, face mask, CPAP, BiPAP, or mechanical ventilation. The veteran received all of these forms of oxygen therapy plus oxymizer and high-flow nasal cannula.1 -Medications such as diuretics are used to help remove from the body.3 -A diet low in sodium and fat has to be beneficial. Additionally a fluid restriction of 1-1.5L/d may be warranted.1 End Renal Disease* ICD-10-CM N18.6 -When individuals with chronic kidney disease have a glomerular filtration rate (GFR) of 15 mL/min/1.73m^2) or less along with -Abnormal functions associated with ESRD include a dangerous amount of wastes building up within the large increases in blood pressure, - Medical treatments include HD, peritoneal dialysis (PD), CRRT, or kidney transplant.1 -Patients will often present with iron-deficiency anemia, low vitamin D status, and altered bone mineral metabolism. These patients -Malnutrition is a huge concern with this population, especially ages 65 and above.4 -These patients require an
it is important to make sure serum phosphorus is within normal limits to ensure refeeding syndrome is not occurring. With CRRT, requirements for phosphorus might actually increase. Therefore continuous monitoring is a must.1, 2 Unstable Angina* ICD-10-CM I20.0 -Chest pain which occurs while at rest.1 -Possible etiologies include CAD and past history of MI.1 -Cardiac dysrhythmias and alterations in electrical transmission of cardiac muscles can be a direct result from hyperkalemia.1 -Erosion or rupture of atherosclerotic plaques takes place.1 -This results in thrombus formation and vasoconstriction.1 -Percutaneous Coronary Intervention (PCI) with stent placement is often necessary.1 The Veteran had a past history of this. -Use of medications that work to break apart clots, oxygen therapy, aspirin, and morphine are additional medical treatments.1 -Diet education with an emphasis on limiting trans and saturated fats.1 -Therapeutic Lifestyle Changes diet has been found to be beneficial.1
Metabolic Acidosis* ICD-10-CM E87.2 -Any type of acidosis not caused by excessive amounts of CO2.1 -In this case study, metabolic acidosis likely occurred due to high levels of bicarbonate excretion from the kidneys.1 -Poor kidney function disrupts the acid buffer system within the body. The kidneys fail to respond to high levels of hydrogen ions in the blood as well as to retain HCO3-.1 -The goal is to treat the main cause of acidosis. It is important to avoid correcting pH too quickly, as that can cause further complications.1 -Nutritionally, it is important to encourage patients to adhere to any fluid restrictions. With CKD, the combination of volume overload and pulmonary edema can create both respiratory and metabolic acidosis.1 Volume (Fluid) Overload* ICD-10-CM E87.7 -The most common culprit to volume overload is a reduction in urine output.1 -When excess fluid is present, fluid will shift into interstitial spaces causing edema.1 -Volume overload increases blood pressure and overworks the heart.1 -Medical treatment will focus on the root cause.1 -In this case, the Veteran received diuretics. -Encourage patients to adhere to fluid and sodium restrictions.1 Anemia, Unspecified ICD-10-CM D53.9 -Unspecified anemia is generally considered more of a symptom due to an underlying disease.1 -A lack of erythropoietin contributes to an overall decrease in the production of red cells and a subsequent drop in -Treatment centers around recombinant human erythropoietin (rHuEPO) as well as iron supplementation either orally or intravenously.1 -Educating patients on heme and nonheme iron food sources. -Educating patients on tips to
-In this case study, the likely cause of anemia was related to poor kidney function and the inability to produce the hormone erythropoietin.1 hemoglobin levels.1 -If left untreated, anemia can lead to any of the following: cardiac and ventricular hypertrophy, angina, CHF, malnutrition, and poor immunological response.1 absorb iron from nonheme food sources (this can be a bit of a challenge since a lot of common acidic used to promote iron absorption are high in potassium).1 Abdominal Aortic Aneurysm without rupture ICD-10-CM I71.4 -A weak portion of the abdominal aorta wall without complete breakage. Usually the vessel widens and forms a rounded dilation.1, 5 -Likely etiologies include CAD, HTN, HLD, poor diet, and lack of physical activity. All of these contribute to plaque formation in vessels like the aorta.1 -Inflammation and insult from plaques in the aorta are the likely cause of the weakened portion of the vessel wall.1 -Often invasive surgical procedures are necessary to correct the dilation. These include open surgery with prosthetic graft placement or the less invasive endovascular aneurysm repair (EVAR).5 -Similar to the nutrition treatments for CAD. -A heart-healthy, low-sodium diet. -Tobacco cessation. -Weight loss -Physical Activity -Regular blood pressure and cholesterol screenings.1
Coronary Artery Disease with Myocardial Infarction ICD-10-CM I25-10 -CAD is a term often used to classify all causes of heart disease which are associated with the narrowing of blood vessels supplying the heart.1 -Etiologies include family history, age, gender, HLD, HTN, T2DM, obesity, poor diet, tobacco use, and physical inactivity.1 -An increase in the hardening of atherosclerotic plaque results in narrowing of blood vessels. If plaque breaks loose and becomes lodged in a narrowed vessel, blood flow ceases and the heart can become deprived of oxygenated blood. The end result is an MI.1 -Drug therapy includes statin drugs, bile acid sequestrants, nicotinic acid, fibric acids, and in the case of an MI nitroglycerin, supplemental oxygen, aspirin, and morphine for pain.1 -One surgical treatment is Percutaneous Coronary Intervention (PCI) with stent placement. The Veteran had a past medical history of this. -Other procedures include atherectomy/endarterectomy, laser angioplasty, Percutaneous Transmyocardial Revascularization (PTMR), and Coronary Artery Bypass Graft (CABG).1 -The goals of nutrition intervention for CAD is to prevent further narrowing of blood vessels which could result in an MI. -Nutrition intervention centers around the Therapeutic Lifestyle Changes (TLC) diet. This diet stresses limiting saturated and trans fats within the diet. This diet promotes consumption of monounsaturated fats, omega-3 fatty acids, and omega-6 fatty acids.1 -Other components of this diet include increasing fiber intake through whole grains,
fruits, and vegetables.1 -Other interventions include physical activity and weight loss.1 Gout ICD-10-CM M1A.9 -Gout is an inflammatory disease. It causes redness, swelling, pain, heat, and rigidity in the impacted joint.1 -Gout occurs when the amount of uric acid in the blood becomes so elevated that uric acid precipitates into crystals within synovial fluid of joints.1 -Risk factors for gout include genetics, being male, old age, obesity, a diet rich in purines, excessive alcohol intake, and use of certain medications -Uric acid is a result of purine metabolism.1 -The synovial fluid is an inadequate solvent for uric acid and therefore precipitate is likely to form there.1 -For mild cases, Nonsteroidal Drugs (NSAIDs) are used to resolve pain and inflammation.1 -For chronic cases, glucocorticoids and cochicine are used to lessen inflammation.1 -Lifestyle changes such as moderate alcohol intake, eating a diet in high/moderate purine rich foods, achieving a healthy body weight, and avoiding crash dieting.1
including aspirin, diuretics, and cyclosporine.1 -Comorbid conditions that can increase the likelihood of gout include HTN, T2DM, HLD, renal insufficiency, and anemia.1 Type 2 Diabetes Mellitus ICD-10-CM E11.8 -The direct result of the body’s inability to use the hormone insulin to transport glucose from the blood into the cells for use as energy.1 -Overtime insulin resistance can cause consistently elevated blood glucose levels. This can lead to damage of blood vessels, nerves, and organs.1 -T2DM can when insulin demand is greater than what the pancreas is capable of producing.1 -On the other hand, the pancreas may be making enough insulin but the cells have developed a resistance to it due to consistently elevated levels.1 -Either abnormality can result in chronically elevated blood glucose levels.1 -Medically, the first route of treatment is glucose lowering medications. There are several drug classes available on the market: biguanides, sulfonylurea agents, thiazolidinediones, GLP-1 receptor agonists, DPP-4 inhibitors, and inhibitors.1 -Perhaps the most commonly used medication is metformin, however its use presents with terrible GI side effects. 1 -If blood sugars are still persistently elevated, the next step in medical treatment is initiation of recombinant human insulin. Several different insulin -T2DM can be managed or prevented through a consistent carbohydrate diet and regular physical activity. 1 -Depending on how the patient learns and what the patient is willing to do, several methods can be used to teach patients about a consistent carbohydrate diet. These
regimens can be used in order to better control blood glucose. 1 -Above all, the most important tool, in terms of medical interventions, is the use of a blood glucose monitor and log book in order to check and monitor blood sugars. 1 include the use of the ADA’s Create Your Plate, the Diabetic exchange system, or carbohydrate counting. 1 -Additional education on healthy, “nutrient-dense” carbohydrate sources vs “empty-calorie” carbohydrate sources may be necessary as well. 1 Hyperlipidemia ICD-10-CM E78.5 -Hyperlipidemia is a term used to describe a lipid panel that reflects an increased likelihood for CAD development.1 -Usually a patient will present with elevated total cholesterol, LDL cholesterol, and Triglyceride -High amounts of cholesterol and lipids in the blood can cause the development of atherosclerotic plaques. 1 -Drug therapy includes statin drugs, bile acid sequestrants, nicotinic acid, and fibric acids. 1 -Nutrition intervention centers around the Therapeutic Lifestyle Changes (TLC) diet. This diet stresses limiting saturated and trans fats within the diet. This diet promotes consumption of monounsaturated
consistency modification took place and to provide them with information on how to carry out a soft diet in the home should they be discharged. 1 Respiratory Therapy -Respiratory therapy is provided by a nurse who is a specialist in diseases of the respiratory system. 1 -He or she is knowledgeable in the various equipment used to provide supplemental oxygen to patients; as well as what indicators to monitor when accessing oxygen status.1 -Good communication between respiratory therapists and RDs is necessary in order to provide the right amount of nutrition to the patient. Energy needs will depend highly on the patient’s current situation in regards to overall oxygenation, what mode of supplemental oxygen they are placed on, and their overall metabolic state. 1 Hemodialysis (HD) -HD requires access to the blood either through an AV fistula or graft. Once access is obtained, a patient is hooked up to a dialysis machine with a semi-permeable membrane referred to as a dialyzer. 1 -Wastes and uremic toxins are removed from blood by the dialyzer and the clean blood is returned to the body. 1 -HD has a significant impact on overall nutrition status. -Several studies looking at elderly populations receiving HD have found an increased likelihood for malnutrition, frailty, and overall mortality.4, 7 Continuous Renal Replacement Therapy (CRRT) -CRRT is often used with acute kidney injury; especially in patients with multiple organ failure.1 -Patients that typically go on CRRT include the hemodynamically unstable, those with inadequate cardiac output, and those who simply cannot tolerate HD. 1 -In the case of this Veteran, he continued to be hypotensive during HD and thus was placed on CRRT. -CRRT is provided continuously at a much slower rate. This allows for a significant amount of fluid to be removed. 1 -With CRRT, energy especially protein needs, are much higher. 1 -As with HD, patients placed on CRRT are at an increased risk for malnutrition simply due to the high levels of catabolism within the body. 1, 8
-May cause edema, belching, gastric distention, cramps, flatulence Carvedilol Tab* 25 mg by mouth two times a day -CHF treatment -Anti-HTN -Non-selective Beta blocker & Alpha1 blocker grapefruit juice -Depletes -Avoid natural licorice -Can cause weight gain, nausea/vomiting, diarrhea Potassium Chloride Injection, Solution 40 MEQ in Sodium Chloride 0.9% Injection 500 mL intravenously Infuse over 4 – 3 doses total -Electrolyte -Mineral Supplementation -Needed due to Veteran’s drop in potassium after Kayexelate administration and diarrhea -May cause GI irritation, nausea/vomiting, diarrhea, flatulence, abdominal pain Sodium Chloride 0.9% Intravenous Bag Injection in Normal Saline 500 mL -Electrolyte -Mineral Supplementation -Fluid replacement -Works to increase blood pressure -Caution with high blood pressure, fluid retention, CHF, kidney disease, liver disease, pleural effusion Naloxone 0.4 mg/mL Injection, Solution Give Once -Opioid -Pain management -Avoid Alcohol Furosemide* 500 mg in Normal Saline 50 mL concentration: Run at 80 mg/hr intravenously -Loop Diuretic -Anti-HTN -To treat edema associated with CHF, renal, or hepatic disease -Depletes potassium, calcium, magnesium, sodium, thiamine, vitamin B-6, vitamin C, and zinc -May cause anorexia, increased thirst, oral irritation, cramps, nausea/vomiting, diarrhea, constipation Albumin 25% (Human) Injection 50 g IV Once Given during HD -Anti-hypoalbuminemia -Often indicated in order to correct fluid -Use with caution when the following conditions are present: cardiac insufficiency, HTN, pulmonary edema, esophageal varices, severe anemia, anuria
Biochemical Data, Medical Tests and Procedures Laboratory data – The dates listed below were labs drawn on the days I visited with the Veteran. Lab Test Normal Range 6/22 6/24 6/27 6/29 6/30 Explanation1, 10 Glucose 70-105 mg/dL 137 H 179 H 144 H 146 H 163 H Hyperglycemia occurs in patients with poorly controlled T2DM. Additionally the Veteran in this case was under high metabolic stress. When the body is in a catabolic state, blood glucose is elevated. This explains why the Veteran was placed on an insulin regimen verses just his glipizide pill. Urea Nitrogen 10-20 mg/dL 125 H 73 H 67 H 54 H 53 H BUN can be elevated with high protein intake, inadequate urea excretion by the kidneys, dehydration, catabolism, CHF, poor dialysis, GI bleeding, and certain medications. After dialysis initiation on the 23rd, BUN did drop but still remained high up until passing. Creatinine 0.6-1.2 mg/dL 7.38 H 5.62 H 2.22 H 3.16 H 2.72 H Creatinine is high during times of muscle damage, catabolism, MI, CKD, poor dialysis,
amounts of diarrhea as a side effect of this drug. White Blood Cell Count 4.5-10.9 k/cmm 12.2 H 11.6 H 12.0 H 13.7 H 14.7 H White blood cells are elevated at times of infection, inflammation, trauma, stress, catabolism, and certain medications. The Veteran arrived at the ER already in a lot of stress due to unstable angina and failing kidneys. As he began to deteriorate, his body was in a complete state of catabolism resulting in continual increases in WBC Count. Hemoglobin 14-18 g/dL Men 6.8 L 7.7 L 7.5 L 7.7 L 7.6 L Hemoglobin can drop due to iron deficiency, anemias, blood loss, and ESRD. Erythropoietin is produced by healthy kidneys. In failing kidneys, erythropoietin no longer works to generate red blood cells and therefore a reduction in overall hemoglobin occurs. Hematocrit 42-52% Men 20.6 L 23.1 L 23.3 L 23.6 L 23.6 L Hematocrit decreases with ESRD, anemias, loss of
Value Value Value intake, poor absorption, or loss. Likely the Veteran’s low iron status was due to a limited production of RBCs which contain hemoglobin. Hemoglobin is what binds and transports iron throughout the body. Total Iron Binding Capacity (TIBC) 250-420 ug/dL 186.4 L No New Value No New No New No New Value TIBC can be low due to malnutrition, chronic disease, infection, and inflammation. The Veteran presented with all four of indicators upon admission. Iron Saturation 20-50 % Men 8.6 L No New Value No New Value No New Value No New Value Iron saturation can be low due to malnutrition, chronic disease, infection, and iron deficiency. The Veteran presented with all four of these indicators upon admission. Transferrin 215-365 mg/dL Men 125.1 L No New Value No New No New Value No New Value Transferrin can be low due to malnutrition, chronic disease, infection, and inflammation. The Veteran presented with all four of these
indicators upon admission. Calculated Estimated Serum Osmolality 275-295 mosm/kg 354 H 320 H 309 H 316 H 310 H Serum osmolality may be elevated during times of hyperglycemia, uremia, dehydration, hypernatremia, or poor secretion of antidiuretic hormone. The Veteran presented to the ER with uremia due to ESRD and hyperglycemia. The Veteran was also placed on diuretics in order to remove fluids. Estimated Glomerular Filtration Rate (EGFR) Normal Kidney Function Value is ~125 mL/min/1.73m^2 7 ESRD Dx 9.6 22.2 18.6 22.1 EGFR provides an estimate of the filtration rate/clearance ability of the glomerulus within the kidney. It is a common value used to stage CKD. Lactic Acid 0.7-2.1 mmol/L No New Value No New Value 1.2 1.6 No New Value Lactic acid is frequently monitored in the critical care setting. This value helps determine the extent of the tissues’ ability to receive oxygen. If the body cannot receive adequate oxygen supply, glucose is metabolized anaerobically
-Ostomy/Wound nurse noted no pressure ulcers on sacrum/coccyx or elsewhere, only some issues on buttocks that appeared to be related to moisture. Excretory -Foley catheter in place -500 mL output over 5 on furosemide Using the Subjective Global Assessment upon initial visit on 6/22/16, I was able to conclude that the Veteran was at moderate risk for malnutrition. The table below conveys my findings. SGA Component Findings Nutrition Implication1 Potential Intervention1 Weight History -Per Veteran’s family, UBW was 160 lb and last weight per CPRS was 159 lb -Veteran presents weight stable = 0 points -At that in time weight per CPRS likely inaccurate due to volume overload. -Determine Veteran’s dry weight and base estimated energy needs off of that weight. -With elderly patients on dialysis, the risk for malnutrition is high. Goal is to maintain weight status. Appetite/Intake -Per Veteran’s family, Veteran has a poor appetite. -Significant appetite/intake changes = 2 points -Nutrition needs would likely be met by diet + oral supplements either in the form of dense -Poor appetite indicates overall inadequate oral intake. -Veteran’s appetite changes likely due to uremia and fluid overload. -A patient on dialysis requires higher energy needs than a healthy person. -If needs are not being met, an individual is at an increased risk for malnutrition. -Potential interventions involve
snacks, Ensure Muscle Health, or ProGelatein = 1 point When BUN and creatinine are elevated, an individual’s appetite is greatly impacted. learning patient’s food likes and dislikes and working with them to modify those favorite foods to be higher in calories/protein. Gastrointestinal Symptoms N/V -Veteran is edentulous and has dentures. I suspected the Veteran’s weight was a reflection of volume overload and his current weight was less than his As a result his dentures fit poorly and were the culprit to his chewing difficulties. If unable to chew solid foods, Veteran would likely consume a reduced percentage at meals. Chewing issues = 1 point -Veteran had experienced 2 bouts of choking and coughing up food when on the AHA diet. Swallowing difficulties = 2 points -Veteran presented with nausea with occasional vomiting since prior to admit. Uremia as a result of renal failure, likely the cause and a primary reason for appetite changes. Nausea issues greater than 3 days = 1 point -Veteran experienced diarrhea as a result of receiving Kayexelate for hyperkalemia. Large volumes of -For chewing and swallowing: Veteran had a consult with speech. Per speech recommendations, the Veteran’s diet needed to be downgraded to a consistency that could be chewed and swallowed safely. -For nausea/vomiting: Veteran may benefit from consuming liquids separately from foods, consuming cold food items, consuming foods with weak aromas, asking nursing to remove tray lid from food outside of room, and consuming bland/dry food items. Monitoring of
Edentulous with dentures Mild bilateral muscle wasting of the temporal and interosseous regions Mild fat loss of the orbital regions Frail arms with thin skin by other health care providers: Ecchymosis on bilateral extremities 2+ pitting extending all the way up -Changes in LOC likely due to medications, disease processes, or pain. -Mild muscle and subcutaneous fat loss indicative of inadequate calorie/protein intake. -Frail arms with thin skin likely due to advanced age. -Ecchymosis indicative of vitamin K, ascorbic acid, or deficiencies. -Pitting can be related to overall fluid status along with inadequate edema, and improve weight status. -Learn patient’s food likes/dislikes to provide a diet rich in calories/protein the patient is more likely to consume. -If intake continues to be poor and malnutrition is of major concern, use of oral nutrition supplements or enteral nutrition may be warranted. -For ecchymosis, supplementation of vitamin K and vitamin C may be warranted with educating patient on foods rich in those nutrients. -For pitting edema caused by volume overload, encourage patient to adhere to fluid restrictions. Provide patient with education on how to better control thirst.
Evaluation of Diet Orders (Nutrition Prescriptions): List diet orders in chronological order. Complete hospital diet history-include all diet orders from date of admission Date of Diet Diet Order EN/PN/PPN/oral/supplements Is Diet Order Appropriate? Why or Why Not? Explain if change in estimated needs. Changes Indicated and Supporting Rationale 6/20/16 2100 kcal American Heart Association (AHA) Diet to choking event, this diet would be appropriate for the Veteran. It provides adequate protein and calories and is limited in sodium which would help with fluid overload. -The VA does an AHA/ADA combination diet order; however the only major differences are fruit items for dessert verses sweets. Since the Veteran has a poor appetite, double restrictions might further exacerbate the issue of overall poor oral intake. -Veteran had not officially been diagnosed with ESRD at this point and therefore had CKD without any type of renal replacement therapy. -His needs at this point were 2169-2531 kcal/d, 80-101 g pro/d, and fluids as indicated by physician due to volume overload. (30-35 kcal/kg and 1.1-1.4 g/kg based on weight of 72.3 kg) 6/21/16 AM NPO Waiting for Speech to Evaluate -This diet is appropriate since the Veteran had a choking event and needs to undergo a swallow study to determine what consistency is safe. -However a diet order of NPO is not appropriate for anything longer than 3 days. -The results of the bedside swallow concluded the Veteran needed a soft diet consistency. He could continue to drink thin liquids as tolerated. 6/21/16 PM – 6/27/16 PM Soft, 2200 kcal American Diabetes Association (ADA) Diet + Chocolate Ensure Muscle Health three times daily between meals -This diet is appropriate in terms of calories, consistency, and blood glucose control. The commercial oral nutrition supplements were implemented to provide additional protein without impacting blood glucose. -Chocolate Ensure Muscle Health provides 160 calories, 16 grams of protein, and 19 grams of carbohydrate compared to Ensure Plus which has 350 calories, 13 grams of protein, and 51 grams of carbohydrate. This will help with blood glucose control.15
INTERVENTIONS, MONITORING AND EVALUATION Date Nutrition Problem(s) Intervention (what was done) Monitoring Criteria (signs/symptoms followed to determine whether interventions worked) Outcome (were nutrition goals met) Intern Action 6/22/16 - Inadequate energy intake - Food- and nutrition-related knowledge deficit -Food &/OR Nutrient Delivery: Meals and Snacks→ (Soft, per Speech recs, Easy to Chew), Diet (2200 ADA, diet) & Nutrition Supplement Therapy→ Medical Food Supplement Therapy (Commercial Beverage; Ensure Muscle Health) -Nutrition Education: Nutrition relationship to health/disease (Importance of protein for wound healing and dialysis treatments) -Food/Nutrition-Related History: Food & Nutrient Intake→ Monitor food intake (amount and types of foods/beverages), total energy intake, modified diet order tolerance -Nutrition-Focused Physical Findings: Monitor nausea/vomiting -Food/Nutrition-Related History: Food & Nutrient Intake→ Macronutrient Intake: Monitor total protein intake, high biological value protein intake (Helps determine if education provided was understood) -Nutrition-Focused Physical Findings: Monitor -Food & Nutrient Intake: Not Met -Nausea/Vomiting: Improved/Resolved -Macronutrient (Protein) Intake: Not Met -Potential pressure injury to buttocks: Not Met -Obtained Veteran’s food preferences/intolerances from family and entered them into Computrition. -I knew he already enjoyed drinking chocolate Atkins shakes so determined it would be appropriate to send him chocolate Ensure Muscle Health three times daily in between meals for additional calories/protein. -Provided nutrition education related to the importance of protein for wound healing and dialysis treatments to his family. Verbalized to family to encourage Veteran to eat all the protein foods on his tray first before satiety sets in. Provided handout from VA Nutrition and Food Services Patient Education Materials Library.
breakfast tray before moving to the other items. 6/27/16 -Inadequate oral intake -Food &/OR Nutrient Delivery: Nutrition Supplement Therapy→ Medical Food Supplement Therapy (Commercial food, ProGelatein), Enteral and Parenteral Nutrition→ Enteral Nutrition (Recommend insert enteral feeding tube) -Nutrition Education: Nutrition Nutrition relationship to health/disease (Importance of calories/protein with CRRT/HD) -Coordination of Nutrition Care by a Nutrition Professional: Collaboration and Referral of Nutrition Care→ Collaboration with other providers -Food/Nutrition-Related History: Food & Nutrient Intake→ Monitor food intake (amount and types of foods/beverages), total energy intake, modified diet order tolerance -Food/Nutrition-Related History: Food & Nutrient Intake→ Macronutrient Intake (monitor total protein intake, high biological value protein intake) -Food/Nutrition-Related History: Food & Nutrient Administration→ Diet History (Enteral nutrition order) & Enteral and Parenteral access (enteral access) -Food & Nutrient Intake: Not Met -Macronutrient (Protein) Intake: Not Met -Food & Nutrient Administration: Not Met -Added fruit punch ProGelatein three times daily with meals for additional calories/protein. Per Veteran’s family he likes gelatin. -Added prune juice to his breakfast tray because Veteran was dealing with some constipation. Relief of constipation could improve overall intake. -Provided additional nutrition education to family related to the importance of calorie/protein intake when undergoing CRRT/HD. Also discussed frozen frozen meal options. Provided handout from the Journal of Renal Nutrition. -Compiled two sets of enteral nutrition recommendations: one tailored to meet Veteran’s needs on CRRT and the other one tailored to meet his needs should he transition back to HD.
-Shared my recommendations at the MICU huddle, a daily interdisciplinary team meeting. 6/29/16 - Enteral nutrition administration inconsistent with needs -Food &/OR Nutrient Delivery: Enteral and Parenteral Nutrition→ Enteral Nutrition (modify concentration of enteral nutrition) -Food/Nutrition-Related History: Food and Nutrient Intake→ Enteral and Parenteral Nutrition Intake (Enteral nutrition formula/solution) -Food/Nutrition-Related History: Food and Nutrient Administration→ Diet History (Diet Order: Enteral Nutrition Order) -Enteral Nutrition Formula: Not correct formula; energy needs not met -Enteral Nutrition Order: order placed but not correct order to meet needs -Viewed tube feeding pump at bedside with 1.2 kcal/mL formula when my recommendations were using a 2 kcal/mL formula. -Notified nursing of this error but then later returned to the pump to find a 1.5 kcal/mL bag hanging. 6/30/16 - Inadequate enteral nutrition infusion -Food &/OR Nutrient Delivery: Enteral and Parenteral Nutrition→ Enteral Nutrition (Modify rate of enteral nutrition) -Food/Nutrition-Related History: Food and Nutrient Intake→ Enteral and Parenteral Nutrition Intake (Enteral nutrition formula/solution) -Food/Nutrition-Related History: Food and Nutrient Administration→ Diet History (Diet Order: Enteral Nutrition Order) -Enteral Nutrition Formula: Once tube feeding resumed; correct formula for new recommendations was used (1.5 kcal/mL) -Enteral nutrition Order: order placed but not correct order to meet needs -Notified Fellow at MICU huddle that once tube feeding was turned back on, I had new recommendations. -Followed nursing flow sheets in order to determine when Veteran became more hemodynamically stable. -Monitored tube feeding pump history and flow sheets to determine if rate had advanced.