Nutrition Database

This assignment is intended to collect information and apply Medical Nutrition Therapy related knowledge
to a disease condition. All data will be kept confidential and anonymous, no patient names, initials,
room numbers, birth dates, or other personal identifiers will be collected.

Intern Name Kelby Brink Clinical Core Rotations: Basic / Intermediate / Advanced

Patient Age 40_____ Sex  Male  Female Your Assessment Date 2/14/19 Admit date 1/11/19

Admitting Diagnosis Gastroparesis

Prior Medical History Type 2 Diabetes, Hypertension, CKD Stage 4

Diet Order Clear Liquids with EN and TPN Supplements none

If applicable, describe food intake since admission or past 5 days (use percentages, expressed as a range or an average,
describe other pertinent issues or if common in facility mark checkbox on right to specify)  Good  Fair  Poor

Jevity 1.5 @ 25mL/hr, AA 15% 450mL, D50 500mL, Lipid 150mL, not consuming clear liquids

Any Food Allergies / Intolerances? none

Height and Weight: HT (in inches and cm)65in, 165.1cm Current WT (in pounds and kg)107kg, 235.4# BMI 39

How was height obtained? stated How was weight obtained? Standing scale

Ideal Body Weight (IBW) 125# % IBW 188 % Usual Body Weight (UBW) 235# % UBW 100 %

If the patient had a weight change, indicate this in pound and kg and % gained/lost and the timeframe. Was this
unintentional or intentional? Give the reason(s). Using the cutoff-percentages was this loss/gain significant?

No recent weight changes, however has not been reweighed since admission

if applicable Dry Weight (in pounds and kg)

if applicable in your facility: What is the patient’s adjusted weight (in pounds and kg)

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)

She is single, non-smoker. She has type 2 Diabetes and is not using her prescribed insulin regimen at home. She
cooks meals for herself or will eat out and she drinks alcohol socially.

Advance Directive:  Yes  No Nutrition related implications?

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Skin Integrity / Chewing and Swallowing Ability / Misc. Info

Is Patients Skin Intact? Yes  No  Braden Score PUSH Score

If no, what is present? Surgical Wound  Decubitus Ulcer 

Does the patient have Edema  if pitting, state stage and site Ascites 

If decubitus ulcer, list stage (I-IV) and site(s)

If decubitus ulcer, is it Improving?  Getting worse? 

Incontinent of urine? Yes  No 

Urinary catheter? Yes  No  output in mL over past 24 hours mL

Date of last BM & consistency 2/13/19, small and loose Bathroom privileges Yes  No 

Are any of the following present? Nausea  Vomiting  Diarrhea  Constipation 

Difficulty Chewing  Difficulty Swallowing 

Own teeth  Edentulous 

Dentures? Yes  No  Fit well? Yes  No 

Unable to feed self  Malabsorption 

Early Satiety  Taste Changes 

Is patient on dialysis? Yes  No  if yes, what type Schedule

Is patient on a ventilator? Yes  No 

Most recent blood pressure 117 /68 is BP stable? Yes  No 

Most recent temperature 97.9 °F

Is patient receiving IV Fluids? Yes  No  if yes, what type / rate / total volume in past 24 hours

If applicable, how many g Dextrose and kcal does this provide?

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Nutrition Focused Physical Exam (fill out all the info in this section you collect during the NFPE. We realized that not all
healthcare settings utilize this yet, and that not all use all parameters listed below. If you do not conduct the NFPE, do your best
to fill in as much info as you can. Much can be assessed visually during a patient visit.)

 Muscle loss / wasting detected? Yes  No 

if yes, mild to moderate or severe? moderate

 Fat loss detected? Yes  No 

if yes, mild to moderate or severe? moderate

 If edema is present (you answered above), is it related to malnutrition? Yes  No 

 If patient experienced weight loss, give the percentage lost and time frame wt loss unknown

 Describe the patient’s intake in the context of the NFPE inadequate intake for > one month

 Reduced Grip Strength? Measured with Dynamometer Yes  No 

if yes, mild to moderate or severe?

 Any potential micronutrient deficiencies present? Yes  No 

if yes, list

 If you think malnutrition is present is it in the context of an

Acute Illness 
Chronic Illness 
Social or Environmental circumstances 

 If you think malnutrition is present, make sure to select an appropriate PES statement towards the end
of this assignment.
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Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)

Drug name(s) Indication Nutritional Implication / food

Interaction
Alteplase Anticoagulant
Amitriptyline Antidepressant Increased fiber
decreased drug
effectiveness, avoid St.
John’s Wart, caution
with grapefruit
Amlodipine Antihypertensive Avoid natural licorice
Apixaban Anticoagulant Avoid herbal products,
avoid St. John’s wart,
caution with grapefruit
Asenapine Antipsychotic Avoid alcohol, increases
appetite, causes
vomiting and
constipation
Clonidine Antihypertensive Avoid natural licorice,
causes edema
Escitalopram Antidepressant Avoid St. John’s wart,
causes nausea,
vomiting, constipation,
increased
tryptophan=increased
side effects
Gabapentin Antiepileptic Causes increased
appetite and weight
gain
Hydralazine Antihypertensive Avoid natural licorice,
interferes with pyruvate
metabolism
Hyoscyamine Antispasmodic Antacids decrease drug
absorption
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Metoprolol Antihypertensive Avoid natural licorice,

causes nausea,
vomiting, diarrhea,
constipation
Pantoprazole Antigerd Decreases absorption of
iron and vit B12, avoid
St. John’s wart and
gingko
Tramadol Analgesic Increases risk of dental
problems
Hydromorphone Analgesic Caution with St. John’s
wart, avoid alcohol
Hydroxyzine Antihistamine Increases risk of dental
problems
Insulin lispro Insulin
Insulin glargine Insulin
Lorazepam Antianxiety Limit caffeine, caution
with grapefruit, avoid
St. John’s wart
Mirtazapine Antidepressant Avoid St. John’s wart,
increased appetite and
thirst
Ondansetron Antiemetic
KCl supplement supplementation
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Nutrition related laboratory values

Lab values list all that

are available – indicate
if abnormal
Nutritional significance if abnormal.
high or low ( or  or
Lab Test Can a nutrition intervention help to correct this abnormal lab value? How?
WNL) and if you have
Make this specific to this particular patient.
multiple labs available,
state if they are
trending up or down.
Na 139
K 4.9
BUN 20
CREAT 2.52 (high) Possible renal issue. Pt does have CKD4, may need protein restriction
GFR 23 (low) Renal issue, will need to watch renal labs
1.8 (low) May not have been consuming adequate protein recently plus added stress from
Albumin
illness/hospitalization. Can try to meet estimated needs to see if it will improve
Prealb
CRP 38.2 (high) Inflammation
279 (high) Pt consistently with high BG. Her T2DM is not controlled plus added stress of
Glucose illness/hospitalization. Need to adjust diet for carb control and possibly insulin
prescription changes.
HgbA1C
Hemoglobin / Hematocrit 9.0 (low)
MCV 88
MCH 28.8
If the patient has an anemia present, can you figure out what anemia it is? If yes, state it here. If you can’t figure it out, what other labs
would you like to have to determine it? To treat this particular anemia, would a mineral or vitamin supplement help? Why or why not,
and what would you recommend?

Unable to determine. Would need MCHC, Vit B12, and RDW labs
Ca 7.9
Phos 3.7
Mg 1.9
Total Cholesterol 250 (high) May need a diet lower in cholesterol
LDL 103
HDL 41
TG 164 (high) May need a lower fat diet
ALT
AST
Alkaline Phos
Total Bilirubin
Amylase
Lipase
BNP
Troponin or CK <0.01

Other relevant labs (e.g. ammonia, blood gases, AIDS/HIV related, etc.)
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Nutritional Needs

What weight will you be using to calculate needs and why? 107kg- current weight

Any stress factors 1.2 , activity factors to consider? 1.1

Note: Understand the difference between resting energy expenditure and total energy expenditure. If you have a stressed
patient, you are likely to use a stress factor. If your patient is in bed moving around and alert, you will likely have to pick an
activity factor for Harris Benedict and Mifflin St.Jeor .

Calculate Total Energy needs using three of the five methods below. Show your work.
1) Harris-Benedict ----655+(9.6*107)+(1.85*165.1)-(4.7*40)=1799*1.1*1.2=2375-500kcals for wt loss= 1875kcal
2) Mifflin St. Jeor ------------(10*107)+(6.25*165.1)-(5*40)-161=1740*1.1*1.2=2297-500kcals for wt loss=1797kcal
3) kcal/kg IBW----------------------------------------------- 22*56kg=1232 25*56=1400 1232-1400kcal
4) Ireton Jones (only use in critically ill) -------  kcal
5) Penn State 2010 equation ----------------------  kcal

What formula did you ultimately use for the Pt & why? Mifflin-obese pt

Calculate Protein needs

How many g/kg would you use & why? 0.8-1g/kg current weight due to CKD 4

Show your work:0.8*107=85 1*107=107

85-107 g/day

Calculate Fluid needs using two of the four methods below. Show your work.
1) ml/kg depending on age -----------------  35ml/day=3745mL
2) Holliday-Segar method -------------------  ml/day
3) RDA method --------------------------------- female= 2700ml/day
4) urine output (urine out +500ml/day)-  ml/day

What formula did you ultimately use for the Pt & why? 2700mL/d- more realistic
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Enteral Calculations (if applicable):

Formula Jevity 1.0 Total volume per day ordered 600 mL

NGT  PEG  Other 

Continuous  25 ml/hr

Bolus (provide schedule and volume) 

Cyclic (provide schedule and volume) 

Any PO / Parenteral intake? Yes  No  if yes, PO Diet Order clear liquid estimated kcal intake 200kcals

Per 1000mL this formula provides: 1060 kcal 55.5 g Pro 840 mL free water

As per total volume (per day) this formula provides: 636 kcal 5.9 kcal/kg

33.3 g Pro 0.31 g Pro/kg

504 mL Free H2O 0.79 mL/kcal

Did the patient receive the total volume ordered in the past 24 hours? Yes  No  if no, how much did the patient
receive (% or mL) If tube feeding was stopped, why & for how long?

Is patient receiving Propofol? If yes, list dosage and kcals from Propofol no

Additional water flushes per day. Amount and frequency 100mL x4 daily mL
(include fluids with meds, ask nursing for amount typically given and estimate total daily intake)

Does the prescription meet the calculated nutrition needs?

Enteral Nutrition provides: 636 Kcal 33.3 g Pro 904 mL Fluid per day.

Compare to Estimated Needs: 1797 Kcal 64 g Pro 2700 mL Fluid

EN meets how much of calculated needs in %? 35% Kcal 52% g Pro 33% mL Fluid

Do you have any recommendations? This will be adequate given her TPN and oral diet combination
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Parenteral Calculations (if applicable): Rate 48.3 mL/hr Continuous  Cyclic  hr/day

Total volume/24hr 1159 mL 2-in-1 Solution  3-in-1 Solution  is formula □ PPN or □ TPN

Any PO or Enteral intake? Yes  No  if yes, estimated kcals from oral intake 200kcals

Carbohydrate % Concentration 30 Grams of dextrose in 1L 150 g Total kcals from dextrose 510

Protein % Concentration 10 Grams of AA in 1L 50 g Total kcals from AA 20

Lipids 10% (1.1kcal/mL)  20% (2kcal/mL)  Grams of lipids infused/day 20 g

Volume of lipid solution provided in 24 hr (if hung separately) mL Total kcals from lipids 200

Is patient receiving Propofol? If yes, list dosage and kcals from Propofol no

Total calories in parenteral nutrition 910

If done in your facility by the RDNs - if patient is on PPN, calculate osmolarity. Refer to textbook or ask preceptors for
resources to calculate this. Show your calculations:

Does the prescription meet the calculated nutrition needs? If not, compare amount of kcals, protein and fluids
provided verses patient estimated needs:

Does the prescription meet the calculated nutrition needs?

Parenteral Nutrition provides: 910 kcal 8.5 kcal/kg

50 g Pro 0.46 g Pro/kg

1159 mL Fluids 10.8mL/kcal

Compare to Estimated Needs: 1767 Kcal 64 g Pro 2700 mL Fluid

PN meets how much of calculated needs in %? 51% Kcal 78% g Pro 42% mL Fluid

Do you have any recommendations? With EN formula, pt is receiving 86% of kcals, 100% protein, and 75% fluids.
Between EN, TPN, and oral diet pt is most likely meeting all of her estimated energy needs.
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Interaction with the IDT (Interdisciplinary Team)

Indicate if you had interactions with
any of these other health care team Describe interactions with or referrals made to any of these
members while providing nutrition health care team professionals, be specific:
care / patient care
 Nursing (RN)

Discussed with MD about pt. She has abdominal pain with or without
TF/TPN/oral diet. We all want to titrate down with TPN and up with TF as
 Physician (MD)
tolerated by the pt. MD was unsure if her abdominal pain was related to
gastroparesis or if it is related to possible opioid dependence. She refuses
to titrate down on her pain medication- Dilaudid
 Social Worker (SW)

 Speech Therapist (ST/SLP)

 Physical Therapist (PT)

 Occupational Therapist (OT)

 Respiratory Therapist (RRT)

 Woundcare / Ostomy Nurse

 Physician’s Assistant (PA)

 Other

Nutrition Diagnosis (P-E-S) Statement

Problem: Inadequate oral intake

related to (Etiology): nausea, vomiting, gastric pain

as evidenced by Signs and Symptoms: intake is less than estimated needs

Interventions (your recommendation as a dietetic intern)

 Titrate tube feeding up and TPN rate down as tolerated. Goal is to come off of TPN and use only TF.

 Offer at least two clear liquid meals each day. While pt complains of abdominal pain with eating, we should
still encourage her to try again
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Nutrition Prescription

 Meet needs through po intake, TF, and TPN combination

Nutrition Goals

 Increase use of po intake or TF to meet energy needs

 Tolerate clear liquid diet

Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)

 TF/TPN rate

 Po intake and abdominal pain associated with it

 weights

 lab values

Discharge Planning (if applicable): List your recommendations / interventions / plan if your patient is being
discharged back home to live alone or with family or if transferred to an assisted living / long-term care facility. For
many clinical sites the discharge planning starts with admission. Even if not certain where the patient will be
discharged to, you as an intern can think of your potential involvement.

Pt goal is to be discharged on TF to be seen by outpatient GI doctors and RDNs to manage TF. When pt is able to
tolerate TF without TPN, will give recommendations as appropriate

 Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not
familiar with)

I had never seen a pt on all three routes of nutrition before this pt.

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