Sage NCP Form

Patient: Mr. P

Student Name: Meshal Samadzada Case: Trauma and EN

Referred for: Assess nutrition status and adequac of TF order

NUTRITION ASSESSMENT
Food and Nutrition Related History: !ecreased a""etite "rior to accident to due flu# $ater%onl inta&e for the ' da s leading u" to accident# less than required maintenance fluids(diuretic to "re)ent *rain s$elling Anthropometric Measurements Age: -ender .t: 1t: 02.2 &g 7M8: +, (o M /0 in. 1t .3: 455 &g 671 '4.2 Biomedical ata! Medical Tests " #rocedures 9a*s(!at Al*umin -lucos .*A4C 76N Creat Na: ;: .g* .ct MC< =ther e e 0(,0(4' N(A N(A N(A N(A 4>+ N(A N(A N(A 4,+ ,.? R7P @ 4.' PA7 @ /.? Po @ ,.+ Mg,: % 4., Medical ia$nosis%Rele&ant 'onditions: Reduced strength# colla"sed A9B lung# maintained on res"irator *ased on antici"ated continuation of )ent su""ort and neurological im"airment# surgical -%tu*e "lacement# A9B su*dural hematoma #ertinent Medications%Supplements%Her(s: Furosemide# Pro"ofol C '+ m9(hr 3 ,> hrs A"ro)ides 0,> &cal(da from li"idB S)in status: 8ntact Pressure 6lcer(Non%healing $oundD Comments: 1arm(dr # "oor turgor# a*rasions(lacerations to the head# surgical incision for -%tu*e "lacement #atient%'lient%Family Medical%Health%'AM History: =*ese Estimated Nutritional Needs Based on 'omparati&e Standards: Calories Protein Fluid 4225 &cal 4>4 g 4225 m9 Current !iet =rder Feeding A*ilit =ral Pro*lems 8nta&e NP=# TF order A"laced * M! 8nde"endent Che$ing Pro*lem -ood AE 2+FB 0(,0(4'B: Start =smolite 4., C 9imited Assistance S$allo$ing Pro*lem Fair Aa""ro3. +5FB goal rate +5 m9(hr Ainfused 3,, 3 E3tensi)e(Total Assistance Mouth Pain Poor AG+5FB hoursB : +5 m9 $ater flush T8! 3 None of the A*o)e3 Minimal @ AG,+FB 3 No Nutritional !iagnosis at this time Proceed to Nutrition !iagnosis 7elo$

NUTRITION

IA*NOSIS
E AEtiolog B "h siological causes increasing nutrient needs as e)idenced * : S ASigns H S m"tomsB conditions associated $ith T3 of T78 and TF order less than estimated needs

P A"ro*lemB 8nadequate enteral nutrition infusion related to:

INTER+ENTION
Recommended Nutrition Prescri"tion: ,, hr Continuous END Promote A.igh "roteinBD ?>/ &cal(m9# +' g "rotein# 245 m9 fluidD Rate '? m9(hr# initiate C 4? m9(hr# ad)ance 45 m9 I ? hr Prostat /> Aliquid "rotein modularB /5 m9 T8! : 45 m9 feeding tu*e flush *efore and after Prostat administration Afor additional '/5 &cal and 05 g "rotein(da B Food or Nutrient !eli)er : PENutrition education: N(A Nutrition Counseling: N(A Coordination of Care Arefer toB: N(A

-oalAsB: Tolerating TF C rate that meets needs of 4225 &cal : 4>4 g "rotein

MONITORIN* " E+A,UATION

8ndicators: -R< Criteria: G +55 m9