Comprehensive Clinical Case Study

Michelle Moriarty April 6th, 2014

Table of Contents
Introduction of Patient and Case Etiology and Pathophysiology of Conditions Clostridium difficile Pneumonia Acute Kidney Injury Acute Respiratory Distress Syndrome Nutrition Practice Guidelines and Patient Interventions Acute Kidney Injury Acute Respiratory Distress Syndrome Pressure Ulcer Enteral Nutrition Tolerance Malnutrition Conclusion References Case Study 3 5 5 5 6 6 6 6 7 8 9 10 12 13 15

Introduction of Patient and Case

The patient is a 56 year old African American male brought to the emergency room on January 30th, 2014, after four days of diarrhea, dyspnea, generalized body aches, nausea, vomiting, abdominal cramping and weakness. He has a past medical history of hypertension, aortic valve replacement and mitral valve repair in 2010 complicated by serratia bacteremia as well as heparin induced thrombocytopenia and thrombosis (HITT). The HITT resulted in the amputation of many toes and fingers as well as a chronic right heel ulcer. The ulcer extends to the calcaneus but has been kept free from infection since 2010. He was admitted to the Coronary Care Unit with a diagnosis of Clostridium difficile (C. diff) colitis, pneumonia and H1N1 influenza. The patients wife notably works at Albany Medical Center and it is believed the patient contracted C. diff through contact with her. His hospital stay has been complicated by acute respiratory distress syndrome (ARDS) secondary to severe pneumonia and influenza, acute kidney injury (AKI) requiring hemodialysis, prolonged intubation resulting in a tracheostomy and PEG tube placement and intermittent difficulty tolerating enteral tube feeding. A timeline of the patients stay is as follows:

January 31st-Patient intubated due to respiratory distress o Osmolite 1.2 at goal rate of 60 ml/hour continuously initiated via orogastric (OG) tube. February 4th-AKI developed and patient was started on intermittent hemodialysis (HD). o Transferred to the Intensive Care Unit (ICU) o Nepro at goal rate of 35 ml/hour continuously with one packet of Pro-stat 64 was initiated o 350 ml gastric residual volume (GRV) reported, tube feed was held February 6th- 180 ml GRV, tube feed held February 7th- ARDS developed o Reglan administered to aid in gastric motility and tube feed tolerance

February 18th- Completed courses of antibiotic and antiviral medications for C. diff and H1N1 February 19th-Stage 2 pressure ulcer on the patients buttock first documented February 20th-Tracheostomy and PEG tube placement surgery February 24th- Kidney function improving with increased urine output, HD discontinued o Osmolite 1.2 at goal rate of 50 ml/hour continuously with one packet of Pro-stat 64 initiated o Patient developed an ileus status post PEG tube placement o Patient vomited and tube feeds needed to be held for 2-3 days while ileus resolved February 27th-Transferred out of the ICU to a non-critical respiratory floor March 2nd-Patient with loose stools multiple times in one day, GI attending held tube feed March 7th-Tube feed goal rate increased to Osmolite 1.2 at 55 ml/hour continuously, continue Pro-stat 64 o Patient on full ventilator support only at night o Passy Muir Valve trials began with Speech Language Pathologist (SLP) o Patient failed the swallow evaluation at this time March 11th- Tube feed goal rate increased to Osmolite 1.2 at 60ml/hour continuously, continue Pro-stat 64 o SLP began trialing pureed foods and nectar thick liquids with patient with good results March 12th-Patient returned to full ventilator support due to respiratory distress March 17th- Biopsy of patients right heel wound showed osteomyelitis March 18th- Partial calcanectomy performed o Patient was able to be weaned off the ventilator post surgery March 19th- SLP recommended PO diet to begin o Cardiac, mechanical soft, thin liquid diet ordered with 25-50% intake per meal March 20th- Ensure Plus BID ordered, 75-100% intake March 22nd- 3 day calorie count started o Patient consumed an average of 555 calories (30% of needs), 40 grams of protein (45% of needs) and 599 ml of fluid (33% of needs) over 9 meals and 3 days. o Patient on room air with tracheostomy plugged March 25th- SLP recommended cardiac, soft texture diet. Patient tolerated well o Patient now with strong voice and able to communicate fully March 27th- Ensure TID ordered, 50-75% intake o Wound vac placed due to non-healing right heel wound March 30th- Documentation of healed stage 2 pressure ulcer on buttock April 1st- SLP recommended cardiac, regular texture diet with 40-60% intake. SLP discontinued following patient since on regular consistency diet o Plastic Surgery MD consulted for non-healing right heel wound. MD states due to severity of wound, a free flap surgery would be needed which would require a higher level of care (i.e. Albany Medical Center). However, due to the patients history of
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HIT, he may not be a candidate for surgery since heparin is necessary. MD states the patient may need a below knee amputation. April 3rd- Patient went for angiogram to assess non-healing right heel wound

Etiology and Pathophysiology of Conditions

Clostridium difficile Colitis Clostridium difficile (C. diff) is the leading cause of noscomial diarrhea in the United States.1 This infection may cause colitis, secretory diarrhea, severe dilation of the colon, perforation of the bowel wall, peritonitis or even death.1 C. diff is a spore forming organism and the spores are resistant to common disinfectant agents, making it easier for health care providers to spread the organism unintentionally to patients.1 The common symptoms of C. diff colitis include watery diarrhea, fever, loss of appetite, nausea and abdominal pain.2 Common complications include dehydration and kidney failure due to severe dehydration.3 C. diff is treated with antibiotics, Flagyl is commonly used.3 Pneumonia4 Pneumonia is a common infection of the lungs caused by bacteria, viruses or fungi which inflame the alveoli. The alveoli fill with fluid or pus resulting in symptoms of coughing, fever, fatigue and difficulty breathing. Pneumonia can be community-acquired, hospital-acquired, health care-acquired or classified as aspiration pneumonia, with community acquired being the most common. If a severe case of pneumonia persists, mechanical ventilation may be required to aid in breathing.

Acute Kidney Injury Acute kidney injury (AKI) formerly called acute renal failure (ARF) is defined as an abrupt decrease in kidney function that includes but is not limited to kidney failure.5 The rapid decrease in renal function results in the failure to maintain fluid, electrolyte and acid-base balance.6 The defining criteria include an increase in serum creatinine by 0.3 mg/dl within 48 hours or a reduction of urine output of < 0.5 mg/kg/hr for 6 hours.5 By using the nomenclature of AKI rather than ARF, it allows for health care professionals to view the condition as a spectrum of injury instead of only renal failure.6 Renal replacement therapy (RRT) is often the appropriate intervention whether it is continuous or intermittent.6 Acute Respiratory Distress Syndrome7 Acute Respiratory Distress Syndrome (ARDS) is caused by direct pulmonary or indirect extrapulmonary insult that precipitates a proliferation of inflammatory cells that then accumulate in the lung making the air exchange difficult. A diagnosis of ARDS is based on acute onset, the presence of bilateral infiltrates, decreased pulmonary wedge pressure, a decreased ratio of partial pressure of arterial oxygen to fraction of inspired oxygen and the absence of left atrial hypertension. Common causes include sepsis, pneumonia or trauma. Patients that develop ARDS most likely have other conditions present that are compromising their health and usually requires mechanical ventilation while the underlying problem is addressed.

Nutrition Practice Guidelines and Patient Interventions:

Acute Kidney Injury

AKI is common in hospitalized patients and occurs in approximately 20 percent of ICU patients.8 These patients have an increased risk of protein-energy wasting due to the highly catabolic state that occurs.9 The importance is placed on the appropriate nutrition interventions being made efficiently in order to decrease the risk for protein-energy wasting. In many patients with AKI, renal replacement therapy (RRT) or hemodialysis (HD) is usually required, whether it be continuous or intermittent. Adequate protein intake is recommended to ensure a positive nitrogen balance due to the increased amount of amino acids and protein that are removed during RRT.10 Fifty percent of protein intake should be of high biological value since it has an amino acid composition that is similar to human protein and can be utilized more efficiently.10 According to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines,10 1.2 grams of protein per kilogram of body weight per day is recommended to maintain neutral or positive nitrogen balance. In the case of the patient in review, he was receiving intermittent RRT every other day and his recommended protein needs were 1.2-1.4 gm/kg/day. Nepro was the recommended tube feed formula since it is formulated for those on dialysis and one packet of Pro-stat 64 was ordered to ensure the patient was receiving adequate protein. Nepro is low in potassium, phosphorous, sodium and is more concentrated in calories to provide less total fluid volume to patients.11 The formula is also carb steady to help in managing blood glucose levels. Acute Respiratory Distress Syndrome It is estimated that 7.1 percent of all patients admitted to an ICU and 16.1 percent of all patients on mechanical ventilation develop acute lung injury or ARDS.7 Regarding the patient in review, he was on full ventilator support in the ICU prior to his diagnosis of ARDS. In order to best determine his energy needs and avoid over or under feeding, which both can be equally detrimental to critically ill patients, the Penn State 2003b equation was used. Using the Penn
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State 2003 equation, his energy needs were estimated at 1801 calories which equivalent to 26 cal/kg of body weight (70 kg). A range of 21-26 cal/kg (1470-1801 cal) was estimated to provide more flexibility when recommending his tube feed. In a study that compared predictive equations for measuring resting metabolic rate for mechanically ventilated, critically ill patients, Frankenfield et al found that in the absence of indirect calorimetry, the Penn State equation is a valid clinical tool and is more accurate than the other equation tested (Ireton-Jones).12 For patients with ARDS, research has shown that using an enteral formula enriched with eicosapentaenoic acid (EPA), gamma-linolenic acid (GLA) and antioxidants results a lower mortality rate, fewer ICU days, more ventilator free days and a lesser chance of development of new organ failure.13 The study focused on patients whose primary diagnosis was ARDS, unlike the patient being reviewed who had multiple diagnoses while in the ICU. The patient was experiencing AKI first and ARDS followed several days later. The decision to keep the patient on Nepro for his AKI rather than switching the formula to Oxepa, which is specially formulated for ARDS, came from clinical judgment and the need to provide the most appropriate nutrition intervention that will result in the best outcome for the patient. Pressure Ulcer Throughout the United States, the prevalence of pressure ulcers in the acute care setting ranges from 10-18 percent.14 Pressure ulcers can reduce the overall quality of life due to pain and increased length of stay.14 There are a number of risk factors for pressure ulcer development including compromised nutritional status, unintended weight loss and protein-energy malnutrition.14 Currently, there are few evidence based guidelines regarding nutrition intervention for pressure ulcers. Clinical judgment and experience as well as taking into

consideration the individual patient case are needed when making nutrition recommendations regarding pressure ulcers. Adequate protein is needed to promote healing, therefore, the recommended protein needs for patients with pressure ulcers is 1.25 to 1.5 gm/kg body weight.14 The patients protein needs were already increased due to HD, the protein recommendation was therefore only changed to reach the higher end of the recommendation of 1.5 gm/kg rather than 1.4 gm/kg based on current evidence based guidelines, the patients stage 2 pressure ulcer and his chronic right heel wound. Since the tube feed recommendation of Nepro at 35 ml/hour did not meet 100 percent of the RDIs, Allbee with C was recommended to ensure the patient was receiving adequate micronutrients which would also aid in healing his pressure ulcer. Unfortunately, this was not ordered by the doctor in a timely manner and the patient was only receiving it for several days before HD was discontinued. Once the tube feed formula was changed to Osmolite 1.2 at 55 ml/hour, this goal rate was meeting 100 percent of his needs for vitamins and minerals, therefore additional vitamin or mineral supplementation was not necessary to aid in healing. Enteral Nutrition Tolerance In enterally fed patients, the most common method to assess tolerance is the use of gastric residual volume (GRV).15 However, there is no evidence based research on what is an acceptable volume for holding enteral feeds. GRVs can range from 150 ml to 500 ml and is highly subjective based on the judgment of the clinician on when to stop the feeding.15 In an enteral tolerance study performed by Gungabisson et al., feed intolerance can be described as large GRV, abdominal distention, vomiting, diarrhea, or subjective discomfort. The study reviewed the prevalence and treatment of enteral feed intolerance in 1,888 ICU patients across 21 countries and found feed intolerance was associated with fewer ventilator-free days, longer length of ICU
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stay and increased mortality compared to patients who were feed tolerant.16 Of the study population, 30.5 percent had enteral feeds interrupted due to feed intolerance with large GRV being the most common cause, affecting 61.6percent of feed intolerant patients.16 Vomiting or diarrhea was the second most common cause, affecting 36.6percent of patients.16 The administration of gastroprokinetic agents was the most common intervention for feed intolerance; metoclopramide (Reglan) being the most frequently used medication.16 The use of gastroprokinetic agents, such as metoclopramide (Reglan) or erythromycin, to aid in gastric motility and decrease the amount of gastric residual is a widely accepted practice even though the efficacy of the agents has only been tested in small studies.15 The patients enteral feed was interrupted several times due to elevated GRV, vomiting or diarrhea. Enteral feeding was held on two separate occasions when GRV was found to be 180ml and 350 ml respectively. Per the hospital standards, enteral feeds should be held when GRV is greater than or equal to 300 ml. Enteral feeding was held when the patient vomited and was found to have an ileus following his PEG tube placement and also when the GI attending chose to hold feeding when the patient was experiencing multiple loose stools in one day. Metoclopramide was ordered and administered after the two occasions of increased GRV to aid in gastric motility and to decrease the risk of future feed intolerance. Malnutrition Malnutrition can most simply be defined as a nutritional imbalance.17 Disease-related malnutrition is associated with increased morbidity and complications, heightened risk of developing infections, increased mortality, longer hospital length of stays, and higher costs of care.18

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Recently, the Academy of Nutrition and Dietetics (AND) and the American Society for Parenteral and Enteral Nutrition (ASPEN) have recommended a standardized set of guidelines and characteristics to be used to identify and document malnutrition in the clinical setting. These universal guidelines will provide more accurate estimates of the prevalence and incidence of malnutrition as well as better guide for appropriate interventions.17 A number of factors affect adult malnutrition including inadequate intake, increased requirements, impaired absorption, altered transport and/or altered utilization of nutrients with weight loss frequently occurring secondary to these factors.17 AND and ASPEN have further defined malnutrition based on etiology with the categories of social and environmental circumstances, chronic illness and acute illness. There is no single factor that classifies an adult as malnourished; therefore, AND and ASPEN have stated that the presence of two or more of the following six characteristics is evidence for diagnosis: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation or diminished functional status as measured by hand grip strength.17 Figure 1 is a malnutrition identification guide. Figure 1: Malnutrition Identification Guide

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There are factors related to acutely ill patients, much like the patient being reviewed, that compromise the recommended nutrition interventions, such as enteral feeding. A patient with severe acute illness under extreme metabolic stress can result in limiting the effectiveness of nutrition interventions and can add to the development of malnutrition.17 Periods of interrupted feedings which can occur quite frequently in critically ill patients due to medicalsurgical interventions or intolerance of enteral feeding, can also contribute to the development of malnutrition.17 Throughout the patients hospital stay, he has continued to lose weight despite adequate enteral feeding and supplemental oral feeding. The patient has lost 10kg overall which is 14.3% of his body weight over 2 months and protein depletion was observed in his clavicle, thigh and calf. These criteria qualify the patient for a diagnosis of malnutrition in the context of acute illness.

Conclusion
The patient is currently still an inpatient at the hospital but has improved considerably given his complicated admission. His hospital stay has been comprised of AKI, ARDS, the development and the healing of a pressure ulcer, tracheostomy and PEG tube placement and enteral feed intolerance. The patient was able to overcome the AKI as well as ARDS and is now breathing room air with his tracheostomy plugged. With the aid of the Speech Language Pathologist, he is able to speak with a strong voice and he is also now tolerating a regular consistency diet with 40-60% intake in addition to his continuous enteral feed and oral supplementation. It is unknown at this time whether the patient will need further surgery for his right heel wound. The patients status will remain as inpatient until he is able to be transferred to a rehabilitation facility.
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References
1. Mahan KL, Escott-Stump S, Raymond JL. Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders. In: KrausesFood and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012:614-615. 2. Frequently Asked Questions about Clostridium difficile for Healthcare Providers. Center for Disease Control and Prevention Web site. http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a1. Updated March 6th, 2012. Accessed March 20th, 2014. 3. C. difficile Infection: Complications. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/c-difficile/basics/complications/con20029664. Updated July 16th, 2013. Accessed March 20th, 2014. 4. Pneumonia: Definition. Mayo Clinic Web site. http://www.mayoclinic.org/diseasesconditions/pneumonia/basics/definition/con-20020032. Updated May 21st, 2013. Accessed March 21st, 2014. 5. KDIGO Clinical Practice Guidelines for Acute Kidney Injury. Kidney Disease Improving Global Outcomes. 2012;2(1). http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO%20AKI%20Guideline.pdf. Published March 2012. Accessed March 15th, 2014. 6. Lewington A, Kanagasundaram S. Acute kidney injury. The Renal Association Web site. http://www.renal.org/guidelines/modules/acute-kidneyinjury#sthash.HSXpbNrF.mn3JWt30.dpbs. Updated March 8th, 2011. Accessed March 15th, 2014. 7. Saguil A, Fargo M. Acute respiratory distress syndrome: diagnosis and management. Am Fam Physician. 2012;85(4):352-358. http://www.aafp.org/afp/2012/0215/p352.html. Published February 15th, 2012. Accessed March 13th, 2014. 8. Acute Renal Failure. Academy of Nutrition and Dietetics Nutrition Care Manual Web site. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5537&lv2=255347 &ncm_toc_id=23011&ncm_heading=Nutrition%20Care. Accessed March 14th, 2014. 9. Fiaccodori E, Maggiore U, Cabassi A et al. Nutrition evaluation and management of AKI patients. J Ren Nutr. 2013;23(3):255-258. http://cdlcsage.cdlc.org/illiad/illiad.dll?Action%3D10&Form%3D75&Value%3D104287. Published May 2013. Accessed March 25th, 2014. 10. Maintenance Dialysis: Management of Protein and Energy Intake. National Kidney Foundation KDOQI Web site. https://www.kidney.org/professionals/kdoqi/guidelines_updates/nut_a15.htm. Accessed March 26th, 2014. 11. Nepro with Carb Steady. Abbott Nutrition Web site. http://abbottnutrition.com/brands/products/nepro-with-carb-steady. Accessed April 2nd, 2014.
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12. Frankenfield D, Smith JS, Cooney RN. Validation of 2 approaches to predicting resting metabolic rate in critically ill patients. JPEN J Parenter Enteral Nutr. 2004;28(4):259-264. http://pen.sagepub.com.library.sage.edu:2048/content/28/4/259.long. Published July 1st, 2004. Accessed April 3rd, 2014. 13. Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med. 2006;34(9):2325-2333. Published September 2006. Accessed March 25th, 2014. 14. Dorner B, Posthauer ME, Thomas D. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory panel white paper. Adv Skin Wound Care. 2009;22(5):212-221. http://ovidsp.tx.ovid.com.library.sage.edu:2048/sp3.11.0a/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=00129334-20090500000008&NEWS=N&CSC=Y&CHANNEL=PubMed. Published May 2009. Accessed March 25th, 2014. 15. Ridley EJ, Davies ER. Practicalities of nutrition support in the intensive care unit: the usefulness of gastric residual volume and prokinetic agents with enteral nutrition. Nutrition. 2011;27:509-512. http://search.proquest.com.library.sage.edu:2048/docview/1130301277/fulltextPDF?accounti d=13645. Published May 2011. Accessed March 27th, 2014. 16. Gungabisoon U, Hacquoil K, Bains C et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. http://pen.sagepub.com.library.sage.edu:2048/content/early/2014/03/17/0148607114526450.f ull.pdf+html. Published March 17th, 2014. Accessed March 31st, 2014. 17. White J, Guenter P, Jensen G et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112:730-738. http://www.sciencedirect.com.library.sage.edu:2048/science/article/pii/S2212267212003280. Published May 2012. Accessed March 25th, 2014. 18. Disease-Related Malnutrition and Enteral Nutrition Therapy. American Society for Parenteral and Enteral Nutrition Web site. http://www.nutritioncare.org/index.aspx?id=5696. Accessed March 27th, 2014.

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Case Study
Patient: TB Referred for: C. diff, H1N1, pneumonia, ARDS

NUTRITION ASSESSMENT
Food and Nutrition Related History: NPO on admission-1/30 Osmolite 1.2 at 60 ml/hour via OG tube-1/31 Nepro at 35 ml/hour with one packet of Pro-stat 64 daily-2/4-2/24 Osmolite 1.2 at 50 ml/hour with one packet of Pro-stat 64 daily via PEG-2/24 Osmolite 1.2 at 55 ml/hour with one packet of Pro-stat 64 daily-3/7 Osmolite 1.2 at 60 ml/hour with one packet of Pro-stat 64 daily-3/11 Cardiac, mechanical soft, thin liquids with 25-50% intake; continue Osmolite-3/19 Ensure BID ordered with 75-100% intake-3/20 3 day calorie count started: 3/22-3/24, Patient consumed an average of 555 calories (30% of needs), 40 grams of protein (45% of needs) and 599 ml of fluid (33% of needs) over 9 meals and 3 days. Cardiac, soft texture diet ordered-3/25 Ensure TID ordered with 50-75% intake-3/27 Cardiac, regular texture diet ordered with 40-60% intake-4/1

Anthropometric Measurements Age: 56 Gender: Male

Ht: 1.8 m 71 inches

Wt: 60 kg Wt Hx: 70 kg dry weight on admission % Wt change: 14.3% loss x 2 months Creat 0.47 L Na+ 132 L K+ 5.6 H Hgb N/A

BMI: 18.5 Healthy weight

Biomedical Data, Medical Tests & Procedures Labs/Date Albumi Glucose HbA1C n 4/1/14 3.1 L 101 N/A

BUN 28 H

Hct N/A

MCV N/A

Other Alk Phos 183 H AST 53 H ALT 68 H

Medical Diagnosis/PMH/Relevant Conditions: Admit Dx: C. diff, H1N1, pneumonia ARDS AKI Tracheostomy and PEG tube placement 2/20 Partial calcanectomy due to osteomyelitis 3/18 PMH: hypertension, aortic valve replacement and mitral valve repair in 2010 complicated by HITT Multiple fingers and toes amputated as well as a chronic right heel wound that extends to the calcaneus as a result of the HITT

Pertinent Medications: Lasix, Mag Ox, Prilosec, Metamucil, Cefazolin Skin status:

Intact

X Pressure Ulcer/Non-healing wound; Comments: non-healing right heel wound s/p partial calcanectomy

Physical Assessment: muscle depletion in clavicle, thighs, calves Estimated Nutritional Needs Based on Comparative Standards: Based on current weight 60 kg Calories: 25- 30 calories/kg Protein: 1.2-1.5 gm/kg

Fluid: 25-30 ml/kg

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1500-1800 calories Current Diet Order Osmolite 1.2 at 60 ml/hr continuously 1 packet of Pro-stat 64 daily Cardiac diet

72-90 grams Feeding Ability Independent Limited Assistance X Extensive/Total Assistance

N/A

Oral Problems Chewing Problem Swallowing Problem Mouth Pain None of the Above Patient wears dentures

1500-1800 ml Intake Good (> 75%) Fair (approx. 50%) X Poor (<50%) Minimal (<25%) NPO

No Nutritional Diagnosis at this time NUTRITION DIAGNOSIS

P (problem) Malnutrition (NI-5.2) related to:

X Proceed to Nutrition Diagnosis Below

E (Etiology) acute illness as evidenced by:

P (problem) Increased Nutrient Needs (Protein) (NI-5.1) related to:

E (Etiology) need for healing as evidenced by:

S (Signs & Symptoms) muscle depletion in clavicle, thighs, calves; 14.3% weight loss over 2 months S (Signs & Symptoms) chronic nonhealing right heel wound

INTERVENTION
Nutrition Prescription: Osmolite 1.2 at 60 ml/hour continuously with 1 packet of Pro-stat 64 daily providing 1828 calories, 95 grams protein, 1181 ml of formula, meeting 100% of the RDIs. Provide 100 ml free water flushes 5 x a day. Cardiac oral diet. Ensure Plus TID Food or Nutrient Delivery: Enteral Nutrition Medical food supplements: commercial beverage General/healthful diet Feeding assistance Nutrition Counseling: N/A Nutrition education: Nutrition Relationship to Health/Disease: importance of choosing high protein foods to aid in healing

Coordination of Care (refer to): Physical Therapist: continue working with PT to increase strength and regain more independence

Goal(s): Prevent further weight loss while admitted Enteral feed tolerance as rate is increased and infusion time is decreased Adequate PO intake

MONITORING & EVALUATION

Indicators: 14.3% weight loss over 2 months Increased GRV, vomiting/diarrhea PO intake less than 60% of estimated needs Criteria: -Weight gain of 0.5-1 lb per week aiming for admit weight of 70 kg through adequate enteral nutrition infusion and PO intake. -Monitor GRV, vomiting/diarrhea and subjective discomfort as tube feed rate is increased and time of infusion is decreased to allow for patient to feel hunger for PO intake while still meeting his estimated needs. -Encourage adequate PO intake and supplementation intake to meet 75% of estimated needs orally to be able to decreased tube feed rate and infusion time.

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