Adime 1
Adime 1
Adime 1
Backus Hospital
Date: 2/15/19
ADIME #1
A : Assessment:
Age: 34 Gender: M Admit Date: 2/12/19 Date Seen: 2/14/19
Admitting Dx: Patient J.S. is a 34 year old male who was readmitted to Backus Hospital on
February 13, 2019 for difficulty breathing (moderate), lethargy and cough occurring over the past
2-3 days before admission. Patient is nonverbal, mother provided medical information. Primary
medical diagnosis for hospitalization is gram-negative pneumonia.
Treatments/Therapies: Upon admission, a chest x-ray was performed to assess the patient’s
condition. The chest x-ray showed signs of pneumonia; low lung volume and right midlung zone
infiltrates and/or atelectasis was present with sharp demarcation with minor fissure. Receiving
sodium chloride 0.9% (NS) infusion 75mL/hour continuously for electrolyte replenishment. J.S.
is also receiving oxygen (2L n/c).
PMHx: On January 24-January 28, 2019 J.S. was admitted for sepsis (SIRS) secondary
to aspiration pneumonia and was transferred to Yale Hospital January 28-February 6, 2019 for
continuous electroencephalogram (EEG) monitoring due to severe frequent seizures. Since home
from Yale no seizures have occurred.
respiratory distress syndrome.5 High caloric needs are recommended for clients with CP,
those with mild CP would be recommended to have fourteen kcal per centimeter height.3
Aspiration pneumonia (reoccurring): When food, drink, vomit or saliva is inhaled into the
lungs. Commonly caused by a disturbance in the normal gag reflex from a brain injury or
swallowing problem resulting in aspiration. 1
**Weight changes in hospital: Weight has been maintained since 5-6# weight loss from previous
admission, January 24, 2019- January 28, 2019.
Nutrition Requirements:
kcal: Mifflin St Jeor X (AF) X (IF) = (9.99 X 50.8 kg) + (6.25 X 152.4 cm) – (4.92 X 34 y/o) + 5 = 1293
kcal
kcal/kg = 34 kcal/kg x 50.8kg = 1727 kcal (30-35kcal/kg range used)--- using 1727kcal due to
severity of condition
Protein gm/kg = 1.2 – 1.5 gm/kg = 61- 76 g PRO= using 76g protein due to severity of condition
**Method 1 was used, followed hospital recommendation. 1962ml is too high, don’t want to over hydrate
patient since he is additionally on IV and receives numerous medications through the G-tube.
Diet Order:
Current Order: Diet NPO
Receiving Ketogenic tube feed formula (Ketocal) with Prosource TF, 60ml continuous
Continuous IV fluid, Sodium Chloride 0.9% Infusion 75ml/hr
Assessment of Appropriateness of current diet order:
The current diet is appropriate, J.S. cannot eat solid food or drinks due to severe swallowing difficulty due
to dysphagia, CP and respiratory failure with hypoxia. J.S. is unable to feed himself and is on aspiration
Carley Bedell
Backus Hospital
Date: 2/15/19
precaution. Due to diarrhea, TF formula will be changed to Ketogenic formula with no insoluble fiber
(Ketovie Peptide) upon discharge due to inaccessibility.
2/14/2019 Sodium (Na) 144 mmol/L 136 – 145 WNL- Well hydrated due to fluids from tube feed,
mmol/L sodium chloride continuous IV fluid
2/14/2019 Red Blood Cell 3.95 4.7 – 6.1 Low decreased from 4.24 from 2/13/19, may have
(RBC) cells/mcL cells/mcL decreased due to pneumonia
4/10/2014 Hemoglobin (Hb) 13.9 g/dL 14 - 18 Low value, may have decreased due to pneumonia
g/dL
2/14/2019 Hematocrit (Hct) 38.9 % 42 – 52 % Low value, decreased from 2/13/19, may have
decreased due to pneumonia
Physical Assessment:
Was unable to be see patient due to inability to verbalize and intellectual disability. It was necessary to wait
for mother to be present for conversation and therefore, was unable to meet with patient since mother wasn’t
at the hospital. J.S. is bed ridden but recent reports state he is awake, alert and has no acute distress. He is
receiving oxygen (2L n/c). No wheezing, rale or rhonchi. No seizures since released from Yale in the
beginning of February.
D (Diagnosis) PES:
Enteral Nutrition Composition Inconsistent with Needs (NI-2.5) related to deficient fiber intake as
evidenced by excessive diarrhea.
I (Intervention):
Organized into 4 categories:
Food and/or Nutrient Implement ketogenic formula with soluble fiber, Ketovie Peptide
Delivery (providing 1.5kcal/ml; 2.6g fiber; 6g MCT/serving) in place of current
formula, Ketokal formula. Switch 60ml/hr to 48ml/hr to meet calorie
requirements.
Nutrition Education Educate mom on preparation and administration of Ketovie Peptide formula
Nutrition Counseling N/A
Coordination of Yale Dietitian Adrianna involved in monitoring patient, doctor assigned to
Nutrition Care patient, and nursing staff administering TF
Carley Bedell
Backus Hospital
Date: 2/15/19
Meal Plan:
1. For current Dx explain- Foods Allowed, Foods Not Allowed, Diet Instruction Materials if appropriate.
Describe in your own words the rationale for diet restrictions/modifications
Foods Allowed NPO
Foods Not Allowed N/A
Diet Instruction If diarrhea continues evaluate EN composition and assess other contributing factors
Materials if appropriate such as medication.
1727kcal-120kcal=1607kcal left
1800ml-130ml=1670ml left
****45ml/hr was used instead of 60ml/hr as currently prescribed due to possible error. 60ml/hr when
calculated was resulting in significantly higher kcal than recommended. No ml free water was listed on
formula composition, 1.5kcal/ml typically provides 76% water which was used to calculate free water.
Macronutrient/Micronutrient Calculations:
Macronutrient DRI’s:
Adults above 18y= 2403kcal
Fat (20-35%)= 53-67g
2403x.2=481kcalx 1g/9kcal=53g| 2403x.25=600.75kcalx 1g/9kcal=67g
Patient J.S. nutrient consumption from EN formula had significantly higher fat (148g) than DRI
(53-67g), protein (67g) is within DRI recommendations (40-140g) and carbohydrates (15g) are
significantly below DRI’s (270-390.5g). The calories of the formula (1727kcal) was much lower than DRI’s
for an active adult male (2403kcal). This is because of the patients compromised health conditions that
require a ketogenic diet (low carbohydrate, high fat). His lack of mobility, but compromised health require
fewer calories than the DRI. Most of the patients micronutrient consumption is around the DRI amount
except potassium and vitamin D were lower and vitamin C, Phosphorus, Iron, Calcium were higher. The
formula varies in the nutrients due to the nutrient needs required to control/reduce seizure occurrences and
severity.
Notably, since 60ml/hr was not calculating properly EN formula prescription should be reassessed.
Carley Bedell
Backus Hospital
Date: 2/15/19
Calculations:
BMI calculation: kg/ m2
278 lbs/ 2.2 (kg/ lb) = 126kg
5 feet 8 inches = 68 inches* 2.54 (cm/ in) = 173 cm = 1.73m
50.8 kg / 1.524 m2
BMI = 22→ Normal
𝐶𝑢𝑟𝑟𝑒𝑛𝑡 𝑊𝑒𝑖𝑔ℎ𝑡
Usual Weight %: ∗ 100
𝑈𝑠𝑢𝑎𝑙 𝑊𝑒𝑖𝑔ℎ𝑡
112
= 119 ∗ 100 = 94%
References: