Professional Documents
Culture Documents
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Support Line December 2007 Volume 29 No. 6
the PES statement, the diagnosis is on best available evidence and the which they individualize to meet the
a nutrition problem that will resolve clinical judgment of the RD. It is not nutrition prescription by manipulating
with the dietitians intervention. The the current nutrition order, but rather formula volume and composition.
etiology is the root cause of the an individualized statement of the needs Nutrition support dietitians may also
nutrition problem. It may be improved of the patient at a given moment in prescribe medical food supplements
or eliminated with the nutrition time. In critically ill patients, the (ND-3.1) and participate in nutrition-
intervention. The signs and symptoms nutrition prescription may be adjusted related medication management
are monitored by the dietitian to deter- frequently as medical diagnoses (e.g., (ND-6). The purpose of the nutrition
mine progress toward resolving the acute renal failure, hepatic encephalopa- intervention ultimately is to correct
nutrition diagnosis. For example, the thy), treatments (e.g., surgical procedures, the nutrition diagnosis, remove the
nutrition support dietitian may calculate medications), and the patients condition etiology, or reduce the signs and
the carbohydrate intake of a critically (e.g., wound healing, weaning from symptoms.
ill patient with hyperglycemia, rule the ventilator) change.
out excessive carbohydrate intake as a An example of a nutrition prescription Nutrition Monitoring and
nutrition diagnosis, and suggest the for a critically ill patient might be as Evaluation
need for an increased insulin dose. simple as 1,800 kcal and 65 g protein. The monitoring and evaluation step
Diagnosing nutrition problems and It might be expanded to include specific of the NCP is defined as the review
writing a PES statement that is both amounts of fat, vitamins, minerals, and measurement of the patient/clients
correct and meaningful is a rigorous fluids, and bioactive substances. Ideally, status at a scheduled or preplanned
task. It involves validating assessment the nutrition prescription is based on follow-up point with regard to the
data, clustering and comparing signs the latest evidence-based standards, but nutrition diagnosis, intervention/plans
and symptoms to develop differential where data are lacking, the RD applies goals, and outcomes (1). Evaluation is
diagnoses, and systematically eliminating clinical judgment and institutional the systematic comparison of current
them until a diagnosis is derived from tradition to the nutrition prescription. findings with previous status, interven-
the signs and symptoms. The RD implements one of 13 tions, goals, or a reference standard.
nutrition interventions that are designed Almost 50 monitoring and evaluation
Nutrition Intervention
to reduce the gap between the patients strategies have been identified in the
The nutrition intervention is defined current and ideal intake. Each nutrition nutrition monitoring and evaluation
as a specific action that remedies a intervention consists of a definition, a step of the NCP. Effectiveness of the
nutrition diagnosis and consists of two unique number, and a reference sheet intervention is monitored by changes
components: the plan and the imple- describing the details of the intervention in the signs and symptoms listed in the
mentation. The first step in planning and usual application. Nutrition support PES statement. In Table 1, the inter-
nutrition intervention is the nutrition dietitians are strongly identified with vention (potassium supplementation
prescription. The prescription is based enteral and parenteral nutrition (NC-2), ND-3.2) should resolve the nutrition
diagnosis and can be monitored using
Table 1. General Format for the Three-part Nutrition Diagnostic the sign (serum potassium level) in the
Statement (PES Statement) With a Sample Statement PES statement.
For critically ill patients or others
General Format receiving nutrition support, the diag-
problem (P) related to etiology (E) as evidenced by signs and symptoms (S) nosis may resolve, but the monitoring
Sample PES statement and evaluation portion of the NCP
(P) Inadequate intake of potassium (NI 55.1) related to (E) increased urinary continues for the duration of the
losses with amphotericin B administration, as evidenced by (S) declining serum nutrition intervention. The monitor-
potassium levels. ing and evaluation step incorporates
changes from baseline in biochemical
Sample Nutrition Prescription and medical tests, anthropometric
Increase potassium intake to 2 mEq/kg each day. data, intake and output, and other
Sample Nutrition Intervention familiar nutrition support monitoring
Mineral (potassium 40 mEq/day) supplements (ND-3.2) as needed to maintain parameters. Thus, the fourth step of
serum potassium levels within normal limits. the NCP incorporates the familiar
components of the nutrition support
Sample Nutrition Monitoring and Evaluation
dietitians assessment in a more
Monitor potassium intake (FI-6.2); serum potassium level (S-2.2)
systematic approach that enables
Note: The (P), (E), (S) and numbers for the nutrition diagnostic term (NI 55.1), measurement of nutrition outcomes
nutrition intervention term (ND-3.2), and nutrition monitoring and evaluation and ultimate demonstration of the
terms (FI-6.2 and S-2.2) are included for the convenience of the reader; they are
not necessarily recorded in the medical record. RDs effectiveness.
(Continued on page 16)
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Support Line December 2007 Volume 29 No. 6
Application Terminology Reference Manual (4). parameters selected reflect the authors
The NCP is designed for use with These terms should not be adapted personal practice philosophy, which
individual patients as well as groups and or modified because they are designed includes an evidence-based approach
populations. The remainder of this to describe and capture the RDs to patient management. Of course,
article illustrates how the NCP and activities related to the NCP. nutrition support practice varies widely
standardized language may be applied The following case provides an and others might use a different approach
over several days. The case is presented example of how the standardized to problems presented. The reader is
using the assessment, diagnosis, inter- language of dietetics and the ADIME encouraged to set aside differences in
vention, monitoring, and evaluation format can be used for medical record opinion on how the patient is managed
(ADIME) format. Table 2 contains documentation. The author appreciates and focus on how the standardized
general guidelines for incorporating that some RDs would provide a much terminology may be applied.
key features of the NCP into some more detailed note, while others would
limit their documentation to information Case
popular documentation formats. The
examples of chart notes also contain unavailable elsewhere in the medical HF is a 27-year-old previously
diagnostic, intervention, and monitor- record. The intent is not to specify a healthy male who was admitted to the
ing and evaluation terms from the level of detail, but to provide sufficient intensive care unit (ICU) following
International Dietetics and Nutrition detail to describe the case. The inter- emergency surgery for a ruptured
ventions and monitoring and evaluation appendix. He weighed 82 kg on
admission and was at ideal weight for
his height of 6 ft 1 in. His temperature
Table 2. General Guidelines for Incorporating the Nutrition Care
was 100.4F, and his white blood cell
Process Into Six Common Documentation Formats
count was elevated (14103/mcL) on
ADIME PGIE admission. Other laboratory findings
A = Assessment P = Problem were unremarkable. On hospital day 2,
D = Diagnosis or Diagnosis or HF was being weaned from the ventila-
PES* statement PES* Statement tor and expected to transfer out of the
I = Intervention G = Goal ICU later in the day. The intravenous
Nutrient Prescription Nutrient Prescription (IV) fluids of D5.45 saline were run-
Nutrition Intervention I = Intervention ning at 125 mL/h. Because all patients
Goal Nutrition Intervention admitted to the ICU are automatically
M = Monitoring Goal seen by an RD, a note must be entered
E = Evaluation E = Evaluation into his medical record before the
patient is transferred to the floor.
SOAP DAR Cumulative patient data are shown
S = Subjective D = Data in Table 3.
O = Objective Diagnosis or
A = Assessment PES* Statement Initial Assessment and Diagnosis
Diagnosis or A = Action As part of the initial assessment, the
PES* Statement Nutrient Prescription RD reviewed the medical record for
Nutrient Prescription Nutrition Intervention biochemical data, the results of medical
tests and procedures, and anthropomet-
P = Plan Goal
ric measures. Because HF was on a
Nutrition Intervention R = Response
ventilator, the food/nutrition and
Goal
client history was limited to a brief
PIE DAR-O conversation with family members,
P = Problem D = Data who stated that he was eating well
Diagnosis or Diagnosis or until 2 days prior to admission. Given
PES* Statement PES* Statement the elevated blood glucose value, the
I = Intervention A = Action RD inquired about a history of
Nutrition Intervention Nutrient Prescription diabetes, which was negative.
E = Evaluation Nutrition Intervention
Nutrition Diagnostic Reasoning
Goal
R = Response The RD reviewed the assessment
O = Output data and compared the findings with
potential nutrition diagnoses. Because
*PES=Problem, Etiology, Signs and Symptoms where Problem is a diagnostic term and
Etiology, Signs and Symptoms are derived from the corresponding reference sheet for of the elevated blood glucose value,
the diagnostic term. the RD evaluated the dextrose content
of the IV fluids and determined that it
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Support Line December 2007 Volume 29 No. 6
was likely insufficient to contribute to data from the nutrition assessment, Determining the Nutrition Prescription
hyperglycemia. The elevated blood then writing the patient has no The nutrition prescription concisely
glucose concentration appeared to be a nutrition diagnosis at this time. This states individualized recommended
transient stress response following statement would be substantiated by dietary intake. It is based on current
surgery, and the RD confirmed that published guidelines that clearly state reference standards and dietary guide-
the surgeons had addressed the hyper- that a previously healthy patient could lines adjusted for the patients health
glycemia by ordering insulin coverage. easily tolerate up to 7 days without condition and nutrition diagnosis (3).
Because the hyperglycemia was not nutrient intake (10). However, the The level of detail for the nutrient
nutrition-related, the dietitian ruled ruptured appendix made HF a candi- prescription can be adjusted based on
out excessive carbohydrate intake date for postoperative complications, the patients condition as well as practice
(NI-53.3). and a return to the ICU was a reason- standards, institutional convention, and
Clearly, HF was well nourished. The able expectation. Because HF had clinical judgment. Thus, the require-
RD did not identify any significant been eating well prior to admission ments for lipid, carbohydrate, and
nutrition problems except that he was and had been NPO for less than 24 individual nutrients could be specified
NPO. However, the patient would hours, the RD diagnosed inadequate as needed. For HF, the RD based the
have a diet ordered in time for the protein-energy intake (NI-5.3), calorie and protein prescription on
evening meal. In this case, the RD primarily because the definition of the published standards (10). The recently
could simply decline to diagnose a diagnosis refers to changes in physiologic released evidence-based guideline for
nutrition problem by recording the needs of short or recent duration (3). critically ill patients also could be used,
(Continued on next page)
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Support Line December 2007 Volume 29 No. 6
especially if a long-term ICU stay was etiology. In this case, inadequate protein- tered (DTR) can verify that the patient
anticipated (11). energy intake will be alleviated with is eating and report any identified
a general diet (ND-1), which will be problems to the RD. Table 4 illustrates
Nutrition Intervention ordered as soon as the patient is weaned a sample initial note in the ADIME
The nutrition intervention is designed from the ventilator. Once the diet is format that incorporates the nutrition
to treat the nutrition diagnosis or its ordered, the dietetic technician regis- diagnosis, prescription, nutrition
General diet providing 2,050 calories and 100 grams Intervention #3__________________________________
of protein.________________________________________ Goal (s)_________________________________________
_________________________________________________
NUTRITION MONITORING AND EVALUATION
Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL
#1 Energy intake (F1.1.1) _________________________ #1 Consumes >2,000 kcal/day______________________
#2 Protein intake (FI-5.2.1) _______________________ #2 Consumes >90 grams of protein per day___________
#3_______________________________________________ #3 _____________________________________________
Note: Terms in bold text are drawn directly from the International Dietetics and Nutrition Terminology Reference Manual. They are defined
within the language and should not be modified. The codes (numbers in parenthesis) are included for the convenience of the reader, but
it is not necessary to include them in the medical record.
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Support Line December 2007 Volume 29 No. 6
intervention, and monitoring and had a cumulative input and output that Nutrition Intervention
evaluation. was positive by almost 15 L, no extra- Consistent with unit protocol and
ordinary sodium losses, and a sodium an evidenced-based guideline, the RD
Follow-up on Hospital Day Four
intake from his IV fluids in excess of continued to restrict HF to 14 to
HF was transferred to the floor as
his requirements (3,10). The RD 18 kcal/kg/day for the first week in the
planned, but on hospital day 3, his
attributed the hyponatremia to the ICU (15). During the second week, the
temperature reached 102F, and he
cumulative input and output, which RD might recalculate energy require-
complained of abdominal pain. That
resulted from medically necessary IV ments based on the Penn State Equation:
afternoon, he underwent small bowel
fluids administered during surgery and (HB (0.85)+VE(33)+Tmax(175)-6433),
resection for ischemic necrosis. Results
the postoperative stress response. She as recommended in the evidence-based
of the operation included a temporary
diverting ileostomy. His ileocecal valve elected to monitor the serum sodium, guide for critically ill patients (16).
and colon were intact, with about 200 which she knew would normalize with This information would be incorpo-
cm of small bowel in continuity and postoperative diuresis. She suggested rated into the nutrition prescription.
the remaining segment excluded by on rounds a reduction in the current In this setting, the RD had obtained
the diverting colostomy. IV fluid rate, documented the positive clinical privileges to place the feeding
On hospital day 4, the RD found cumulative input and output in the tube and write orders for EN and PN
that HF weighed 94 kg. His skin was assessment, and adjusted the nutrition and monitoring if consulted by the
warm and dry to the touch, and he had intervention to reflect the need for physician to do so. The RD reviewed
+2 pedal edema. Bowel sounds were maximally concentrated formula. the assessment data and developed a
inaudible, and an ileostomy bag was in The RD also noticed the sharp plan of care with the surgeons. The
place, but there was no drainage. increase in serum glucose concentration decision was made to initiate a small
Nasogastric (NG) tube output was and evaluated HF for a diagnosis of bowel feeding tube because the NG
about 100 mL over the previous altered nutrition-related laboratory suction would interfere with gastric
8-hour shift. Ventilator settings were value, glucose (NC-2.2) (3). However, feedings. In another patient, the RD
intermittent ventilation of 24 breaths/ the carbohydrate intake of 150 g might have placed an NG tube based
min, FiO2 of 80%, and 6 cm of posi- (1.2 mg/kg/min) was far below the on recent evidence denying a clear
tive end-expiratory pressure. The max- recommended maximum of 472 g advantage of small bowel over NG
imum temperature was 100.6F. Blood (4 mg/kg/min per day) (14), and this feeding (11). The RD selected a stan-
cultures were positive for Staphylococcus diagnosis was ruled out. A diagnosis of dard formula with the highest possible
epidermis and Escherichia coli. He was excessive carbohydrate intake (NI-53.2) protein content to balance the dextrose
receiving D5.45 lactated Ringer at was ruled out for the same reason. The calories from the IV fluids and the fat
125 mL/hr. Vancomycin and ampho- elevated blood glucose was attributed calories from the propofol. Additional
tericin B were started postoperatively. to impaired glucose metabolism com- protein could be added if the propofol
An insulin drip was started according monly seen in sepsis, and the amount and IV fluids continued. The RD did
to unit protocol, and a multiple of insulin administered via a continuous not select an immune-enhancing formula
vitamin infusion was ordered. insulin infusion (insulin drip) was because such formulas are not recom-
increased per unit protocol. mended for routine use (15). Table 5
Nutrition Diagnostic Reasoning The RD also noticed the magnesium shows a sample nutrition progress note.
The RD recognized that HF had value of 1.6 mg/dL. She evaluated the
patients recent magnesium intake and Follow-up on Hospital Days Eight
developed sepsis, according to the
noted that HF had not received and Ten
widely used criteria of the American
magnesium supplementation since On hospital day 8, HF weighed 98 kg.
Academy of Chest Physicians (12), and
admission. He was asymptomatic, but His blood glucose values were within
considered a second nutrition diagnosis:
likely had increased urinary losses of the acceptable range established by the
increased nutrient needs (NI-5.1) (3).
magnesium associated with ampho- team managing his blood glucose and
However, the definition of increased insulin. However, his renal function
needs is increased need for a specific tericin administration, which would
continue for several more days. The was declining, consistent with his
nutrient compared to established ref- clinical course of sepsis and antibiotic
erence standards. Because there was RD added inadequate mineral intake
(magnesium) (NI-55.1) to the list of administration. His IV fluids were
no evidence that HF required more 0.45 saline at 80 mL/hr. Enteral feed-
calories or protein than specified in diagnoses because HF had a lower-
than-recommended intake based on ings were held because he had 2 L of
reference standards for a critically ill liquid stool in a 24-hour period. Stool
patient with sepsis, that diagnosis was physiologic needs, which is consistent
with the diagnostic criteria for inade- output had decreased sharply since
rejected (13). cessation of feeding 8 hours earlier. The
The RD noticed a marginally low quate mineral intake. She spoke with
the surgeon, who ordered 2 g of physicians attributed the stool output
serum sodium concentration, but to the length and/or condition of his
quickly rejected inadequate mineral magnesium sulfate IV to correct
intake (sodium) (NI-55.1) because HF the intake deficit. (Continued on page 21)
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Support Line December 2007 Volume 29 No. 6
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Support Line December 2007 Volume 29 No. 6
remaining bowel and recommended that feedings. Inadequate mineral intake identify and document nutrition-
feedings be held. The RD recognized (magnesium) resolved with ongoing related problems and their resolution.
that HF had altered gastrointestinal magnesium supplementation in the The anticipated result is improved
(GI) function (NC-1.4), but also con- PN. Altered GI function persisted. The communication with other profession-
tinued to have inadequate intake from decline in serum phosphorus values als, increased visibility of the dietitians
enteral/parenteral nutrition (NI-2.3). suggested to the RD the possibility of role, and clearer documentation of the
The RD could revise the PES statement an altered nutrition-related laboratory dietitians unique contribution to
for the inadequate enteral/parenteral value (phosphorus) (NC-2.2) (3). patient care.
intake to include altered GI function However, she rejected the diagnosis
Readers are encouraged to log in to the DNS
as an etiology. However, the altered because the decrease in phosphorus
GI function was the nutrition diagnosis listserve to discuss this article with the author.
concentrations likely represented
driving a change in therapy, and two refeeding hypophosphatemia, which is Annalynn Skipper, PhD, RD, FADA, has
separate diagnoses were recorded. not included in NC-2.2. The diagnosis more than 25 years experience as a nutrition
The RD and the surgeons were con- also could have been inadequate mineral support dietitian. She is an author and
cerned that HF had suboptimal intake intake (NI-55.1) (phosphorus). How- consultant in Oak Park, Ill.
for most of the 8 days since admission. ever, the RD selected imbalance of
In some instances, the feeding would nutrients (NI 5.5) to describe more References
be held and subsequently restarted. precisely the relationship between 1. Lacey K, Pritchett E. Nutrition care
However, in light of this patients process and model: ADA adopts road
phosphorus and carbohydrate. After
map to quality care and outcomes
deteriorating condition, marginal GI discussion with the surgeons, the RD management. J Am Diet Assoc. 2003;
function, and an accumulating calorie supplemented the PN with an additional 103:10611071.
deficit, the decision was made to start 20 mEq of sodium phosphate and 2. Nutrition Diagnosis: A Critical Step in
PN and reinitiate enteral feedings as anticipated resolution of hypophos- the Nutrition Care Process. Chicago, Ill:
tolerated. The surgeons changed the American Dietetic Association; 2005.
phatemia the next day (Table 7). The 3. Nutrition Diagnosis and Intervention:
central line, and the RD ordered 1 L RD also informed the nurse of an Standardized Language for the Nutrition
of PN containing 60 g amino acids increase in dextrose intake and the Care Process. Chicago, Ill: American
(0.7 g/kg) and 200 g (1.6 mg/kg/min) potential for an increased insulin Dietetic Association; 2006.
dextrose to be administered over 24 4. International Dietetics and Nutrition
requirement. Terminology Reference Manual. Chicago,
hours daily with electrolytes, decreased On hospital day 14, HF was stable Ill: American Dietetic Association; 2007.
potassium, and increased acetate to and weaned off the ventilator. A general 5. American Medical Association. CPT
accommodate declining renal function. healthful diet was ordered (ND-1), 2007 Professional Edition. Chicago, Ill:
She ordered a 250-mL bottle of 20% American Medical Association; 2007.
and HF was transferred out of the ICU 6. American Medical Association. AMA
lipids to be administered as an IV rider to the care of another RD. The ICU Physician ICD-9-CM 2007, Volumes 1 &
over 12 hours daily. She planned to RD signed off and transferred care to 2. Chicago, Ill: American Medical
increase the feeding to goal the follow- the RD on the floor (RC-2). Association; 2007.
ing day and checked to ensure that 7. NANDA International. Nursing
laboratory tests were ordered for Conclusion Diagnosis: Definitions and Classification
2005-2006. Philadelphia, Pa: NANDA
monitoring. Sample follow-up The NCP is a four-step problem- International: 2006.
documentation is found in Table 6. solving process that can be used to 8. American Physical Therapy
On hospital day 10, HF weighed 97 kg. identify nutrition problems that the Association. Guide to Physical Therapist
The RD had decreased his IV fluids to Practice. 2nd ed. Fairfax, Va: American
RD can treat independently. The stan- Physical Therapy Association; 2003.
20 mL/hr and increased his PN to goal dardized language is used to describe 9. Bowen JL. Educational strategies to
the day before. Despite declining renal nutrition diagnoses, interventions, and promote clinical diagnostic reasoning.
function, phosphorus concentrations monitoring and evaluation. The NCP N Engl J Med. 2006;355:22172225.
declined from 4.0 to 2.6 mg/dL. His 10. A.S.P.E.N. Board of Directors and the
and standardized language are Clinical Guidelines Task Force. Guide-
stool output had slowed to 1 L/24 hr. designed for use by RDs caring for lines for the use of parenteral and enteral
Blood glucose control was acceptable patients or clients of all ages and levels nutrition in adult and pediatric patients.
on the insulin drip. If blood glucose of complexity. Critically ill patients JPEN J Parenter Enteral Nutr. 2002;
values remained below 150 mg/dL, the 26(suppl):1SA138SA.
with myriad intercurrent medical and 11. Critical Illness Evidence-Based
surgeons would consider administering nutritional problems present chal- Nutrition Practice Guideline. Available
octreotide for the diarrhea, but PN lenges in applying the NCP that can at: http://www.adaevidencelibrary.
was scheduled to continue until the be overcome with clear thinking that com/topic.cfm?cat=2799. Accessed
diarrhea was better controlled. November 20, 2006.
clusters detailed information used to 12. Bone R, Balk R, Cerra F, et al.
Nutrition Diagnostic Reasoning manage critically ill patients. The Definitions for sepsis and organ failure
NCP and standardized language of and guidelines for the use of innovative
The inadequate EN and PN has dietetics is designed to describe the therapies in sepsis. The ACCP/SCCM
resolved with the achievement of goal nutrition problems that the RD can (Continued on page 23)
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Support Line December 2007 Volume 29 No. 6
NUTRITION DIAGNOSIS
#1 Problem Inadequate intake from enteral nutrition infusion (NI-2.3)________________________________________
Etiology related to feeding intolerance____________________________________________________________________
Signs/Symptoms as evidenced by intake less than needs______________________________________________________
#2 Problem Altered GI function (NC-1.4)___________________________________________________________________
Etiology related to bowel resection_______________________________________________________________________
Signs/Symptoms as evidenced by 2 L stool output that declined when enteral feedings discontinued________________
#3 Problem ______________________________________________________________________________________________
Etiology ______________________________________________________________________________________________
Signs/Symptoms _______________________________________________________________________________________
NUTRITION INTERVENTION
Nutrition Prescription
The patient/clients individualized recommended dietary Intervention #1 Initiate parenteral nutrition (ND-2)___
intake of energy and/or selected foods or nutrients Goal (s) 1 L of PN containing 60 g amino acids and
based upon current reference standards and dietary 200 g dextrose over 24 hours. Administer 250 mL of
guidelines and the patient/clients health condition 20% lipids over 12 hours separately with reduced
and nutrition diagnosis. (specify) potassium (20 mEq) and increased (maximum)
acetate relative to baseline._________________________
1.5 L PN providing 100 g of protein and 340 g of dextrose
over 24 hours daily with an IV rider of 250 mL of 20% lipids Intervention #2 Order parenteral nutrition
daily over 12 hours. Electrolytes to meet baseline needs are monitoring protocol______________________________
80 mEq Na, 30 mEq K, 20 mmol phosphorus, 10 mEq Goal (s) Identify feeding intolerance_________________
calcium, 8 mEq Mg (with 1/3 chloride and 2/3 acetate).
Will also give 10 mL MVI, 3 mL trace elements, and Intervention #3__________________________________
40 mg famotidine daily_______________________________ Goal (s)_________________________________________
___________________________________________________
NUTRITION MONITORING AND EVALUATION
Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL
#1 Parenteral access (FI-3.1.1) ______________________ #1 Parenteral access patent_________________________
#2 Parenteral formula (FI-3.1.2)_____________________ #2 Parenteral formula administered as ordered________
#3 Parenteral formula rate/schedule (FI-3.1.5)________ #3 Parenteral formula administered as ordered________
#4 Energy intake (F1.1.1)___________________________ #4 Parenteral formula contains 1420 calories__________
#5 Protein intake (FI-5.2.1)_________________________ #5 Parenteral formula contains 60 g/protein__________
#6 Total carbohydrate intake (FI-5.3.1)_______________ #6 Carbohydrate intake from all sources <472 g/day____
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Support Line December 2007 Volume 29 No. 6
Consensus Conference Committee. 14. Wolfe R, O'Donnell T Jr, Stone M, feedings for critically ill patients. J Am
American College of Chest Physicians/ Richmand D, Burke J. Investigation of Diet Assoc. 2006;102:12261241.
Society of Critical Care Medicine. factors determining the optimal glucose 16. Frankenfield D, Smith J, Cooney R.
Chest. 1992;101:16441655. infusion rate in total parenteral nutrition. Accelerated nitrogen loss after traumatic
13. Cerra FB, Benetiz MR, Blackburn GL, Metab Clin Experiment. 1980;29:892900. injury is not attenuated by achievement
et al. Applied nutrition in ICU patients: 15. Kattelmann KK, Hise M, Russell M, of energy balance. JPEN J Parenter
a consensus statement of the American Charney P, Stokes M, Compher C. Enteral Nutr. 1997;21:324329.
College of Chest Physicians. Chest. 1997; Preliminary evidence for a medical
111:769777. nutrition therapy protocol: enteral
1.5 L parenteral nutrition providing 100 g of protein and Intervention #2 Dietitian will order parenteral
340 g of dextrose over 24 hours daily with an IV rider of nutrition monitoring protocol_______________________
250 mL of 20% lipids daily over 12 hours. Electrolytes to Goal (s) Identify feeding intolerance_________________
meet baseline needs are 80 mEq Na, 30 mEq K, 20 mmol
phosphorus, 10 mEq calcium, 8 mEq Mg (with 13 chloride Intervention #3 Dietitian will increase the phosphorus
and 23 acetate), 10 mL MVI, 3 mL trace elements, and in the PN to 39 mmol_____________________________
40 mg famotidine daily _______________________________ Goal (s) Serum phosphorus level of 4.0 mg/dL________
___________________________________________________
NUTRITION MONITORING AND EVALUATION
Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL
#1 Parenteral formula rate/schedule (FI-3.1.5) ________ #1 I&O sheet reflects PN administered as ordered_____
#2 ________________________________________________ #2 Serum phosphorus within normal limits___________
#3 ________________________________________________ #3 ____________________________________________
23