Case Study Questions Jax Dunham

Case Study 8 Questions
1. Identify the major physiological controls for gastric emptying.
- The rate of gastric emptying is by the hormones and the nerves. When carbohydrates,
fats, or amino acids come into the duodenum, inhibitory mechanisms decrease the
fundic pressure which allows for the gastric emptying of nutrients into the small intestine
(Mahan, 2017)
2. List and discuss physiological factors that may lead to the diagnosis of gastroparesis.
- The physiological factors that may lead to the diagnosis of gastroparesis include viral
infections, diabetes and surgeries. Other clinical conditions that are associated with
gastroparesis include acid-peptic disease, gastritis, disorder of the smooth gastric
muscle, neuropathic disorders, and post gastric surgery. Gastroparesis is overall very
complex because of how many hormonal and neural factors can impact it.
(Mahan, 2017)
3. According to the American College of Gastroenterology, scintigraphy is the gold

standard for diagnosis of gastroparesis. This test was performed on Mrs. Williams.
Explain this test and discuss how her results confirm her diagnosis. Are there other
diagnostic tests that could be used?
- This test involves the patient ingesting a radionucleotide labeled meal and scintigraphy
images are taken over the course of about 4 hours. Gastric emptying is considered
abnormal when greater than 50% of the meal is retained after 2 hours or greater than
10% is retained after 4 hours. Her result of 85% of the meal being retained after 2 hours
confirms her diagnosis because it was greater than 50% after 2 hours. Other tests that
can be used include the gastric emptying breath test or by using a wireless motility
capsule.
(Mahan, 2017) (Diagnosis of Gastroparesis, 2018)
4. What are the common signs and symptoms of gastroparesis? Explain how they may
lead to nutritional deficits.
- Clinical symptoms of gastroparesis include bloating, decreased appetite and anorexia,
fullness, nausea/vomiting, early satiety, and postprandial hypoglycemia. Nausea and
vomiting can lead to decreased nutrient absorption and therefore deficits. Decreased
appetite, anorexia, fullness, and early satiety can all potentially lead to malnutrition and
nutritional deficits due to a lack of oral intake.
(Mahan, 2017)
5. Summarize the current recommendations for nutrition therapy for

gastroparesis.Choose at least 3 of the recommended dietary modifications and explain
why each may assist with control of symptoms or improve nutritional status.
- Current recommendations for nutrition therapy for gastroparesis include implementing
small and more frequent meals, shifting to a diet of more pureed or liquified food, and
restricting high fiber foods. Implementing smaller and more frequent meals helps to
speed up gastric emptying when compared with large meals that increase early satiety,
create stomach distension, and delay gastric emptying. Diets that consist of more pureed
or liquified foods are beneficial because this can often help with gastric emptying due to
a lower volume and less breakdown required. Avoiding high fiber foods is also very
important because fiber (particularly pectin) can slow down gastric emptying which is
something that we want to avoid in gastroparesis patients.
(Mahan, 2017)
6. If a patient with gastroparesis is not able to meet his or her nutritional needs orally,
what type of enteral feeding recommendations are appropriate?
- Some enteral feeding recommendations that could be appropriate in this scenario
include the placement of enteral tube feeds via a nasoenteric small bowel feeding tube
or a PEG/J tube. This will allow for the nutrition to bypass the stomach. A PEG/J tube
also can allow for an alternative route for the venting of gastric secretions which can help
to alleviate nausea and vomiting in the patients.
(Mahan, 2017)
7. Calculate the patient’s %UBW and BMI. What does this assessment tell you?
- BMI: 20.3
- 703 x 126 lbs/ [66 in]2 = 20.3
- %UBW: 76%
- Current weight / usual weight
- 126 lbs / 166 lbs = 0.76 = 76%
- This assessment tells me that she has lost a significant amount of weight over the last
year due to her nausea and lack of appetite. This is a strong indicator for gastroparesis.
8. Calculate energy and protein requirements for Mrs. Williams. Explain how you
determined these recommendations.
- (10 x 57.27kg) + (6.25 x 168 cm) - (5 x 49) - 161 = 1217 x 1.3 AND 1.5 = 1582-1825
kcals/day
- 72-86 g pro/day (1.25-1.5 g/kg)
9, Estimate her caloric intake from her usual dietary intake. How does this compare to
your calculated energy requirements?
- Her estimated caloric intake is around 95 kcals/day based on her usual dietary intake.
This is much less than her estimated energy requirements which is probably why she
has lost 40 pounds in the past year.
(Food Calculator: Carbs, Calories, Fat, Protein and More, n.d.)
10. Identify the most pertinent nutrition problems and corresponding nutrition diagnoses
and write at least 2 PES statements for them
- Altered gastrointestinal function related to changes to the gastroparesis as evidenced by
85% of initial gastric contents retained 120 minutes after consumption, >40 pounds lost
over the previous year, constant nausea and occasional vomiting, medical history of a
hiatal hernia, and low hemoglobin, hematocrit, and mean cell hemoglobin levels.
- Severe chronic disease related to malnutrition related to gastroparesis as evidenced by
Estimated energy intake < 75% of estimated energy requirement for ≥ 1 month and 14%
weight loss in the past year.
11. Determine the appropriate intervention for your diagnoses.

- Provide continuous PEG enteral nutrition so that the patient may receive smaller and
more frequent feedings throughout the day to help with gastroparesis.
12. Identify measurable outcomes for each of your interventions. What are possible
nutrition concerns that you may want to address in a follow up visit with Mrs. Williams?
- Reassess whether or not the intervention has worked properly in accordance to
monitoring lab values, weights, and patient symptoms. If patient responds well to
continuous enteral nutrition, evaluate options related to intermittent enteral nutrition for
patient needs.
Case Study 8 Works Cited
Diagnosis of Gastroparesis. (2018, January). Retrieved October 30, 2020, from
https://www.niddk.nih.gov/health-information/digestive-diseases/gastroparesis/diagnosis
Food Calculator: Carbs, Calories, Fat, Protein and More. (n.d.). Retrieved October 30, 2020,
from https://www.webmd.com/diet/healthtool-food-calorie-counter
Mahan, K. L., & Raymond, J. L. (2017). Krause's Food & The Nutrition Care Process. Amman:
Elsevier.

1. Outline the pathophysiology of heart failure. Onset of heart failure usually can be
traced to damage from an MI and atherosclerosis. Is this consistent with Mrs. Maney’s
history?
- Heart failure arises as a result of damage or stress to the heart muscle from either acute
MI or through hemodynamic pressure or volume overloading. HF can progress
asymptomatically since silent damage may occur without notice. Through the
progression of HF, the function and shape of the left ventricle may alter by undergoing
hypertrophy in effort to sustain proper blood flow. In the case of Mrs. Maney, her history
is consistent with the onset of heart failure since she suffers from Coronary Artery
Disease (CAD) which is caused by atherosclerosis (buildup in plaques within arteries).
(Mahan, 2017)
2. Identify specific signs and symptoms in the patient’s physical examination that are
consistent with heart failure. For any three of these signs and symptoms, write a brief
discussion which connects them to physiological changes that you described in
question #1.
- Some signs and symptoms that the patient had in the physical examination consistent
with heart failure include shortness of breath, fluid retention (2+ pedal edema), and
fatigue (patient collapse). Shortness of breath is linked to the blood’s lowered ability to
flow due to blood flow restriction related to atherosclerosis.. Fluid retention via edema is
connected to the declining serum sodium levels in those with HF caused by fluid
overload. Fatigue is related to HF due to improper blood flow to areas around the body.
(Mahan, 2017)
3. Heart failure is often described as R-sided or L-sided failure. What is the difference?
How are the clinical manifestations different?
- Left sided heart failure means that the left ventricle can’t pump enough oxygen-rich
blood to the body whereas right sided heart failure means that the right ventricle cannot
pump enough blood to the lungs. In L-sided heart failure, a patient may experience a
reduced ejection fraction (Left Ventricle can’t contract normally) or preserved ejection
fraction (Left Ventricle can’t relax normally). R-sided heart failure is usually a result of
L-sided failure and symptoms include edema in feet, ankles, legs, and abdomen and
veins can be visible in the neck.
(363 Cardiovascular Disease and Heart Failure PowerPoint)
4. Mrs. Maney’s husband states that they have monitored their salt intake for several
years. What is the role of sodium restriction in the treatment of heart failure? What level
of sodium restriction is recommended for the outpatient with heart failure? What
difficulties may a patient have in following a sodium restriction?
- Sodium restriction’s role in the treatment of heart failure is to help negate fluid retention
and edema and can also decrease urinary sodium secretion and even fatigue. There are
many studies that have looked into the amount of sodium that should be consumed for
those with heart failure, but a 2 gram sodium restriction is usually prescribed for those
with HF. When following sodium restrictions, patients may have difficulty with adherence
to a low sodium diet. This can be due to multiple factors which includes regional and
cultural cuisine differences in sodium levels. For this reason, the type of sodium
restriction that is prescribed should be the least restrictive diet which will help achieve
the desired results.
(Mahan, 2017)
5. Why is Mrs. Maney placed on a fluid restriction? How will this assist with her treatment
of her heart failure? What specific foods are typically “counted” as fluid?
- Mrs. Maney is on a fluid restriction because it is necessary for proper diuresis and we do
not want to further overload the body with fluids. Doing so will help with her heart failure
treatment because the diuresis will help with the patient's sodium levels by decreasing
the amount of water in the vascular space. Foods that are typically “counted” as fluid
include foods that become fluid at body or room temperature such as popsicles. Other
foods to look out for that are higher in water include lettuce, watermelon, celery,
cucumbers, and other fruits/vegetables with high levels of water.
(Mahan, 2017)
6. Identify any common nutrient deficiencies found in patients with heart failure.
- Common nutrient deficiencies for those with heart failure include magnesium and thiamin
due to poor dietary/food intake and the use of diuretics which will increase excretion.
(Mahan, 2017)
7. Identify factors that would affect interpretation of Mrs. Maney’s weight and body
composition. Look at the I/O record. What will likely happen to Mrs. Maney’s weight if this
trend continues.
- The main factor that would affect the interpretation of Mrs. Maney’s weight and body
composition would be fluid retention due to the retention of fluids impacting the patient’s
body composition and weight. When looking at Mrs. Maney’s I/O record, it should be
noted that she has a net intake of +408 ml of water. If this continues, she may continue
to retain water and her edema could remain steady.
8. Calculate Mrs. Maney’s energy and protein requirements. Explain your rationales for
the weight you have used in your calculation.

- Energy Estimated Needs: 1200-1460 kcals/day (25-30 kcals/kg OR Mifflin x 1.3-1.5
using 47.7kg)
- 25 kcals/kg x 47.7 kg = 1192 kcals & 30 kcals/kg x 47.7 kg = 1431 kcals
- Mifflin: (10 x 47.7kg) + (6.25 x 157.5cm) - (5 x 65) - 161 = 975 kcals
- 975 x 1.3 = 1268 kcals
- 975 x 1.5 = 1463 kcals
- I used this weight because it was her actual body weight at the time which means
that the calculation will give her proper energy.
- Protein Estimated Needs: 60-75 g/pro/day (1.2-1.5g/kg IBW)
- 50.1 kg x 1.2 g/kg = 60 g
- 50.1 kg x 1.5 g/kg = 75 g
- I used IBW for this patient because she showed severe muscle wasting in her
temples which signifies that the patient needs to maintain lean body mass.
9. Do you have any evidence that Mrs. Maney may be malnourished? Identify factors that
may support a diagnosis of malnutrition.
- Evidence that may support the diagnosis of malnutrition includes energy intake meeting
<75% of estimated needs for >1 month and severe muscle wasting in temples from the
NFPE.
10. Malnutrition in heart failure is often referred to as cardiac cachexia. What is cardiac
cachexia? What are the characteristic symptoms? Explain the role of the underlying
heart disease in the development of malnutrition.
- Cardiac cachexia is the end result of heart failure. It is the involuntary loss of at least 6%
of nonedematous body weight throughout the course of a six month period. Unlike
normal malnutrition which is mostly associated with large losses of adiposity, cardiac
cachexia is associated with severe losses of lean body mass (muscle). Symptoms of
cardiac cachexia include constipation, abdominal pain, nausea, a sense of fullness,
malabsorption, anorexia, hepatomegaly, and liver tenderness. These symptoms lead to
the development of malnutrition in patients with HF by a lack of blood flow to the
digestive system which leads to a loss of bowel integrity.
(Mahan, 2017)
11. Do you feel that Mrs. Maney may benefit from enteral feeding? What guidelines would
you use to make this decision? Outline a nutrition therapy regimen for her that includes
formula choice, total volume, and goal rate.
- In the case that Mrs. Maney is unable to continue oral intake due to poor appetite, I
believe that using enteral feeding could be beneficial to her. To assess if she should be
placed on EN, I would analyze her oral intake. If her oral intake was not sufficient for her
energy needs, I would then move to EN.
- A sample EN order may be:
- Start with Isosource 1.5 at 20 ml/hr and advance to rate of 40 ml/hr after 8 hours.
Goal rate will provide 1440 kcals, 66g protein, 168g CHO, 734ml water, 96% RDI
for vitamins and minerals.
12. Identify any abnormal biochemical values associated with Mrs. Maney’s heart failure
or CVD:
Laboratory Value Normal Value Pt’s Value & Date
Na+ 136-145 mEq/L Na 135 mEq/L (2/20)
BNP <100 pg/ml 1025 pg/ml (2/20)
CRP <1.0 mg/L 338 mg/L (2/20)
HDL >59 mg/dl in females 30 mg/dl (2/20)
LDL <130 mg/dl 152 mg/dl (2/20)
13. The following drugs/supplements were prescribed for Mrs. Maney. Give the medical
rationale for the use of each. In addition, describe any nutritional concerns for Mrs.
Maney while she is taking these medications.
- Lanoxin: Lanoxin helps to increase the force of the heart’s contractions which can help
with HF. Drug can lead to hypokalemia and hypomagnesemia so is=t is important to
consume proper magnesium and potassium through diet.
- (Cardiac Medications, n.d.) (Mahan, 2017)
- Lasix: Lasix is a diuretic that causes the body to expel of excess fluid and sodium
through the urine. It is important to avoid licorice ince it may counteract diuretic effects. It
is also important to maintain a diet high in zinc, potassium, magnesium, and calcium.
- (Cardiac Medications, n.d.) (Mahan, 2017)
- Dopamine: Dopamine helps the heart to beat more forcefully which will lead to increased
urine production. This helps rid the body of excess fluids and sodium.
- (Salamon, 2019)
- Thiamin: Thiamin is an important coenzyme in the reactions that fuel myocardial
contraction. For this reason, thiamin deficiency can cause decreased energy and weaker
heart contraction, meaning that supplementation can be vital for those with HF such as
Mrs. Maney
- (Mahan, 2017)
14. Select two nutrition problems and complete a PES statement for each.
- Severe protein-calorie malnutrition related to inadequate oral intake secondary to chronic
illness as evidenced by severe muscle wasting in temples and energy intake meeting
<75% of estimated needs for >1 month.
- Altered nutrition related lab values r/t suspected iron deficiency as evidenced by patient
report of <75% intake of estimated energy needs, HGB 10, RBC 3.72, Hct 29%, and iron
42 (µg/dl).
15. Mrs. Maney was not able to tolerate the enteral feeding because of a nursing report
for diarrhea. What recommendations could be made to improve tolerance to the tube
feeding.
- To increase tolerance of tube feeding, I might first decrease the amount of formula that is
being administered in the tube feed. Since the formula has a higher water content, it may
help with symptoms of diarrhea by reducing the fluid intake. I would also consider a more
calorically dense formula for the patient since it would have a lower water content than a
less calorically dense formula.
16. The tube feeding was discontinued because of continued intolerance. Parenteral
nutrition was not initiated. What recommendations could you make to optimize Mrs.
Maney’s oral intake.
- To optimize Mrs. Maney’s oral intake, I would recommend including meal supplements
such as Boost three times per day with meals. By doing this, It would allow for the
patient to reach her caloric and protein needs to ensure proper body function when
dealing with HF.
17. Outline steps you would take to assist Mrs. Maney as she prepares for discharge.
Include a specific nutrition education that you would include.
- I would prepare an education for Mrs. Maney specifically related to a 2g sodium and 1.5L
diet prior to her being discharged. I would also educate her on her thiamine
supplementation so that she can better understand why she is taking it for HF.
Cardiac Medications. (n.d.). Retrieved October 30, 2020, from
https://www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack/
cardiac-medications
Elsevier.
Salamon, M. (2019, August 06). How Heart Failure Is Treated. Retrieved October 31, 2020,
from https://www.verywellhealth.com/how-heart-failure-is-treated-3892476
1. Mr. Seyer has been diagnosed with cancer of the tongue, which is a type of head and
neck cancer. Head and neck cancers are categorized by the area where they begin.
Describe these primary areas.

- The primary areas that are categorized under head and neck cancers include cancers of
the oral cavity (lips, inside of mouth, front portion of the tongue, roof/floor of mouth), the
oropharynx (back of tongue and throat behind oral cavity), the larynx, and the
esophagus.
(Mahan, 2017)
2. What are the major risk factors for the development of head and neck cancer? Does
Mr. Seyer’s medical record indicate that he has any of these risk factors?
- The major risk factors associated with head and neck cancer include the use of tobacco,
alcohol consumption, Human Papillomavirus (HPV), GERD, gender (greater in men),
and age (greater over 40). Mr. Seyers has risk factors associated with head and neck
cancer such as testing positive for HPV, smoking 2 packs per day, consuming 1-2
alcoholic beverages most days, being male, cand being over the age of 40.
(Head and Neck Cancer - Risk Factors and Prevention, 2019)
3. Mr. Seye’s biopsy results indicated an HPV positive tumor. What is HPV? Does this
imply a better or worse outcome?
- HPV or the Human Papillomavirus is the most common sexually transmitted disease
found in the United States It is also shown that those that have HPV related head and
neck cancers can have significantly improved outcomes if their cancer is associated with
the sexually transmitted disease.
(HPV and Oropharyngeal Cancer, 2020) (Kimple, 2015)
4. Mr. Seyers cancer was described as Stage IV T2 N2b. Explain this terminology, which
is used to describe staging for malignancies.
- Stage IV describes a cancer that has spread to distant part of the body and is no longer
localized. T2 refers to the size of the main tumor. The higher the number is following the
“T”, the larger the tumor is or the more it has grown into nearby tissue. In this case, T2
would be a moderately sized tumor. N2b describes the number and the location of the
lymph nodes that contain cancer. The higher the number that follows “N” is, the higher
the number of cancer containing lymph nodes there are. In this case, N2b would mean
that it has spread to a moderate amount of lymph nodes.
(Cancer Staging, 2015)
5. Cancer is generally treated with a combination of therapies. These can include surgical
resection, radiation therapy chemotherapy, and immunotherapy. The type of malignancy
and staging of the disease wil, in part, determine the types of therapies that are
prescribed. Define and describe each of these therapies. Briefly describe the mechanism
for each. In general, how do they act to treat a malignancy?
- Surgical Resection: This therapy works by removing all or part of the cancerous tumor.
By doing this, it can help to mitigate the spread of the cancer further. This is done by
surgically taking the cancerous tumor or part of it out of the body.
- Radiation Therapy: Radiation therapy uses external or internal beam radiation to slow
cancer growth by damaging the DNA within the cancerous cells.
- Chemotherapy: This therapy works by utilizing drugs to stop or slow the growth of cancer
cells. This can be done orally, by IV, injection, intrathecally, intra-arterially, or
intraperitoneally.
- Immunotherapy: This therapy works by helping the immune system fight the cancer. This
is a type of biological therapy which uses substances made of living organisms to treat
the cancer. This can be done via t-cell transfer therapy, immune checkpoint inhibitors,
and monoclonal antim=bodies.
(Types of Cancer Treatment, n.d.)
6. Mr. Seyer had a partial glossectomy and right neck dissection of 9/7. Describe these
surgical procedures. How may these procedures affect him nutritionally?

- A partial glossectomy is a surgery which removes part of the tongue. This is done via the
mouth while the patient is under anaesthesia. A right neck dissection is a surgery that is
conducted to remove cancerous lymph nodes from the body. These procedures will
likely mean that the patient cannot eat or drink for multiple days after the operation to
ensure proper healing. This means that the patient may be put on TPN or EN to provide
proper nutrition.
(Partial Glossectomy Information for Patients, 2018) (Neck Dissection, 2020)
7. Many cancer patients experience changes in nutritional status. Briefly describe the
potential effect of cancer on nutritional status.
- Cancer and its treatments can affect the nutritional status of a patient by affecting taste,
smell, appetite, and the ability to eat enough food or properly absorb nutrients. This can
lead to malnutrition, anorexia, and cachexia in some cancer patients. With this patient, in
particular, cancer could cause dysphagia since he has cancer in the tongue which could
impact nutritional status.
(Mahan, 2017)
(Nutrition in Cancer Care (PDQ®)–Patient Version, 2018)
8. Surgery, radiation, and chemotherapy affect nutritional status. Describe the potential
nutritional and metabolic effects of these treatments.
- Chemotherapy can cause nutritional effects by leading to loss of appetite, nausea,
vomiting, sores in the mouth or throat, constipation, diarrhea, and trouble swallowing.
Radiation therapy can cause loss of appetite, nausea, vomiting, sores in the mouth or
throat, constipation, diarrhea, trouble swallowing, choking/breathing problems, bowel
obstruction, and colitis. Surgery can lead to loss of appetite, trouble swallowing, trouble
chewing, and feeling full after eating small amounts of food.
(Nutrition in Cancer Care (PDQ®)–Patient Version, 2018)
9. Calculate and evaluate Mr. Seyers %UBW and BMI.

- %UBW = 86.9%
- 90 kg / 103.6 kg = 0.869
- BMI = 26.1
- 90 kg / (1.854 m)^2
10. Summarize your findings regarding his weight status. Classify the severity of his
weight loss. What factors may have contributed to his weight loss?
- He has severe weight loss since he has lost over 10% of his body weight within 6
months. A major factor contributing to this weight loss may have been that the patient
began experiencing significant pain while eating. He has also stated that he has poor
appetite and that he gets full quickly when eating which could lead to weight loss.
11. What does the research tell us about the relationship between significant weight loss
and prognosis in cancer patients?
- The research tells us that the relationship between significant weight loss and prognosis
in cancer patients is poor. “One limitation of using weight loss as a surrogate for
malnutrition is that it does not take into account the time course of the weight loss or the
type of tissue loss” (Nutrition in Cancer Care (PDQ®)–Health Professional Version,
2020).
(Nutrition in Cancer Care (PDQ®)–Health Professional Version, 2020)
12. Estimate Mr. Seyer’s energy and protein requirements based on his current weight.
- Energy Estimated Needs: 1529-1784 kcals/day(Mifflin x 1.2-1.4 using 90kg)

- 2250-2700 kcals/day (25-30 kcals/kg)
- Protein Estimated Needs: 108-155 g/pro/day (1.2-1.5g/kg)
13. Estimate Mr. Seyers fluid requirements based on his current weight.
- Estimated Fluid Needs: 2250-2700 ml/day (1ml/kcal)
14. What factors noted in Mr. Seyer’s history and physical may indicate problems with
eating prior to admission?
- The patient noted that he began experiencing significant pain while eating. He has also
stated that he has poor appetite and that he gets full quickly when eating which could
lead to weight loss.
15. Mr. Seyer is currently receiving enteral nutrition, specifically Isosource HN at 75 ml/hr
per PEG tube.
a. Calculate the amount of energy and protein that will be provided at this rate.
- 75 ml/hr x 24 hr = 1800 ml/day x 1.2 kcals/ml = 2160 kcals/day
- 1.8 L/day x 54 g pro/L = 97 g protein
b. Next, by assessing the information in the intake/output record, determine the actual
amount of enteral nutrition he received on September 11.
- He actually received 1735 ml of formula on 9/11 which equates to 2082 kcals and
93 grams of protein.
c. Compare this to his estimated energy requirements,
- Compared to his estimated energy requirements, he is receiving slightly less than
his estimated needs in both calories and protein administered.
d. Compare fluids required to fluids received. Is he meeting his fluid requirements? How did
you determine this? Why would you evaluate his output when assessing fluid intake?
- He appears to be meeting his fluid needs because he has a net I/O of 285 ml on
9/11 which means that he is taking in more fluid than he is getting rid of. He is
also meeting his fluid requirements based on the amount provided through tube
feed and IV. It is important to evaluate output when assessing fluid intake
because it can signify if the patient is retaining more fluid than he is consuming.
16. What type of formula is Isosource HN? One of the residents taking care of Mr. Seyer
asks about a formula with a higher concentration of omega-3 fatty acids, antioxidants,
arginine, and glutamine that could promote healing after surgery. What does the
evidence indicate regarding nutritional needs for cancer patients and, in particular,
nutrients to promote postoperative wound healing? What formula may meet this profile?
17. Are any clinical signs of malnutrition noted in the patient’s admission history and
physical.
- Yes, the patient has had a greater than 10% weight loss in 6 months, severe muscle
depletion in temples, and patient report of tongue pain, poor appetite, and rapid
satiation.
18. Review the patient’s chemistries upon admission. Identify any that are abnormal and
describe their clinical significance for this patient, including the likely reason for each
abnormality and its nutritional implications.
- Lab values that were abnormal for the patient included low RBC, low hematocrit, low
hemoglobin, low bilirubin, low protein, and low albumin. This may have been caused due
to the patient experiencing low intake due to tongue pain, low appetite, and early satiety.
19. Mr. Seyer has been diagnosed with a life-threatening illness. What is the definition of
terminal illness?
- Terminal illness is a condition or disease state which cannot be cured and is likely to
lead to the death of the person.
(What is terminal illness, 2019)
20. The literature describes how a patient and his/her family may experience varying
levels of emotional response to a terminal illness. These may include anger, denial,
depression, and acceptance. How may this affect the patient’s nutritional intake? How
would you handle these components in your nutritional care? What question might you
have for Mr; Seyer or his family? List 3.

- Depending how the patient responds emotionally to the terminal illness, it could impact
appetite and willingness to adhere to a nutritional intervention. With a terminal illness, I
would handle it is important to understand that nutrition support can extend a patient’s
life to the point that quality of life and the patient’s right to determine their future come
into play. For these reasons, it is important to adjust the nutrition care accordingly with
both nutrition and the patient’s needs in mind. Questions that I may ask Mr. Seyer or his
family include:
- How have you been feeling about eating since your diagnosis?
- Has your appetite changed at all since your diagnosis?
- Is there anything that you want to include in your diet once you are able to eat
food orally again?
(Mahan, 2017)
21. Select two high-priority nutrition problems after Mr. Seyers surgery and complete the
PES statements for each.
- Chronic disease related malnutrition r/t squamous cell carcinoma of right anterior tongue
as evidenced by greater than 10% weight loss in 6 months, severe muscle depletion in
temples, and patient report of tongue pain, poor appetite, and rapid satiation.
- Unintended weight loss r/t decreased ability to consume sufficient energy as evidenced
by greater than 10% weight loss in 6 months, poor appetite, rapid satiation, severe
muscle wasting in temples, and squamous cell carcinoma of right anterior tongue
creating pain while eating.
22. For each of the PES statements you have written, establish an ideal goal and an
appropriate intervention.
- Recommend EN for patient via a PEG from patient surgical resection.

- Recommend that the patient continues to receive enteral nutrition. Recommend moving
to higher calorie formula to meet energy needs.
23. Does his current nutrition support meet his estimated nutritional needs? If not,
determine the recommended changes. Discuss any areas of deficiency and ideas for
implementing a new plan.
- It does not state what formula the current patient is having administered. However, it
does show that he is receiving 1735 ml/day of formula on his I/O chart. If we were to
assume that he was administered an Isosource HN formula (to meet his protein needs)
he would be getting 2082 kcals per day and 78 grams of protein per day. He would need
to be given a more energy dense formula at a higher rate to meet his needs of
2250-2700 kcals/day and 108-155 g/pro/day.
24. How may these interventions (from question 22) change as he progresses
postoperatively? Discuss how Mr. Seyer may transition from enteral feeding to an oral
diet.
- As the patient begins to heal from his surgery, his caloric needs will decrease due to less
energy needs to support proper healing. When transitioning from enteral feedings to an
oral diet, the patient should be using meal supplementation (such as Boost) to meet his
caloric needs. Since the cancer and surgery affected his tongue, it may also be in the
best interest to implement some sort of dysphagia diet so that the patient doesn’t have to
worry about choking as much while he regains control of swallowing.
25. List the factors you should monitor for Mr. Seyer while he is receiving enteral
nutrition therapy.
- Will monitor for diet advancement and start clear liquid implementation and potential
meal supplementation/dysphagia diet order.
- Will monitor weights for assessment of fluid loss and weight fluctuation.
- Will monitor labs to assess nutritional adequacy.
- Will monitor enteral nutrition tolerance.
26. Mr. Seyer will receive radiation therapy and chemotherapy as an outpatient. In
question #8, you identified potential nutritional complications with both. Choose one of
the nutritional complications and describe the nutrition intervention that would be
appropriate for you to recommend.
- Radiation therapy can cause loss of appetite, nausea, vomiting, sores in the mouth or
throat, constipation, diarrhea, trouble swallowing, choking/breathing problems, bowel
obstruction, and colitis. If the patient begins to specifically experience sores in the mouth
or throat/esophagus, the patient may not want to eat, creating the need for enteral
nutrition. The intervention could be to place an NG tube to get around the discomfort
from the sores, or a PEG tube could even be placed if the patient experiences symptoms
for a long time.
27. Identify major assessment indices you would use to monitor his nutritional status
once he begins therapy.
- The main thing that I would monitor in this patient once his therapy begins is his weight.
If he experiences any symptoms that lead to him eating less such as loss of appetite,
nausea, or trouble swallowing, it could lead to inadequate nutrient intake in the patient. I
would also monitor his nutrient intake as well as I could based on his reports of intake. If
he is on enteral nutrition, this will be much easier to calculate.
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1. Describe the normal exocrine and endocrine functions of the pancreas.
- Exocrine
- Pancreatic cells secrete enzymes and other substances into the the intestine
(lumen) to aid in digesting fats, protein, and carbohydrates.

- Endocrine
- Pancreatic cells create glucagon, somatostatin, and insulin to allow for nutrient
absorption into the bloodstream to help monitor glucose homeostasis.
(Mahan, 2017)
2. Determine the potential etiology of both acute and chronic pancreatitis. What
information provided in the physical assessment supports the diagnosis of acute
pancreatitis?
- The etiology of both acute and chronic pancreatitis includes chronic alcoholism,
smoking, body weight, diet, trauma, gallstones, biliary tract disease, genetic conditions,
hypertriglyceridemia, hypercalcemia, certain drugs, and some viral infections. From the
assessment of the patient, his excessive alcohol intake and high triglyceride levels
(hypertriglyceridemia) support his diagnosis of acute pancreatitis. His physical
assessment also includes dry mucous membranes, rapid aspiration, and acute
abdominal pain also support his diagnosis.
(Mahan, 2017)
3. What laboratory values or other tests support this diagnosis? List all abnormal values
and explain the likely cause for each abnormal value.
- High Glucose (142 mg/dl): Likely due to the fact that the pancreas is involved with the
secretion of insulin and glucagon to help monitor glucose levels. Since the pancreas is
damaged, glucose levels are thus impacted.
- High Triglycerides/Hypertriglyceridemia (585 mg/dl): This is caused since the pancreas
is injured and this will affect lipid metabolism.
- High BUN/Creatinine: This is likely due to intravascular volume depletion, but patients
with pancreatitis also often have renal dysfunction which can cause the elevated levels
(Wu, 2011).
- High Lipase/Amylase: These two enzymes help digest fats (lipase) and carbohydrates
(amylase). These are two enzymes created in the pancreas, and in pancreatitis, these
levels elevate drastically (Pancreatitis, 2019).
(Mahan, 2017)
4. The physician lists an APACHE score in his note. What factors are used to determine
this score? What does this mean? Also define Ranson’s Criteria and the Atlanta Criteria.
- The factors used to determine the APACHE score include past history of organ failure,
acute kidney injury, creatinine, potassium, age, temperature, blood pH, heart rate, mean
arterial pressure, respiratory rate, sodium, hematocrit, WBC count, and blood
oxygenation. The score is used to calculate the risk of mortality in the ICU, and it can
help to predict complications associated with pancreatitis. His APACHE score of 4
means that the patient is not at a high risk of complications (Smith, n.d.). The Ranson
criteria also uses multiple measures to assess the severity of acute pancreatitis
(Gaillard, n.d.). The Atlanta Criteria also looks at classification of acute pancreatitis. This
criteria aims to look at both local and systematic determinants of severity to help form an
internationally agreed upon classification of acute pancreatitis severity (Pfleger, n.d.).
6. Historically, the patient with acute pancreatitis was made NPO. Why?
- The historical use of NPO in those with acute pancreatitis has been used until the pain
and nausea have subsided. The thought process as to why this works is because food
intake may stimulate the pancreas to release its enzymes which could further inflame the
pancreas.
(Paauw, 2016)
7. The physician has written an order for a nutrition consult. Using the most current
literature, explain the role of enteral feeding in acute pancreatitis. Do you agree with the
initiation of enteral feeding? Why/why not?

- Enteral feeding has proven to be very beneficial for those with severe acute pancreatitis
(SAP). Enteral feeding can reduce mortality and infectious complications associated with
SAP. I personally agree with the use of enteral feeding in those with SAP because doing
so will allow for the patient to have the required nutrition to stay healthy enough to
undergo treatment for SAP. On top of this, the literature states that it reduces risk for
mortality in patients which is an important factor to notice.
(Oláh, 2014)
8. Does the patient’s case indicate the use of an immune-modulating formula?
- No studies have yet to determine the merit of using immune-modulating formulas in
those with pancreatitis. For this reason, the patient’s condition does not indicate this type
of formula.
(Mahan, 2017)
9. Assess Mr. Mahon’s height and weight. Calculate his BMI and % usual body weight.
- BMI: 34.4
- 111.4 kg / (1.803 m)^2 = 34.4
- %UBW: 126%
- 111.4 kg / 88.6 kg = 1.26
10. Evaluate Mr. Mahon’s initial nursing assessment. What important factors noted in his
nutrition assessment will affect your nutrition recommendations?
- The patient’s report of vomiting and not being able to keep food down, his report of
increased alcohol intake, his report of gaining 50 pounds over the last 5 years, and his
usual dietary intake will all play a role in affecting my nutrition recommendations.
11. Determine Mr. Mahon’s energy and protein requirements. Explain the rationale for the
method you used to calculate these requirements.

- Energy Estimated Needs: 2750-3350 OR 2730-3150 kcals/day (25-30 kcals/kg OR
Mifflin x 1.3-1.5 using 111.4kg)
- Protein Estimated Needs:
- 115-155 (1.5-2.0g/kg IBW)
- 1.3-1.4g/kg ABW= 135-155g
- I used the activity factor of 1.3-1.5 for estimating his estimated caloric needs because it
allowed for his caloric needs to fall within the range that was calculated using 25-30
kcals/kg. This also seemed like an appropriate activity factor given that his activity will be
lower to moderate given that he is fighting an acute illness.
- Since the patient is in acute pain/trauma from the pancreatitis, I gave him higher protein
needs by using 1.5-2.0 g of protein per kg.
12. Determine Mr. Mahon’s fluid requirements. Compare this with the information on the
intake/output record.
- Estimated Fluid Needs: 2750-3350 (1ml/kcal)

- Compared to the patient’s I/O record, the patient appears to be getting more fluid
through the IV than what I had estimated which means that he is getting proper
fluid levels throughout the day.
13. From the nutrition history, assess Mr Mahon’s alcohol intake. What is the average
caloric intake from alcohol each day using the information that he provided to you?
- Based on his intake of a 6-pack of beer and 4-5 bourbon shots daily, Mr. Mahon has
about 10-11 drinks per day. The average alcoholic drink has 14 grams of pure alcohol.
At this rate Mr. Mahon has 980-1078 kcals/day from pure alcohol alone.
- 10 drinks x 14 g/drink x 7 kcals/g = 980 kcals/day
- 11 drinks x 14 g/drink x 7 kcals/g = 1078 kcals/day
(What Is A Standard Drink?, n.d.)
14. List all the medications that Mr. Mahon is receiving. Determine the action of each
medication and identify any drug-nutrient interactions that you should monitor.
- Imipenem
- This medication is used to treat serious infections that are caused by bacteria in
areas such as the urinary tract, blood, and stomach (Imipenem and Cilastatin
Injection, n.d)
- Pepcid
- This medication is used to treat ulcers and conditions in which the stomach
produces too much acid (Famotidine, n.d.).
- Meperidine
- This medication is an opioid pain reliever to help with the patient’s pain as it
relates to his acute pancreatitis (Meperidine, n.d.).
- Ondansetron
- This medication is used to prevent the symptoms of nausea and vomiting
(Ondansetron, n.d.).
- Colace
- This medication is used as a stool softener to relieve any constipation found in
patients (Stool Softeners, n.d.).
- Milk of Magnesia
- This medication is also used to relieve symptoms of constipation by helping to
retain water in the stool (Magnesium Hydroxide, n.d.).
- Ativan
- This medication is used to treat anxiety and produce a calming effect in the
patient (Ativan Oral: Uses, Side Effects, Interactions, Pictures, Warnings &
Dosing, n.d.).
15. Identify all the pertinent nutrition problems and the corresponding nutrition
diagnoses.
- Patient eating minimally for the past 3 days
- Inadequate oral intake
- Excessive energy intake/alcohol intake
- Obesity
- Vomiting/nausea/abdominal pain
- Altered GI function
16. Write your PES statement for each nutrition problem.
- Inadequate oral intake r/t vomiting, nausea, abdominal pain, and acute pancreatitis as
evidenced by reported minimal intake 3 days PTA and current NPO status with need for
nutrition support
- Obesity r/t suspected excessive energy intake and excessive alcohol intake as
evidenced by reported daily intake of 6 pack of beer and 4-5 shots equaling an
estimated 980-1078 kcals/day and an increase of 26% of weight in the past 5 years.
- Altered GI function r/t acute pancreatitis as evidenced by abdominal pain, nausea,
vomiting, elevated amylase(543 U/L), and elevated lipase (980 U/L).
17. Determine your enteral feeding recommendations for Mr. Mahon. Provide a formula
choice, goal rate, and instructions for initiation and advancement.
- Calculations:
- 3300 kcals / 1.2 kcals/ml = 2750 ml = 2.75 L
- 2800 kcals / 1.2 kcals/ml = 2333 ml = 2.33 L
- 2750 ml / 24 hours = 114 ml/hr
- 2333 ml / 24 hours = 97 ml/hr
- 2.75 L x 54 g pro/L = 149 g pro
- 2.75 L x 156 g CHO/L = 429 g CHO
- 2.75 L x 810 ml water/L = 2228 ml water
- 2750 ml / 1250 ml = 220% RDI vitamins/minerals
- 3000 ml - 2228 ml water = 772 ml / 24 hr = 32 ml/hr
- Isosource HN starting at 90 ml/hr, advancing 5 ml/hr every 8 hours until goal rate of 115
ml/hr is administered continuously by pump via NJ tube. TF at goal provides 3300 kcals,
149 g protein, 429 g carbohydrates, 2228 ml water, 220% RDI for vitamins/minerals.
Recommend additional free water at 32 ml/hr.
18. What recommendations can you make to the patient’s critical care team to help
improve tolerance to the enteral feeding?
- To help improve tolerance to enteral feeding, I would recommend starting at the

recommended starting administration rate. If there is a lack of tolerance, consider
implementing a more calorically dense formula for the patient to reduce volume.
19. List factors that you would monitor to assess tolerance and adequacy of nutrition
support.
- Will monitor labs including glucose levels, BUN, Creatinine, lipase, amylase, and
electrolytes.
- Will monitor for tolerance to enteral nutrition prescription
- Will monitor for diet progression and start of oral nutrition
- Will monitor patient weight to assess that he is receiving adequate nutrition via EN.
20. If this patient’s acute pancreatitis resolves, what will be the recommendations for him
regarding nutrition and his alcohol intake when he is discharged.
- Upon his discharge, I would recommend to the patient that he drastically reduced his
alcohol intake. Doing so will not only help him reduce his excess energy intake, but it will
also help reduce his risk for other conditions such as cirrhosis, cancers, and even
another pancreatitis event. I would also inform him about packing his own food for lunch
to prevent eating out. I might also discuss options that he could have while eating out to
eat more nutritionally conscious.
21. Write an ADIME note that provides your initial nutrition assessment and enteral
nutrition recommendations.
- ADIME note already submitted via bblearn.

Ativan Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (n.d.). Retrieved
October 30, 2020, from https://www.webmd.com/drugs/2/drug-6685/ativan-oral/details
Famotidine. (n.d.). Retrieved October 30, 2020, from

https://medlineplus.gov/druginfo/meds/a687011.html
Gaillard, F., & Bell, D. (n.d.). Ranson criteria. Retrieved October
30, 2020, from https://radiopaedia.org/articles/ranson-criteria?lang=us
Imipenem and Cilastatin Injection. (n.d.). Retrieved October 30, 2020, from
Magnesium Hydroxide. (n.d.). Retrieved October 30, 2020, from
Elsevier.
Meperidine. (n.d.). Retrieved October 30, 2020, from
Oláh, A., & Romics, L. (2014, November 21). Enteral nutrition in acute pancreatitis: A review of
the current evidence. Retrieved October 30, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239498/
Ondansetron. (n.d.). Retrieved October 30, 2020, from
Paauw, D. (2016, May 14). Myth of the Month: NPO good for people with pancreatitis?
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108861/gastroenterology/ myth-month-npo-good-people-pancreatitis
Pancreatitis. (2019, October 21). Retrieved October 30, 2020, from
https://labtestsonline.org/conditions/pancreatitis
Pfleger, R., & Knipe, H. (n.d.). Revised Atlanta classification of acute pancreatitis. Retrieved
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-of-acute-pancreatitis-2?lang=us
Smith, H., & Abdulmanan, M. (n.d.). APACHE score. Retrieved
October 30, 2020, from https://radiopaedia.org/articles/apache-score-2?lang=us
Stool Softeners. (n.d.). Retrieved October 30, 2020, from
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https://www.niaaa.nih.gov/alcohols-effects-health/overview-alcohol-consumption/
what-standard-drink
Wu, B., Bakker, O., & Papachristou, G. (2011, April 11). Blood Urea Nitrogen in the Early
Assessment of Acute Pancreatitis: An International Validation Study. Retrieved October
30, 2020, from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/227077
1. COPD includes two distinct diagnoses. Outline the similarities and differences
between emphysema and chronic bronchitis.
- Chronic bronchitis describes the inflamed bronchi which lead to mucus, cough, and
difficulty breathing whereas emphysema is a form of long-term lung disease
characterized by the destruction of the lung parenchyma with a lack of elasticity. They
are similar in the way that they are generally not reversible. They differ in the way that
emphysema brings patients greater chance of dyspnea and cachexia whereas chronic
bronchitis more often results in hypoxia, hypercapnia, and complications such as
pulmonary hypertension and right heart failure.
(Mahan, 2017)
2. What risk factors does Mrs. Hoffman have for this disease?
- Mrs. Hoffman’s risk factor for COPD includes a history of smoking (1 pack per day for 46
years) which is a primary factor in the development of COPD.
(Mahan, 2017)
3. Identify at least 4 signs and symptoms described by the physician’s history and
physical that are consistent with Mrs. Hoffman’s diagnosis. Then describe the
pathophysiology that may be responsible for each symptom.
- 1+ bilateral pitting edema

- This occurs since oxygen exchange is compromised which means that blood
cannot pump as well through the necessary organs such as the kidneys and liver
to remove fluids from the body.
- Reports of confusion in the morning
- Due to lack of oxygen reaching brain
- Shortness of breath
- Due to damage in lungs which decreases efficiency of oxygen exchange
- Coughing up a lot of phlegm
- Due to increased mucus production cause from chronic bronchitis
(COPD, 2020)
(Swelling, 2015)
4. Mrs. Hoffman’s medical record indicates previous pulmonary function tests as follows:
baseline FEV 50.7 L, FVC 51.5 L, FEV/FVC 46%. Define FEV, FVC, and FEV/FVC and
indicate how they are used in the diagnosis of COPD. How can these measurements be
used in treating COPD?
- FEV stands for forced expiratory volume which measures how much air a person can
exhale during a forced breath (either 1st, 2nd, or 3rd breath). FVC stands for forced vital
capacity which is the total amount of air exhaled during the FEV test. The FEV/FVC is a
ratio which helps to define overall lung function and air capacity. These measurements
help to diagnose COPD by measuring lung function and comparing it to that of a healthy
individual. These measurements can be helpful in treating COPD by helping practitioners
understand whether or not a patient’s lung disease is getting worse or whether the
medications provided are improving breathing.
(Forced Expiratory Volume and Forced Vital Capacity, 2019)
5. Look at Mrs. Hoffman’s arterial blood gas values from the day she was admitted.
a. Why would arterial blood gasses (ABGs) be drawn for this patient?
i. This test is used to assess how well someone’s lungs are able to move oxygen
into the blood as well as move carbon dioxide out of the blood. Since the patient
is experiencing symptoms that indicate lung problems, this test can help her be
diagnosed.
b. Define each of the following and interpret Mrs. Hoffman’s Values.
i. pH: This measures the hydrogen ions in the blood. We want to see values that
are in between 7.35 and 7.45 in the blood.
ii. pCO2: Measures the pressure of carbon dioxide dissolved in the blood and how
well it can move out of the body.
iii. SO2: Oxygen saturation measures how much oxygen is being carried by the
hemoglobin in RBCs.
iv. HCO3-: This measures bicarbonate which is a chemical that keeps blood pH
from becoming too acidic or basic.
c. Mrs. Hoffman was placed on oxygen therapy. What lab values tell you the therapy is
working?
i. Lab values that tell you that the oxygen therapy is working include pCO2, SO2,
and pO2 since they directly show if oxygen transfer is increasing.
(Arterial Blood Gases, 2019)
6. Mrs. Hoffman has quit smoking. Shouldn’t her condition now improve? Explain.
- It is likely that Mrs. Hoffman’s condition will not improve all that much. This is because
the effects of smoking have already led to emphysema and chronic bronchitis which are
generally not reversible.
(Mahan, 2017)
7. What is a respiratory quotient? How is this figure related to nutritional intake and
respiratory status?
- Respiratory quotient is the ratio produced CO2 to O2 that is consumed while food is
being metabolized. This is related to nutritional status because it takes into account the
carbon found in fat, carbohydrates, protein, and even ethanol. Using nutrition in
conjunction with respiratory gas levels can help to serve as a pathway to helping ABGs
through dietary intake.
(Respiratory Quotient - Energy Sources, n.d.)
8. What are the most common nutritional concerns for someone with COPD? Why is a
patient with COPD at higher risk for malnutrition?
- The most common nutritional concerns for a COPD patient include malnutrition and low
body weight. A patient is at a higher risk for COPD because they expend extra energy by
working to breath and by fighting frequent respiratory infections. Energy expenditure for
breathing increases nearly ten times for those with COPD compared to those of a
healthy population.
(Mahan, 2017)
9. Calculate Mrs. Hoffmans’s %UBW and BMI. Do either of these values indicate that she
is at nutritional risk? How would her 1+ bilateral pitting edema affect evaluation of her
weight?
- %UBW =79%-82% (1 year ago = 85% UBW)

- 119 lbs / 145 lbs = 0.82 = 82%
- 119 lbs / 150 lbs = 0.79 = 79%
- BMI = 21
- 54.09 kg / (1.6 M)^2 = 21.07
- Her %UBW indicates that she may be at a nutritional risk because she has lost ~15% of
her body weight in just the past year alone which may put her at risk for malnutrition
which is common in COPD patients.
- Her 1+ bilateral pitting edema could affect the evaluation of her weight because it
signifies that she is retaining fluids which may add to her weight. This can make it seem
as though her BMI is higher and that she hasn’t lost as much weight.
10. Calculate Mrs. Hoffman’s energy and protein requirements. What is your rationale?
- Energy Estimated Needs: 1498-1820 kcals/day (Mifflin x 1.4-1.7 using 54.09kg)

- Protein Estimated Needs: 68-81 g/pro/day (1.25-1.5g/kg)
- I made her activity factor high due to her expending excess energy while breathing with
COPD. I also gave her moderate protein so that she can maintain lean body mass and
muscle to help with her breathing.
11. Using Mrs. Hoffman’s nutrition history and 24 hour diet recall, do you think that she
has adequate oral intake? Explain.
- Given that the patient’s 24 hour recall had very small amounts of food throughout the
day, I would say that her intake is not adequate. As stated by the patient, she has eaten
very little over the past 2 days and food doesn't taste good to her (bitter). This paired
with her recall suggests that she is not receiving adequate oral intake .
12. Evaluate Mrs. Hoffman’s Laboratory values. Identify those that are abnormal. Which
of these may be used to assess her nutritional status?
- Abnormal values: CO2 (H), Bicarbonate (H), Anion Gap (L), Bilirubin (L), Albumin (L),
Prealbumin (L), White Blood Cell (H), RBC (L), Hemoglobin (L), Hematocrit (L), pCO2
(H), O2 (L), HCO3 (H)
- Values that may be used to asses her nutritional status could include RBC, hemoglobin,
and hematocrit levels because they can be used to assess her iron levels. You can also
use pCO2, O2, and HCO3- to continually assess ABG levels to note if there is too much
CO2 production from the diet.
13. Why may Mrs. Hoffman be at risk for anemia? Do her laboratory values indicate that
she is anemic?
- Due to having lower oxygen levels in the blood, there is less hemoglobin containing
RBCs which can lead to anemia in those with COPD. Her laboratory values of low RBC,
low hemoglobin, and low hematocrit all point to anemia.
(Anemia and COPD, 2018)
14.What factors can you identify from her nutrition interview that contribute to her
difficulty eating?
- Based upon her nutrition interview, her poor appetite, rapid satiation, increased
coughing, and reports of food not tasting as good and tasting bitter all contribute to her
difficulty of eating. She also has loose fitting dentures which can make eating more
difficult.
15. Select two high-priority nutrition problems and write PES statements for each.
- Chronic disease related malnutrition r/t stage 1 COPD as evidenced by moderate loss of
fat in orbital area, severe loss of muscle in clavicles and temples, patient report of poor
appetite, and 15% unintentional weight loss over over past year
- Inadequate energy intake r/t decreased ability to consume sufficient energy as
evidenced by 15% unintentional weight loss over over past year, patient report of poor
appetite, patient report of difficulty eating due to lack of energy, loosely fitting dentures,
report of looser fitting clothes, and estimated intake from diet less than needs based on
measured RMR.
16. For each PES statement you have written, establish an ideal goal (based on the signs
and symptoms) and an appropriate intervention (based on etiology).
- Chronic disease related malnutrition

- Support nutritional intake to keep patients weight stable
- Provide meal replacement formula (Boost or Ensure) NPO to meet needs of
1284-1498 kcals/day, 68-81 g/pro/day, 30-45% of kcals from fat, and 40-55% of
kcals from carbohydrates.
- Inadequate energy intake
- Increase patient’s ability to consume food orally
- Help patient get better fitting dentures and provide education to both patient and
her daughters about how to aid in purchasing and preparing meals so that patient
may have more energy to eat.
17. What goals might you set for Mrs. Hoffman as she is discharged and beginning
pulmonary rehabilitation?
- Increase caloric intake via mouth (refer patient to Boost meal supplements to help reach
recommended intake)
- Decrease carbohydrate intake and increase fat intake to reduce CO2 production
- Eat recommended amounts of protein to help retain lean body mass
- Reduce early satiety by eating smaller and more frequent meals
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https://perf2ndwind.org/anemia-and-copd/
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https://www.uofmhealth.org/health-library/hw2343
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Elsevier.
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1. What are the current thoughts regarding the etiology of type 1 diabetes mellitus
(T1DM)? No one else in Rachel’s family has diabetes-is this unusual? Are there any other
findings in her family medical history that would be important to note?

- It is suspected that the etiology of T1DM is caused by auto-immune dysfunction which
causes pancreatic beta cell destruction and eventually absolute insulin deficiency. It is
not unusual that nobody else in the family has diabetes. In fact, the main requirement is
that a person inherits risk factors for diabetes from both parents. It is important to note
that the patient’s sister has Celiac Disease which is also an autoimmune disease like
T1DM meaning that genetics may play some role.
(Mahan, 2017) (Genetics of Diabetes, n.d.)
2. What are the standard diagnostic criteria for T1DM? Which are found in Rachel’s
medical record?
- The standard diagnosis criteria for T1DM include an A1C of 6.5% or higher, a random
blood glucose test with levels exceeding 200 mg/dL, and a fasting blood glucose test
with levels above 126 mg/dL. In Rachel’s case, her medical record shows that she has a
random blood glucose test which was well above the 200 mg/dL level reaching 683
mg/dL on her day of admission (5/4). Her medical record also shows an A1C level above
6.5% with her levels being at 14.6%.
(Type 1 diabetes, 2020)
3. Dr. Cho requested these labs be drawn: Islet cell antibody screen, TSH, thyroglobulin
antibodies, C-peptide, immunoglobulin A level, hemoglobin A1C, and tissue
transglutaminase antibodies. Describe how each of these is related to the diagnosis of
T1DM.
- C-peptide (Mahan, 2017)
- This test measures the amount of C-peptide in the blood and urine. This and
insulin are both released from the pancreas at the same time in similar amounts
which allows for us to analyze how much insulin is being made. In T1DM this
level is either very low or at zero since the pancreas makes very little of it.
- Islet cell antibody screen (Islet Autoantibodies in Diabetes, n.d.)

- This test is primarily used to distinguish T1DM from other diabetes because
these antibodies are only found in those with autoimmune diseases.
- TSH (Wu, n.d.)
- This test measures thyroid function. Thyroid dysfunction is common in diabetic
patients, and it can lead to metabolic disturbances. In T1DM, the presence of
anti-TPO antibodies may signal T1DM.
- Thyroglobulin antibodies (Thyroid Antibodies, n.d.)
- This test assesses whether or not there are autoimmune disorders of the thyroid
(T1DM is an autoimmune disorder).
- Immunoglobulin A (Immunoglobulin A Deficiency, n.d.)
- This is an antibody blood protein that functions as a part of the immune system.
Since T1DM is an autoimmune disease, these levels would be lower than usual
due to immune dysfunction.
- Hemoglobin A1C (Dansinger, M. (2018)
- This test measures how much glucose is bound to hemoglobin in the RBCs.
Having higher levels signals that insulin is not working properly to take glucose
out of the bloodstream in T1DM.
- Tissue transglutaminase antibodies (Blood Test: Tissue Transglutaminase IgA, IgG (for
Parents) - Nemours KidsHealth, n.d.)
- This test is used to assess if the patient has an autoimmune disorder that attacks
gluten. The antibody used to attack the gluten is known as tissue
transglutaminase, so higher levels may indicate immune system dysfunction.
4. Using the information from Rachel’s medical record, identify the factors that would
allow the physician to distinguish between T1DM and T2DM.
- One main factor that would allow for the physician to distinguish between T1DM and
T2DM is the excessively low C-peptide levels in her labs. In T1DM, this level is either
very low or at zero since the pancreas makes very little C-peptide which indicates the
body’s inadequate insulin production as opposed to insulin resistance in T2DM.
(C-Peptide Test, n.d.)
5. Describe the metabolic events that led to Rachel’s symptoms and the subsequent
admission to the ED (polyuria, polydipsia, polyphagia, fatigue, weight loss), integrating
the pathophysiology of T1DM in your discussion.
- Polyuria is a frequent symptom in those with T1DM because the kidneys have to get rid
of the excess glucose that is circulating through the blood, and this is done via urination.
With frequent urination comes excessive thirst (polydipsia) due to the abnormal loss of
fluid from urination. Polyphagia occurs since the body is not able to utilize glucose
properly, so the body feels a need for more energy intake. This is also why fatigue
occurs due to the lack of energy/glucose being transported properly to the cells due to a
lack of insulin.
6. Describe the metabolic events that result in the signs and symptoms associated with
DKA. Was Rachel in this state when she was admitted? What precipitating factors may
lead to DKA?
- Diabetic Ketoacidosis is the result of inadequate insulin for glucose use in the body. As a
result, the body begins to rely on fat for energy, and ketones are formed. For this reason
, common signs and symptoms associated with DKA are glucose levels <600 mg/dL,
and the presence of ketones in the blood or urine as well as polyuria, polydipsia,
dehydration, and fatigue. Rachel was in this state when she was admitted because she
was experiencing polydipsia, polyuria, and fatigue while her labs showed glucose levels
<600 mg/dL (683 mg/dL) and presence of ketones in the urine.
(Mahan, 2017)
7. Rachel will be started on a combination of Apidra prior to meals and snacks with
glargine given in the a.m. and p.m. Describe the onset, peak, and duration for each of
these types of insulin. Her discharge dosages are as follows: 7 u glargine with Apidra
prior to each meal or snack – 1:15 insulin:carbohydrate ratio. Rachel’s parents want to
know why she cannot take oral medications for her diabetes like some of their friends do.
What would you tell them?
- Apidra is a rapid-acting insulin with an onset between 10-30 minutes, a peak within 30 to
90 minutes, and an overall duration of 1-5 hours. Glargine is a long-acting insulin with an
onset between 1-2 hours, no peak, and a duration of 20-36 hours. If Rachel’s parents
were to ask about oral medication, I would explain to them that the reason that they see
their friends take oral medication is because they probably have T2DM as opposed to
T1DM. The reason why Rachel needs injections instead is because she will need to
have the insulin go directly into the bloodstream so that she can instantly see better
outcomes at specific levels with regards to blood glucose after eating meals.
(Maryniak, n.d.)
8. Rachel’s physician explains to Rachel and her parents that Rachel’s insulin dose may
change due to something called a honeymoon phase. Explain what this is and how it
might affect her insulin requirements.
- During this phase, exogenous insulin demands are much lower for up to 1 year because
endogenous insulin secretions recover after the proper treatment of ketoacidosis and
hyperglycemia. This occurs because the beta cell loss is not 100% complete at this point.
However, her insulin levels will eventually rise due to continual loss of beta cells and
their function.
(Mahan, 2017)
9. How does physical activity affect blood glucose levels? Rachel is a soccer player and
usually plays daily. What recommendations will you make to Rachel to assist with
managing her glucose during exercise and athletic events?
- Physical activity can affect blood glucose levels by leading to hypoglycemia, especially
after exercise. This is due to the increased insulin sensitivity after a workout and the
need to replete liver and muscle glycogen stores. For those with T1DM, hyperglycemia
can be a result of high intensity exercise due to a greater increase of counterregulatory
hormones. This causes the lover to release glucose in levels that are higher than actual
glucose use. To help manage her glucose levels during her athletic events, I would
recommend that she consumes 15 grams of carbohydrates for every 30 to 60 minutes of
physical activity. I would also recommend that she monitors her blood glucose levels
before, during, and after exercise so that she can better assess how to regulate her
levels.
(Mahan, 2017)
10. At a follow up visit, Rachel’s blood glucose records indicate that her levels have been
consistently high when she wakes in the morning before breakfast. Describe the dawn
phenomenon. Is Rachel experiencing this? How might it be prevented?
- The dawn phenomenon is described as the increased need for insulin due to a rise in
fasting glucose levels.It arises if insulin levels decline between predawn and dawn or if
hepatic glucose production increases overnight. It appears that rachel is experiencing
the dawn phenomenon, and she may be able to prevent this by administering a
long-acting insulin before bed to keep her insulin levels stable throughout the night.
(Mahan, 2017)
11. The MD ordered a carbohydrate-controlled diet when Rachel begins to eat. Explain
the rationale for monitoring carbohydrate in diabetes nutrition therapy.

- The reasoning for a carbohydrate controlled diet for Rachel is because carbohydrate
intake directly affects blood glucose levels. If rachel was not properly monitoring her
carbohydrate intake with her insulin doses, she could have drastic rises in her blood
glucose. If she wants to properly manage this blood glucose, properly controlling and
understanding carbohydrate intake is a key factor.
(Mahan, 2017)
12. Outline the basic principles of Rachel’s nutrition therapy to assist in control of her
T1DM.
- To control her T1DM, Rachel will be encouraged to keep her protein and fat intake
consistent when carbohydrate counting. This is because these 2 macronutrients do not
greatly affect blood glucose levels like that of carbohydrates. Maintaining consistent
intake of protein and fat will allow for Rachel to have an easier time assessing what her
carbohydrate limits are throughout the day. She should also pay key attention to which
carbohydrates she is consuming and how much grams of carbohydrates are in a
carbohydrate serving/choice (15 grams). This will allow for her to quickly analyze what
she is eating and how it can affect her blood glucose.
(Mahan, 2017)
13. Assess Rachel’s ht/age, wt/age, and BMI. What is her desirable weight?
- Height: 60in/152.4cm
- This height puts her at the 75th percentile for height/age for females at the age of
12.
- Weight: 82lbs/37.27kg
- This weight puts her at about the 25th percentile for weight/age for females at the
age of 12.
- BMI: 16
- 37.7kg / (1.52m)^2 = ~16
- Her desirable weight based on the growth chart for the age of 12 is ~92 lbs which is just
above her weight that she was measured at her prior fast-care clinic check (90 lbs).
(2 to 20 years: Girls Stature Weight-for-age percentiles, n.d.)
14. Identify any abnormal lab values measured upon her admission. Explain how they
may be related to T1DM.
- Glucose + (Urine)
- Due to high amounts of glucose being filtered by kidneys from blood stream
- Ketones + (Urine)
- Due to DKA present in patient due to fats being utilized instead of glucose due to
lack of insulin
- Glucose: 683 mg/dL
- This is an abnormally high rate and it consistent with the high levels found in
those with T1DM (also indicates DKA)
- HbA1C: 14.6%
- This shows that there is an abnormally high percent of glucose bound to
hemoglobin in RBCs which shows a lack of insulin in the body.
- C-peptide: 0.1 ng/ml
- This shows that there is a low amount of insulin in the body since this is released
with insulin. In T1DM this level is very low due to a lack of pancreatic secretion
which differentiates T1DM from T2DM.
(Mahan, 2017)
15. Determine Rachel’s energy and protein requirements. Be sure to explain what
standards you used to make this estimation.
- Energy Estimated Needs: 1325-1545 kcals/day (Mifflin x 1.2-1.4 using 37.27kg)

- Protein Estimated Needs: 1.3-1.4g/kg ABW= 48-52g
- I used these standards to measure her energy and protein needs because they
implement her moderate to high levels of physical activity in the activity factor due to her
playing soccer.
16. Prioritize 2 nutrition problems and complete the PES statements for each.
- Unintended weight loss r/t diagnosis of Type 1 DM as evidenced by weight loss >5% of
body weight within 30 days and patient report stating that clothes fit slightly looser.
- Inconsistent carbohydrate intake r/t Type 1 DM as evidenced by hyperglycemia, weight
loss, and irregular carbohydrate consumption throughout meals.
17. Determine Rachel’s initial nutrition prescription using her diet record from home as a
guideline, as well as your assessment of her energy requirements.
- In general, nutrition recommendations as they pertain to macronutrients for patients with

diabetes are about what they are for the general population. The most important factor is
that all macronutrient intakes are consistent so that the patient can accurately monitor
their carbohydrate intake. For this reason, protein should equate for 15-20% of calories,
fat should account for 25-35% of calories, and carbohydrates should account for 40-60%
of calories. These ranges would allow for Rachel to reach her energy and protein
requirements as calculated previously. When looking at her diet record, I would look at
her being a picky eater as described by the parents. It is okay for her to be selective with
her foods, but incorporating more foods is always a great idea to help her reach her
nutritional goals. I would also recommend that she becomes accustomed with the
amounts of carbohydrates in the foods that she commonly eats so that she can get used
to understanding carb-counting.
(Mahan, 2017)
18. What is an insulin to carbohydrate ratio? Rachel’s physician ordered her ICR to start
at 1:15. If her usual breakfast is 2 Pop-tarts and 8oz. skim milk, how much Apidra should
she take to cover the carbohydrate in this meal?
- An insulin to carbohydrate ratio is a ratio that can be established for patients to know
how much insulin to take based on their carbohydrate intake. In this case, 1 unit of
rapid-acting insulin is to be taken for every 15 grams of carbohydrates that are
consumed. Each pop-tart has 36 grams of carbohydrates in them (2 pop tarts = 72
grams total) and 8 ounces of skim milk has ~12 grams of carbohydrates equaling about
84 grams of CHO in this breakfast. When 84 is divided by 15, you get that Rachel should
take ~ 6 doses of Apidra (5.6 to be exact).
(Pop-Tarts® Strawberry - SmartLabel™, (n.d.) (Bell, 2016)
19. Dr. Cho set Rachel’s fasting blood glucose goal at 90-180 mg/dL. If her total daily
insulin dose is 33 u and her fasting a.m. blood glucose is 240 mg/dL, what would her
correction dose be?
- Since one unit will drop the blood sugar by 50 mg/dL, 2 units of insulin would be required
to get her blood glucose to the goal set by Dr. Cho.
(Calculating Insulin Dose, n.d.)
20. Write an ADIME note for your initial nutrition assessment.

- Included in case 16 note that was already submitted.
21. When Rachel comes back to the clinic, she brings the following food and blood
glucose record with her.
a. Determine the amount of carbohydrates she is consuming at each meal.

b. Determine whether she is taking adequate amounts of Apidra for each meal
according to her record.
Time Diet Grams Exercise BG (mg/dl) Insulin Recomme

CHO dose taken nded dose
7:30 am (Pre) 150 5 u Apidra 127g / 15g

2 Pop-tarts 36g + 36g = ~8.5
+ 27g + doses
1 banana 28g =
16 oz. 127 g of
skim milk CHO
with
Ovaltine (2
tbsp
10:30 am
12:00 pm 64g + 16g (Pre) 180 6 u Apidra 80g / 15 g

2 slices of = = ~5
pepperoni 80 g CHO doses
pizza
2 chocolate
chip
cookies
Water
2:00 pm Granola 16 g CHO PE class 16g / 15 g

Bar (30 min) = 1 dose
4:30 pm 25g + (Pre) 110 45g / 15 g

Apple 7g+13g= = 3 doses
6 saltines 45 g CHO
with 2 tbsp
peanut
butter
5:00-6:30 16 oz 31 g CHO Soccer (Pre) 140 31 g / 15 g

pm Gatorade Practice = 2 doses
(1.5 hours)
6:30 pm 33g+6g+2 (Pre) 80 5 u Apidra 92 g / 15 g

Chicken 5g+28g = = ~6
with doses
92 g CHO
broccoli
stir-fry (1 c
fried rice,
2 oz.
chicken, ½
c broccoli)
Egg roll - 1
2 c skim
milk
8:30 pm 2 c ice 62g+7g = (Pre) 150 4 u Apidra 69 g / 15 g

cream with 69 g CHO = ~4.5
2 tbsp doses
peanuts
(Food Calculator: Carbs, Calories, Fat, Protein and More, n.d.)

2 to 20 years: Girls Stature Weight-for-age percentiles. (n.d.). Retrieved October 30, 2020, from
https://www.cdc.gov/growthcharts/data/set1clinical/cj41c022.pdf
Bell, B. (2016, October 26). Is Whole Milk Better Than Low-Fat and Skim Milk? Retrieved
October 30, 2020, from https://www.healthline.com/nutrition/whole-vs-skim-milk
Blood Test: Tissue Transglutaminase IgA, IgG (for Parents) - Nemours KidsHealth. (n.d.).
Retrieved October 30, 2020, from https://kidshealth.org/en/parents/test-ttg.html
C-Peptide Test. (n.d.). Retrieved October 30, 2020, from
https://medlineplus.gov/lab-tests/c-peptide-test/
Calculating Insulin Dose. (n.d.). Retrieved October 30, 2020, from
https://dtc.ucsf.edu/types-of-diabetes/type1/treatment-of-type-1-diabetes/
medications-and-therapies/type-1-insulin-therapy/calculating-insulin-dose/
Dansinger, M. (2018, November 01). HbA1c (Hemoglobin A1c): A1c Chart, Test, Levels, &
Normal Range. Retrieved October 30, 2020, from
https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c
Food Calculator: Carbs, Calories, Fat, Protein and More. (n.d.). Retrieved October 30, 2020,
from https://www.webmd.com/diet/healthtool-food-calorie-counter
Genetics of Diabetes. (n.d.). Retrieved October 30, 2020, from
https://www.diabetes.org/diabetes/genetics-diabetes
Immunoglobulin A Deficiency. (n.d.). Retrieved October 30, 2020, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/i
immunoglobulin-a-deficiency
Islet Autoantibodies in Diabetes. (n.d.). Retrieved October 30, 2020, from
https://labtestsonline.org/tests/islet-autoantibodies-diabetes
Elsevier.
Maryniak, K. (n.d.). Insulin Update: Just the Facts. Retrieved October 30, 2020, from
https://www.rn.com/nursing-news/insulin-update-just-the-facts/
Pop-Tarts® Strawberry - SmartLabel™. (n.d.). Retrieved October 30, 2020, from
https://smartlabel.kelloggs.com/Product/Index/00038000551321
Thyroid Antibodies. (n.d.). Retrieved October 30, 2020, from
https://medlineplus.gov/lab-tests/thyroid-antibodies/
Type 1 diabetes. (2020, August 22). Retrieved October 30, 2020, from
https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/
diagnosis-treatment/drc-20353017
Wu, P. (n.d.). Thyroid Disease and Diabetes. Retrieved October 30, 2020, from
http://journal.diabetes.org/clinicaldiabetes/v18n12000/pg38.htm
1. The patient has suffered a gunshot wound to the abdomen. This has resulted in an
open abdomen. Define open abdomen. The medical record describes the use of a wound
“VAC.” Describe this procedure and its connection to the diagnosis for open abdomen.
- An open abdomen is a term that refers to a defect of the abdominal wall that exposes
the viscera of the abdomen. A VAC is a vacuum assisted closure which serves as a
method of decreasing the air pressure around a wound to help the healing process
which is used for the open abdomen wound in this patient. This process helps to pull all
of the edges of the wound together as well.
(Open Abdomen, n.d.)
(Yetman, 2020)
2. The patient underwent gastric resection and repair, control of liver hemorrhage, and
resection of proximal jejunum, leaving his GI tract in discontinuity. Describe the potential
effects of surgery on this patient’s ability to meet his nutritional needs.

- The potential effects that this has on the patient’s nutrition needs include malabsorption
of nutrients (and therefore inadequate caloric intake) and potential for anemia due to
blood loss from the liver hemorrhage. The jejunum is an important site for malabsorption
in the small intestine which is a major reason for him having potential for malabsorption.
(Mahan, 2017)
3. The metabolic stress response to trauma has been described as a progression through
three phases: the ebb phase, the flow phase, and finally the recovery or resolution.
Define each of these and determine how they may correspond to this patient’s hospital
course.
- Ebb Phase: This phase develops within the first 24-48 hours after injury. It is
characterized by the reconstruction of the body tissue in attempts to introduce
homeostasis. This stage is associated with shock, hypovolemia, and tissue hypoxia.
There is also typically decreased cardiac output, oxygen consumption,, and body
temperature in this phase.
- Flow Phase: This phase begins between days 2-7 and is marked by an increased
production of glucose, free fatty-acid release, circulating levels of insulin,
catecholamines, glucagon, and cortisol.
- Recovery Phase: Stabilization and homeostasis begin to occur.
(Mahan, 2017)
4. Acute-phase proteins are often used as a marker of the stress response. What is an
acute-phase protein? What is the role of C-reactive protein in the nutritional assessment
of critically ill trauma patients? What other acute-phase proteins may be followed to
assess the inflammatory stress response?
- Acute phase proteins are secretory proteins in the liver that are altered in response to
injury or infection. C-reactive protein plays the role of telling us about inflammation within
the body. Once the C-reactive protein levels begin to decrease, it means that the patient
has entered an anabolic period which means that a more intensive nutrition therapy
could be beneficial. Other acute phase proteins that may be followed to assess
inflammatory stress response include ferritin, transferrin, and retinol-binding protein.
(Mahan, 2017)
5. Metabolic stress and trauma significantly affect nutritional requirements. Describe the
changes in nutrient metabolism that occur in metabolic stress. Specifically address
energy requirements and changes in carbohydrate, protein, and lipid metabolism.
- Energy Requirements:
- Trauma patients have a substantial increase in energy expenditure associated
with the magnitude of the injury. Due to the body repairing large amounts of
tissue, the body requires higher loads of energy for support of those functions.
Patients with trauma may also need higher amounts of protein (1.2-2 g/kg
depending on metabolic stress). Fats and carbohydrates should stay in the
percentage ranges of what they normally would be, but if extra calories are
needed, increasing lipids could help the patient meet their caloric needs.
(Mahan, 2017)
6. Metabolic stress and trauma significantly affect nutritional requirements. Describe the
changes in nutrient metabolism that occur in metabolic stress. Specifically address
energy requirements and changes in carbohydrate, protein, and lipid metabolism.
7. Using current evidence-based guidelines, explain the decision-making process that
would be applied in determining the route for nutrition support for the trauma patient.
- Due to the fact that this patient’s jejunum function is compromised due to surgical
resection, his GI tract’s ability is not acceptable for EN. This means that he would have
to have TPN administered first. As his GI recovery continues, EN may be able to be
introduced slowly.
8. Calculate and interpret the patient’s BMI
- BMI: 34.8
- 109 kg / (1.77 m)^2) = 34.8
- This BMI puts the patient into the “obese” class based off of BMI.
9. What factors make assessing his actual weight different on a daily basis?
- His fluctuating fluid levels make it hard to assess the patient's actual weight. This is
because he can be experiencing different levels of fluid retention due to inflammation
and edema. You would also have to utilize a bed weight since the patient is recovering
and cannot stand at the moment to get weighed.
10 Calculate energy and protein requirements for Mr. Perez. Use at least two methods
(including the Penn State) to estimate his energy needs. Explain your rationale for using
each one. For the Penn State calculation, the minute ventilation is 3.5 L/minute and the
maximum temperature is 39.2.
- 2725-3815 kcals/day (25-35 kcals/kg)

- 3092-3504 kcals/day (Mifflin x 1.5-1.7 using 109 kg)
- I used a high activity factor because the patient will have increased energy
expenditure since he is recovering from surgery and a wound.
- Penn State: (3500 x 0.96) + (39.2 x 167) + (3.5 x 31) - 6212 = 4780 kcals
- Protein Estimated Needs: 164-218 g/pro/day (1.5-2.0g/kg IBW for BMI >30)
- I gave him increased protein needs due to him undergoing surgery and having an
open wound.
11. What does indirect calorimetry measure?
- Indirect calorimetry measures inhaled and exhaled gas flows, volumes, and
concentrations of oxygen and carbon dioxide which can be used to measure energy
requirements/expenditure in patients such as this one who has had trauma.
(Nickson, 2019)
12. Compare the estimated energy needs calculated using the predictive equations with
each other and with those obtained by indirect calorimetry measurements.
- The estimated energy requirements that were calculated using indirect calorimetry was
stated to be 3657 kcals/day. This is very similar to the calculations that I got using Mifflin
St Jeor (3092-3504 kcals/day) and the estimation of 25-35 kcals/kg (2725-3815
kcals/day) which shows that indirect calorimetry was accurate with the patient’s needs.
13. Interpret the RQ value. What does this indicate?
- RQ stands for respiratory quotient which is an indication for how the fuel mixture is being
metabolized by the patient. In this case, the patient’s RQ value is 0.76 which indicates
that the mixture is currently being used to produce fat.
(Mahan, 2017)
14. What factors contribute to the elevated energy expenditure in this patient?
- The factors that contributed to the elevated energy expenditure in this patient include
having severe trauma from an open gunshot wound. He also has increased energy
needs due to metabolic stress from his surgery.
(Mahan, 2017)
15. Mr. Perez was prescribed parenteral nutrition. Determine how many kilocalories and
grams of protein are provided with his prescription. Read the nutrition consult follow-up
and the I/O record. What was the total volume of PN provided that day?
- As described in the patient diet order, the parenteral prescription provides 2964 kcals
and 194 g of protein per day. Based on the I/Os, the total volume of parenteral nutrition
that was provided was 3312mL.
16.Compare this nutrition support to his measured energy requirements obtained by the
metabolic cart on 3/26. Based on the metabolic cart results, what changes would you
recommend be made to the TPN regimen, if any? What are the limitations that prevent the
health care team from making significant changes to the nutrition support regimen?
- The patient’s metabolic cart is measured at 3657 kcals which is adequate given his
estimated needs. At this point there is not much that I could change since the patient is
also being administered propofol which adds 924 kcals to the patient’s intake. Increasing
energy via TPN would risk overfeeding the patient, and he cannot come off of this
medication.
17. The patient was also receiving propofol. What is this, and why should it be included
in an assessment of his nutritional intake? How much energy did it provide?
- Propofol is a drug that is used to help a patient stay asleep while they are under general
anesthesia for surgery or other procedures. This should be included in the assessment
of the patient’s nutritional intake because it provides such a high amount of energy while
being administered. If this was not taken into consideration, it could lead to overfeeding
in a patient. The propofol provided a total of 924 kcals of energy daily.
(Propofol: Uses, Dosage, Side Effects & Warnings, n.d.)
18. The RD recommended that trickle feeds be initiated. What is this and what is the
rationale? The RD recommended the formula Pivot 1.5 for these trickle feeds. What type
of formula is this, and what would be the rationale for choosing this formula?
- Trickle feeds are tube feeds that provide ~10ml/hr of a given formula. Trickle feeds can
be beneficial to critically ill patients if provided within 48 hours because the may reduce
the risk of hospital acquired infection. This is because these feeds allow for continual gut
stimulation. Pivot 1.5 is a calorically dense formula, and its rationale for being used is
that it provides more nutrients with less overall volume. This can be beneficial for both
tolerance and for reducing fluid fluctuations/retention in the patient.
(Drnandyala, 2016)
19. List abnormal biochemical values for 3/29, describe why they might be abnormal, and
explain any nutrition-related implications.
- High ALT/AST
- Elevated due to hemorrhage of the liver
- High C-reactive protein

- Elevated due to inflammation from trauma (gunshot wound)
- Low RBC
- Low due to blood loss from liver hemorrhage
- Low Hematocrit
- Low due to blood loss from liver hemorrhage
- Low Albumin
- Protein losses from trauma and open wound
- Low Prealbumin
- Low due to high inflammation from trauma
20. Current guidelines recommend using a nitrogen balance study to assess the
adequacy of nutrition support.
a. According to the Powell (2012) article (see bibliography below), what adjustments should
be made to assess for nitrogen losses through fistulas, drains, or wound output?
- I was not able to access this scientific article.
b. A 24-hour nitrogen collection is completed for Mr. Perez with results of UUN 42 g.
Calculate his nitrogen balance.
- NB = (Protein intake (g) / 6.25) - (UUN) + 4
- (194 / 6.25) - (42) = -10.96
21. Identify the nutrition diagnosis you would use in your follow-up note. Complete the
PES statement.
- Altered GI function r/t GSW, open abdomen, and surgery as evidenced by lack of bowel
sounds, lack of stool, abdominal distension, and resection of the proximal jejunum.
22. For the PES statement that you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).
- Based on current metabolic energy expenditure (3657 kcals/day), continue with current
TPN feeding since overfeeding is not indicated.
- Consider moving to trickle feed for patient when recovery is adequate to reduce risk for
infection and to support GI stability..
23. What are the standard recommendations for monitoring the nutritional status of a
patient receiving nutrition support?
- While monitoring nutrition support, we should pay attention to patient weight, lab values,
and fluid status so that you can assess the adequacy of the nutrition being provided.
24. Hyperglycemia was noted in the laboratory results. Why is hyperglycemia of concern
in the critically ill patient? How was this handled for this patient?
- Hyperglycemia is caused in critically ill patients due to increased levels of stress. This
increase of stress causes the increased production and uptake of glucose secondary to
gluconeogenesis and elevated hormonal levels. This level is of concern because we do
not want to administer nutrition that will cause even high levels of blood glucose. For this
patient, hyperglycemia was handled by administering TPN and making sure not to
overfeed the patient.
(Mahan, 2017)
25. What would be the standard guidelines and subsequent recommendations to begin
weaning TPN and increasing enteral feeds?
- The standard for weaning off of TPN should be to slowly integrate EN and reduce TPN
and note the patient’s tolerance of the change. You can eventually reduce the TPN by ½
can integrate more enteral feeding in response. The patient’s tolerance should be
consistently monitored and EN should reduce if tolerance begins to decrease.
(Critical Care Nutrition Practice Management Guidelines, n.d.)

Drnandyala. (2016, September 13). Nutrition. Retrieved October 30, 2020, from
https://pocketicu.com/index.php/2016/09/13/nutrition
Critical Care Nutrition Practice Management Guidelines. (n.d.). Retrieved October 30, 2020,
from https://www.vumc.org/trauma-and-scc/sites/vumc.org.trauma
-and-scc/files/public_files/Manual/nutrition-protocol.pdf
Elsevier.
Nickson, C. (2019, April 16). Indirect Calorimetry and Metabolic Cart • LITFL • CCC Nutrition.
Retrieved October 30, 2020, from https://litfl.com/indirect-calorimetry-and-metabolic-cart/
Open Abdomen. (n.d.). Retrieved October 30, 2020, from
https://www.uptodate.com/contents/management-of-the-open-abdomen-in-adults
Propofol: Uses, Dosage, Side Effects & Warnings. (n.d.). Retrieved October 30, 2020, from
https://www.drugs.com/propofol.html
Yetman, D. (2020, March 23). Wound VAC Process, Benefits, Side Effects, Complications, and
Cost. Retrieved October 30, 2020, from https://www.healthline.com/health/wound-vac

Case Study Questions Jax Dunham

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Case Study Questions Jax Dunham

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Case Study 8 Questions

1. Identify the major physiological controls for gastric emptying.

3. According to the American College of Gastroenterology, scintigraphy is the gold

5. Summarize the current recommendations for nutrition therapy for

11. Determine the appropriate intervention for your diagnoses.

Diagnosis of Gastroparesis. (2018, January). Retrieved October 30, 2020, from

MI or through hemodynamic pressure or volume overloading. HF can progress

Disease (CAD) which is caused by atherosclerosis (buildup in plaques within arteries).

discussion which connects them to physiological changes that you described in

How are the clinical manifestations different?

veins can be visible in the neck.

(363 Cardiovascular Disease and Heart Failure PowerPoint)

difficulties may a patient have in following a sodium restriction?

the desired results.

cucumbers, and other fruits/vegetables with high levels of water.

to retain water and her edema could remain steady.

the weight you have used in your calculation.

Laboratory Value Normal Value Pt’s Value & Date

Na+ 136-145 mEq/L Na 135 mEq/L (2/20)

BNP <100 pg/ml 1025 pg/ml (2/20)

CRP <1.0 mg/L 338 mg/L (2/20)

HDL >59 mg/dl in females 30 mg/dl (2/20)

LDL <130 mg/dl 152 mg/dl (2/20)

Case Study 6 Works Cited

Cardiac Medications. (n.d.). Retrieved October 30, 2020, from

Case Study 32 Questions

Describe these primary areas.

alcohol consumption, Human Papillomavirus (HPV), GERD, gender (greater in men),

(​Head and Neck Cancer - Risk Factors and Prevention, 2019​)

imply a better or worse outcome?

the sexually transmitted disease.

(​HPV and Oropharyngeal Cancer, 2020)​ (​Kimple, 2015​)

is used to describe staging for malignancies.

that it has spread to a moderate amount of lymph nodes.

(​Cancer Staging, 2015​)

resection, radiation therapy chemotherapy, and immunotherapy. The type of malignancy

for each. In general, how do they act to treat a malignancy?

surgically taking the cancerous tumor or part of it out of the body.

cancer growth by damaging the DNA within the cancerous cells.

cells. This can be done orally, by IV, injection, intrathecally, intra-arterially, or

and monoclonal antim=bodies.

(​Types of Cancer Treatment, n.d.​)

surgical procedures. How may these procedures affect him nutritionally?

(​Partial Glossectomy Information for Patients, 2018)​ (​Neck Dissection, 2020​)

potential effect of cancer on nutritional status.

impact nutritional status.

(Nutrition in Cancer Care (PDQ®)–Patient Version, 2018​)

nutritional and metabolic effects of these treatments.

- Chemotherapy can cause nutritional effects by leading to loss of appetite, nausea,

throat, constipation, diarrhea, trouble swallowing, choking/breathing problems, bowel

chewing, and feeling full after eating small amounts of food.

(Nutrition in Cancer Care (PDQ®)–Patient Version, 2018​)

9. Calculate and evaluate Mr. Seyers %UBW and BMI.

and prognosis in cancer patients?

type of tissue loss” (​Nutrition in Cancer Care (PDQ®)–Health Professional Version,

(​Nutrition in Cancer Care (PDQ®)–Health Professional Version, 2020​)

- Energy Estimated Needs: 1529-1784 kcals/day(Mifflin x 1.2-1.4 using 90kg)

- Estimated Fluid Needs: 2250-2700 ml/day (1ml/kcal)

lead to weight loss.

per PEG tube.

- 75 ml/hr x 24 hr = 1800 ml/day x 1.2 kcals/ml = 2160 kcals/day

- 1.8 L/day x 54 g pro/L = 97 g protein

amount of enteral nutrition he received on September 11.

(Head and Neck Cancer - Risk Factors and Prevention, 2019)

(HPV and Oropharyngeal Cancer, 2020) (Kimple, 2015)

(Cancer Staging, 2015)

(Types of Cancer Treatment, n.d.)

(Partial Glossectomy Information for Patients, 2018) (Neck Dissection, 2020)

(Nutrition in Cancer Care (PDQ®)–Patient Version, 2018)

(Nutrition in Cancer Care (PDQ®)–Patient Version, 2018)

type of tissue loss” (Nutrition in Cancer Care (PDQ®)–Health Professional Version,

(Nutrition in Cancer Care (PDQ®)–Health Professional Version, 2020)

(What is terminal illness, 2019)

October 30, 2020, from https://www.cancer.gov/about-cancer/treatment/side-effects/

levels elevate drastically (Pancreatitis, 2019).

internationally agreed upon classification of acute pancreatitis severity (Pfleger, n.d.).

(What Is A Standard Drink?, n.d.)

30, 2020, from https://radiopaedia.org/articles/ranson-criteria?lang=us

Retrieved October 30, 2020, from https://www.mdedge.com/chestphysician/article

October 30, 2020, from https://radiopaedia.org/articles/revised-atlanta-classification

October 30, 2020, from https://radiopaedia.org/articles/apache-score-2?lang=us

(Forced Expiratory Volume and Forced Vital Capacity, 2019)

(Arterial Blood Gases, 2019)

(Anemia and COPD, 2018)