FNES 365 CASE STUDY WIN WONG NAME: Julianne M Barredo 4/27/22

QUESTIONS

***All ques ons must be referenced using APA or AMA style***

1. The pa ent had a cerebral artery aneurysm. What is an aneurysm? He also had a craniotomy.
De ne craniotomy.

An aneurysm is a widening or ballooning of a blood vessel that occurs when the walls of the
artery begin to weaken or deteriorate. Aneurysms can be ignited in the aorta, parts of the neck
and legs, and in other major blood vessels. They can cause internal bleeding, rupture, and may
even be fatal if not treated in me.

A craniotomy is a surgical procedure that is performed to remove a por on of the skull in order
to e ec vely remove a brain tumor or any foreign/abnormal ssues, remove any clo ng,
alleviate pressure due to injury, or reconstruct a fracture or aneurysm. The skull por on
removed during the procedure is o en placed back at the site it was removed.

2. De ne dysphagia. What is the primary nutri on implica on of dysphagia?

Dysphagia is the general inclusive term for a swallowing disorder which is characterized by an
underlying impairment, which can disable normal swallowing anatomy and/or physiology.
Dysphagia can present in several di erent forms due to several involuntary mechanisms of
swallowing. The primary nutri on implica on of dysphagia is the increased risk of malnutri on
and dehydra on due to poor PO or reduced energy and uid intake.

3. The pa ent had a PEG placed. What is a PEG? Why was it placed?

A PEG is a Percutaneous Endoscopic Gastrostomy; a permanent gastric tube inserted directly

into the stomach leaving an opening to administer medica ons and nutri on. To insert the PEG,
local anesthesia is used and an endoscopic procedure is performed to place the tube. It is
comfortable for the pa ent and diminishes nasal/upper GI irrita on, as well as allowing for bolus
feeds. It was placed due to his residual swallowing dysfunc on following an intuba on and
complica ons during the course of hospital treatment.

4. The pa ent scored as a high risk for pressure injury on the Braden Scale. What is the Braden
Scale? What are the factors that that make this pa ent a high risk?

The Braden Scale is a scoring diagnos c used to iden fy pa ents at risk of developing pressure
injuries and pa ents for pressure sore risk. It is composed of sub-scales such as sensory
percep on, skin moisture, ac vity, mobility, fric on and shear, and nutri onal status. The factors
that make Mr. Wong a high risk are his criteria scores. His skin is occasionally moist which
requires linen changing, his nutri on scored “probably inadequate, he is chairfast, rendering his
mobility very limited and non-weight-bearing, and his fric on/shear is at a 1, requiring
moderate-maximum assistance, and in order to be li ed he must be slid against sheets, and he
frequently slides down in the bed which requires the need for being reposi oned mul ple mes,
and leads to constant fric on.
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 5. The pa ent’s diet order is for Jevity 1.2 at 40 ml/hr x 24 hr. Using the nutri onal informa on
below, calculate the calories, protein and free water he is receiving from the formula in a day.
Values are per 1 L.

1.2 kcal/mL 55.5 g/pro/L 807 ml Free Water/L

Total Volume
40 ml/hr x 24 hr = 960 mL
Total Kcal
1.2 kcal/mL x 40 mL x 24 hr = 1152 kcal
Protein
55.5 g = x = 53,280 = 53.28 = 53 g pro
1000 ml 960 mL 1000
Free Water
807ml = x = 774,720 = 774.72 = 775 mL free H2O
1000 ml 960 mL 1000
6. Discuss per nent medica ons and any food drug interac ons for THIS pa ent.

Per nent medica ons to note include:

Reglan: Monitor blood glucose in DM pt’s as it may change insulin demands. Avoid alcohol.

Pepcid: May decrease Iron and B12 absorp on. Monitor Iron and B12 stores.

Zantac: May decrease Iron and B12 absorp on. Monitor Iron and B12 stores.

7. Discuss any abnormal lab values and possible e ology of abnormal values for THIS pa ent.

Lab values read abnormal for:

CBC with Di eren al:

Hemoglobin: Low, 12.3 g/dL (13.5-16.5 WNL)

WBC (cells/mL): High, 11,500 cells/mL (4,500-10,000 WNL)

Segmented Neutrophils: Low, 52 (54-62 WNL)

Urinalysis:

Urobilirubin: Low, 0.4 mg/dL (trace 0.5-1 WNL)

WBCs: Low, 0.8 WBCs/hpf (</= 2-5 WNL)

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 Squamous Epithelial Cells: Low, 0 SEC/hpf (</= 15-20 WNL)

A possible e ology for these lab values could be blood loss d/t craniotomy and CVA, and
in amma on. High WBC’s indicate an immune response to sites of in amma on, which coincide
with Mr. Wong’s current state. He is s/p craniotomy, and his body is reac ng to stress. Hb may
decrease a er Mr. Wong’s aneurysm, coupled with blood loss during surgery.

8. Calculate the following and provide a classi ca on for each: IBW, %IBW, BMI, UBW, %UBW and
% weight change if applicable.

Pt is 145lbs, 69 in.

IBW: MALE: 106 lbs + (9” x 6 lbs) = 106 lbs + 54 lbs = 160 lbs
%IBW: (145/160) x 100 = 90.625% -> 91 % Classi ed as No Risk
BMI: (145/69^2) = (145/4761) = 0.03045 x 703 = 21.410 = 21.4 Classi ed as Normal
UBW: 159 lbs
%UBW: (145/159) x 100 = 91.19 % -> 91 % Classi ed as Mild Nutri on Risk
% Weight Change: MALE: (159-145)/159 = 14/159 = 8.805 % -> 8.8 % weight loss x < 1 month
Classi ed as Severe Weight Loss
9. Calculate the pa ent’s energy, protein and uid needs. Explain your ra onale for each (why did
you choose that es mated energy formula/amount/range).

ENERGY: I chose the Rule of Thumb for normal weight, with Moderate-Severe stress (35-45 kcal/
kg). Win has criteria for malnutri on based on severe weight loss (8.8 % x <1mo), and is
currently under metabolic stress due to a recent CVA, DVT, Dysphagia, a craniotomy, and OP.

kcal/day = 35 (65.9) = 2306.5 = 2307 = 2300

kcal/day = 45 (65.9) = 2965.5 = 2966 = 2900

Es mated kcal needs= 2300-2900 kcal/day

PROTEIN: I am choosing 1.4-1.6 g/kg/day for Win. Again, he has criteria for malnutri on based
on severe weight loss (8.8 % x <1mo), and is currently under metabolic stress due to a recent
CVA, Dysphagia, a craniotomy, and sx wounds from the craniotomy that require protein to heal.
Win needs a higher amount of protein due to this stress.

1.4 g x 65.9 kg = 92.26 = 92 g/day

1.6 g x 65.9 kg = 105.44 = 105 g/day

90-105 g/day

FLUID: I chose this amount because Win is over 65, based on his body weight.

25mL/kg = 25 x 65.9 kg = 1647.5, round to 1650 mL/kg/day

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 10. From the NCP terminology, provide a nutri on diagnosis with a complete PES statement(s).

(New) Unintended Weight Loss related to lack of self-feeding ability (physiologic-metabolic

e ology) as evidenced by post-CVA complica ons, 8.8 % weight loss x 7 days, and dysphagia.

(New) Swallowing Di culty related to recent stroke and intuba on (physiologic-metabolic

e ology) as evidenced by post-CVA complica ons, SLP consult, PEG insert, and dysphagia.

11. For each PES statement, provide an interven on(s). You must use NCP terminology.

Nutri on Prescrip on:

2300 - 2900 kcal/day (Based on 35 - 45 kcal/kg actual wt)
90 - 105 g/day (Based on 1.4 - 1.6 g/kg , actual wt)
1650 mL/kg/day (Based on 25 mL/kg/day, >65yoa actual wt)

Food and nutri on delivery:

Enteral Nutri on - Modify composi on, rate, and volume of enteral nutri on.
Recommend enteral nutri on: Jevity 1.2 at 80 mL/hr x 24 hr
Begin at 30 mL and increase 20 mL q 4 hr un l goal rate of 80 mL/hr reached.
Provides 2304 kcal, 107 g pro, 1549 mL free H2O

12. Use the NCP terminology, and then describe what you will monitor and evaluate.

Will monitor and evaluate:

Enteral Nutri on Intake- Enteral nutri on formula/solu on
Weight- Measured wt
Nutri onal Anemia Pro le- Hemoglobin

13. Provide SMART goals for your interven on (s).

Food and Nutrient Intake:

Energy es mated intake from enteral nutri on in 24 hours:
Pt will meet 100% of needs via EN within 48 hrs (New goal)

Anthropometric Measurements:
Measured wt - Pt will return to IBW (160 lbs) x 2 weeks (New goal)

Biochemical Data:
Hemoglobin
WBC (cells/mL)
All lab values will return to WNL in 1 week. (New goal)

14. Complete and submit the ADIME note from EHR Go.

ADIME Note.
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 15. Each ques on should be referenced correctly within the answer and a complete reference list
provided at the end of the case. AMA or APA style may be used.

Works Cited.

Works Cited

1.) Gylys, B. A., & Wedding, M. E. (2017). Medical Terminology Systems: A body systems
approach (8th ed.). F.A. Davis Company. ISBN-13: 978-0-8036-5867-7

2.) Mahan L. K. & Raymond, J. L. (2021). Krause’s food & the nutrition care process. (15th
ed.). St. Louis, MO: Elsevier/Saunders. ISBN-13: 978-0323636551

3.) What is an aneurysm? www.heart.org. (2021, April 13). Retrieved May 4, 2022, from https://
www.heart.org/en/health-topics/aortic-aneurysm/what-is-an-aneurysm

4.) NCI Dictionary of Cancer terms. National Cancer Institute. (n.d.). Retrieved May 4, 2022,
from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/craniotomy

5.) Jennifer Whitlock, R. N. (2021, October 24). Are you at risk for anemia after surgery?
Verywell Health. Retrieved May 5, 2022, from https://www.verywellhealth.com/anemia-after-
surgery-3156852
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