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NSC 325 Parenteral Nutrition Case Study

100 points

Shannon is a 29 year old Caucasian female currently intubated and sedated in the ICU due to domestic abuse. Today is hospital day #3. She had surgery after being admitted from the emergency department to repair her small bowel, colon, liver and spleen due to multiple abdominal stab wounds. Her abdomen is currently firm and distended with negative bowel sounds. She has a nasogastric tube in place which has drained 1800 mL out in the past 24 hours. A triple lumen has been inserted into the superior vena cava. Patient reportedly had been having some health issues prior to admission. She is employed as a lab tech at a local university and told her Mom that she had lost 10 lbs. in the last 2 months due to work-related stress. She was having lots of abdominal cramps and had really lost her appetite. She has two children aged 4 and 6. IV fluids are running at 100 mL/hr with D5W and ½ normal saline with 20 mEq/d of KCl. I/Os reflect 2 liters of fluid received in surgery. A nutrition support consult has been ordered to start parenteral nutrition.

Ht: 5’7” Current Wt: 125 lbs. (~57 kg) Usual Wt: 130 lbs. (2 months ago)

Nutrition-focused physical exam: patient appears thin but no overt signs of nutritional deficiencies; abdomen is firm and distended with negative bowel sounds.

Current medications: meds for sedation and pain control; antibiotics to decrease infectious complications

Labs: Sodium: 135 (135-145) Potassium: 4.0 (3.5-5.5) Chloride: 99 (99-112)

Bicarb: 26 (22-29) Glucose: 91 (65-99) BUN: 10 (8-24)

Creatinine: 0.8 (0.6-1.1) Albumin: 2.8 (3.5-5.5) Phos: 2.4 (2.5-4.5)

Mg: 1.5 (1.5-2.5) WBC: 11 (4-11) Hemoglobin: 12 (11-15.8)

Vital Signs: Temp: 100° MAP: 59, 60, 59, 58, 57

I/Os for the past 2 days: hospital day #1: 3240/2500 mL hospital day #2: 2800/2300 mL

Complete a nutrition assessment. Address whether parenteral nutrition is indicated or not (10 points):

Create 2 PES statements (6 points):

P: P:

E: E:

S: S:

Write a nutrition prescription (8 points):

Energy:

Protein:

Fluids:

PN goal rate:

Calculate how many grams of the following are your goals for PN to meet the above nutrition prescription; show your work (6 points):

Grams of Dextrose per day needed:

Grams of Protein per day needed:

Grams of Fat per day needed:

Complete an order form for parenteral nutrition and show your work for how you determined how many milliliters you need from each of the macronutrients. Show how you determined your PN goal rate AND discuss why you chose which “stock” solution you used for determining your PN solution (18 points):

Dextrose:

Amino Acids:

Fat:

Fluids:

PN Day # _________ Weight used for calculations: ________ kg

All additives are based on amount per DAY

AMOUNT PER DAY:			☐PN sliding scale insulin – check box to obtain a finger-stick level every 6 hours
Dextrose		grams
Amino acids		grams	FSBG	Regular Insulin subQ
Lipids		grams	Less than 70 mg/dL	Call physician
Sodium Chloride	100	mEq	140-179 mg/dL	3 units
Sodium Acetate	60	mEq	180-199 mg/dL	4 units
Sodium Phosphate	0	mEq	200-249 mg/dL	6 units
Potassium Chloride	60	mEq	250-299 mg/dL	9 units
Potassium Phosphate	20	mEq	300-349 mg/dL	12 units
Potassium Acetate	0	mEq	350-399	15 units
Magnesium Sulfate	10	mEq	More than 400 mg/dL	Call physician
Calcium Gluconate	10	mEq
MVI (Adult)	10	mL
Trace Elements	1	mL
Regular insulin		units
Famotidine		mg
Thiamine		mg
Folic Acid		mg
Zinc sulfate		mg
Vitamin C		mg

______Start PN at _____mL per hour for ___ hours and decrease MIV to _____ mL/hr;

After 8 hours if FSBG < 200 mg/dL, increase PN to: _____ mL per hour and decrease MIV rate to: _____ mL/hr

then after 8 hours if FSBG < 200 mg/dL, increase PN to: ______mL per hour and decrease MIV rate to: _____ ml/hr

then after 8 hours if FSBG < 200 mg/dL, increase PN to GOAL RATE of ______mL per hour & decrease MIV rate

to: _____ ml/hr

TOTAL fluid volume per day is: ________ mL/d (PN rate & MIV rate together)

Date for lab draw: ________

____TPN-A labs (CBC with Diff, CMP, Pre-albumin, Mag, Phos, Calcium, Trig)

____TPN-B labs (BMP, Mag, Phos, Calcium, Albumin)

____Daily weight	_____Daily intake and output _____ Other ____________________________

List potential complications that may arise related to parenteral nutrition during this admission for Shannon (5 points):

FOLLOW-UP (20 points):

On follow-up today (see data below in the Table), Shannon’s PN is at goal rate. Today is PN day #6. Her IV is running at 40 mL/hr with ½ normal saline and 20 mEq/d of KCl. She is also getting the medication Lasix today to help with her fluid management. Based on the following information and trends you notice, what recommendations, IF ANY, would you make for her PN be today? DISCUSS which changes you would make and WHY (10 points):

Also complete a new PN order form if you wish to make any changes (10 points)

PN Day #	1	2	3	4	5	6
Weight:	56.8 kg	55 kg	56.9	57	58.7	59
Labs:
Sodium	138	140	142	139	136	134
Potassium	4.0	4.1	4.0	4.2	3.8	3.6
Chloride	108	110	108	110	106	103
HCO2	26	25	25	24	24	22
Glucose	91	120	140	190	220	235
BUN	10	9	9.5	8	9	9
Creatinine	0.8	0.8	0.7	0.8	0.75	0.7
Phosphorus (2.5-4.5)	2.2	2.0	2.2	1.9	2.0	2.0
Magnesium (1.5-2.4)	1.9	1.5	1.8	1.8	1.5	1.1
Prealbumin (16-40)	10			8
Albumin	2.8			2.7
Total Bilirubin (0.1-1.0)	0.1			0.2
AST (7-55)	33			37
ALT (8-48)	40			42
WBC	11	11.5	11.5	13	14	14.9
Hemoglobin	12.5	12.5	12	11.9	11.9	11.8
FS glucose*: (70-99) (= sliding scale insulin provided)	150 (3 u), 140 (3 u), 130, 135	160 (3 u), 160 (3 u), 180 (4 u), 185 (4 u)	150 (3 u), 160 (3 u), 175 (3 u), 175 (3 u)	185 (4 u), 160 (3 u), 190 (4 u), 195 (4 u)	180 (4 u), 175 (3 u), 195 (4 u), 205 (6 u)	195 (4 u), 200 (6 u), 220 (6 u), 215 (6 u)
Temperature (centigrade)	38.6	38	39	39	39.5	40
Input/Output: Urine Stools NG Other:	Input: PN + IV 2000 mL None 1800 mL	Input: PN + IV 2430 mL None 1850 mL	Input: PN + IV 2400 mL None 1700 mL	Input: PN + IV 2400 mL Smear 1560 mL	Input: PN + IV 2400 mL None 1450 mL	Input: PN + IV 2400 mL None 1200 mL

PN Day # _________ Weight used for calculations: ________ kg

All additives are based on amount per DAY

AMOUNT PER DAY:			☐PN sliding scale insulin – check box to obtain a finger-stick level every 6 hours
Dextrose		grams
Amino acids		grams	FSBG	Regular Insulin subQ
Lipids		grams	Less than 70 mg/dL	Call physician
Sodium Chloride	100	mEq	140-179 mg/dL	3 units
Sodium Acetate	60	mEq	180-199 mg/dL	4 units
Sodium Phosphate	0	mEq	200-249 mg/dL	6 units
Potassium Chloride	60	mEq	250-299 mg/dL	9 units
Potassium Phosphate	20	mEq	300-349 mg/dL	12 units
Potassium Acetate	0	mEq	350-399	15 units
Magnesium Sulfate	10	mEq	More than 400 mg/dL	Call physician
Calcium Gluconate	10	mEq
MVI (Adult)	10	mL
Trace Elements	1	mL
Regular insulin		units
Famotidine		mg
Thiamine		mg
Folic Acid		mg
Zinc sulfate		mg
Vitamin C		mg

______Start PN at _____mL per hour for ___ hours and decrease MIV to _____ mL/hr;

After 8 hours if FSBG < 200 mg/dL, increase PN to: _____ mL per hour and decrease MIV rate to: _____ mL/hr

then after 8 hours if FSBG < 200 mg/dL, increase PN to: ______mL per hour and decrease MIV rate to: _____ ml/hr

then after 8 hours if FSBG < 200 mg/dL, increase PN to GOAL RATE of ______mL per hour & decrease MIV rate

to: _____ ml/hr

TOTAL fluid volume per day is: ________ mL/d (PN rate & MIV rate together)

Date for lab draw: ________

____TPN-A labs (CBC with Diff, CMP, Pre-albumin, Mag, Phos, Calcium, Trig)

____TPN-B labs (BMP, Mag, Phos, Calcium, Albumin)

____Daily weight	_____Daily intake and output _____ Other ____________________________

Today is hospital day #10. Her abdomen appears soft and non-distended. The PN is still running at goal rate. She is stable with a MAP of 65. She is still intubated and sedated. Would you make any recommendations for altering her nutrition care plan at this time; if so, complete either a new PN or EN form (10 points)?



Describe your plan for reassessment while the patient is on PN (5 points): Answer the following short answer questions regarding PN management (these questions are not related to case study): List 3 ways to control blood glucose levels with parenteral nutrition (2 points): 2. Today is day #2 of PN for Kyle. His potassium level is 3.2 (normal: 3.5-5.5) and his phosphate level is 2.0 (normal 2.5 to 4.5). PN is running at 30 mL/hr and the MIV is running at 90 mL/hr with 20 mEq of KCl. List 2 recommendations for correcting his labs (2point): 3. Chloride and Acetate in the PN solution are used to management what (2 point)? Scott’s has been on PN for 3 days and his serum magnesium level this am is 1.2 (normal range: 1.5-2.5). Based on the following information, what would you recommend (2 points)? PN day#1: Mg = 1.9 PN day#2: Mg = 1.5 PN day#3: Mg = 1.3 What labs would you monitor to assess someone’s renal function (1 point)? What micronutrients do you need to monitor closely with declining renal function – list 3 (1 points): List the 3 ways potassium can be provided in the PN. Today is day 4 for Tierney. Based on the following, what would you recommend based on her potassium level (2 points)? Labs: Na: 142 (135-145) K: 3.2 (3.6-5.5) Cl: 110 (101-111) HCO3: 18 (21-31) BUN: 22 (5-20) Cr: 1.1 (0.6-1.2) Glucose: 92 (70-99) Phos: 4.5 (3-4.5) GFR: 77 (normal range: >60)

Order forms below

PN Day # _________ Weight used for calculations: ________ kg

All additives are based on amount per DAY

AMOUNT PER DAY:			☐PN sliding scale insulin – check box to obtain a finger-stick level every 6 hours
Dextrose		grams
Amino acids		grams	FSBG	Regular Insulin subQ
Lipids		grams	Less than 70 mg/dL	Call physician
Sodium Chloride	100	mEq	140-179 mg/dL	3 units
Sodium Acetate	60	mEq	180-199 mg/dL	4 units
Sodium Phosphate	0	mEq	200-249 mg/dL	6 units
Potassium Chloride	60	mEq	250-299 mg/dL	9 units
Potassium Phosphate	20	mEq	300-349 mg/dL	12 units
Potassium Acetate	0	mEq	350-399	15 units
Magnesium Sulfate	10	mEq	More than 400 mg/dL	Call physician
Calcium Gluconate	10	mEq
MVI (Adult)	10	mL
Trace Elements	1	mL
Regular insulin		units
Famotidine		mg
Thiamine		mg
Folic Acid		mg
Zinc sulfate		mg
Vitamin C		mg

______Start PN at _____mL per hour for ___ hours and decrease MIV to _____ mL/hr;

After 8 hours if FSBG < 200 mg/dL, increase PN to: _____ mL per hour and decrease MIV rate to: _____ mL/hr

then after 8 hours if FSBG < 200 mg/dL, increase PN to: ______mL per hour and decrease MIV rate to: _____ ml/hr

then after 8 hours if FSBG < 200 mg/dL, increase PN to GOAL RATE of ______mL per hour & decrease MIV rate

to: _____ ml/hr

TOTAL fluid volume per day is: ________ mL/d (PN rate & MIV rate together)

Date for lab draw: ________

____TPN-A labs (CBC with Diff, CMP, Pre-albumin, Mag, Phos, Calcium, Trig)

____TPN-B labs (BMP, Mag, Phos, Calcium, Albumin)

____Daily weight	_____Daily intake and output _____ Other ____________________________

Tube Feeding Orders – check the box

Start TF via ☐ NGT/OGT ☐ Nasoduodenal (NDT) ☐ Nasojejunal (NJT)

☐ PEG/Gastrostomy ☐ Jejunostomy

Administration:

☐ Continuous ☐ Bolus ☐ Intermittent

Type of Formula:

	Osmolite 1.2: 1.2 kcals/mL, 55.5 grams of protein/liter; 82% free water and meets or exceeds RDIs for micronutrients in 1200 mL
	Jevity 1.2: 1.2kcals/mL, 55.5 grams of protein/liter, 81% free water meets or exceeds RDIs for micronutrients in 1250mL (contains 17g fiber per liter)
	Osmolite 1.5: 1.5 kcals/mL, 63 grams of protein/liter; 76% free water, meets or exceeds RDIs for micronutrients in 1000 mL
	Jevity 1.5: 1.5 kcals/mL, 63.8 grams of protein/liter; 76% free water and meets or exceeds RDIs for micronutrients in 1000 mL
	Pivot 1.5: 1.5 kcals/mL, 93.8 grams of protein/liter; 75% free water and meets or exceeds RDIs for micronutrients in 1000 mL
	Glucerna 1.2: 1.2 kcals/mL, 60 grams of protein/liter, 81% free water, and meets or exceeds RDIs in 1250 mL
	Two Cal HN: 2 kcals/mL, 83.5 grams of protein/liter, 70% free water, and meets or exceeds RDIs in 948 mL
	Vital AF 1.2: 1.2 kcals/mL, 75 grams of protein/liter, 81% free water, 5 gms of fiber/liter and meets or exceeds RDIs for micronutrients in 1185 mL
	Vital High Protein: 1 kcal/mL, 87.3 grams of protein/liter, 84% free water, and meets or exceeds RDIs in 1500 mL
	Nepro: 1.8 kcal/mL, 81 grams of protein/liter, 73% free water, and 12.6 g fiber/L. Low in sodium, potassium and magnesium (<1 g/L). Micronutrient blend designed for renal failure.
	Modular Protein Supplements: ProSource NoCarb (30mL packet), 15 protein, 60kcals ProSource Plus (30mL packet), 15g protein, 100kcals ProCel (1 packet= 5 g pro and 25 kcal)

Rate – Initiation & Advancement:

Monitoring:

☐Elevated the head of the bed 30-45°

☐Water flushes w/ ____ mL every ____hrs

☐Water flush before and after feedings with _____ mL sterile water

☐ Other ____________________________________________

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Parenteral Nutrition Case Study