ࡱ>  Ybjbj .P|84t\et"ddddddd,fieeedd[Cab:]8d,e0\e]PjjpCaCa|ee\ej :   Nutrition Care Process A systematic problem-solving methodto critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care. 1. Patient Information: InitialsAAMedical Dx For This AdmitQuadriplegic, Infantile Cerebral Palsy (CP)Age6 yearsGenderMaleEthnicity/Religion-----PhysicianDr. MurphyOccupation-----Insurance CoverageMedicaidAllergies/IntolerancesNKDACare Giver (If Needed)----- 2. Medical Hx: IdentifyFamily / Social Hx Born in refugee camp in Kenya. Family unable to meet his needs moved to SDCH in 2008. Past Medical / Surgical Hx Medical: epilepsy, pneumonias, sleep apnea (obstructive), congenital dislocation of the hip, scoliosis, periventricular leukomalacia, esophageal reflux, asthma and mixed development disorder. Surgical: tonsillectomy, adenoidectomy, supraglottoplasty (2002), tracheostomy (2008), fundoplication with G-tube and subsequent revisions of hiatal hernia and a baclofen pump. Symptoms Related to Current Diagnosis Patient is stable at this time.  Summary of Important Events While in Hospital Over the last 4 years: gastrostomy, tracheostomy and dysphagia.Procedures Done While in Hospital (Include Dates) or Procedures that are Planned None AA transfers to Primary Childrens Medical Center for procedures, but has not had any recently. 3. Anthropometrics: Current Weight: 17.9 kg Current Height: 107 cm UBW: ~17-18 kg IBW: 19-20 kg (determined by growth chart; 50%tile for his height) % IBW: 94% [17.9 kg/19 kg x 100] BMI: 15.6 [17.9 kg/1.07 cm/1.07 cm] Weight History: Date/TimeWeight9/23/201217.9 kg9/16/201217.9 kg9/9/201218.1 kg9/2/201217 kg8/26/201217.7 kg7/29/201216.9 kg6/24/201217 kg5/27/201216.3 kg4/29/201217.1 kg3/25/201217.4 kg Interpret weight history and give possible explanations for variation in the weights recorded. Include in your explanation recent weight loss prior to admission and state whether the weight loss was intentional or unintentional: AA has remained weight stable for the last six months. The tube feeds have been adequately meeting nutritional needs to maintain the patients weight. However, the tube feed supplementation has recently been increased in attempt to meet target weight of 19-20 kg. AA is smaller than all other children of the same age due to the condition; therefore the patients IBW is determined using 50%tile for weight/height ratio. 4. Estimated Energy Needs (1): 650 850 kcals/day (6-8 kcal/cm ht) Calculation: 6 kcals x 107 cm = 650 kcals 8 kcals x 107 cm = 850 kcals Male ECE = (66.47 + 13.74 W + 5.07 H 6.76 A) X (activity factor) Female ECE = (655.1 + 9.56 W + 1.85 H 4.68 A) X (activity factor) * For obese patients (> 125% of IBW), use formula for obesity Estimated Energy Needs (2): 66.47 + 13.74(17.9 kg) + 5.07(107cm) 6.76(6 years) x 1.2 = ~975 kcals/day These needs are slightly high for AAs needs; kcal/kg is more accurate for this patients condition and nutritional needs. For calculations use: ABW if BMI < 27 and use IBW if BMI > 27 Patients ageKcal/kg 18-6425-30 kcal/kg65-7924-26 kcal/kg> 80 years22-25 kcal/kgCritical care patients22-24 kcal/kgExtensive wound care or RF with goal for anabolismIf tolerance allows, consider extra 2-5 kcal/kgMorbid obesity20 kcal/kg* Use higher range if patient hypermetabolic, hepatic disease, increased activity level, wounds and renal failure. Use lower range if obese, activity is low, metabolic intolerance present My calculated recommendations for this patient at South Davis Community Hospital were formulated using the following standard estimates of 6-8 kcal/cm ht energy needs, 1.2-1.5 g/kg protein needs, and 90-110 mL/kg fluid needs. Justification for my calculated recommendations: Energy/caloric needs are based off of cm of height, due to the patients age. AA has a lower caloric need due to the cerebral palsy and quadriplegic diagnoses. The patient has very minimal to no activity in a day; therefore the patient doesnt require quite as many calories to maintain. AAs protein needs remain at 1.2-1.5 g/kg for muscle maintenance. The patients fluid needs are based off the standard of a 5-6 year old. Kcal/day: 650 850 kcals/day (6-8 kcal/cm ht) Calculation: 6 kcal x 107 cm ht = ~650 kcals 8 kcal x 107 cm ht = ~850 kcals Grams of protein/day: 22-27 g (1.2-1.5 g/kg) Calculation 17.9 kg x 1.2 g/kg = ~22 g 17.9 kg x 1.5 g/kg = ~27 g Fluid needs/day: ~1600 2000 mL/day (90-110 mL/kg) Calculation: 17.9 kg x 90 mL = ~1600 17.9 kg x 110 mL = ~2000 Nitrogen needs/day: 3.52 4.32 g/day Calculation: 22 g/6.25 = 3.52 27 g/6.25 = 4.32 NPC:N ratio: 25:1 [used median calories (750 kcals) and protein (24.5 g) to calculate] Calculation: 24.5 g x 4 kcal/g = 98 kcals (calories from protein) 750 kcals 98 kcals = 652 kcals (non-protein calories) 24.5 g pro/6.25 = 3.92 (nitrogen needs at 126 g/protein) 98 kcals/3.92 = 25:1 (NPC:N ratio at 24.5 g protein) 5. Biochemical: (latest 2/21/2012) Laboratory Information DateDateTest6/282/21NormalHct-----39.9 35-44%Hgb-----13.2 11.5-14.5 g/dLMCV-----88.377-95 um^3/RBCCRP-----8.4 H<0.8 mg/dLWBC-----10.74,000-12,000/uLRBC-----4.524.0-4.9 million/mm^3PLT-----264177-406 x 1000/uLANC-----8.2 H1500-8000 mm^3Vit D38-----30-149ng/mL Provide evidence-based interpretation for nutrition-related values: The latest recorded lab values date back to February 2012, which are no longer current or of concern. AA has been stable over the last six months and there has been no need to recheck lab values, indicated by lack of current labs. Based on the February lab values, the patient had very normal labs. AAs elevated CRP was likely high due to infection. The ANC likely elevated due to the bodies response to the infection, producing more neutrophils to fight off foreign substances. 6. Medications: Medication (include dose)UseDiet-related side effects/restrictionsSigns/symptoms experiences by patientBaclofen 10 mg q6hrs prnAntispasmodic Avoid alcohol. Nausea. Vomiting. Constipation.NoneDiastat 7.5 mgAntiepilepticDecreased weight. Increased appetite.NoneElemental Calcium 500 mg b.i.d.Mineral SupplementAnorexia. Ensure adequate fluid intake.NoneKeppra 500 mg b.i.d.AntiepilepticAnorexia. NoneMiralax capful in 6-8 oz q.d.LaxativeNot absorbed from GI tract. Nausea. Bloating. Flatulence.NoneMotrin 150 mg q8hrs prnAnalgesicNausea. Vomiting. Dyspepsia. Abdominal pain. NoneNystatin 5 cc swish and suction PO t.i.d. prnOral Candidiasis TreatmentGI distress. Nausea. Vomiting. Diarrhea.NonePediatric Glycerin Suppository q.o.d.LaxativeNausea. Increased intestinal peristalsis. Decreased weight.NonePediatric multivitamin q.d.Mineral SupplementAnorexia. Ensure adequate fluid intake.NoneRobinul 0.5 mg b.i.d.AntiulcerBloating. Nausea. Loss of taste. Constipation.NoneTylenol 250 mg q4hrs prnAnalgesicAvoid alcohol.None 7. Clinical Evaluation: Circle observed signs of nutrient deficiency: Hair: Loss Mouth: Stomatitis Thin, sparse Cheilosis Nails: Spoon shape Glossitis Transverse ridging Gingivitis Skin: Dry, scaling Teeth: Missing Jaundice Poorly fit dentures Dermatosis Muscles: Edema Petechiae Muscle wasting DQ ulcer: Stage _____ Eyes: Icteric Identify observed signs of nutrient deficiencies and list possible nutrition-related causes: Patients skin is intact; no edema present and AA is showing no signs of nutrient deficiency. Describe any physical handicaps that affect intake. Determine patients ability to perform activities of daily living: AA is currently tracheostomy and vent dependent. Patient is also a quadriplegic and is wheelchair bound; therefore AA will always require further assistance to maintain ADLs. 8. Dietary: Date & timeDiet orderPO %Assess tolerance to dietIs diet adequate to meet patients needs?9/27/2012TF: Nutren Jr with Fiber @ 220 mL (TV=660 mL/day) + 480 mL free water @ 100 mL/hr q shift0%Well toleratedYes Identify and evaluate any chewing/swallowing problems. Include in your explanation interventions taken to modify diet: Patient has chewing and swallowing difficulties, indicated by the strict tube feed recommendation. AA will remain solely on enteral nutrition, consuming nothing PO. Obtain a diet history when needed for diet instructions or to discern patients nutritional status when appropriate: No diet history was obtained from this pediatric patient. AA has been on enteral feeds for years and doesnt have any PO intake recorded. Meal & timeFood & preparation methodAmountN/A N/AN/A Evaluate diet history by using dietary software. Interpret findings: N/A Determine if food security influences diet. List possible interventions available to improve food procurement: AA has been a resident at SDCH for about 4 years, and is not experiencing food insecurities at this time. 9. Education: List all nutrition education given to the patient. Determine if there are any social, emotional, or physical factors that affect adherence to the education. Assess patients understanding, compliance, and receptivity: No education was given to the patient at this time. 10. Coordination of Nutrition Care: Determine if any referrals need to be made to other programs or services and explain why: No further referrals need to be made at this time. Patient has been stable for last six months. 11. Nutrition Screening: Currently patient is assessed at moderate nutrition risk based on the nutritional standards at South Davis Community Hospital. Justification for degree of nutrition risk assessed: AA is assessed at moderate nutrition risk due to his permanent dependency on tube feed supplementation. The patient is stable and nourished, though remains dependent on nutrition support. AA has a target goal weight at 19 kg, indicating the patient needs to gain a few pounds. Nutrition Note: Nutrition Assessment(s) and Follow-Up Note(s) based on South Davis Community Hospital format: Assessments (only back six months; AA has lived in this facility for 4 years): 9/27/2012 TF increase: Recommend another increase in TF supplementation, as patient did not respond to previous intervention. Recommend increasing Nutren Jr with Fiber at 220 mL qs (TV = 660 mL/d). Will continue with protein powder, benefiber and 480 mL H2O qs. This will provide 717 kcals/d (6.7 kcals/cm ht), 26 gm protein (~1.4 gm/kg IBW) and ~2000 mL/d (105 mL/kg IBW). Will monitor weight and make goal for target weight of 19 kg. Will continue to monitor to ensure patient meets goal. 8/14/2012 TF increase: Pt has had an increase in growth, which caused a drop in %tile. Recommend increasing Nutren Jr with Fiber to 200 mL qs (TV = 600 mL/d). Will continue with protein powder and H2O of 200 mL qs. This will provide 625 kcals (5.7 kcals/cm ht), 25 gm protein (1.3 gm/kg) and 2010 mL H2O (106 mL/kg). Will monitor weight trend and make goal for target weight of 19 kg. Will continue to adjust feeds to ensure patient meets goal. 7/16/2012 Quarterly: Patient has been stable for this last quarter in relation to nutrition status. Weight is appropriate for height and within range. EN formula and regimen continue to remain appropriate to maintain nutritional needs. Meds are notable for Keppra, MVI, Ca. Skin is intact. Will continue with current plans and goals to make recs prn. 4/16/2012 Quarterly: AA plots at the 50th%tile wt/age and ht/age based on the life expectancy CP growth charts. Weight gain of 7% in 6 months, 4% in one month. Height varies due to technical errors. AA continues to receive additional protein powder and fiber to maintain nutrient needs. Skin is intact. No labs to address at this time. AA also received MVI and Ca daily. Other notable meds are Keppra and Baclofen. Will continue with current plans and goals at this time. Will increase nutrition as needed to maintain age/condition optimal nutrition and growth. Diagnosis (PES Statement): Inadequate oral intake R/t mechanically ventilated, swallowing difficulty AEB dependence on supplemental feeds, inability to independently take PO. Intervention: Continue to provide enteral feeds (Nutren Jr with Fiber @ 220 mL qs + 480 mL H2O qs) Maintain adequate nutritional status. Good hydration and skin turgor. Nutrition labs WNL, when available. Monitor & Evaluation: Monitor daily weights, labs, skin and hydration status Monitor tolerance to enteral nutrition Patient Follow-Up: If no F/U note was written, provide patient follow-up information and prognosis. Identify what the patients needs are long-term and how best to meet those needs: A follow up assessment was not scheduled at this time. Every patient is discussed daily in rounds, so if something comes up the Dietitian will make it a priority to see them or in this case, adjust the tube feed supplementation. AA has been stable and we are looking to increase the patients weight to 19 kg, which is ideal. Aside from the occasional 10% tube feed increase, the patient receives a quarterly every 4 months and an annual follow-up to ensure AA is adequately meeting nutritional needs. The patient had an annual follow-up, which is provided below. 10/11/2012 - Annual: AA is assessed at moderate nutrition risk R/t inadequate oral intake AEB tube feed dependency. Patient will remain on tube feed supplementation and is stable at this time. AAs weight has increased to 19.7 kg, meeting his target goal. Patient as at the 70%tile based on height/condition and should have no further weight gain at this time. Current diet order is Nutren Jr with Fiber at 220 mL + 480 mL free H2O at 100 mL qs. This will provide 717 kcals/day (6.7 kcal/cm ht), 26 gm protein (1.3 gm/kg) and ~2000 mL/day (101 mL/kg). Skin is intact. Notable meds are pediatric MVI, Baclofen and Elemental Ca. Will continue with current interventions and make adjustments and recs prn. Disease Synopsis: Cerebral Palsy Brief explanation of disease: Cerebral Palsy is a group of syndromes that hinders voluntary movements and may be the outcome of prenatal developmental deformities or damage to the central nervous system after birth (1). Cerebral Palsy will not be diagnosed in the newborn stages, since the disease changes so much throughout the first year of life (2). Relation to nutrition care plan: AA is a 6-year-old male with the diagnosis of infantile Cerebral Palsy. Cause, Incidence & Risk Factors: Cause: The onset of Cerebral Palsy may be determined by a number of things, including but not limited to, prematurity, neonatal encephalopathy, utero disorders, perinatal asphyxia, stroke and further CNS infections (1). These symptoms may occur before, during or after birth. Incidence: Cerebral Palsy develops in 0.1-0.2% of children and 15% of premature infants (1). In the United States alone, about 10,000 children develop Cerebral Palsy each year (2). Risk Factors: Prior to pregnancy Cerebral Palsy may be more likely to develop when pregnancies are spaced too close together or too far apart (2). During pregnancy Cerebral Palsy may develop during pregnancy due to physical deformities, twin gestation, abnormal fetal presentation, growth retardation or maternal hypothyroidism (2). Around/after birth Cerebral Palsy may occur in premature infants, premature separation of the placenta or neonatal encephalopathy (2). During infancy, Cerebral Palsy may be initiated by bleeding in the brain, head injuries, brain infections or severe jaundice (3). Relation to nutrition care plan: The cause of AAs Cerebral Palsy is unknown at this time. However, the patient likely experienced one of these common problems or may have faced developmental issues with pregnancy. Signs, symptoms & tests: Signs & Symptoms: Symptoms vary among children. The symptoms may be extremely mild or very severe, may affect one or both sides of the body and may affect either the arms or legs, or both (3). Before diagnosing a specific syndrome, the child may experience a delay in motor development, muscle weakness, abnormal walking, persistent infant reflex patterns, speech difficulty, seizures, hearing or vision problems and altered muscle tone (1) (3). All of the above may indicate early onset of cerebral palsy. Tests: With suspicion of Cerebral Palsy, a cranial MRI or CT head scan are performed (1) (3). The MRI can catch most of the malformations related to Cerebral Palsy (1). Relation to nutrition care plan: AA has severe symptoms and the disease has affected the patients whole body, therefore, the patient has limited range of motion. AA also has many of the listed symptoms of the disease, including muscle weakness, speech difficulty, seizures and altered muscle tone. All of these symptoms have become permanent with the onset of the disease. Medical Treatment: There is no cure for Cerebral Palsy, so managing the disease and allowing the patient to be as independent as possible is the main goal (3). There are a few different options for treatment that will allow the patient to be as high functioning as possible (1). These include: Physical and occupational therapy allow patients to gain strength and develop good muscle movement (1). Braces, drugs or surgery (for muscle spasms) decrease the amount of muscle spasms experienced by the patient. Some common drugs include: botulinum toxin (injected into muscle to decrease contractures), baclofen and benzodiazepines (1). Assistive devices may allow for mobility and communications, assistance to maintain range of motion and allow the child to complete more activities of daily living unassisted (1). Relation to nutrition care plan: AA is unable to perform activities independently, as the course of the disease affected the patients whole body. The patient participates in physical therapy at the hospital to maintain muscle mass. AA is also participating in drug therapy, including baclofen and has received botulinum treatments in the past. AA uses assistive devices, and is permanently wheelchair bound. Nutrition Treatment: Often patients with Cerebral Palsy experience chewing and swallowing difficulties, which would lead to permanent nutrition support (1). Relation to nutrition care plan: AA has always struggled with chewing and swallowing. Therefore, the patient has been placed on long-term enteral nutrition. With enteral nutrition, the patient is able to meet all nutritional needs adequately. Complications: Many complications arise with Cerebral Palsy patients, including but not limited to osteoporosis, arthritis, contractures, pneumonia, scoliosis, seizures, bowel obstructions, hip dislocations, poor communication skills and lack of nutrition (3). Relation to nutrition care plan: AA has developed many complications arising from Cerebral Palsy. The patient is currently dealing with contractures, scoliosis, seizures, pneumonia and poor communication. All of these complications are being addressed with therapies. Disease Management & Prevention: Management: The best way to manage Cerebral Palsy is to allow children to gain maximum independence, based on the individual level of motor development (1). Let the child participate in movement, speech, school, self-care and other activities, as they are able to (2). Prognosis: Many patients with Cerebral Palsy are able to lead close to normal lives and most will survive into adult years (1). Prevention: Cerebral Palsy may not be preventable, but getting the best possible prenatal care will decrease the risk of infantile Cerebral Palsy (3). Mothers with certain medical histories may need to be followed more closely throughout the pregnancy to ensure proper care and development of the infant (3). Relation to nutrition care plan: AA is participating in therapies, attending school in the community and taking part in activities offered through SDCH at this time. References 1. Porter R. The MERCK Manual of Diagnosis and Therapy. 19th ed. Whitehouse Station, NJ: Merck Sharp & Dohme Corp., A Subsidiary of Merck & Co., Inc.; 2011. 2. Venes D. Tabers Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: F.A. Davis Company; 2009. 3. PubMed Health. The Cerebral Palsy page. 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