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Chapter 5 Nutrition Care Process ●


Skin (specify) (PD-1.1.8): She has an abdominal surgical wound resolving with current treatments. Both heels are red and soft. She has a resolved wound area on her coccyx that is starting to redden but is not open at this time.


Client History (CH): ●


➤ ➤ ➤ ● Personal data (CH-1.1): Age (CH-1.1.1): 75 years old


Role in family (CH-1.1.9): Married Gender (CH-1.1.2): Female


Social history (CH-3.1): Living/housing situation (specify) (CH-3.1.2): History of multiple hospital- izations and stays at other LTC facilities for rehab


●


Treatment/therapy (CH-2.2): Medical treatment/ therapy (specify) (CH-2.2.1): Medical diagnoses are urinary tract infection (UTI), hypo- natremia, hypocalcemia, hypomagnesemia, anemia, ileostomy, inability to ambulate at this time, and PEG tube placement.


●


Patient/client/family medical/health history (CH-2): Other/specify (CH-2.1.14): Patient’s medical history includes dehydration, poor appe- tite, hypertension (HTN), colitis, peritonitis, col- ectomy, small bowel resection, endometrial cancer, and generalized weakness. She experi- enced nausea and vomiting prior to her recent admission to the hospital.


Comparative Standards (CS): ●


➤ ➤


Weight and growth recommendations (CS-5): IBW (CS-5.1.1): 115 +/– 12 lbs (52.2 +/– 5.4 kg) Reference BMI (CS-5.1.2): 23


● Energy needs (CS-1): ➤


➤


Estimated energy needs (CS-1.1.1): 1,909 kcal/d


Method for estimating needs (CS-1.1.2): Using Mifflin-St Jeor’s calculations, current esti- mated RMR is 1,129 kcal/d; estimated TDE is calculated as RMR × activity factor (1.3) × injury factor (1.3).


● Estimated protein needs (CS-2.2): ➤


Total protein estimated needs (CS-2.2.1): 52.2 to 67.9 g/d


➤


Method for estimating needs (CS-2.2.3): 1 g protein per kg IBW–1 g protein per kg desired body weight


● Fluid needs (3): ➤


Total fluid estimated needs (CS-3.1.1): 1,980 mL/d


➤


Method for estimating needs (CS-3.1.2): 30 mL per kg actual weight


●


63


Note: The NCP Codes are listed only for reference and are not included in the documentation.


Nutrition Diagnosis


AC is given a nutrition diagnosis of excessive enteral infusion (NI-2.4):


Excessive enteral infusion (P) related to increased oral intake (E) as evidenced by reported intake greater than 75% and complaints of being too full (S). A second nutrition diagnosis of excessive fluid intake (NI-3.2) is also documented:


Excessive fluid intake (P) related to intake greater than calculated needs (E) as evidenced by volume of oral and enteral fluids consumed (S).


Note: The NCP Codes are listed only for reference and are not included in the documentation.


Nutrition Intervention


The RDN documents the following nutrition prescription for AC: Regular mechanical soft diet (2,200 kcal and 92 g protein per day), plus 1.5 kcal/mL enteral formula in 1-can bolus (355 kcal, 15.1 g protein, and 180 mL water) at bedtime and if less than 50% eaten per meal, 100 mL water before and after feedings. To address the first nutrition diagnosis (excessive enteral infusion), the following intervention is planned:


●


ND-2.1.5 Enteral nutrition: Enteral formula 1.5 one-can bolus at bedtime and if less than 50% eaten per meal. Goals: Decrease enteral feeding to allow increased oral intake at meal and main- tain usual body weight range (UBWR); wean from feeding tube


To address the second nutrition diagnosis (excessive fluid intake), the following intervention is planned:


●


Enteral nutrition: Feeding tube flush (ND-2.1.9): 100 mL water before and after feedings. Goals: Hydration and patency of tubing


Monitoring and Evaluation


The following indicators are documented to monitor and evaluate how AC responds to the nutrition inter- ventions for her first nutrition diagnosis (excessive enteral infusion):


●


Total energy intake (FH-1.1.1.1): Criteria: Intake record: More than 50% per meal


●


Enteral intake (FH-1.3.1.1): Criteria: Nursing notes: Tolerance of bolus feeding at bedtime, frequency of bolus feedings at meals


Weight (AD-1.1.2): Criteria: Weight: Stable weight in UBWR


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