NUTRITION CARE PROCESS NOTE Reason for consult: Nutrition Assessment and Therapy Cachexia, weight loss, blood

glucose management post-surgery, Stage IV Rectal Cancer. NUTRITION ASSESSMENT Clinical: Mr. I is a male with general weakness and failure to thrive, weight loss, a sacral stage II pressure ulcer and hypoglycemia leading to a fall. LAR w/ end colostomy for T3N1 rectal adenoca exploratory lap, LOA, placement of abscess drain C diff positive final chemotherapy Liver mets on PET, proven with bx 7/2013 started chemotherapy prior to possible liver lobe resection c/b diarrhea, n/v and wt loss 11/2013: small bowel obstruction requiring parenteral nutrition resolved w/o surgical intervention 1/13/2014: hepatectomy and cholecystectomy ____________________________________________________ Subjective: Veteran appears very frail and weak, there is noticeable swelling on his right arm and hand which he reports is from a recent fall after a hypoglycemic episode. He feels frustrated that he was told to limit sugar, now he is being encouraged to eat more sugar to prevent lows. He has a slight appetite, but refuses to eat the food here. Occasionally leaves the hospital to get food if he has the strength. He is willing to drink some of the Boost nutrition supplements. He reports a current weight of 143#. Diet: Veteran reports only eating one meal per day. Some foods he eats include fiber 1 cereal mixed with captain crunch and milk. Chili noodles, and meatloaf. No complains when eating foods high in fats. He reports drinking water at home. ____________________________________________________ Dietary/Alimentation/Elimination: Current diet order: CONSIST CARB + calorie count (results Monday) Food allergies/intolerances: no allergies reported. Veteran feels that cheese blocks his colostomy so he avoids it Chew/Swallow function: He does not report any issues chewing or swallowing and has his own teeth. Documented intake: (- indicates not documented) 03/06/2014 B 50%, L 25%, I/O: 590/950 ml N/V/C/D: none reported Last BM: Empties his colostomy bag once a day and reports it is normal in color. ____________________________________________________ Anthropometric: Height: 68.5" Current weight: 145" 02/09/2014 Weight history: 151" 02/05/2014 144" 01/30/2014 155" 12/19/2013 BMI: 21 kg/m2 Ideal body weight: 157# Range: 141-173# % ideal body weight: 92% Weight loss: 6% (10 lbs) in 45 days Estimated needs: dosing wt = 66 kg (current body weight) Calories: 1800-2000 kcal/day (MSJ x 1.2-1.4) Protein: 90 grams/day (1.4 g/kg) for wound healing Water: 2000 ml/day (1ml/kcal) D 10% PMH: 8/19/2011: 12/9/2011: 1/19/2012: 5/30/2012: 5/22/2013: 10/2013:

Nutrition physical findings: Overall appearance: Veteran appears weak and has poor muscle tone in his swollen arm **Will obtain a more thorough nutrition physical exam tomorrow Drains: Foley- reddish brown urine output JP drain- yellow output Colostomy- appeared to be full with liquid but unable to visualize contents Skin: WOUND CARE CONSULT-- Stage 2 pressure wound to coccyx measures approx. 0.7cm in diameter. Abrasions to right and left elbows. Functional status: Independent with feeding, weak with risk for falling ____________________________________________________ Nutritionally significant medications: 1) Dextrose 50% inj,soln 25 grams (50ml) ivp prn indication: for treatment of hypoglycemia per hypoglycemia protocol. 2) Furosemide tab 20mg po bid 3) Gabapentin cap,oral 900mg po tid 4) Glucagon inj 1mg/1vial sc prn indication: for treatment of hypoglycemia per hypoglycemia protocol. 5) Glucose gel,oral contents of 1 tube 40% po prn indication: for treatment of hypoglycemia per hypoglycemia protocol. 6) Insulin aspart inj supplemental sc qid-insu-supp for pre-meal/bedtime hyperglycemia. give mealtime suppl scale dose at cbg check time even if pt does not eat, or npo dose if npo. high dose (bmi >30 or tdd >80 units/day) 7) Lactated ringers 1000ml inj,soln in lactated ringers sol. 1000 ml 100 ml/hr iv 8) Lorazepam tab 1mg po bid prn for anxiety or sleeplessness for ptsd 9) Metoprolol tartrate tab 12.5mg po q12h hold if hr < 70, sbp < 110 10) Omeprazole cap,ec 20mg po bid wm 11) Oxycodone hcl tab 5-10 mg po q4h prn for pain Biochemical: ALBUMIN CBC 2.3 L 03/05/2014 20:00

03/05/2014 20:00 WBC 14.3 H RBC 3.38 L HGB 10.5 L HCT 31.8 L MCV 93.8 MCH 30.9 MCHC 33.0 RDW 22.6 H PLT 453 H MPV 7.2 L

CHEM 7 PANEL 03/05/2014 20:00 GLUCOSE 249 H UREA NITROGEN 15 CREATININE 0.8 SODIUM 129 L POTASSIUM 3.3 L CHLORIDE 94 L CO2 26 ANION GAP 12 EGFR 99 PHOSPHATE 2.6 03/05/2014 MAGNESIUM 2.0 02/09/2014 CALCIUM 7.8 L 03/05/2014 GLUCOSE 249 H 03/05/2014 Last 2 CBGs:

20:00 05:30 20:00 20:00

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NUTRITION DIAGNOSIS Inadequate oral intake related to altered GI function, decreased food acceptance, moderate appetite as evidenced by a 6% weight loss in 45 days, albumin 2.3, and recent hypoglycemia. Nutrition status: Moderately compromised NUTRITION INTERVENTION -Discussed food preferences with Veteran, he agreed to eating some smaller meals including cereal at breakfast and sandwiches for lunch and dinner. -Feeding tube was brought up to Veteran and he did not reject the idea Active Standing Orders: All Meals 1 X CALORIE COUNT All Meals 1 X ODD ITEMS OK Break 1 C BOOST+ CHOCOLATE Break 1 C CEREAL, RAISIN BRAN Break 1 C CEREAL, FROSTED FLAKES Noon, Even 1 C BOOST+ SHAKE, 6OZ, VANILLA Noon 1 C SAND ROAST BEEF Noon, Even 1 A MUSTARD, PKT Noon, Even 1 C TOMATO/LETTUCE FOR SANDWICH Even 1 C SAND HAM Nutrition goals: -Adequate PO intake -Wound healing -CBG 80-180 Nutrition recommendations: -Supplemental tube feeding is an option if Veteran is unable to have meet caloric needs NUTRITION MONITORING/EVALUTATION Routine