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Kultur Dokumente
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Severe Malnutrition
in the context of chronic illness
ASPEN Diagnostic Patient’s Signs and BMI: 24.5 kg/m2
Characteristics Symptoms
EMR wt hx:
Energy Intake ~50% of meals 198# (5/2017)
195# (11/2016)
Interpretation of 26# weight loss
Weight Loss 13% x 4 months UBW: 195# 87% UBW
Muscle Loss Temple region:
Wound: Stage II Pressure Ulcer
scooped, depressed
Clavicle bone visible
Fluid Accumulation 2+ BIL edema:
generalized, periorbital
Patient’s Estimated Nutrition Needs
3+ BIL edema: 2350-2750 kcal/day (30-35 kcal/kg CBW 78 kg)
dependent, R arm
78-94 g PRO/day (1.0-1.2 g/kg CBW)
Reduced Grip 7.5 kg - weak
Strength ~ 2350 mL fluids/day (1.0 mL/kcal)
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/22 Follow up / Provide cafeteria menu; emphasize importance of adequate intakes; goal of intake >75% of larger food order
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Date Reason for Note / Assessments, Interventions, and Recommendations
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Electrolyte fluctuation related to glucose influx
Low potassium, phosphorus, magnesium
Increased sodium and water retention
9/16 Initial assessment / Follow up to define malnutrition; offer supplements; change MCC diet to HCC; consider general diet
9/26 Follow up / Recommend diet advancement to general; increase supplement consumption- order in place when no longer NPO
9/28 Follow up / Provide cafeteria menu; share concern for pt’s safety with family and staff; TF discussion (PEG) palliative care
10/2 Follow up; hypoglycemic event / Continued poor intakes; calorie count; nutrition support (NG or PEG) warranted at <50%
estimated nutrition needs; 60 g CHO per meal; HS snack; continuous dextrose source; ↓ Lantus; encourage ↑ intakes
10/4* Follow up; calorie count interpretation / Discussed dinner mishap with RN; pre-ordered dinner trays; Send two supplements TID
10/6* Follow up; calorie count interpretation / CC extension; talked with palliative care and speech therapy; monitor weight; TF recs
10/9* Follow up; calorie count interpretation; hypoglycemic event / “Recommend continuous TF,” nocturnal if diet advances;↓ Lantus
10/12* Follow up / Respiratory MD note = ”nutrition is of concern;” recalculated needs utilizing refeeding syndrome precautions
10/13* Addendum / Care team aware of patient’s nutrition deficits; ICU daily rounding meeting: respiratory MD shared his concerns
Pulmonology
ICU
Respiratory
Oncology
Nursing
Speech Therapy
Palliative Care
Palliate = to make less severe or pleasant without removing the cause
Goal of comfort and best quality of life – for patients and families
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cranial pachymeningitis treated by oral methotrexate: a case report and review of literature.
Rheumatology International, 28(7), 713-718.
Diffuse large B-cell lymphoma. (n.d.). Retrieved from https://www.cancer.org/cancer/non-hodgkin-
lymphoma/treating/b-cell-lymphoma.html
Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2012). Krause’s food and the nutrition care process. (13th
ed.). St. Louis, MO: Elsevier Saunders
Marinella, M. A. (2008). Refeeding syndrome in cancer patients. International Journal of Clinical Practice, 62,
460-465.
Pachymeningitis. (n.d.). Retrieved from https://www.patientslikeme.com/conditions/1866-
pachymeningitis
Wang, A. S., Armstrong, E. J., & Armstrong, A. W. (2013). Corticosteroids and wound healing: Clinical
considerations in the perioperative world. American Journal of Surgery, 206(3), 410-417.
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