Nutrition Care

Conference
Evergreen Healthcare Center
December 2, 2013

Sarah Leahy
Overview of Patient
Initials: S.S.
Gender: Female
Age: 52 years
Readmitted on 4/6/2010
Seen on 10/17/2013
Physical Signs
Patient is bed ridden with extreme
muscle weakness due to multiple
sclerosis diagnosis
Was unable to conduct interview with
patient because of limited cognitive and
communication ability
Psychosocial
Patient has been in assisted living for over 15
years
Completely non-ambulatory, and dependent
for all activities of daily life
Limited cognitive function and extreme muscle
weakness has resulted in complete aphasia
Patient has two sons and parents who are
involved in making all major decisions

Anthropometric Data
Height: 54
Weight: 156lbs
BMI: 26.8

Clinical data:
Blood pressure: 124/64
Temperature: 96.5 F
IBW: 120 +/- 10%
% IBW: 130%
Adjust BW: 129lbs
Medical History
Advanced Multiple Sclerosis (MS)
Gastrostomy
Dysphagia and Aspiration
Respiratory Failure
Tracheostomy
Hypothyrodism
Anemia
Anxiety/Depression
Dementia

Chief Diagnosis
Advanced Multiple Sclerosis (MS)
Irreversible central nervous system deterioration
leading to muscular dystrophy
Progressive disease with varying symptoms
depending on individual case
Patient SS suffers from immobility, inability to
move limbs, extreme muscle weakness, and
chronic pain
Disease has also affected her cognitive function,
brain function and ability speak or communicate

Medical Nutrition Therapy
Patient received gastrostomy and insertion
of gastric feeding tube
Will need to monitor the following:
Patients risk for malnutrition
Long term weight management and
maintenance
Proper nutrient intake, deficiencies and potential
health risks
Fluid intake, output, and retention
Tube Feed
Closed system Pump
Open system pump
Medications
Furosemide
Diuretic, antihypertensive
Prevent water retention by patient
Nexium
Antiulcer, antigerd, antisecretory
Different laxatives to prevent constipation
Bisacodyl, milk of magnesia,
Antianxiety and antidepressant medications
Lorazepam, Cymbalta,
Biochemical Data
Lab Name Patients
Range
Normal
Range
Nutritional Significance
BUN 5 7-18
mg/dL
Low levels may indicate individual is in
a negative nitrogen balance, this may
be a result of being underfed, and is
seen in individuals experiencing
starvation
Glucose 183 70-106
mg/dL
Increased levels may signify diabetes
mellitus, MI, CHF or infection
Calcium 8 8.5 -10.5
mg/dL
Important to monitor to make sure
levels are adequate because of
supplement use, potential medicine
interactions and history of
osteoporosis.
Potassium 2.9 3.5-5.1
mmol/L
Dangerous to be low and needs to be
monitored and supplemented. Low
levels could be associated with
potential medicine or supplement
interactions
Diet Order
NPO Peg Tube Feeding (G-tube)
Description: FS Vital 1.5 at 45mL
20 hrs/day (5pm-1pm)
180 mL H20 flush every 6 hours

Nutrition Needs:
Calories: 1365 kcals/day

Product Name Vital 1.5 Cal
Indications of use
Calorically dense, peptide-based, elemental formula for
patients experiencing malabsorption, maldigestion or
impaired GI function and/or GI intolerance
Nutrient Values Per 1L
Cal/mL 1.5
Protein (g) 67.5
Carbohydrate (g) 187
Fat (g) 57.1
Fiber (g) 6
Sodium (mg) 1500
Potassium (mg) 2000
Calcium (mg) 1000
Phosphorus (mg) 1000
Magnesium (mg) 400
Water (g) 764
Features
Advanced blend of hydrolyzed protein, structured lipid, and
prebiotic to support excellent absorption and tolerance
Source: Johnson Memorial hospital Enteral Nutrition Formulary 2012
G-Tube Feeding Calculations
Per one 24hr Period
FS Vital 1.5 at 45mL for 20 hrs./day with 180 mL H20 flush
every 6 hrs.
Total Volume of Formula: 45ml x 20hrs = 900 ml (0.9L)
Total Calories: 900 ml x 1.5 cal/ml= 1350 calories
Protein: 0.9 L x 67.5g protein = 60.75 grams protein per day
60.75g protein/ 71 kg Body weight = 0.85 g/kg protein
60.75 x 4 = 243 calories from protein
Carbohydrates: 0.9L x 187g= 168.3 grams CHO per day
168.3 x 4 = 673 calories from CHO
Fat: 0.9L x 57.1 = 51.39 g fat
51.39 x 9 = 463 calories from fat

G-Tube Fluid Calculations
Per one 24hr Period
FS Vital 1.5 at 45mL for 20 hrs./day with 180 mL H20 flush every 6
hrs. (4x day)
Fluid:
0.9 L x 764g= 687.6 ml water from formula
180 ml flush 4x a day = 720ml Free water
Total Fluid = 1408 ml water per day

The amount of flush given per day can be altered to change the amount of
water the patient is receiving each day.
May need to be increased if patient is in a diseased state or if patient
demonstrates signs of dehydration
Fluid may need to be decreased if patient is experiencing water retention.
Pertinent Vitamin and
Minerals
Calcium supplement
Increase calcium because of low lab values
May be due to medication interactions
Important to supplement to prevent breakdown of bone
Potassium Supplement
Increase potassium because of dangerously low lab values
Low potassium levels are most likely due to diuretic
medication interactions, which can cause potassium loss
through urine


Nutrition Care Process
Diagnosis:
Swallowing difficulty (NC-1.1)
PES Statement
Patient with difficulty swallowing related to
physiological causes of multiple sclerosis as
evidenced by total dependences on PEG tube
feeding for nutrition

Nutrition Care process
Intervention
Continue with current diet order of Vital 1.5 45mL for
20 hrs./day
Continue with 180ml flush every 6 hours
Assess gastric residual volume
Monitoring/Evaluation
Monitor weight with weekly weight
Monitor edema to check for swelling and potential for
water retention
Monitor any GI intolerances
References
Academy of Nutrition and Dietetics. (2012). Nutrition Care Manual.
Retrieved from Academy of Nutrition and Dietetics Web Site:
http://nutritioncaremanual.org/auth.cfm?p=%2Findex%2Ecfm%3F&err=NotLoggedIn "
Definition." Mayo Clinic. Mayo Foundation for Medical Education and
Research, 15 Dec. 2012. Web. 30 Nov. 2013. <http://
www.mayoclinic.com/health/multiple-sclerosis/DS00188>.
Pocket Guide for International Dietetics & Nutrition Terminology (IDNT)
Reference Manual: Standardized Language for the Nutrition Care
Process. 4th ed. Chicago, IL: American Dietetic Association, 2013.
Print.
Mahan, Kathleen. (2012). Krause's Food & the Nutrition Care Process
(13th ed.). St. Louis, Missouri : Elsevier Inc.
"National Multiple Sclerosis Society." What is Multiple Sclerosis? :
National MS Society. N.p.,. Web. 30 Nov. 2013. <http://
www.nationalmssociety.org/about-multiple-sclerosis/what-we-
know-about-ms/what-is-ms/index.aspx>.
Zaneta Pronsky, S. J. (2012). Food Medication Interactions (17th ed.).
Birchrunville: Food Medication Interactions.
Picture sources
http://www.fairview.org/healthlibrary/Article/89700
http://pedsurg.ucsf.edu/conditions--procedures/gastrostomy-tubes.aspx