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Patient Care Report #3. NIKITA PRABHU SPRING 2014 UMCB. Patient History. 31 y/o Caucasian female No significant PMH Married, stay-at-home mother with a young son. Anthropometrics. Weight : 60.5 kg (133#) Height : 162.56 cm (5’4”) Standard Wt : 54.54 kg (120#) - PowerPoint PPT Presentation
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Patient Care Report #3NIKITA PRABHU
SPRING 2014
UMCB
Patient History 31 y/o Caucasian female
No significant PMH
Married, stay-at-home mother with a young son
Anthropometrics Weight: 60.5 kg (133#)
Height: 162.56 cm (5’4”)
Standard Wt: 54.54 kg (120#)
% Standard Wt: 110%
Current Hospitalization February 14th – March 3rd
Admitted after falling in home and hitting head on tile
Was unresponsive and intubated at scene
Brought from San Marcos home via EMS
Admitting diagnoses: Intracranial hemorrhage Cerebal edema Bilateral subdural hematoma Occipital skull fracture Acute respiratory failure
Admitting Diet Order: NPO with plan for EN by Day 3 of admission
Day 4: ▪ NTR consulted for TF recs
▪ Currently on propofol @ 1.9 ml/hr (~50 kcal/day)
▪ RD rec trickle feeds until propofol rate is stable or off
Estimated Energy Needs: (via Penn State)
▪ 1,452 – 1,513 kcal/day (24-25 kcal/kg)
▪ 79 – 91 gm PRO/day (1.3-1.5 gm/kg)
▪ Pt started on 1.2 cal standard w/out fiber @ 15 ml/hr + 2
packets protein powder Qday, advanced as tolerated to goal of
50 ml/hr
▪ Provides: 1,540 kcal & 79 gm PRO OR 25 kcal/kg & 1.3 gm
PRO/kg (100% of needs)
Day 4: ▪ NTR consulted for TF recs
▪ Currently on propofol @ 1.9 ml/hr (~50 kcal/day)
▪ RD rec trickle feeds until propofol rate is stable or off
Estimated Energy Needs: (via Penn State)
▪ 1,452 – 1,513 kcal/day (24-25 kcal/kg)
▪ 79 – 91 gm PRO/day (1.3-1.5 gm/kg)
▪ Pt started on 1.2 cal standard w/out fiber @ 15 ml/hr + 2
packets protein powder Qday, advanced as tolerated to goal of
50 ml/hr
▪ Provides: 1,540 kcal & 79 gm PRO OR 25 kcal/kg & 1.3 gm
PRO/kg (100% of needs)
Day 6:▪ Pt seen for EN follow up
▪ Pt still on trickle feeds via OGT▪ Propofol ↑ to 23.4 ml/hr (~618
kcal/day)
▪ Currently receiving 30% of kcal and 25% PRO needs
▪ Spoke with MD resident to ↑TF to 30 ml/hr (100% kcal needs &
60% PRO needs)
Day 4: ▪ NTR consulted for TF recs
▪ Currently on propofol @ 1.9 ml/hr (~50 kcal/day)
▪ RD rec trickle feeds until propofol rate is stable or off
Estimated Energy Needs: (via Penn State)
▪ 1,452 – 1,513 kcal/day (24-25 kcal/kg)
▪ 79 – 91 gm PRO/day (1.3-1.5 gm/kg)
▪ Pt started on 1.2 cal standard w/out fiber @ 15 ml/hr + 2
packets protein powder Qday, advanced as tolerated to goal of
50 ml/hr
▪ Provides: 1,540 kcal & 79 gm PRO OR 25 kcal/kg & 1.3 gm
PRO/kg
Day 6:▪ Pt seen for EN follow up
▪ Pt still on trickle feeds via OGT▪ Propofol ↑ to 23.4 ml/hr (~618
kcal/day)
▪ Currently receiving 30% of kcal and 25% PRO needs
▪ Spoke with MD resident to ↑TF to 30 ml/hr (100% kcal needs &
60% PRO needs)
Day 8: ▪ Pt is now s/p day 4 craniectomy
▪ Pt vomited x2 yesterday & TF was stopped
▪ CDO: NPO (will be receiving PEG today- TF at 35 ml/hr prior to
NPO)
▪ Wt trending ↑ (+10 kg) due to fluid overload based on I/O▪ Pt is no longer on pressors
▪ RD rec that restart TF @ trickle feeds via PEG
▪ ↑ rate to 50 ml/hr to provide 1,490 kcal & 79 gm PRO (25
kcal/kg admit wt & 1.3 gm PRO)
Day 11:▪ Pt has been @ goal rate of 50 ml/hr since Day 8 (100% needs)▪ Pt had first 2 BM since admit & wts have stabilized close to admit
wt (@ 62.6 kg)
▪ Pt is on trach collar and tolerating well
▪ RD rec to switch pt to standard formula with fiber
*NEW* Estimated Needs1,512-1,634 kcal/day (25-27 kcal/kg
admit wt)73-91 gm PRO/day (1.3-1.5 gm/kg
admit wt)
▪ New TF regimen: 1.2 cal standard w/ fiber @ 50
ml/hr + 2 packets protein powder provides 1,634 kcal & 85 gm PRO
(100% needs)
Day 11:▪ Pt has been @ goal rate of 50 ml/hr since Day 8 (100% needs)▪ Pt had first 2 BM since admit & wts have stabilized close to admit
wt (@ 62.6 kg)
▪ Pt is on trach collar and tolerating well
▪ RD rec to switch pt to standard formula with fiber
*NEW* Estimated Needs1,512-1,634 kcal/day (25-27 kcal/kg
admit wt)73-91 gm PRO/day (1.3-1.5 gm/kg
admit wt)
▪ New TF regimen: 1.2 cal standard w/ fiber @ 50
ml/hr + 2 packets protein powder provides 1,634 kcal & 85 gm PRO
(100% needs)
Day 15: ▪ Pt has begun to open eyes and
react to sounds▪ Pt is able to cough on her own
Day 18: ▪ Pt has been transferred to Texas
Neuro rehab facility
Osmolite @ 15 mL/hr w/ propofol
Osmolite @ 30 mL/hr w/ propofol
Osmolite @ 50 mL/hr Jevity @ 50 mL/hr0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
Kcal per Formula
Average EstimatedKcal Needs
Osmolite @ 15 mL/hr w/ propofol Osmolite @ 30 mL/hr w/ propofol Osmolite @ 50 mL/hr Jevity @ 50 mL/hr0
10
20
30
40
50
60
70
80
90 PRO gm per Formula
Minimum EstimatedProteinNeeds
Lab Test Normal 2/14 (Day 1) 2/17 (Day 4) 2/19 (Day 6) 2/21 (Day 8) 2/24 (Day 11)
BUN 8-20 mg/dL - - <5 (L) - -
Sodium 136-145 mmol/L - 150 (H) 146 (H) - -
Potassium 3.6-5.0 mmol/L 2.7 (L) 3.5 (L) 3.5 (L) - -
Phos - 2.4 (L) - - -
Glucose 70-110 mg/dL - 144 (H) - - 111 (H)
Labs
Lab Test Normal 2/14 (Day 1) 2/17 (Day 4) 2/19 (Day 6) 2/21 (Day 8) 2/24 (Day 11)
BUN 8-20 mg/dL - - <5 (L) - -
Sodium 136-145 mmol/L - 150 (H) 146 (H) - -
Potassium 3.6-5.0 mmol/L 2.7 (L) 3.5 (L) 3.5 (L) - -
Phos - 2.4 (L) - - -
Glucose 70-110 mg/dL - 144 (H) - - 111 (H)
Labs
s/p craniectomy w/ ↑ fluid drainage
Lab Test Normal 2/14 (Day 1) 2/17 (Day 4) 2/19 (Day 6) 2/21 (Day 8) 2/24 (Day 11)
BUN 8-20 mg/dL - - <5 (L) - -
Sodium 136-145 mmol/L - 150 (H) 146 (H) - -
Potassium 3.6-5.0 mmol/L 2.7 (L) 3.5 (L) 3.5 (L) - -
Phos - 2.4 (L) - - -
Glucose 70-110 mg/dL - 144 (H) - - 111 (H)
Labs
Inadequate nutrition from TF
↑ stress response in body
Medications albuterol inhalation : bronchodilator
amantadine : anti-viral
bacitracin topical : abrasions
cefepime : anti-bacterial
erythromycin : anti-microbial
famotidine : ↓gastric acid secretion
Reglan : anti-emetic
fentanyl drip : pain
propofol (day 1-7) : sedation
Intracranial Hemorrhage
Bilateral subdural
hemotomaSkull fracture
Intracranial Hemorrhage
Bilateral subdural
hemotomaSkull fracture
Intracranial Pressure
Respiratory Failure
Intracranial Hemorrhage
Craniectomy
Bilateral subdural
hemotomaSkull fracture
Intracranial Pressure
Respiratory Failure
PropofolIntracranial
Hemorrhage
Bilateral subdural
hemotomaIntubation
Respiratory Failure
Craniectomy
Intracranial Pressure
Skull fracture
Propofol
Trickle Feeds
Intracranial Hemorrhage
Bilateral subdural
hemotomaIntubation
Osmolite @ 15-30 mL/hr
Respiratory Failure
Craniectomy
Intracranial Pressure
Skull fracture
↑ Needs
Trach collar
Propofol
Trickle Feeds
Intracranial Hemorrhage
Bilateral subdural
hemotomaIntubation
Osmolite @ 15-30 mL/hr
PEG placement
Respiratory Failure
Craniectomy
Intracranial Pressure
Skull fracture
100% of Needs
↑ Needs
Trach collar
Propofol
Trickle Feeds
Intracranial Hemorrhage
Bilateral subdural
hemotomaIntubation
Osmolite @ 15-30 mL/hr
PEG placement
Jevity @ 50 mL/hr
Transfer to Texas Neuro
Respiratory Failure
Craniectomy
Intracranial Pressure
Skull fracture
