Case Study #1: Lauren Baker

Due: No Later Than Monday February 29, 2016 Before Exam 1

54 Year Old Female

Ht: 57

Wt: 360 lbs

Chief Complaint: Abdominal Pain, Nausea and Vomiting

Diagnosis: Abdominal Abscess
Client Medical History:
Hypertension, Diabetes, Morbid Obesity
Activity patient is inactive but does some housework.
Past Surgical History: C-Section, Gall Bladder Removal
Pt is status post abdominal surgery for removal of abdominal abscess. Pt experienced
Sepsis with Respiratory Distress and is now mechanically ventilated. Pt is NPO for 48
hours. Pt currently has an Orogastric Tube in place. Pt is sedated on Propofol @ 23
mL/hr.
HgbA1c 12.6, Blood Glucose 400 mg/dL, BUN 64, Creatinine 2.54,
Vent status: 9.49, Temp: 37.3.
In YOUR OWN WORDS answer the following questions.
1. Is this patient experiencing Metabolic Stress? Why? Should you recommend a
Pre-Albumin Lab at this time? If so, what should be considered? If not, at what
point should you recommend this lab? Explain your answers in detail.
This patient is experiencing Metabolic Stress. She has septic, her BUN is
elevated, as well as her HgbA1c and Blood Glucose levels. She is currently
hyperglycemic. I would recommend a pre-albumin lab once she begins eating because
a pre-albumin lab determines if a person is malnourished and/or in need of nutrition. A
pre-albumin lab determines how much protein is in the body, as well as inflammation,
liver disease or necrosis of the tissue. Once she is hemodynamically stable and getting
nutrition into her system, order the lab and order it again in 3-5 days to see if the levels
have changed.
2. Calculate this patients BMI, IBW & %IBW.
BMI: (360 X 703) / (67)^2 = 56 morbidly obese
IBW: 100 + 5(7) = 135 lbs +/- 10%
%IBW: Weight / IBW X 100
360 / 135 X 100 = 266%

3. Calculate her nutrition needs. Show your work in detail.

(10 X 163.6) + (6.25 X 170.2) - (5 X 54) - 161 = 2269
2269(0.96) + 9.49(31) + 37.3(167) - 6212 = 2489 kcals
4. Use your formulary card and determine the most appropriate Tube Feeding
Formula. Why did you choose this formula? What else should be considered in
your choice of Tube Feeding Formula? Explain your answer in detail.
Osmolite 1.5 Cal. I chose Osmolite 1.5 Cal because it had an increased
protein and calorie need and had no fiber. Since this patient is vented, I did not
want to give a tube feeding with fiber because of needing to use the restroom. I also
chose the 1.5 over the 1.2 because it is more calorically dense and less volume. In
order for the patient to heal and get off the vent, I need her to get nutrients,
especially protein in her to repair. I also considered the fat content. She she is
currently on propofol, so she is already getting 607 kcal from fat daily. I also had to
watch the carbohydrate content because I did not want to put the patient refeeding
syndrome or cause her to have CO2 retention, then we cannot take her off the vent.

5. Calculate the amount of calories and protein the patient should receive from
Tube Feeding Formula per day based on Question 3. How much free water will
she receive from Tube Feedings per day? How many calories is this patient
receiving from Propofol? How would you consider the amount of Propofol when
providing nutrient needs from daily Tube Feedings? Show your work in detail.
calories: 2489kcals/18hrs = 138/1.5 = 92
90 X 18 X 1.5 = 2430kcals
protein: 62.7g/L > 0.0627g/mL
90 X 18 X 0.0627 = 102 g/mL protein
free water: 1mL/kcal > 2430 kcal X 1mL/kcal = 2430 mL water/day
76% / 100 = 0.76 X 2430 = 1846.8 mL of free water
2430 - 1846.8 = 583.2 mL of additional water needs
calories from Propofol: 1.1kcal/mL/hr
1.1 X 23mL/hr = 25.3 X 24 = 607.2 kcals/day
I would consider Propofol when providing nutrient needs from daily Tube Feedings as a
big part of her fat intake. From the tube feeding alone, she is getting 79.5 kcals from fat
(49.1g/L / 1000 = 0.0491 X 18 X 90 = 79.5). Between the Propofol and tube feeding she
is getting 686.7 kcal from fat daily. Overall, she is getting 28% of her daily calories from
fat, which is in the acceptable AMDR range.