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Sex
DOB
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CNSC
Dietitian
Addendum
I of2
Age
I
Plan of Care
Problem: Nutrition lnterventions
lntervention: Parenteral Nutrition
Continue to assist with TPN in this 58 y.o. Male admitted postop with an open abd for complicated
ostomy
takedown - ventral hernia repair and component separation with \l/hitman patch. On 214 taken
to OR for exploration due to the presence of bilious fluid within the pelvic drain found enteric leak. On
3/5 taken to OR for skin graft.
lndication for TPN is open abdomen with 4 fistulas
-Rec: continue supplementary TPN with cyclic x 12hr:40 ml x t hr; increase to 100 ml/hr x 10 hr;
decrease to 40 ml x t hr to provide 12 Kcallkg, 1.0 Gm protein/kg, no lipids in vol of 1080 ml/day
(dosing wt: 70 Kg)
-CBG monitoring q 6 hr and cover with ss insulin as needed
-Due to increased TF rate and national shortages, NaPhos eliminated from TPN.
-Please provide PHOS-NaK, 1 pkt 2 - 3 xlday as needed for maintenance when able to give meds via
Gl tract ( 1 pkt =25A mg phos,280 mg K, & 160 mg Na)
-Due to national shortage of lV MVl, will provide MVI MWF; once pt is able to take oral meds or meds
PFT, please give Cerovite 15 mL oral liquid or house multivit with minerals.
-Due to national shortage of selenium, TPN will contain 60 mcg extra selenium MWF in addition to
standard trace mineqal dose.
-Due to shortage of zinc, TPN will not contain extra zinc in addition to standard trace mineral dose.
-Will continue to assist with electrolyte, fluid, insulin changes prn
-Rec stop TPN when TF rate is tol at 4Sml/hr (providing 75o/o of goal rate).
lntervention: Enteral Nutrition
-TF on hold, until after surgery. Prior to hold, pt tolerating 3Oml/hr, with no residuals, which provided pt
with half of his goal rate, and 864 kcal and 54 gm PRO) .
-Rec trickle enteral nutrition at a rate of 10 ml advance in 20 ml increments q 4-8 hr to goal of 60ml
-Rec goal TF of Peptamen AF(elemental type in EPIC)@60 ml/hr with Prosource BID providing 1850
kcal, 139 gm pro, and 1 165 ml useable fluid
-Rec when off all lVFs flush DHT with 50 ml x 5 for hydration
-Rec Nancy's Kefir 80 mlTlD for Probiotics Rx
-Glutamine BID
-Monitor TF tol, vol, labs, bowel and fluid status
Comments:
Nutrition Dx: Pt with altered Gl fx r/t fistulas & open abdomen AEB bowel rest, NPO status, and need
hisa58y.o.Malewhoiss/pGSWtotheabdomen(2!23l2012),was.admitted"I
Admitted now with a colostomy,
Tf,iortwo months, had multiple surgeries and was left in discontinuity.
three mucous fistulas and large ventral abd defect, plan for colostomy takedown.
PMH: GERD
(1129) OR - total abdominal colectomy, ileorectal anastomosis, placement of abthera dressing,
takedown of colostomy, mucus fistula and transverse colon fistulas x 2, extremely complex and difficult
lysis of adhesions.
(1/30) Pt reports good appetite, stable wt prior to surgery.
02101113 - Washout, Wittman patch, temporary abdominal closure
02103113 - Washout, tightening of \Mttman patch, temporary abdominal closure
02104113 - Washout, closure of enterotomy, debridement of necrotic omentum, tightening of Wittman
patch, flexible sigmoidoscopy, temporary abdominal closure
31612013