PN Case Studies (60 pts)
Please show all calculations. Points will be deducted if calculations are not
shown.
TOTAL SCORE: 59/60 well done.
Case Study #1 (25 Points)
PN was initiated on this 65 year old female. Weight is 132#. You determine her
estimated nutritional needs are 1800 Kcal and 85 g PRO d/t having a stage 3 P/U
on her coccyx. TPN was initiated d/t non functional GI tract d/t colon Cancer. It
is anticipated that she will receive chemotherapy and during this time will require
TPN for nutritional support. She will be NPO at this time because of
malabsorption during treatment. This female does not have Diabetes. Orders
were written as follows: Main solution of 500 ml of 8.5% Amino Acids mixed with
500 ml of 30% Dextrose. 500 ml of 10 % lipid emulsion will be piggybacked into
line with main solution.
1. How many Total Calories does this provide? (hint: show
calculations for calories from protein, calories from CHO and
calories from lipids and then add together for total calories) (4 pts)
500ml x .085 = 42.5 g PRO
42.5 g PRO x 4kcal/g = 170 Kcal
500ml x .30 = 150 g CHO
150 g CHO x 3.4 = 510 Kcal
500ml x 1.1Kcal/ml = 550Kcal
Total Calories = 1230 +4
2. How many grams of Protein does this provide? (1 pt)
42.5 g Protein +1
3. What would the rate be for the main solution over 24 hours? (hint:
this is figured without the lipids since they are piggybacked into the
line with the main solution) (1 pt)
1000ml / 24 hours = 42 ml/hr +1
4. Does this meet estimated nutritional needs as stated above for
calories and protein? (1 pt)
No, it is fewer Kcal and Pro than estimated needs. +1
5. Based on your answer in question 4, what would your
recommendations be to meet estimated nutritional needs for this
person? (hint: be specific. For example, what would you increase
or decrease your solution to? Most likely you will adjust PRO and
CHO and leave lipids the same) (2 pts)
I would increase the solution to 1000ml amino acids and 900ml dextrose
of the same concentration. +2
6. How many Total Calories does your revised solution provide? (Hint:
show calculations for calories from protein, calories from CHO, and
calories from fat and then add together to get total Calories). (4 pts)
1000ml x .085 = 85 g PRO
85 g PRO x 4 Kcal/g = 340 Kcal
900ml x .30 = 270 g CHO
270 g CHO x 3.4 = 918 Kcal
500ml x 1.1Kcal/ml = 550Kcal
Total Kcal = 1808 Kcal +4
7. How much protein does your revised solution provide? (1 pt)
85 g PRO +1
8. Does your revised solution provide too many g of CHO per day
based on the following formula (Kg x 1.44 x 5)? Why? (2 pts)
60 x 1.44 x 5 = 432 g CHO/day
No my revised solution does not provide too many g CHO because my
revised solution provides only 270gm CHO/d and it is less than 432 g
CHO. +2
9. What percentage of Kcal comes from protein? Is this within the
recommended guidelines for protein? (2 pts)
19% of Kcal are coming from PRO, this is between the recommended
guideline of 15% to 20%. +2
10. What rate will your revised main solution need to run at over 24
hours? (hint: this is figured without the lipids since they are
piggybacked into the line with the main solution) (1 pt)
1900ml / 24 hours = 79ml/hr +1
11. Why do you think that the PN was initiated at the solution that it
was? (2 pts)
I think it was initiated at this solution to observe overall tolerance and to
keep CHO at 150g and increase as tolerated. +2
12. When this person is receiving goal rate (your revised
recommendations), what do you need to monitor daily? What do you
need to monitor weekly? (3 pts) +3
Daily: Clinical status, catheter site, temperature, I & O, and Accu Checks
(every shift)
Weekly: Weight, BUN, Ca, Phosphorus, Magnesium, TG, liver function
enzymes, H & H, platelets, prealbumin
13. Write a PES statement for this case. (1 pt)
Less than optimal parenteral nutrition (NI-2.8) r/t initiation of PN as
evidenced by a solution of only 1230 Kcal and 42.5 g PRO compared to a
calculated estimated need of 1800 kcal and 85 g pro/day. +1
Case Study #2 (35 pts)
Resident is receiving PN only. Main solution is 1000 ml of 8.5% Amino Acids
mixed with 500 ml 50% Dextrose. 200 ml of 20% lipid emulsion is being
piggybacked into line with main solution. This solution is currently meeting
estimated nutritional needs for Kcal and protein. The MD states that this resident
is ready to transition from PN to enteral nutrition. It is decided that Impact 1.5 will
be used over 18 hours during the day. Information about Impact 1.5 is as
follows:
Product
Impact 1.5
Calories/mL
1.5
Protein
(g/L)
84
% Cal Pro
22
Osmolality
mOsm/kg
550
Water
(mL/L)
780
1. How much Protein and Total Calories does this provide? (hint:
show calculations for calories from protein, calories from CHO and
calories from lipids and then add together for total calories) (5 pts)
1000ml x .085 = 85 g PRO
85 g PRO x 4 Kcal/g = 340 Kcal
500ml x .50 CHO = 250 g CHO
250 g CHO x 3.4 Kcal/g = 850 Kcal
200ml x 2 Kcal/ml = 400 Kcal
Total Kcal = 1590 +5
2. What would the rate be for the main solution over 24 hours? (hint:
this is figured without the lipids since they are piggybacked into the line
with the main solution) (1 pt)
1500ml / 24 hrs = 62.5 ml/hr +1
3. What would you initiate the TF at initially without changing the PN to
determine GI tolerance over 18 hours? (1 pt)
I would initiate at a low rate, 30ml/hr, to determine GI tolerance +1
4. It is decided that the resident is tolerating the TF well, but MD wants
to increase TF gradually. The team decides to increase the T/F
incrementally by 10 ml/hr every day goal rate is reached.
a. What is the goal rate for TF over 18 hours when PN has been
stopped? (hint: include water flush orders). (2 pts)
59 ml/hr and 220ml water flush every 6 hours +2
b. How many Kcal, PRO, and free water does this provide? (3 pts)
1590 Kcal, 89 g PRO and 827 mL/L +3
c. On day 2, after you increased initial TF by 10 ml/hr, what would
you change the TPN to (Amino Acids and Dextrose) to
compensate for the increase in TF? (Hint: you do not need to
piggyback lipids since the TF will contain fat). (2 pts)
283 ml of 8.5% Amino Acids mixed with 245 ml 50% Dextrose

How many Kcal and PRO does the TF provide at day 2
rate? (2 pts)
60 Kcal/hr = 1080 Kcal over 18 hours
3.4 g PRO/hr = 61 gm PRO over 18 hours +2

How many Kcal and PRO does the TPN provide on day
2? (2 pts)
416.5 Kcal and 24 gm PRO +2

What is the total Kcal and PRO from TF and TPN? (2
pts)
1592.5 Kcal/d and 85 gm/PRO +2
d.
With increasing the TF by 10 ml/hr each day, when can you
discontinue the TPN and what would the TF rate be on this
day? Why can you discontinue the PN on this day? (4 pts)
I would discontinue PN on the third day. The TF rate would be
50ml/hr and you can discontinue PN on this day because we would
then be reaching 75% of nutritional needs by enteral feeding alone.
+4

How much Kcal, PRO, free water does the TF provide on
this day (hint: with goal water flush?)(3 pts)
1350 Kcal, 76 g PRO and 702 mL of free water and 880 mL
of water flushes +3
e. After PN is discontinued and this resident is on TF at their goal
rate, this resident begins eating p.o. meals that provide 500
Kcal, 25 g PRO/d, and 500 cc fluids/d. What would you adjust
the TF to over a 12 hour period at night? (include water flush).
(2 pts)
60.5 ml/hr x 12 hours +1 with 211ml water flushes every 4 hours
1500 – 500 ml from diet – 566 ml from TF= 434 ml for flushes /4 = 108
mL every 4 hours -1
f. What would this new rate of TF provide (Kcal, PRO and free
water?) (3 pts)
1089 Kcal, 61 g PRO, 566 free water +3
g. What would you look for to determine if this resident is not
tolerating TF? What signs would you look for to determine if
they were meeting estimated nutritional needs adequately? (3
pts)
I would check for vomiting, diarrhea, constipation and/or abdominal
distention to make sure that TF was being tolerated. I would also
monitor weight, hydration status, GI motility and labs (glucose,
electrolytes, BUN, creatinine, Alb, pre-alb, Ca, P and Mg) to make
sure TF was being tolerated and to determine if nutritional needs
were being met. +3
DUE: July 30, 2012 Please upload your assignment to the “PN Case
Studies” dropbox in the “Assignments” folder on k-state online