Erica Burdon
March 23, 2012
CASE STUDY 3
1. Nutritional Status
a. IBW (Hamwi Formula)
Women 5 5”
Women 100 + (5 x 5) = 125lbs
The patient’s weight indicates that she weighs ten pounds less than her ideal body weight.
b. % IBW= Actual/Ideal x 100
115/125 x 100 = 92%
The patient’s percent IBW is in a normal range but she is at risk for mild malnutrition.
c. % UBW = Actual/Usual x 100
115/145 x 100 = 79%
The patient’s percent UBW indicates that she is in the moderate malnutrition range.
d. % Weight Loss = Usual Weight – Actual Weight / Usual Weight x 100
145 – 115/145 x 100 = 21%
After doing this equation the patient has a 21% weight loss within unlimited time which
indicates severe weight loss.
2. Calculate the energy requirements
Harris Benedict
Female: 655.1 + (9.6 x 52.3kg) + (1.9 x 165.1cm) – (4.7 x 43) x 1.6 injury factor = 2,030
kcals/day
3. Calculate the protein requirements
1.4g/kg x 56.8 kg = 79.5 grams rounded to 80 grams protein
Two in one PN with 25 % dextrose and 5% amino acids @ 83ml/hr with 250 ml of 20%
lipids piggybacked.
4. Calculate grams of CHO provided by TPN at goal rate.
83 ml/hr x 24 hrs = 1992 ml
1992ml x .25 = 498 g dextrose
5. Calculate grams of protein provided by TPN at goal rate.
1992 ml x .05 amino acids = 99.6 g amino acids
6. Calculate the total calories provided by TPN at goal rate.
498 g Dextrose x 3.4 kcals/g = 1,693 kcals
99.6 Protein x 4 kcals/g = 398 kcals
250ml x 2.0 kcals/ml = 500 kcals
1,693 kcals dextrose + 398 kcals protein + 500 kcals lipids= 2591 kcals
7. Calculate the % of calories provided as fat
500kcal lipid/2591 total kcals x 100 = 19 %
8. Compare the total calories and protein provided by the TPN to the patients needs. Is
TPN at the goal rate appropriate?
The patient’s needs from the Harris Benedict = 2,030 calories and is receiving 2,591 calories
from the TPN. She is receiving about 550 more calories from TPN. The patient needs 80g/kg of
protein and is receiving 99.6g of protein from the TPN. The goal rate for calories is not
appropriate since it is high and the patient can be at risk for refeeding syndrome. The protein on
the other hand is adequate since it is better to always have more since she just had a colostomy.
9. Dextrose g/kg
7mg/kg/min ASPEN GUIDELINES
60min/hour x 24 hour/day = 1440 min/day
52.3 kg female
7mg x 52.3g x 1440 min = 527,180 mg or 527.2g dextrose/day
527.2 x 3.4 = 1,792 kcals this would provide from dextrose
527.2 g dextrose/d = (527.2/ 52.3) = 10g/kg
Dextrose Mg/kg/min
Dextrose 498g x 1000 = 498,000mg
498000mg/52.3kg= 9540.2
9540.2/1440 = 6.6 mg/kg/min
The solution provided does not meet the guidelines since it is above 6g/kg and 4 mg/kg/min
as shown in the above equations.
10.
A – 43 yo female, admitted to hospital with colon cancer. The patient is five days out of her
recovery from a colectomy. Past Medical History reveals colon cancer and GERD. A catheter
was placed in the brachial vein for administration of TPN. TPN for pt. was initiated at 42ml/hr x
24 hrs to determine tolerance. Two-in-one PN 25% dextrose and 5 % amino acids @ 83ml/hr
with 250 ml of 20% lipid piggybacked. The p. is 5 feet 5 inches and currently weighs 115lbs, her
usual body weight before cancer diagnosis was 145lbs. Pt. is 79% of her usual body weight and
she is 92% of her ideal body weight. Her percent weight loss 21% her body weight in an
unlimited amount of time. BMI: 19 classifying her in the normal category close to being
underweight. Labs values of Mg – 1.1 Meq/l, PO4 – 2.4 mg/dl and K+ - 3.2 Meq/L are low
which may indicate risk of refeeding syndrome. Also, low values of albumin and pre-albumin
may indicate mild protein depletion and that her body is under physiological stress. The patients
estimated needs from the Harris Benedict calculation using a 1.6 injury factor was 2,030
kcals/day. Her protein intake should be 80g of protein in order to reach ideal body weight.
D – Inadequate energy intake related to diagnosis of cancer as evidence by 21% weight loss in an
unknown amount of time, 79% UBW and 92% IBW and poor PO intake.
I – Nutrient Delivery
66 ml/hr x 24 hrs = 1,584 ml
1584 ml x .25 = 396 g dextrose
1584 ml x .05 amino acids = 79 g amino acids
396 g Dextrose x 3.4 kcals/g = 1,346 kcals
79 g Protein x 4 kcals/g = 316 kcals
250ml x 2.0 kcals/ml = 500 kcals
1,346 kcals dextrose + 316 kcals protein + 500 kcals lipids= 2,162 kcals
I recommend the TPN order to be at 66 ml/hr for 24 hours in order to prevent refeeding
syndrome. I do not agree with what the physician put the patient on since looking at the lab
values she may be at risk of refeeding syndrome. This goal rate will provide 396 g dextrose, 79 g
amino acids, 1346 kcals dextrose, 316 kcals protein, 500 kcals lipids and a total amount of 2,162
kcals.
M+E – Monitor patient’s potassium, magnesium, and phosphate levels daily in order to watch
for refeeding syndrome by regularly checking lab values. Monitor TPN daily in order to make
sure patients is receiving appropriate kcal, protein, fat and fluid needs. Check patients weight
gain weekly in order to make sure patient is achieving a normal weight.