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Name: Heidi Washburn (I used the 2nd edition IDNT) BRIGHAM YOUNG UNIVERSITY

NDFS 466 Clinical Worksheet #3

CLINICAL WORKSHEET #3

High Risk Pregnancy, Metabolic Disorders, High Risk Infant Purpose(s)

1. To complete nutrition assessment, diagnosis, and intervention, monitoring and evaluation for a case patient.

2. To practice the application of clinical judgment. Note: When using “Clinical Judgment” there may be no “one” right answer to most of the questions asked, therefore it is important to explain or justify your answers.

3. To advance nutrition care process skills. 4. To improve chart note writing skills

General Guidelines

1. Complete two of the case studies in the worksheet 2. Worksheets must be completed electronically 3. Upload the cases in Learning Suite in the assignment section.

a. The worksheets must be uploaded as a Word document (.doc or .docx) b. Name file LastName_FirstName_Worksheet_3 For example if my name was John

Doe the file would be names Doe_John_Worksheet_3 4. Graded assignments will be returned, with comments, via Learning Suite

Sources for completing worksheet. Assume these are the sources available:

• Nutrition Care Manual -- Adult and Pediatric (online) • IDNT Manual • Any textbooks from NDFS courses • ADA Evidence Analysis Library (online) and noted journal articles • Class Lecture Notes from any NDFS course • Websites for formula companies (e.g. Nestle, Mead Johnson, Abbot) • Course Readings

Citations List sources used at the end of the case and cite sources as appropriate throughout worksheet. Cite works as indicated in the student handbook. Points

• Each case is worth 12.5 points a total of 25 points for the full worksheet. • Choose TWO (2) of the three case studies to complete.

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Case #1: Gestational Diabetes

Section 1. Thinking about Gestational Diabetes

1. When should pregnant women be screened for gestational diabetes? Why does screening take place at this time?

A women should be screened for gestational diabetes between 24 and 28 weeks gestation.1 This is because during the first trimester, glucose levels are generally lower. Then, gestational diabetes occurs as hormone levels change in the 2nd trimester and glucose levels tend to be higher.

2. What is the test is used for screening for gestational diabetes? 75-g 2-h Oral glucose tolerance test2 (though one source I found said that 50 g is used6)

3. How is the test administered? First, the woman fasts overnight, or for 8 hrs. Then blood glucose is drawn. Then, the woman drinks the 75 g glucose solution. Blood glucose is taken after 1 hour and 2 hours.2

4. What are the diagnostic criteria for this test? GDM is diagnosed if the blood glucose levels fall in these categories: Fasting ≥92 mt/dL (5.1 mmol/L) 1 h ≥180 mg/dL (10.0 mmol/L) 2 h ≥153 mg/dL (8.5 mmol/L)2

QT is a 27-year-old Hispanic female pregnant with her second child. She had an oral glucose tolerance test (OGTT) during her 25th week of pregnancy.

QT’s doctor informed her that she tested “high.” Her fasting glucose was 110 mg/dl and her 1 hr post glucose ingestion was 210 mg/dl. The doctor diagnosed QT with gestational diabetes and referred her to a dietitian for counseling. During the outpatient visit you (the dietitian) obtained the following information. Q.T. is 5'5" tall; her prepregnancy weight was 135 lb. She currently weighs 156 lbs. She has a sedentary job working as a data entry specialist. She tries to walk during her lunch break, but hasn’t been very consistent. She states she had morning sickness during her first trimester and hardly ate a thing, but recently has been very hungry all of the time. Her first baby was weight 9 lbs 3 oz. Her mother has had Type II diabetes for 5 years and take the medication Glucotrol.

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A typical day’s intake is as follows: 7:30 am Breakfast

• 2 slices of toast with margarine and jam • 1 ½ cups sugar frosted flakes cereal with 2 cup lowfat milk and a banana sliced up. • Coffee with sugar and cream • 12 oz orange juice

10:00 am Snack

• 8 oz low-fat yogurt • 2 large graham cracker squares

12:30 pm Lunch

• Ham or Turkey sandwich with cheese, mayo and mustard • Small package of chips (1-2 oz) • 1 piece of fruit e.g. apple, orange, etc. • 4 small cookies e.g. Oreos • 1 can regular soda pop or 12 oz low-fat milk

3:00 pm Snack

• 1 stick cheese • 8 Ritz crackers • 12 oz juice grape juice

6:30pm Dinner (varies daily, but often one of the following menus:)

• Chicken, rice, veggies, salad, glass of milk • Spaghetti with meat sauce, garlic bread, salad, milk • Burritos, refried beans, rice, chips, salsa, soda pop

9:30 pm Snack (varies, but usually one of following)

• popcorn and regular soda pop • cookies or cake and lowfat milk • 2 scoops ice cream with chocolate syrup

Section 2: Preparing for the chart note (assessment, diagnosis, intervention, monitoring) Get the assessment started To help you get the assessment started completed the following few question

1. List any risk factors QT has for gestational diabetes Family history of diabetes, Hispanic3

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2. Determine QT’s needs for energy, protein, and fluid. (Type needs in chart below.)

Indicate wt used for calculations, formula used (e.e. HBE, Penn, Kcal/Kg, etc.) write out name of formula and equation as appropriate, and any activity/stress factors.

Needs Equation Used Activity/Stress

Factors Energy (Kcals) 2408-2632 kcal EER = 354 – 6.91 x age + PA x

(9.36 x wt + 726 x ht)3

Pregnancy equation: EER + (8 x weeks gestation) + 180 3

1 - 1.12

Protein (g/d) At least 78 g/day 1.1 g/kg/day1, 2 Fluid (ml/d) 1500 – 2300

mL/day 1500 mL-2300 mL/day3 (National Academies recommendation)

Weight Used (lb) 70.9 kg Use the box below to show your calculations and justify equations and weight used. Include citations. EER = 354 – 6.91 x age + PA x (9.36 x wt + 726 x ht) Sedentary: 354 – 6.91 (27) + 1 x (9.36 (70.9) + 726 x (1.65)) = 2028 kcal Low active: 354 – 6.91 (27) + 1.12 x (9.36 (70.9) + 726 x (1.65)) = 2252 kcal Pregnancy = (2028-2252) + 200(8x25) + 180 = 2408-2632 kcal I used the pregnancy equation from Krause pg 32 to determine her needs using an activity factor of 1 – 1.12 (which is sedentary to low-active.)3 She does exercise some, but is pretty inconsistent. NCM stated that energy needs for women with GDM can be calculated using the same equations as regular pregnant woman.2

For protein, we learned in class that pregnant women in the 2nd and 3rd trimesters need to get 1.1 g/kg/day.1 In general, it is not harmful to get more protein, so the restriction does not need to be tight. As long as she is getting 78 g, her and her baby’s needs will be met. For fluid, I found the recommendation that pregnant women should drink 1500-2300 ml/day, depending on climate, etc.3 In meeting with her I would emphasize the importance of drinking enough fluids, about 6-8 glasses per day, emphasizing water as the best source of fluid.3 I used her current weight for the equations because none of them specifically said that the equations were based on her pre-pregnancy weight. Get the nutrition diagnosis started

3. Write Two Diagnosis Statements using PES format for two of QT’s problems. Be sure to use the appropriate format as indicated in the IDNT book.

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• Inappropriate intake of simple sugars (NI-5.8.3) related to excessive added sugars from food and drink as evidenced by dietary report of drinking up to 5 high carbohydrate drinks per day and other high sugar foods.

• Excessive oral food/beverage intake (NI-2.2) related to overreacting to hunger during pregnancy as evidenced by patient’s report of always being hungry and excessive weight gain during pregnancy.

Get interventions started To help you get intervention ideas flowing complete the following questions.

4. What is the recommended energy distribution for carbohydrate, protein, and fat for gestational diabetes?

Less than 45% carbohydrate, 10-35% protein, and 20-35% fat.2

5. List specific recommendations for carbohydrate intake and diabetes Based on the DRI, a minimum of 175 g carbohydrate per day is recommended and total carbohydrate intake should be less than 45% to reduce the risk of hyperglycemia.2 It is good to have fewer of the allotted carbohydrate in the morning (because of the tendency toward hyperglycemia in the morning) and to have the carbohydrates spread throughout the day.1

6. Describe any consequences with excess wt gain during pregnancy Increased risk of gestational diabetes, increased risk of a high birth weight baby, increased risk of c-section and increased risk of preeclampsia.2 The mother also had a harder time returning to her pre-pregnancy weight. The baby can also experience health problems later in life related to the excess wt gain during pregnancy such as increased risk for obesity.

7. What advice would you give to her about wt gain for the remainder of her pregnancy? I will make sure to tell her that she needs to continue gaining weight for the health of her baby. I would advise her to continue to gain weight, but at a slower rate. She needs to gain 25-35 pounds based on her BMI of 22.5. That would mean that the goal was for her to attain 160 to 170 pounds at the end of her pregnancy. According to growth charts, at 25 weeks, she is about 3 pounds above the highest recommended weight gain (with 21 pounds). If she gains just under a pound per week (about .9 pounds), she will come back into the normal range.3 I would not emphasize weight gain so much as eating healthily and maintaining her blood glucose. I think that these will help her with adequate weight gain more than if she were to concentrate on not gaining too much weight.

8. QT is concerned that she caused the diabetes by eating too many treats over the Christmas holidays. In layman terms, briefly explain to QT the actual cause of her gestational diabetes. (Hint: include the hormonal effects of pregnancy, but in layman terms.)

The changing hormone levels in your body from pregnancy change the blood glucose levels (or the amount of sugar in your blood).1 Some women’s blood sugar is more effected than others. This is dependent on your genes. So, if you have family with diabetes, you are more likely to get

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diabetes, especially in pregnancy.7 Exercise and avoiding high sugary foods can help women keep their blood sugar at the right level, but every woman is different. Some women cannot make enough insulin (a hormone that helps keep your blood sugar levels low enough). If diet and exercise doesn’t keep blood sugar levels normal, the woman needs to take extra insulin through a shot to help her body maintain a normal blood sugar level.

9. QT is very fearful of possibly having to take insulin. Can her blood sugars be controlled

with oral hypoglycemic agents? Explain There are very few options for oral hypoglycemic agents during pregnancy. Glyburide is one option, but could be dangerous to the fetus (there is not enough evidence to know for sure.) She would have to sign an informed consent if she were to take glyburide.1 QT probably can control her blood glucose levels through diet and exercise. She will need to make sure that she spreads out her glucose and doesn’t eat too many carbs during the day.

10. Create a meal pattern for QT you may use carb choices or grams of carb. List how many

carb choices OR grams of carb you would give for any meals and snacks. If not using a snack write none in the carb choice/gram column. Note only one column needs to be filled in – e.g. the carb choice column OR the carb grams column depending on your meal planning method. (You don’t need to include sample meals/menus – just the pattern.)

Total Kcal/day estimate from above: Meal/Snack # Carb Choices # Carb grams Breakfast 2 30 Snack 2 30 Lunch 4 60 Snack 2 30 Dinner 4 60 Snack 2 30 Total Carb per day in g 240 Total Carb choices per day 16

11. What items would you discuss in counseling QT about protein and fat intake? I would emphasize eating finding lean sources of protein. It seems as if she is eating some good sources of protein: low-fat yogurt, sandwich meat, chicken, etc. I would go over low fat hamburger, not adding too much cheese (or adding a low fat cheese instead of full fat cheese) nor adding to much mayo to sandwiches. I would also ask her about the type of milk that she drinks, emphasizing that skim or 1% would be good options.

12. What would be appropriate recommendations for exercise for QT? A brisk walk after meals would be appropriate and may help blood sugar levels.3

1 hour of physical activity 3 days per week with maternal heart rate between 120 and 130 beats/min would be advantageous.3

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13. Fill in a nutrition prescription and at least two interventions, goals, indicators, and criteria

for evaluation. Remember your interventions are aimed at resolving a nutrition problem/diagnosis and its etiology. Indicators are what you will use to measure change. The criteria for evaluation shows what you expect the indicator to do (i.e. go up, down, maintain, etc.)

Nutrition Prescription:

Intervention Goal/Expected Outcome

Indicator(s)

Criteria for evaluation

Decrease added sugar in her diet (ND-1.3)

Maintain blood glucose levels within the normal range for pregnancy

Blood glucose test Fasting blood glucose: 90 g/dl Blood glucose after a meal: 120 mg/dl.

Follow a diabetic exchange diet with 2 exchanges for breakfast and snacks and 4 exchanges for lunch/dinner. (ND-1.2)

Maintain blood glucose levels. Gain weight within the expected range for her BMI.

Blood glucose test Weight

Fasting blood glucose: 90 g/dl Blood glucose after a meal (2hrs): 120 mg/dl.3

Weight gain: achieving 25-35 pounds of weight gain for the entire pregnancy.3

Section 3. Type your initial chart note

1. Type your Initial Assessment chart note in the box below. You are now writing a note that contains all steps of the nutrition care process, not just the assessment step. The note should contain assessment, diagnosis, intervention, goals, and what indicators you plan to monitor. Although you identified two PES statements and two interventions in your preparation above – you may choose to only use one PES and one intervention as appropriate to case. The intervention section should contain the nutrition prescription. Use as much space as needed to complete. Consider the format – how will you make your assessment readable by others on the healthcare team? Be sure to include an assessment of QT pregnancy weight gain and comparison to weight standards. Hint look at your NDFS 405 pregnancy weight gain information in addition to other sources.

Intervention: Follow a diabetic exchange diet with 2 exchanges for breakfast and snacks and 4 exchanges for lunch/dinner. (ND-1.2)

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Goals: Maintain blood glucose levels. Gain weight within the expected range for her BMI. Criteria: Fasting blood glucose: 90 g/dl, Blood glucose after a meal (2hrs): 120 mg/dl. Weight gain: achieving 25-35 pounds of weight gain for the entire pregnancy. Assessment: recently diagnosed with GDM, BMI 22.5, wt gain during 25 weeks of pregnancy: 21 pounds (over normal weight standards by 3 pounds). Diagnosis: Inappropriate intake of simple sugars (NI-5.8.3) related to excessive added sugars in food and drink as evidenced by dietary report of drinking up to 5 high carbohydrate drinks per day.

2. What CPT (Current Procedural Terminology) Code would you use for the initial assessment? CPT Code # Description 97802 Medical nutrition therapy; initial

assessment and intervention, individual, face-to-face with the patient4

3. What ICD-9 code would you use for the initial assessment?

ICD-9 Code # Description 648.8 Diabetes mellitus complicating pregnancy

childbirth or the puerperium5

Section 4. Follow-Up Visit QT also visited the diabetes nurse educator who instructed her about blood glucose monitoring. QT was requested to keep a glucose log along with her food records. She checked her blood glucose 4x/day. When the diabetes evaluated her records three weeks later QT was told that she would need insulin therapy. Note: Your answers in this section are now occurring as a follow-up visit three weeks later.

1. What are the indicators for the initiation of insulin therapy? “If glucose goals exceed the target range (fasting: 65-95 mg/dl, 1 hr postprandial less than 140 mg/dl, 2 hr postprandial less than 120 mg/dl) on two or more occasions in a 1- to 2-week period without some obvious explanation from food records or if glucose levels are consistently elevated because of patient’s dietary indiscretions after MNT intervention.”3

2. How would you begin her insulin therapy (types of insulin, amounts given at what times of day – generally.), indicate if using basic or physiological regimen? (Hint: look in the Utah Diabetes Pregnancy Practice Recommendations)

Give 33 units of insulin before breakfast and 16.5 units of insulin before dinner (using basic).6 She should test her fasting blood glucose and test her blood glucose 2 hours after her meal.

3. How will you modify insulin as her pregnancy progresses, indicate if using basic or physiological regimen?

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If her fasting blood glucose was less than 95 g/dl and her 2 hours after blood glucose was less than 120 (on average), she would just need to come to the clinic each week of her pregnancy for follow-up, but no changes in insulin doses would be made. If either of these is not met, changes need to be made. If the fasting blood glucose is too high, the insulin given before dinner should be increased 2-4 units. If her blood glucose 2 hours after is too high, rapid acting insulin should be used (basic regimen). If the patient is consistently hypoglycemic, insulin should be reduced by 2-4 units.6

4. What are going to be the best monitors to assure a successful outcome of this pregnancy?

Blood glucose level will be the best monitor.6 Also, weight gain will be a good monitor to assure a successful outcome. (The doctor will track other measures of whether or not the baby is healthy, these will help with the nutrition side of the pregnancy.)

5. Is Q.T. at risk for developing diabetes later in life? How can she reduce this risk? Making lifestyle and dietary changes.2 She can consistently exercise (30 min 5 times per week). She can decrease her high sugar drinks (soda pop and excess fruit drinks). She can focus on eating a healthy diet containing fruits and vegetables and avoiding high fat and high sugar foods. She can also breastfeed after she gives birth.2 Breastfeeding has been shown to decrease the risk of getting diabetes later in life.

6. What areas would you focus on in your follow-up nutrition counseling session? Reemphasize the need to follow the diet prescribed, following the carb exchanges. Answer any questions that she has about insulin and how to monitor glucose levels. Reemphasize decreasing sugary drinks, particularly soda pop, and replacing them with water or low-fat milk. Also focus on reducing high sugar foods and those with added sugar. Emphasize lifelong healthy nutrition practices along with exercise.

7. What CPT (Current Procedural Terminology) Code would you use for the follow-up visit? CPT Code # Description 97803 Re-assessment and intervention, individual,

face-to-face with the patient.4

8. What ICD-9 code would you use for the follow-up visit?

ICD-9 Code # Description 648.8 Diabetes mellitus complicating pregnancy

childbirth or the puerperium5

References:

1. Williams P. Lecture notes. Advanced Dietetic Practices, Brigham Young University. Winter 2013.

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2. Nutrition Care Manual. Available at http://www.nutritioncaremanual.org/index.cfm. Accessed April 9, 2013.

3. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St Louis, MO. Elsevier Enc; 2008.

4. American Association of Diabetes Educators. Diabetes Education Services Reimbursement Tips for Primary Care Practice. June 2010. Accessed April 9, 2013. Available at http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/Diabetes_Education_Services6-10.pdf.

5. ICD-9Data.com. Accessed April 9, 2013. Available at http://www.icd9data.com/2012/Volume1/630-679/640-649/648/648.0.htm

6. Utah Department of Health. Diabetes in Pregnancy. April 2009. Available at

http://health.utah.gov/diabetes/pdf/udpr/udpr_section2_gestational_apr09.pdf.

7. Nair AV, Hocher B, Verkaart S, van Zeeland F, Pfab T, Slowinski T, Chen Y, Schlingmann KP, Schaller A, Gallati S, Bindels RJ, Konrad M, Hoenderop JG. Loss of insulin-induced activation of TRPM6 magnesium channels results in impaired glucose tolerance during pregnancy. Proc Natl Acad Sci U S A. 2012;109:11324-11329.

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Case #2: Pediatric PKU

Mary is a 6-year-old girl who was diagnosed with PKU at birth. Her parents have been doing well with her diet and Mary is usually a good eater. Mary is in first grade this year and will be eating lunch at school. Her mother is seeking advice on how to approach the school regarding Mary’s diet. Mary is currently using Phenex-2 three times a day. She is 107 cm tall and weighs 21.4 kg. (Readings on LearningSuite will be helpful for many of these questions) Section 1: Preparing for the chart note (Assessment, diagnosis, intervention, monitoring)

1. Using a growth chart, assess Mary’s height, weight, and BMI for her age.

Assessment Height 107 cm 5th percentile for height Weight 21.4 kg 50-75 percentile for weight BMI 18.7 95th percentile for BMI

2. What are her protein needs? Show calculations. Cite source. 1.1 g/kg/day1 (Tables found on learning suite) 1.1 x 21.4 = 23.5 g/day for a normal 6 year old

23.5 x (125-130%)1 = 29.4 – 30.6 g/day

3. What are her phenylalanine needs? Show calculations. Cite source

4. What are her energy needs? Show calculations. Cite source

5. What are her fluid needs? Show calculations. Cite source

Get the nutrition diagnosis started In previous cases you documented all possible problems in particular diagnosis domains. To enhance your clinical skills you need to think through that process, but only document PES

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statements.

6. Write Two Diagnosis Statements using PES format for two of QT’s problems. Be sure to use the appropriate format as indicated in the IDNT book.

Get interventions started To help you get intervention ideas flowing complete the following questions about Mary’s formula prescription.

7. How much of daily protein should come from formula (i.e. % of pro)

8. How much formula do you recommend to be given each day? List the amount of protein

and Kcals provided by this amount of Phenex-2.

9. How often during the day would you recommend Mary drink the formula?

10. What other formulas would be appropriate choices for Mary?

11. What types of information would you provide to Mary’s mother regarding Mary’s diet and school?

12. Fill in a nutrition prescription and at least two interventions, goals, indicators, and criteria for evaluation. Remember your interventions are aimed at resolving a nutrition problem/diagnosis and its etiology. Indicators are what you will use to measure change. The criteria for evaluation shows what you expect the indicator to do (i.e. go up, down, maintain, etc.)

Nutrition Prescription:

Intervention Goal/Expected Outcome

Indicator(s)

Criteria for evaluation

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Section 2. Type your initial chart note

1. Type your Initial Assessment chart note in the box below. You are now writing a note that contains all steps of the nutrition care process, not just the assessment step. The note should contain assessment, diagnosis, intervention, goals, and what indicators you plan to monitor. Although you identified two PES statements and two interventions in your preparation above – you may choose to only use one PES and one intervention as appropriate to case. The intervention section should contain the nutrition prescription. Use as much space as needed to complete. Consider the format – how will you make your assessment readable by others on the healthcare team?

2. What CPT (Current Procedural Terminology) Code would you use for the initial

assessment? CPT Code # Description

3. What ICD-9 code would you use for the initial assessment? ICD-9 Code # Description

Section 3. Make a meal plan

1. Using the table below plan a one day menu for Mary that meets the nutritional needs as calculated. Include the formula, and all foods eaten during the day. (Use the green and white PKU exchange list in the computer room). You can add/delete rows as needed.

List estimated kcal, pro, and phe needs in box below. (This should be what you calculated above)

One Day Menu

Serving mg Phe and

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Time Food Size

Phe Exchange gm Prot Kcal

TOTAL

References:

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Case #3: High Risk Infant

Day 1 A 26 week gestation female infant is admitted to the NICU. Her birth weight (day1) is 850 gm, which is appropriate for gestational age. After an initial bout of respiratory distress, and treatment with surfactant, she is stabilized and placed in an incubator. A 10% Dextrose solution is started as an IV. After 12 hours, small amounts of TPN are begun through an umbilical catheter. Day 2 , she has gained 30 g. and the serum sodium and urine volume are low. She is diagnosed with a hemodynamically significant patent ductus arteriosus. Medication (Indomethacin) is given to close the PDA. Section 1: Preparing for the chart note (Assessment, diagnosis, intervention, monitoring) Get the assessment started To help you get the assessment started completed the following few question

1. What caused the initial weight gain for this infant currently? The weight gained must be water weight.2 The infant has not been given adequate nutrition to gain weight (she has only gotten a small amount of dextrose with the IV and small amounts of TPN half way through the day). We are trying to stabilize her first, and then help her to grow.

2. What is the expected growth velocity for this infant? 15-20 g/kg/d1 = 12.75 – 17 g/day

3. Calculate the parenteral nutritional needs of this infant based on 850 g body weight. (Note: assume needs for growth, not maintenance.)

Amount Justification Energy 90-100 kcal/kg/d =

76.5 – 85 kcal This is the recommendation from Krause, as cited in class.1

Protein 2-4 g/kg/d = 1.7 – 3.4 g PRO

2-3 g/kg/d was indicated for initial rate while the max rate is 4 g/kg/day.1

Fluid 50-120 mL/kg/d = 42.5 - 102 mL

For an infant weighing less than 1 gram, they should be getting anywhere from 50-120 mL/kd/d.1

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Get the nutrition diagnosis started In previous cases you documented all possible problems in particular diagnosis domains. To enhance your clinical skills you need to think through that process, but only document PES statements.

1. Write Two Diagnosis Statements using PES format for two of baby’s problems. Be sure to use the appropriate format as indicated in the IDNT book.

Predicted suboptimal energy intake (NI-1.6)* related to minimal nutrition support as evidenced by chart notes indicating small amounts of TPN. Breastfeeding difficulty (NC-1.3) related to prematurity as evidenced by extremely low birth weight and inability to adequately suck.** *I didn’t find this in IDNT 2nd ed, but in the PNCM. I assume that it is added to later editions, and fits much better than inadequate energy intake because I have no measure for that. **Though the diagnosis didn’t state that, I assume that it is true, and if in a hospital, I would have walked in and checked.

Get the intervention started To help you get the assessment started completed the following few question

1. Why is the dextrose given initially? To maintain blood glucose levels.1 When infants are so premature, they have very little control on their glucose levels because they don’t have a lot of glycogen stores. A consistent stream of glucose is often used to maintain blood glucose levels.

2. List access types and typical dextrose concentrations for parenteral nutrition in premature infant. Peripheral IV line, PIC, Umbilical catheter As stated in class, usually 2-3% Dextrose is used.1

3. What types of vitamin/mineral supplementation should be considered for this infant?

Tri-Vi-Sol, Poly-Vi-Sol1

Probably get 2 mL/kg/day or 1.7 mL class notes (baby is less than 2.5 kg)1

4. Fill in a nutrition prescription and at least two interventions, goals, indicators, and criteria

for evaluation. Because you were not asked to calculate a parenteral order in this case, the nutrition prescription can be more general i.e. parenteral nutrition to meet needs of XX kcal, etc. Remember your interventions are aimed at resolving a nutrition problem/diagnosis and its etiology. Indicators are what you will use to measure change.

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The criteria for evaluation shows what you expect the indicator to do (i.e. go up, down, maintain, etc.)

Nutrition Prescription:

PTN to meet needs for growth: 76.5 – 85 kcal, 1.7 – 3.4 g PRO, and 42.5 - 102 mL fluid.

Intervention Goal/Expected Outcome

Indicator(s)

Criteria for evaluation

Modify the rate of TPN (ND-1.2) to meet needs for growth: 76.5 – 85 kcal, 1.7 – 3.4 g PRO, and 42.5 - 102 mL fluid

Infant achieves a growth appropriate for her age.

Weight Length Head circumference

Weight gain: regain birth weight by the 2nd of 3rd week of life3

Length increase and head circumference increase at an appropriate rate in accordance to expected standards of growth. (Krause 1133-4)3

Team meeting (RC-1.1) to discuss initiation of enteral feedings.

Infant achieves full feedings through the GI tract.

Nurse’s chart indicating feedings.

1. Initiation of enteral feedings through NG tube. 2. Enteral feedings reach the rate at which PTN is discontinued. 3. Successful feedings by bottle and/or breastfeeding.

Section 2. Type your initial chart note

1. Type your Initial Assessment chart note in the box below. You are now writing a note that contains all steps of the nutrition care process, not just the assessment step. The note should contain assessment, diagnosis, intervention, goals, and what indicators you plan to monitor. Although you identified two PES statements and two interventions in your preparation above – you may choose to only use one PES and one intervention as appropriate to case. The intervention section should contain the nutrition prescription. Use as much space as needed to complete. Consider the format – how will you make your assessment readable by others on the healthcare team? You are completing and writing the initial assessment note on Day#2

Intervention: Increase the rate of TPN gradually to obtain the needed nutrition for growth: 76.5 – 85 kcal, 1.7 – 3.4 g PRO, and 42.5 - 102 mL fluid. Goals: Infant achieves a growth appropriate for her age. Indicators: weight, length, and head circumference. (see charts on Krause pg 1133-4) Assessment: Infant has gained 30 g, while on 10% dextrose solution, and having minimal urine

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output. Small amount of TPN have been initiated. Diagnosis: Predicted suboptimal energy intake (NI-1.6) related to minimal nutrition support as evidenced by chart notes indicating small amounts of TPN.

2. What CPT (Current Procedural Terminology) Code would you use for the initial assessment? CPT Code # Description 99468 Initial inpatient neonatal critical care, per

day, for the evaluation and management of a critically ill neonate, 28 days of age or less4

3. What ICD-9 code would you use for the initial assessment? Even though there may be

more than one ICD-9 code that could be used, just choose one. ICD-9 Code # Description 747.0 patent ductus ateriosis5

Section 3. Follow-up Monitoring and Reassessment You attend team meetings and review the baby’s chart every day. Below are findings from your monitoring. Day 4, the body weight has decreased 50 g. or 6% of the birth weight and serum electrolytes are normal. TPN is increased and full feeding goals are achieved.

1. Why did the weight decrease by day 4? It seems as if the baby’s kidneys started to function. Hopefully, the baby is not retaining water so much anymore. The water that the baby previously retained as well as the water from the extracellular tissues (common, especially in premature infants) has now been excreted.3 Also, the baby has not been receiving full nutrition for the first 4 days of her life and had to draw upon body stores. Now that she is receiving her full feeding goals, we expect her to start regaining this weight and starting to grow.3

Day 6 Feedings of milk from the infant’s own mother are begun at 0.7 ml. every 2 hours by bolus oral gastric tube. Feedings are well tolerated. Enteral feedings are advanced by 10 ml/kg/day, and parenteral fluids are decreased concurrently. Day 6 wt 850 g

2. Calculate what the initial enteral feedings provided Total Calories 5.6 cal 6.62 Kcal/Kg Protein .1176 .138 g/Kg Wt used .85 kg

Show calculations below

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Calories = (.67 cal/mL)x(.7 mL)x(12 times/day) = 5.628 cal 5.628 cal/.85 kg = 6.62 kcal/kg Protein = (1.4 g)/(100 mL)x(.7 ml)x(12 times/day) = .1176 g .1176/.85 kg = .138

3. What was the purpose of the initial feeds? The purpose of the initial small feedings is “to stimulate gastrointestinal enzymatic development and activity, promote bile flow, increase villous growth in the small intestine, and promote mature gastrointestinal motility.”3 The purpose is not to provide full nutrition, but to assess tolerance to feedings so that we can gradually advance feedings from parenteral to enteral. 4. Is breast milk the best choice of enteral feedings for this infant? Explain

Yes, it is almost always the best choice for feeding an infant (unless a metabolic inability to digest breast milk is detected.) During the first month of lactation, the composition of milk from mothers with preterm babies and those with term babies are different. Preterm moms have higher sodium and protein concentrations in their milk. Breast milk also has nutrients that are more bioavailable: zinc and iron. It also has a unique mix of amino acids and long-chain fatty acids. Also, there are factors in breast milk that are not in formula: live cells, macrophages, antimicrobial factors, secretory immunoglobulin A, hormones, enzymes, and growth factors. Breast milk from the infant’s mother has been shown to help infants grow the most rapidly and reduces the incidence of complications, such as sepsis or necrotizing enterocolitis.3

5. Are there any nutrients that breast milk may be inadequate in?

Yes. Breast milk does not seem to have adequate calcium and phosphorus for the infants’ needs. Normal bone mineralization does not occur when a premature baby is fed only breast milk.3

6. What would you use for nutritional supplementation for the breast milk? Human Milk Fortifier1 (several types are available: from Similac or Enfamil.3)

7. On Day 6 you reassess the baby and in your chart note make a recommendation for a new nutrition prescription. Make a recommendation for enteral nutrition for this infant using breast milk and human milk fortifier? (Based on 850 g body weight)

Note: Mix Enteral Feed as Breast milk + human milk fortifier (1 pkt to 25 ml BM)

Rate of Feed 100 ml/day 4.17 ml/hr or

8.33 mL bolus every 2 hrs

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Kcals provided BM 67 Kcals/day Protein provided BM 1.4 g/d Kcal provided HMF 14 kcal/d Protein provided HMF 1 g Total Kcals 81 Kcals/day 95 kcal/kg Total Protein 2.4 g/d 2.82 g/kg/d Goal Kcals from above 76.5 – 85 kcal Kcals 90-100 Kcal/kg Goal Pro from above 1.7 – 3.4 g PRO g/d 2-3 g/kg/d

Show calculations below 76.5 – 85 kcal, 1.7 – 3.4 g PRO, 42.5 - 102 mL fluid 100 mL / 24 = 4.17 Kcal = 100 x .67 = 67 kcal PRO = 1.4 g/ 100 ml = 1.4 g HMF cal = 3.5 x 4 (b/c we will use 4 pkt per day) = 14 kcal HMF Pro: .25 g x 4 = 1 g/day

8. What complications might you watch for with enteral feeding of the premature infant? Aspiration Excessive feeding Sepsis Blood in the stool Necrotizing enterocolitis3

9. What type of things would you monitor for these complications?

Vomiting of feedings to assess tolerance of feeding volumes Abdominal distention Gastric residuals (check amount and presence of bloody or bilious gastric residuals) Frequency and consistency of stool Presence of blood in the stool3

10. In section 1 you indicated the initially expected growth velocity. What do you expect

growth rates to be long term? i.e. how will growth rates change as the baby gains weight? I would expect to see a baby’s growth follow his/her gestational age. So, using the CDC charts, we can plot the baby’s growth with the age calculated from gestational age (i.e. a 32 week premature baby would continue to be plotted 8 weeks behind his/her actual age).3 Once the baby reaches 2 years old, we can use a regular growth chart for children without adjusting for prematurity.1

11. What are potential medical problems this infant may experience due to her prematurity? Cerebral palsy, hydrocephalus, cognitive impairments, autism, blindness, and/or deafness.3

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12. In your chart note for Day 6 you update your nutrition interventions and goals. Fill in at least one new intervention, goal, indicator, and criteria for evaluation.

Intervention Goal/Expected Outcome

Indicator(s)

Criteria for evaluation

Advance (10 mL/day) enteral nutrition with breast milk + HMF (1 pkt for 25 mL) to 8.33 mL q 2 hrs, providing 95 kcal and 2.4 g of protein.

Infant achieves a growth appropriate for her age and tolerates GI feedings well.

Weight Length Head circumference Gastric residuals Abdominal distention

Weight gain: 12.75 – 17 g/day1 Length increase and head circumference increase at an appropriate rate in accordance to expected standards of growth.3

Gastric residuals less than 50%.3

No abdominal distention.

13. What CPT (Current Procedural Terminology) Code would you use for the follow-up

assessment? CPT Code # Description 99469 Subsequent inpatient neonatal critical care,

per day, for the evaluation and management of a critically ill neonate, 28 days of age or less

14. What ICD-9 code would you use for the follow-up assessment?

ICD-9 Code # Description 765.23 25-26 completed weeks of gestation

You continue to follow the baby daily and on Day 12 note the following. Day 12 Wt 940 g (average 15 g/day gain) full enteral feedings are established, and parenteral nutrition is discontinued. – Good Job – your MNT is working! References:

1. Williams P. Lecture notes. Advanced Dietetic Practices, Brigham Young University. Winter 2013.

2. Pediatric Nutrition Care Manual. Available at http://www.nutritioncaremanual.org/index.cfm. Accessed April 9, 2013.

3. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St Louis, MO. Elsevier Enc; 2008.

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4. CPT Pediatric Coding Updates 2009. Accessed April 9, 2013. Available at http://www.tnaap.org/Files/Coding/CPT_CodingUpdates-2009.pdf.

5. ICD-9Data.com. Accessed April 9, 2013. Available at http://www.icd9data.com/2012/Volume1/630-679/640-649/648/648.0.htm