Date: February 12, 2022

C a s e S t u d y P r e s e n t a t i o n

MNT for Acute

MNT for Acute
Pancreatitis
Pancreatitis Group Members
ACACIO, Marianne
GRANADA, Mark Daniel
ALCARAZ, Dominic
LISING, Karl Ludwig
CALUBAQUIB, Francheska Mai
PUNO, Alyssa Mel
CRUZ, GerImaia
PUYAT, Evan Vladimir
EMATA, Aimee Rose
C O N T E N T S
Understanding the Disease and
01
Pathophysiology

Understanding the Nutrition

02
Therapy

03 Nutrition Assessment

04 Nutrition Diagnosis

05 Nutrition Intervention

Nutrition Monitoring and

06
Evaluation
01
Understanding
the Disease and
Pathophysiology
Question No. 1
Describe the normal exocrine and endocrine functions of the
pancreas.
ANSWER:
Exocrine glands in the pancreas produce enzymes essential for digestion.
To process proteins, these chemicals incorporate trypsin and chymotrypsin;
amylase for carb assimilation; and lipase to separate fats These pancreatic
juices are released into a series of ducts when food reaches the stomach,
resulting in the main pancreatic duct. The pancreatic duct joins the typical bile
duct to form Vater's ampulla, which is situated in the duodenum, the first
portion of the small intestine. In the liver and the gallbladder, the normal bile
duct begins and delivers another huge stomach related juice called bile. The
pancreatic juices and bile delivered into the duodenum help the body to
process fats, proteins, and carbs.
04
Question No. 1
Describe the normal exocrine and endocrine functions of the
pancreas.
ANSWER:
Pancreas' endocrine piece comprises of islet cells (Langerhans islets) that
straightforwardly produce and deliver fundamental chemicals into the
circulatory system. Insulin, which acts to bring down glucose, and glucagon,
which acts to build glucose, are two of the major pancreatic chemicals. It is
fundamental for the working of key organs, including the mind, liver, and
kidneys, to keep up with legitimate glucose levels.

05
Question No. 2
Determine the potential etiology of both acute and chronic pancreatitis. What
information provided in the physical assessment supports the diagnosis of acute
pancreatitis?
ANSWER:
Acute pancreatitis is a short-term inflammation of the pancreas. It might be
anything from a minor ailment to a serious, life-threatening condition.
Gallstones is one of the common cause of pancreatitis, produced in the
gallbladder, enzymes from the pancreas are forced back into the pancreas
by preventing them from going to the small intestine. Alcohol-induced
pancreatitis is most likely caused by acinar cells prematurely activating
digestive and lysosomal enzymes, as well as increased, viscous secretions
that obstruct tiny pancreatic channels and hypertriglyceridemia when
triglycerides exceed 10 mmol/l (900 mg/dl), they are present in the
bloodstream. Pancreatic capillaries are occluded, resulting in ischemia, as
well as the release of pancreatic lipase and acinar structural changes. 06
Question No. 2
Determine the potential etiology of both acute and chronic pancreatitis. What
information provided in the physical assessment supports the diagnosis of acute
pancreatitis?
ANSWER:
Chronic pancreatitis is an inflammation of the pancreas that does not heal or
improve with time, but instead worsens and causes irreversible damage to the
pancreas. A patient's capacity to digest food and produce pancreatic
hormones is eventually compromised by chronic pancreatitis. The most
common cause of chronic pancreatitis is drinking a lot of alcohol over a long
period of time, other causes include: An attack of acute pancreatitis that
damages your pancreatic ducts, a blockage of the main pancreatic duct
caused by cancer. Cystic fibrosis which the body makes very thick, sticky
mucus. The mucus causes problems in the lungs, pancreas, and other organs,
and people with with hereditary pancreatitis develop chronic pancreatitis, a
constantly inflamed pancreas. in which the pancreas is persistently inflamed,
occurs in those who have inherited pancreatitis. Type 1 diabetes and
pancreatic cancer are more likely in adults with genetic pancreatitis.
07
Question No. 2
Determine the potential etiology of both acute and chronic pancreatitis. What
information provided in the physical assessment supports the diagnosis of acute
pancreatitis?
ANSWER:
The physical assessment that supports the diagnosis of acute pancreatitis
include Transabdominal Ultrasound because gallstones are the most prevalent
cause of acute pancreatitis, this procedure is frequently performed during
hospitalization to check the gallbladder for stones. During acute pancreatitis,
endoscopic ultrasound test isn't always necessary. It is more intrusive than
transabdominal ultrasonography since it involves a doctor inserting a thin,
flexible tube into the stomach. The clinician can view pictures of the gallbladder,
pancreas, and liver by attaching a camera and ultrasound probe at the end of
the tube. Magnetic resonance imaging (MRI), a non-invasive process that
creates cross-sectional pictures of the body's components, is used in the MRCP
procedure. The patient rests in a cylinder-like tube after being mildly sedated. A
CT creates three-dimensional pictures of the body's structures. When a patient is
not recuperating as rapidly as predicted after a bout of acute pancreatitis, it
may be conducted when a diagnosis is questionable or many days after
hospitalization to assess the amount of pancreatic damage. 08
Question No. 2
Determine the potential etiology of both acute and chronic pancreatitis. What
information provided in the physical assessment supports the diagnosis of acute
pancreatitis?
ANSWER:
The physical assessment that supports the diagnosis of acute pancreatitis
include Transabdominal Ultrasound because gallstones are the most prevalent
cause of acute pancreatitis, this procedure is frequently performed during
hospitalization to check the gallbladder for stones. During acute pancreatitis,
endoscopic ultrasound test isn't always necessary. It is more intrusive than
transabdominal ultrasonography since it involves a doctor inserting a thin,
flexible tube into the stomach. The clinician can view pictures of the gallbladder,
pancreas, and liver by attaching a camera and ultrasound probe at the end of
the tube. Magnetic resonance imaging (MRI), a non-invasive process that
creates cross-sectional pictures of the body's components, is used in the MRCP
procedure. The patient rests in a cylinder-like tube after being mildly sedated. A
CT creates three-dimensional pictures of the body's structures. When a patient is
not recuperating as rapidly as predicted after a bout of acute pancreatitis, it
may be conducted when a diagnosis is questionable or many days after
hospitalization to assess the amount of pancreatic damage. 09
Question No. 3
What laboratory values or other tests support this diagnosis? List all
abnormal values and explain the likely cause for each abnormal value.
ANSWER:

High levels of BUN & Creatinine and Proteinuria indicates the patient is
dehydrated and It is also possible that there is acute kidney injury (AKI).
Hyperglycemia is also evident on the laboratory result. The patient is in
flow phase of metabolic response to stress wherein the glucose
production is upregulated via Gluconeogenesis, Glycogenolysis, &
Proteolysis.
Ketonuria is caused by inadequate carbohydrate intake and excessive
fat intake as evidenced by the patient’s food history of eating very little
for the past 3 days & drinking too much alcohol. It is also caused by
Gluconeogenesis.
Elevated levels of High levels of ALT, AST, Alkaline Phosphatase, Elevated
levels of Bilirubin, & Urobilinogen, indicate liver damage.
10
Question No. 3
What laboratory values or other tests support this diagnosis? List all
abnormal values and explain the likely cause for each abnormal value.
ANSWER:

Hypoalbuminemia and High C-Reactive protein indicates an ongoing

inflammation in the body.
Elevated Cholesterol, High LDL, and Hypertriglyceridemia increase the
risk of acquiring Coronary Artery Disease or Atherosclerosis which
can lead to myocardial infarction and stroke.
Leukocytosis, Neutrophilia, High levels of Segmented Neutrophils, &
Bandemia indicate the presence of inflammation and possible
infection in the body.

11
Question No. 4
The physician lists an APACHE score in his note. What factors are used to determine this score? What does this mean? Ranson’s Criteria and the Atlanta Criteria are also
used to determine the severity of pancreatitis. Define each of these sets of criteria.

ANSWER:
APACHE stands for Acute Physiology and Chronic
Health Evaluation
The APACHE II Score is computed using the 3 basic
components: Age Points, Chronic Health Points, &
Acute Physiologic Score. The Age point is only
concerned with the age of the patient with respective
score of 0-6. The Chronic health Points is concerned
with the patient’s history of past illness or surgeries.
While the Acute Physiologic Score contains 12
Physiologic Variables like Temperature, Heart
Rate/HR, Mean Arterial blood Pressure/MAP,
Respiratory Rate/RR, Oxygenation (A-a Gradient or
Partial Pressure of Oxygen PaO2), Serum Sodium,
Potassium, Creatinine, Arterial pH, WBC, Hematocrit,
and Glasgow Coma Scale /GCS.

Photo Reference: http://www.scymed.com/en/smnxpw/pwfbd770.htm

12
Question No. 4
The physician lists an APACHE score in his note. What factors are used to determine
this score? What does this mean? Ranson’s Criteria and the Atlanta Criteria are also
used to determine the severity of pancreatitis. Define each of these sets of criteria.
ANSWER:
Ranson’s Criteria Atlanta Criteria
a tool for significant prognostic value for predicting The revised Atlanta classification requires at least 2
the severity and mortality of acute pancreatitis of the following criteria be met for the diagnosis of
11 parameters are examined: acute pancreatitis:

At Admission (a) abdominal pain suggestive of pancreatitis

a. Age (>55 yr) (b) serum amylase or lipase level greater than three
b. WBC count (16,000 m3) times the upper normal value
c. Blood Glucose (>200mg/100mL) (c) characteristic imaging findings
d. Serum Aspartate Transaminase (AST) (>250 unit/L)
e. Serum Lactate Dehydrogenase (LDH) (>350 units/L) The Revised Atlanta Classification identifies 4
severity of Acute Pancreatitis:
During the first 48 hours
f. Serum Calcium level (<8mm/mL) a. Non-Severe AP
g. Hematocrit (decrease of >10%) b. Severe AP
h. Arterial oxygen (<60mm Hg) c. Interstitial Edematous Pancreatitis (IEP)
i. Blood Urea Nitrogen (>5mg/dL) d. Necrotizing Pancreatitis
j. Base Deficit (>4 mEq/L)
k. Sequestration of fluids (>6000 mL)
13
Question No. 5

What are the potential complications of acute

pancreatitis?
ANSWER:
Acute pancreatitis is a condition wherein the pancreas gets inflamed due to an
early activation of digestive enzymes inside the pancreas which if not treated
early, serious complications may arise such as:
Infections – Patients with acute pancreatitis are susceptible to infections
because their pancreas gets weak due to the strong digestive enzymes that
damage the tissues of the pancreas.

Pseudocysts – These forms due to the collection of leaked pancreatic enzymes

that can cause serious complications such as internal bleeding when it
ruptures.

Diabetes – Aside from releasing digestive enzymes in digestion, the pancreas

also releases Insulin and glucagon that helps in controlling the blood sugar.
Thus, when a patient suffers from an acute pancreatitis the amount of insulin
and glucagon formed in the body will be affected resulting in diabetes. 14
Question No. 5

What are the potential complications of acute

pancreatitis?
ANSWER:
Acute respiratory distress syndrome – Patients with acute pancreatitis project
an inflammation. As a body’s response to inflammation, inflammatory
chemicals will be released into the bloodstream that triggers different parts of
the body to become inflamed including the lungs. Air sacs inside the lungs
called alveoli, get inflamed and filled with water causing breathing difficulties.

Renal failure – Low levels of oxygen affects the renal circulation and function of
kidneys.

Malnutrition – It can be due to the problem with the production of pancreatic

enzymes that are required for the digestion and absorption of food in the body.

Pancreatic cancer – A patient who is suffering from a chronic inflammation of

the pancreas for a long time would potentially be at risk for cancer.
15
02
Understanding
the Nutrition
Therapy
Question No. 6

Historically, the patient with acute pancreatitis was

made NPO. Why?
ANSWER:
Based on our previous discussion, NPO stands for Nil per Os or Nothing by Mouth.
There are various medical conditions that tend to impede this usual route of
feeding. In Mr. JM’s current situation, the admission order of his diet was NPO since
as mentioned earlier, he was diagnosed of having acute pancreatitis.

Here are as follows the rationale why the medical practitioners carefully and
critically came up with this medical management:

As the stomach and small intestine are both guided by the accessory organs of
gastrointestinal tract: pancreas, liver, and gallbladder, hence, when the food
ingested will be down now on the stomach, it will automatically stimulate the
production of digestive enzymes from the pancreas.

17
Question No. 6

Historically, the patient with acute pancreatitis was

made NPO. Why?
ANSWER:
According to the patient’s admission history and physical examination, he
experienced intensive abdominal tenderness, nausea, and vomiting
several days ago. His abdomen also exposed hypoactive bowel sounds
which may be caused by obstructions. Therefore, nutrition support either
an enteral or parenteral feeding should be initiated in order to supply the
needed nutrients without the extreme production of pancreas’ digestive
enzyme.

Whereas, the medical professionals, esp. The physician and nutritionist-

dietitian will only allow the oral feeding if and only if the symptoms such as
N/V, abdominal pain, and the inflammation of the pancreas as a whole will
gradually falter.

18
Question No. 7
The physician has written an order for a nutrition consult. Using the most current
literature and ASPEN guidelines, explain the role of enteral feeding in acute
pancreatitis. Do you agree with the initiation of enteral feeding? Why or why not?
ANSWER:
According to recent meta-analyses and ASPEN guidelines, enteral nutrition has
the ability to reduce mortality and morbidity risk of patients with acute
pancreatitis compared to parenteral feeding. It is said to show larger therapeutic
benefit in lowering the risk of pancreatic infections and multi-organ failure.

Yes. We would agree with the initiation of enteral feeding to the patient during the
first 24-48 hours of his hospitalization because based on our research, in doing
so, it may help to prevent the breakdown of the mucosal barrier and subsequent
bacterial translocation. It also has the potential to improve the patient’s digestive
motility and reduce bacterial overgrowth.

The placement of the end of the tube is recommended to be placed in the

jejunum called as, nasojejunal tube feeding which is noted to minimize patient’s
pain due to pancreatic stimulation.
19
Question No. 8

If you have recommended enteral feeding, does this patient’s

case indicate the use of an immune-modulating formula?
ANSWER:
Immune-modulating formula, these are a kind of supplement that helps to
activate, enhance, or restore the normal immune function of a weakened
immune system by a disease or surgery. These formulas include arginine,
glutamine, nucleic acids, and omega-3 fatty acids which are crucial and
is given to patients who have low immune response to a certain illness.

The laboratory results of the patient specifically, his WBC and neutrophil
values showed an elevated count from the normal values which means
that their immune system is reacting to the disease and does not in need
for any immune-modulating formulas.

Based on research, these formulas should only be used in patients who

are leukopenia (low WBC count) or those with slow immune response.
21
03Nutrition
Assessment
Question No. 9

Assess Mr. JM’s height and weight. Calculate his BMI and
% usual body weight.
ANSWER:

Height: 5’11 (71 inches)

5 x 12 = 60 + 11 (inches) = 71 inches
71 x 0.0254 = 1.8034
Weight: 245 lbs
Lbs to Kg = 245 ÷ 2.2 = 111 kg

245 (current weight) - 50 (gain weight) = 195 lbs (UBW)

%UBW: current body weight ÷ usual body weight x 100

UBW% = 245 ÷ 195 x 100 = 125.6%

23
Question No. 9

Assess Mr. JM’s height and weight. Calculate his BMI and
% usual body weight.
ANSWER:

BODY MASS INDEX

Weight (kg)
BMI =
Height (m ) 2

111 kg
BMI = 2
(1.8024)

34.13 = Obese Type 2 (WHO Asia-Pacific)

24
Question No. 10
The physician lists an APACHE score in his note. What factors are used to determine
this score? What does this mean? Ranson’s Criteria and the Atlanta Criteria are also
used to determine the severity of pancreatitis. Define each of these sets of criteria.
ANSWER:
On Mr. JM’s initial nursing assessment: the abdominal appearance
exposed that he’s in a obese condition since he gained almost 50 lbs over
the last 5 years; for the abdomen’s palpation, a tense surface has been
seen; bowel function indicates continent which is a good indicator that the
patient can be able to control his bowels. However, on his bowel sounds,
regardless on its quadrant, it stated a P, hypo which connotes present yet
hypo (low sounds). Hence, as a recommendation, foods that can
exacerbate the gas production such as beans, lentils, corn, pasta,
potatoes, and other starchy foods must be avoided.

25
Question No. 10
The physician lists an APACHE score in his note. What factors are used to determine
this score? What does this mean? Ranson’s Criteria and the Atlanta Criteria are also
used to determine the severity of pancreatitis. Define each of these sets of criteria.
ANSWER:
For the patient’s nutrition assessment, his excessive intake of alcohol, constant
vomiting and nausea along with his weight gain over the last 5 years will impact
the nutritional management, in general. The vomiting and nausea will affect our
recommendations because it’s important to keep in mind that it is hard for Mr. JM
to eat and keep the food down. To achieve and establish a proper weight goal, we
will recommend to decrease his caloric intake while also intervening his current
condition. His food history exposed that he become fond of fatty foods with a
combination of alcohol intake. Whereas, we will also recommend that he will start
with the basics of eating three meals with two snacks per day, and concentrate on
having whole grains, fruits and vegetables like cucumber, lettuce or spinach.
Gradual omission of alcoholic beverage, whether beer, bourbon, wine, and other
mixed drinks should be observed and monitored. This will help to ease the
episodes of symptoms and will also reduce his hospitalization.
26
Question No. 11
Determine Mr. JM’s energy and protein requirements. Explain the
rationale for the method you used to calculate these requirements.
ANSWER:

TER = DBW x PAL

DBW using Tannhauser Method
72 x 35 kcal/kg (light physical activity)
5’11 = (5 feet x 12 inches) + 11 inches TER = 2520 ~ 2500 kcal/day
= 71 inches x 2.54 cm/inch
= 180.34 cm
Protein Requirements: Acute Pancreatitis
= (180.34 cm - 100)
(1.2 - 1.5g/kg/day)
= 80. 34
= 80.34 - (10% of 80.34)
Lower range: 72 x 1.2 g/kg = 86.4 g
= 80.34 - 8.034
Upper range: 72 x 1.5 = 108 g
DBW = 72.306 or 72 kg

Protein requirements = 108 g ~ 110 g

27
Question No. 12
Determine Mr. JM’s fluid requirements. Compare this with the
information on the intake/output record.
ANSWER:

35 mL/Kg x 111 Kg = 3,890 ml (using his energy requirement)

Mr. MJ’s fluid intake is 4,500 ml/kg, which is lower than his output of
4,879ml/kg, which means his renal function is working which means
his fluid requirements should be increased to (30-35 ml/kg) to prevent
dehydration

28
Question No. 13
From the nutrition history, assess Mr. JM’s alcohol intake. What is his average
caloric intake from alcohol each day using the information that he provided to you?
ANSWER:
156 Kcals per beer x 6 pack of beer = 924 Kcal/day from beer

100 kcals/serving x 4-5 shots = 400-500 Kcals/day from Bourbon

Approximately 1,350 Kcal from his daily intake, and on the weekends,
his caloric intake from calories will be greater than this calculated
amount because it includes wine and mixed drinks.

29
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Imipenem (1000 mg every 6 hrs)

DRUG'S ACTION: This is a drug with an ability to lowers the microbial activity, esp. the
gram-negative and gram-positive aerobic and anaerobic bacteria,
and even multi-resistant strains, which can be found in respiratory,
skin, bone, gynecologic, urinary tract, and intra-abdominal.
Imipenem overcome the infectious characteristic of bacteria by
inhibiting its own cell synthesis by binding PBPs.
DRUG-NUTRIENT When taken with the Lorazepam, its therapeutic effect on the
INTERACTIONS: individual will be reduced. On the other hand, the amount of
nutrients such as folic acid, potassium, Vitamin B2, Vitamin B6,
Vitamin B12, Vitamin C, and Vitamin K may become depleted as a
result of Imipenem consumption.
30
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Famotidine (20 mg IVP every 12 hrs)

DRUG'S ACTION: Famotidine is the medication used to prevent such ulcers that might
be happened in the stomach and intestine. As it is categorized in the
Histamine-2 Blocker (H2), it inhibits the gastric acid production.
Hence, it help on the management of most gastrointestinal such as
ulcer, gastritis, Zollinger-Ellison Syndrome, GERD, and muscle
spasms.
DRUG-NUTRIENT When taking Famotidine tablet, liver injury may occur. As Famotidine
INTERACTIONS: decreases the acid production, some medication (such as
Acetaminophen) that requires stomach acid to be fully absorbed
might as well be inhibited. Foods with caffeine and alcohol increase
the instances of a gastric irritation.
31
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Meperidine (50–150 mg IV every 3 hrs prn)

DRUG'S ACTION: An opioid agonist which is administered through an intramuscular
injection with the purpose of providing relief to a moderate to
severe level of pain. Like a morphine, it communicates with the
brain to alter the body’s natural action and reaction. According to
some studies, it is the usual second option for the management of
acute pain.
DRUG-NUTRIENT Some medications that are also given to the patient have a
INTERACTIONS: contraindications when inducted in combinations: Docusate
Sodium, Magnesium Hydroxide, Lorazepam, and Ondansetron. It
can cause constipation, hence, increase the consumption of
dietary fiber, together with the water. It shouldn’t be taken with
alcohol.
32
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Ondansetron (2–4 mg IV every 4–6 hrs prn)

DRUG'S ACTION: It become a medication that should be given when needed since it
helps to decrease the instances of nausea and vomiting.
Ondansetron's antiemetic activity is most likely due to the selective
antagonism of 5-HT3 receptors on neurons in either the peripheral
or central nervous systems, or both, depending on where they are
situated.
DRUG-NUTRIENT It can be taken with or without food. However, when administered
INTERACTIONS: together with medications such as Lorazepam and Meperdine,
some adverse effects may be seen.

33
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Docusate sodium (100 mg po two times daily prn, if no bowel

movement)
DRUG'S ACTION: This medication is one of the types of laxatives, which is beneficial
for the soft stool output. It helps in minimizing the abdominal
cramps induced by constipation.

DRUG-NUTRIENT A chronic use of this drug may decreases the mineral, magnesium;
INTERACTIONS: however, it increases the presence of potassium in the stool.

34
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Magnesium Hydroxide (30 mL po daily prn)

DRUG'S ACTION: This drugs possess two usages: antacid and laxative. As an antacid,
it is taken to decrease the level of pain caused by heartburn, upset
stomach, sour stomach or acid indigestion; its laxative property
promotes the normal bowel movement in a duration of 30 minutes
to 6 hours.
DRUG-NUTRIENT Magnesium Hydroxide decreases the proper absorption of drugs
INTERACTIONS: such as Aluminum Hydroxide, Penicallamine, Bisphosphates,
Ketoconazole, Quinolones or Tetracycline. On the other hand,
enhances the absorption of ibuprofen. In some studies, Magnesium
Hydroxide impairs the absorption of Folic Acid and dietary iron.

35
Question No. 14
List all medications that Mr. JM is receiving. Determine the action of each
medication and identify any drug–nutrient interactions that you should monitor.

ANSWER:

MEDICATION: Lorazepam (0.5–1 mg po every 8 hrs prn)

DRUG'S ACTION: Lorazepam is known as it has sedative and anxiolytic effects. It is
used to at least have relief from depressive symptoms even in just a
short period of time.

DRUG-NUTRIENT If currently taking this, avoidance of alcohol and caffeine intake is

INTERACTIONS: recommended. Intake of Imipenem and Meperidine in fusion with
Lorazepam could have an adverse effects. On the other hand, in
combination of Magnesium hydroxide, it prevents the Magnesium
excretion that lead to a high serum level.

36
04
Nutrition
Diagnosis
Question No. 15

Identify at least 3 of the most pertinent nutrition problems

and the corresponding nutrition diagnoses.
ANSWER:
The patient steadily increased his alcohol intake over time. Excessive
alcohol intake

The patient has gained 50lbs gradually over the past 5 years because
of a busy schedule and lack of physical activity. Obesity

The patient usually consumes coffee at breakfast with a bagel or

toast, lunch is usually a sub sandwich or pizza. Undesirable food
choices
38
Question No. 16

Write your PES statement for each nutrition problem.

ANSWER:
Excessive alcohol intake related to depression, as evidenced by
patient history of drinking 6 pack beer, 4–5 “shots” bourbon daily;
weekends: beer, bourbon, wine, and other mixed drinks

Obesity (Obese Type II), related to busy schedule as evidenced by

lack of physical activity and gradual unintentional weight gain

Undesirable food choices, related to busy schedule as evidenced by

patient history of usually eating out (fast foods)
39
05 Nutrition
Intervention
Question No. 17
Determine your enteral feeding recommendations for Mr. JM. Provide a
formula choice, goal rate, and instructions for initiation and advancement.
ANSWER:

Goal rate: Peptamen at 100

mL/hr. That will start at 20mL/hr,
titrate by 10-20 mL/hr every 4
hours to goal. This will provide
2520 kcal, and 126 grams of
protein. For his total fluid intake
will be 2400mL. This goal rate
will monitor whether the patient
can tolerate the amount
recommended or if vomiting or
issues arise.
Photo Reference: https://www.google.com/url?
sa=i&url=https%3A%2F%2Fwww.lazada.com.ph%2Fproducts%2Fn
estle-peptamen-400g-
i842314271.html&psig=AOvVaw1bEYFvv3ii2aEx-
Photo Reference: https://www.google.com/url?sa=i&url=https%3A%2F%2Ftogether.stjude.org%2Fen- EqAdhVE&ust=1644218946792000&source=images&cd=vfe&ved=

41
us%2Fdiagnosis-treatment%2Fprocedures%2Ffeeding-tube-placement-for-enteral- 0CAsQjRxqFwoTCKCWmIXH6vUCFQAAAAAdAAAAABAe
feeding%2Fplacement-nasogastric-ng-nasojenjunal-nj-tubes.html&psig=AOvVaw3cviwqDJ-
symkFjuSYcs08&ust=1644218842106000&source=images&cd=vfe&ved=0CAsQjRxqFwoTCMjHu9LG
6vUCFQAAAAAdAAAAABAD
Question No. 18

What recommendations can you make to the patient’s critical

care team to help improve tolerance to the enteral feeding?
ANSWER:
Monitor the patient every 4 hours if he experiencing enteral feeding
complication such as vomiting, abdominal pain, and diarrhea that can hinder
the improvement of the tolerance of the patient in administering the enteral
nutrition.
If the patient does not tolerate the enteral feeding it’s possible to start at slow
rate and continuous administration of EN, with delayed increase and decrease
of EN amount, may avoid the inappropriate interruption and discontinuation of
EN, thereby enabling early achievement of the target amount.
Administration of prokinetic drugs, such as metoclopramide or erythromycin,
had been shown to improve gastric emptying and intestinal intolerance.
Prokinetic agents may be effective in patients with high risk of aspiration or
those with intolerance to gastric EN.
If complete enteral nutrition is not possible or not tolerated, this nutritional
support should be combined with parenteral nutrition. Usually, the combine
nutritional support allows the patient to reach the nutrition goals. 42
06
Nutrition
Monitoring and
Evaluation
Question No. 19
List factors that you would monitor to assess tolerance and
adequacy of nutrition support.
ANSWER:

Factors that we need to monitor to assess tolerance and adequacy of

nutrition support are the following;
Listening for Bowel Sounds
Measuring Gastric Residual Volumes
Observing for Abdominal Distention and Discomfort
Observing for Nausea and Vomiting

44
Question No. 20
If this patient’s acute pancreatitis resolves, what will be the recommendations
for him regarding nutrition and his alcohol intake when he is discharged?
ANSWER:
Mr. JM's current acute pancreatitis will be treated and he will be discharged
from the hospital. Advise him to abstain from alcohol. This is very important
because it is a main cause of pancreatitis in the first place. An occasional drink
would be fine, but his goal should be avoiding alcohol all together. To improve
lifestyle and biological markers (blood pressure, triglycerides, cholesterols, etc.).
Also limit caffeine consumption, as well as eat small frequent low-fat meals, avoid
fast food, fried foods, and highly processed foods to aid in the pancreas
continued healing process and also by having a low-fat diet. Mr. JM’s nutrition will
need to be assessed by dietary assessments.

45
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:
Nutrition Assessment
FOOD/NUTRITION RELATED HISTORY
Eats out a little in 3 days. Usually eats out for dinner; coffee and bagel toast in the
morning; and lunch usually a sub sandwich or pizza
He no longer exercising due to busy schedule in graduate school
Alcohol use: 6 pack beer, 4–5 “shots” bourbon daily; weekends: beer, bourbon, wine,
and other mixed drinks
He was trying to stop his anti-depressant medications since he’s alcohol intake
increases.
Eaten very little over the past 3 days because of pain, nausea, and vomiting.
Fluid Requirement: 1900 - 2400 mL
Scheduled Medications: Imipenem, Famotidine, Meperidine, Ondansetron,
Docusate sodium, Magnesium hydroxide and Lorazepam.
46
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:
Nutrition Assessment
ANTHROPOMETRICS
Weight - 245 lbs
Weight change - increased 50 lbs over the last 5 years
Height - 5’11
BMI - 34.13 - Obese Type 2 (WHO, Asia Pacific)
DBW - 72 kg
UBW - 195 lbs.
%UBW - 125.6%
BIOCHEMICAL DATA, MEDICAL TEST, AND PROCEDURES
Elevated BUN, Creatinne Serum, Glucose, Bilirubin total/Direct, Akaline Phosphate,
ALT, AST, CPK, Lactate Dehydraogenase, Lipase, Amylase, CRP, Cholesterol, LDL,
Triglycerides, WBC, Neutrophil, SEGS, BANDS , Protein, Ketones, Biliburin, Uribilinogen,
PROT CHK
Low Albumin 47
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:
Nutrition Assessment
NUTRITION FOCUSED PHYSICAL FINDINGS
General Appearance: Pale, obese male in obvious distress
Abdominal: Hypoactive bowel sounds, abdominal tenderness, rebound, guarding,
nausea, and vomiting
CLIENT HISTORY
29 years old, Male
Single
Filipino
Roman Catholic
PhD student in computer science; in school full-time; works as research assistant in
department
Lives with roommate
Patient has medical diagnosis of depression
Undergone surgery of appendectomy at age 12
Patient has maternal history of breast cancer and paternal history of hypertension
48
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:

Nutrition Diagnosis
Excessive alcohol intake related to depression, as evidenced by patient history of
drinking 6 pack beer, 4–5 “shots” bourbon daily; weekends: beer, bourbon, wine,
and other mixed drinks
Obesity (Obese ​Type II), related to busy schedule as evidenced by lack of physical
activity and gradual unintentional weight gain
Undesirable food choices, related to busy schedule as evidenced by patient history
of usually eating out (fast foods)

49
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:

NUTRITION MONITORING AND

NUTRITION INTERVENTION
EVALUATION
Monitor Mr. JM’s tolerance to enteral
It is recommended Peptamen at 100 mL/hr. nutrition support of the patient. Also to
That will start at 20mL/hr, titrate by 10-20 reassess the EN formula of the patient may
mL/hr every 4 hours to goal. This will provide take place based on changes and to make
2520 kcal, and 126 grams of protein. sure they are accurate for the patient’s
needs.

50
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:

NUTRITION MONITORING AND

NUTRITION INTERVENTION
EVALUATION
Weight will need to be reassessed. Monitor
Establish a weight goal the patient can his weight every week to see if he's making
accept that range to 67-77 kg. any progress, and at the end of the week,
see whether he's progressively getting
closer to his goal weight.

51
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:

NUTRITION MONITORING AND

NUTRITION INTERVENTION
EVALUATION
Provide a food diary to the patient that he
Encourage the patient to strictly avoid
will use to write all of his food and fluid
drinking alcohol and follow low fat diet
intakes.

Check the 3-day food recall with fluid

Increase water and fluid intake that will be intake upon the next scheduled check-up
2400 mL or 8-10 glasses per day to evaluate his food intake if he achieved
and followed his diet.
52
Question No. 21

Write an ADIME note that provides your initial nutrition

assessment and enteral feeding recommendations.
ANSWER:

NUTRITION MONITORING AND

NUTRITION INTERVENTION
EVALUATION
Monitor the input or output of the patient
Check the laboratory values and and include the electrolytes, nitrogen
input/output intake of the patient. balance, glucose, and other lab values
(Lipase, Amylase, and CRP)

53
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Jones, J. (2021, September 20). APACHE Score. Radiopaedia. Retrieved February 4, 2022 from
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Quinlan, J. D. (2014, November 1). Acute pancreatitis. AAFP American Academy of Family Physicians.
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