Inpatient GI


Step 1: Assess

Gathering Data for an Assessment

Gather the following information for your assessment:

  1. Clinical Data: History of presenting illness (HPI), investigations, pathology, scheduled procedures, consultations, medical orders (medications, infusions), clinical documentation (fluids in and out, bowel movements, drains and tubes, vitals, and documentation of symptoms), medical plan, disposition plan.
  2. Anthropometric Data: Weight, height, BMI, % weight change, % usual body weight, physical assessment, subjective global assessment.
  3. Nutritional Requirements: energy, protein, and fluid.
  4. Biochemical Data: Laboratory values.
  5. Dietary Data: Estimation of caloric/protein/ fluid requirements, hospital diet order, dietary restrictions, allergies, eating behaviour and patterns, 24 hour recall, calorie counts, supplements, previous nutrition interventions.

Before asking the patient questions for your assessment, make sure to introduce yourself and set the agenda for the discussion.

Subjective Global Assessment

According to the Canadian Malnutrition Task Force:

Subjective global assessment (SGA) is the gold standard for diagnosing malnutrition. SGA is a simple bedside method used to diagnose malnutrition and identify those who would benefit from nutrition care. The assessment includes taking a history of recent intake, weight change, gastrointestinal symptoms and a clinical evaluation.

You can refer to the SGA Form (PDF, 2017) from Dr. Jeejeebhoy and the Canadian Malnutrition Task Force for further practice.

Watch the video below (6:36) from UC San Diego Health. It demonstrates a nutrition-focused physical exam for identifying malnutrition. Note: captions were not uploaded for this external video, but you can read a read a transcript for the video (PDF) instead.

Case Study: Meet Sam

Sam Stevenson, our patient for this case study, is flashing a warm and friendly smile. He is an adult male with groomed facial hair and short dark brown hair. He had small diamond stud earrings and a black sweater.

Your patient, Sam Stevenson

You are a Registered Dietitian (RD) in the Gastroenterology unit of a hospital. The patient you are assessing is a 42 year old male named Sam Stevenson. You have been following this patient but your assessment (for the purposes of the case study) is on day 2 post-operation/ hospital admission.

Clinical Data

Clinical data can include, but is not limited to:

  • Reason for visit: hospital visit or RD assessment.
  • Past medical history (PMHx): health history to date.
  • History and presenting illness (HPI): symptoms, surgeries, prognosis, tests (i.e. CT scan, ultrasound)
  • Current medical orders: IV infusions, medications (IV or oral), relevant consultations (i.e. RD, Speech Language Pathologist (SLP), Physiotherapist (PT),  Gastroenterologist, etc.).
  • Clinical documentation: Fluids intake (i.e. oral, IV, TPN/EN) and output (i.e. urine, vomit, bowel movements, drains (i.e. catheter, chest tube, surgical site drain) and suctioning (i.e. oral secretions, OGT to straight drain), documentation of tubes (i.e. G-tube vs. NGT) and lines (i.e. PICC), and vitals.
  • Medical care plan and disposition: chemotherapy, radiation therapy, scheduled surgery, transfer to different floor, rehab facility, treatment facility, long term care, home.

Sam’s Clinical Data & Documentation

Review Sam’s clinical data. Take note of components that you think may be of importance for a nutrition care plan or to consider in the context of his patient care.

  • Age: 42-year-old male
  • HPI: 5-year history of Crohn’s disease, frequent hospital admissions for pain and diarrhea, worsening frequency of flares.
  • Admission: 3 days ago for intense pain, diarrhea, nausea and decreased appetite – unable to work for the past 2 weeks – poor dietary intake – has lost over 15 kg over the past two months and 3 kg over the last two weeks.
  • Pathology: Crohn’s disease.
  • Operations/ Procedures: Investigation reveals ischemic tissue in the ileum – GI surgeon performs an ileocaecal resection removing 70 cm of the terminal ileum. Temporary ileostomy to allow the colon to rest (re: extensive inflammation).
  • Consultations: RD consult for diet order progression and ileostomy education.
  • Medications:
    • Prednisone (a corticosteroid): On a daily dose of 10 mg/day for the past 2 months. MD increased dose to 30 mg/day IV while in hospital.
    • Metronidazole (an antibiotic): MD prescribed 500 mg IV while in hospital (post-op)
    • Pantoprazole (a proton pump inhibitor): MD prescribed 40 mg IV while in hospital (post-op)
    • Look up each of these medications and determine why Sam is receiving them and the potential side effects
  • Medical plan: Medical Doctor (MD) plans for Sam to stay in hospital for ~3-5 days post-op for monitoring (pending possible complications). Temporary ileostomy – plan to complete resection in 3 months.
  • Disposition plan: home once stable.

Review Sam’s clinical documentation. Note that your assessment is on day 2 post-op.

  • Day 0 (day of his surgery) post-op: patient was (with ice chips)
  • Day 1 post-op: patient was ordered clear fluids.
  • Symptoms: On day 0, nurse reports that patient was complaining of nausea and fatigue – consumed a cup of ice chips. On day 1, nurse reports that patient is feeling better, is drinking clear fluids (water, juice ~ 800 mL/day) consistently and is walking around the ward (infrequently). Patient still fatigued and weak.
  • Infusions: MD ordered (on day 0 of post-op) IV ⅔ and ⅓ @100 mL/hour = 2400 mL/day
  • Ostomy output: Day 0 = 200 cc; day 1 = 1200 cc; referred to as an ‘active ileostomy’
  • Urine output: Day 0 = 720 mL (~30 mL/hour); Day 1 = 1,500 mL (~60 mL/hour)

As your assessment is taking place on day 2 post-op, you would have access to 2 days worth of important clinical documentation and information to inform your next steps for the nutrition care plan.

A key component is the assessment of fluid intake and ostomy output at this stage. We need to make sure the ostomy is functioning, referred to as an active ileostomy, before progressing Sam’s diet. Fluid intake is an important component of his care plan in regard to preventing dehydration and electrolyte imbalance given his recent surgery. Urine output is important in reviewing Sam’s fluid balance.

Anthropometric Data

Assessment of Body Weight

Body weight is the most used indicator of nutritional status, as it is used for calculating fluid, protein, and energy requirements.

Important considerations to identify include:

  • adjustments in weight (i.e. amputations, fluid retention)
  • if this is the most appropriate weight to use for calculations (i.e. are you overfeeding or underfeeding?)
  • the weight you are feeding

Obtaining height and age is often necessary to further interpret body weight. Body Mass Index (BMI) is commonly used as a classification to evaluate health risk, as demonstrated in the table below. Master’s tables are used for adults aged 65+.

Health risk classification, according to Body Mass Index (BMI)
BMI = weight (in kg) divided by height (in m2)
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Classification BMI Category (kg/m2) Risk of Developing Health Problems
Underweight <18.5 Increased
Normal weight 18.5-24.9 Least
Overweight 25.0-29.9 Increased
Obese class I 30.0-34.9 High
Obese class II 35.0-39.9 Very high
Obese class III >40.0 Extremely high
It is important to use other markers of weight, including % weight change and % usual body weight (UBW) during your assessment to further evaluate your patient’s weight. The calculations in the tables below will help you interpret the findings in regard to severity and indication of malnutrition.
% of weight loss, by time frame and severity
% weight loss = (usual body weight − current weight) × 100
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Time Frame Significant Weight Loss (%) Severe Weight Loss (%)
1 week 1-2 > 2
1 month 5 > 5
3 months 7.5 > 7.5
6 months 10 > 10
Unlimited time 10-20 > 20
% Usual Body Weight (UBW), with malnutrition interpretations
% UBW = (current body weight ÷ usual body weight) × 100
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
UBW range (%) Interpretation
85 – 95 May indicate mild malnutrition
75 – 84 May indicate moderate malnutrition
< 74 May indicate severe malnutrition

Sam’s Anthropometric Data: Body Weight

  • Height: 6’1″ (1.86 m)
    • Imperial to metric conversion: 6’1″ tall = 73.2 inches (12 inches/ft) × 2.54 cm/inch = 186 cm
  • Current weight: 145 lbs (65.9 kg)
    • Imperial to metric conversion: 145 lbs ÷ 2.2 lbs/kg = 65.9 kg
  • Current BMI: 19.1 kg/m²
    • Calculation: 65.9 kg ÷ 1.86 m² = 19.1 kg/m²
  • Usual weight: 180 lbs (reported by patient)
  • Timeframe of weight loss: 2 months
  • % weight loss: 19.4%
    • Calculation: [81.8 kg − 65.9 kg] ÷ 81.8 kg) × 100 = 19.4%
  • % UBW: 80.6%
    • Calculation: (65.9 kg ÷ 81.8 kg) × 100 = 80.6%



Physical Assessment

Another important assessment strategy is to physically evaluate your patient. It is important to go into your patient’s room to evaluate physical signs and symptoms of malnutrition. The SGA provides guidance on how to complete a physical examination by using a head-to-toe method for the assessment of muscle wasting, subcutaneous fat, and fluid retention.

SGA guidance for assessment of Muscle Wasting
Source: Canadian Malnutrition Task Force SGA Form (PDF)
[**] Note: in the elderly, this may reflect aging, not malnutrition.
Physical Examination Normal Moderate Severe
Temple Well-defined muscle Slight depression Hollowing, depression
Clavicle Not visible in males, may be visible but not prominent in females Some protrusion; may not be all the way along Protruding/prominent bone
Shoulder Rounded No square look, process may protrude slightly Square look, bone prominent
Scapula/ribs Bones not prominent Mild depression or bone may show slightly Bone prominent, significant depressions
Quadriceps Well defined Depression/ atrophy medially Prominent knee, severe depression medially
Interosseous muscle between thumb and forefinger (back of hand)** Muscle protrudes, could be flat in females Slightly depressed Flat or depressed area
The interosseous muscle is depressed in a patient with muscle wasting
The interosseous muscle is depressed in a patient with muscle wasting. Photo by Juniper Publishers is licensed under a Creative Commons Attribution 4.0 International License
SGA guidance for assessment of Subcutaneous Fat
Source: Canadian Malnutrition Task Force SGA Form
Physical Examination Normal Moderate Severe
Under the eyes Slightly bulging area. Somewhat hollow look, slightly dark circles. Hollowed look, depression, dark circles.
Triceps Large space between fingers. Some depth to fat tissues, but not ample. Loose fitting skin. Very little space between fingers or finger touch.
Ribs, lower back, sides of trunk Chest is full, ribs do not show. Slight to no protrusion of the . Ribs obvious, but indentations are not marked. Iliac crest somewhat prominent. Indentation between ribs obvious. Iliac crest very prominent.
Hollow, dark circles under the eyes of a young adult male.
Hollow, dark circles under the eyes. Photo by Serdar G., CC0, via Wikimedia Commons
SGA guidance for assessment of Fluid Retention
Source: Canadian Malnutrition Task Force SGA Form
Physical Examination Normal Moderate Severe
Edema None Pitting edema of extremities / pitting to the knees, possible edema if bedridden Pitting beyond knees, sacral edema if bedridden, may also have generalized edema
Ascites Absent Present (may only be present on imaging) Present (may only be present on imaging)


Sam’s Anthropometric Data: Physical Assessment

  • Physical exam reveals moderate muscle wasting and moderate loss of subcutaneous fat
  • Slight depression of temples and protrusion of clavicle and shoulder
  • Ribs showing
  • No distension in abdomen
  • No edema
  • Patient can ambulate, but walks infrequently due to weakness
  • Temperature and respiratory rate normal

Review Sam’s physical assessment data. Overall, the physical assessment using the SGA reveals moderate muscle wasting and moderate loss of subcutaneous fat.

Nutritional Requirements

Energy Requirements

Predictive equations are for estimation purposes only. The most accurate data will provide the most accurate estimation, but without indirect calorimetry this is the best we can achieve. As a result, there is a need for frequent re-assessment of energy requirements.

Factors affecting the accuracy of estimated requirements include:

  • Acute or chronic respiratory distress syndrome
  • Large open wounds or burns
  • Malnutrition with altered body composition
  • Underweight, obesity, limb amputation, peripheral edema, ascites
  • Multiple or neurological trauma
  • Multisystem organ failure
  • Postoperative organ transplantation
  • Sepsis
  • Systemic inflammatory response syndrome
  • Paralytic or barbituate agents

Predictive Equations

Here are three commonly used predictive equations. There are other predictive equations you may use, depending on your area of practice. Accuracy varies by equation and population. Experience is helpful for an accurate selection and utilization of these predictive equations.


  • EER = estimated energy requirements
  • REE = resting energy expenditure (kcal)
  • A = age (years)
  • PA = physical activity
  • W = weight (kilograms)
  • H = height (centimetres, unless otherwise specified)
  • H* = height (metres)
  • Dietary Reference Intakes (DRI)
    • EER: age, physical activity, weight, height
    • Males: EER (kcal) = 662 − 9.53A + PA × (15.91W + 549.6H*)
    • Females: EER (kcal) = 354 − 6.91A + PA × (9.36W + 726H*)
  • Harris Benedict (HB)
    • REE: weight, height, age
    • Males: REE (kcal) = 66.5 + 13.75W + 5.0H − 6.78A
    • Females: REE (kcal) = 655.1 + 9.56W + 1.85H − 4.68A
  • Mifflin-St.Jeor (MSJ)
    • REE: weight, height, age
    • Males: REE (kcal) = 9.99W + 6.25H − 4.92A + 5
    • Females: REE (kcal) = 9.99W + 6.25H − 4.92A − 161
  • Estimated Calories/kg

Activity Factors

Most predictive equations evaluate resting energy expenditure (REE), meaning you need to consider physical activity energy expenditure in addition to the original calculation. The activity factor (AF) is applied to the REE value. Activity factors are not to be used with DRI equations.

Activity Factors (AF) for various activity levels
[*] indicates activities obtained in healthy, free-living people
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Activity Level AF
*Resting (lying or sitting) 1.0 – 1.4
Lying still, sedated or asleep 0.9 – 1.1
Lying still, conscious 1.0 – 1.1
Spinal cord injury, 0-4 weeks post-injury 1.1
Bedrest (moving self around bed) 1.15 – 1.2
Mobilizing occasional on ward 1.15 – 1.4
*Sedentary/ Light Activity (standing for long periods) 1.4 – 1.6
Mobilizing frequently on ward 1.4 – 1.5
Regular, intensive physiotherapy 1.5 – 1.6
*Moderate Activity (continuous movement/slow walking) 1.6 – 1.8

Stress Factors

Most predictive equations evaluate resting energy expenditure (REE), meaning you may need to consider energy expenditure from stress. The stress factor is applied to the REE value.

Stress Factors (SF)  for various clinical statuses
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Clinical Status SF
Cancer 0.8 – 1.5
Elective surgery 1.0 – 1.1
Peritonitis 1.05  – 1.25
Multiple/ long bone fractures 1.1 – 1.3
Fever 1.2 per 1°C > 37°C
Spinal cord injury, 0-4 weeks post-injury 1.2
Sepsis 1.2 – 1.4
Severe infection 1.2 – 1.6
Burns 1.2 – 2.0
Infection with trauma 1.3 – 1.55
Multiple trauma, traumatic brain injury 1.4

Protein Requirements

The table below represents general guidelines for protein requirements according to how hypermetabolic your patient is. Consider your individualized patient to determine the most accurate protein requirement. Experience using these methods is helpful. You can consider calculating requirements using various methods and compare values.

General protein requirements, by patient’s hypermetabolic category
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Patient Category Protein (g/kg)
Not hypermetabolic:

  • Adults not severely ill or injured
  • Adults not at risk of refeeding syndrome
  • Acute elderly patients
0.8 – 1.5

(1.0 – 1.5 for
acute elderly patients)

Moderately hypermetabolic, including:

  • Post-operative (~14 days)
  • Repletion
  • Infection
  • Temperature > 38°C
  • Head injury
  • COPD exacerbation
1.2 – 1.5
Hypermetabolic, including multi-trauma
1.5 – 2.0

The following table represents a more detailed overview of protein requirements specific to various clinical conditions. This may be more useful for you during practice than the general guidelines, if your patient’s clinical status is reflected in this table.

Detailed protein requirements, by patient’s clinical status
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Clinical Status Protein (g/kg)
Normal (non-stressed, non-depleted) 0.8 – 1.0
Postoperative 1.0 – 1.5
Sepsis 1.5 – 2.0
Multiple trauma 1.3 – 1.7
Traumatic brain injury 1.2 – 2.0
Burns 1.2 – 2.0
Catabolism 1.2 – 2.0
Refeeding syndrome 1.2 – 1.5
Cancer 0.8 – 2.0
Hemodialysis 1.1 – 1.2
CCPD/CAPD 1.2 – 1.3
CRRT 1.5 – 2.0
Acute Renal Failure 1.0 – 1.5
Chronic Kidney Disease 0.8 – 1.0
Mild-Moderate Stress 1.2 – 1.3
Moderate-Severe Stress 1.5 – 2.0
Severe + Wound Healing 1.5 – 2.0
HIV (asymptomatic) 1.0 – 1.4
HIV (symptomatic) 1.5 – 2.0
HIV (CD4 < 200/AIDS defining condition) 2.0 – 2.5

Fluid Requirements

The table below represents general guidelines for calculating fluid requirements. Consider your individual patient prior to determining the best method to use. Experience using these methods is helpful. You can calculate requirements using various methods and compare values.

General guidelines for fluid requirements
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Based Upon Method of Fluid Estimation
  • 100 mL/kg for 1st 10 kg
  • 50 mL/kg for next 10 kg
  • 20 mL/kg for each kg > 20 kg
Energy 1 mL per kcal
Age and weight
  • 16 – 30 years, active: 40 mL/kg
  • 20 – 55 years: 35 mL/kg
  • 55 – 75 years: 30 mL/kg
  • > 75 years: 25 mL/kg
Fluid balance Urine output + 500 mL/day

Electrolyte Requirements

The table below represents general guidelines for electrolyte requirements, in consideration of clinical factors. Determination of the best method to use needs to be considered in the context of the individual and their current electrolyte status and bloodwork. This can vary tremendously based on the situation.

General guidelines for electrolyte requirements
Electrolyte Daily Requirements Factors That Increase Needs
Sodium 1 – 2 mmol/kg Diarrhea, vomiting, GI losses
Potassium 1 – 2 mmol/kg Diarrhea, vomiting, medications, refeeding syndrome, GI losses
Calcium 5 – 7.5 mmol/day High protein intake
Magnesium 4 – 10 mmol/day Medications, refeeding syndrome, GI losses
Phosphorous 20 – 40 mmol/day High dextrose loads, refeeding syndrome

Sam’s Nutritional Requirements

Review Sam’s energy, protein, and fluid requirements.

For Sam’s energy requirements, it is important to try different predictive equations to compare.

Harris Benedict equation for Sam:
66.5 + 13.75(65.9) + 5.0(186) − 6.78(42)  = 1618 (REE) × 1.15 (AF: mobilizing infrequently) × 1.2 (SF: recent surgery, inflammation, and infection) = 2233 kcal/day

Regarding his activity factor: these are frequently overestimated. An AF of 1.15 is appropriate for an inpatient who is mobilizing occasionally around the ward. He is still fatigued, weak, deconditioned and is likely not getting up often to walk around.

Regarding the stress factor: an appropriate SF would be 1.0 – 1.2 because of his recent surgery, inflammation and infection. This could change with time and is why these requirements need to be frequently evaluated. In this case, the calculations reveal a range from 1980 to 2300 kcal/day. You can choose the average of these at 2300 kcal/day which provides 35 kcal/kg.

Calories per kg calculation: 30 – 35 kcal/kg × 65.9 kg = 1977 – 2307 kcal/day
Sam’s energy requirements: ~2300 kcal/day (35 kcal/kg)

Protein requirements for Sam should range from 1.2 – 1.5 g/kg/day as he is post-operative and malnourished (physical signs of muscle wasting). Protein is also important in the context of his disease.

Sam’s protein requirements:  79 – 99 g/day (1.2 – 1.5 g/kg/day)

Finally, Sam’s fluid requirements are roughly 2300 mL/day, but keep in mind that Sam has a recent ileostomy meaning he is not using his colon. Fluid intake and hydration is of high importance meaning this will likely need to be adjusted.

Sam’s fluid requirements: 2300 mL/day (35 mL/kg)

Biochemical Data

Laboratory Values

In the hospital, you will have access to a variety of laboratory values. The table below represents common laboratory values to review for all patients. Depending on your patient’s diagnosis, you may have to review additional values.
Common laboratory values
Laboratory Value Normal Range
Glucose (Random) 4.0 – 7.8 mmol/L
Sodium (Na+) 135 – 145 mmol/L
Potassium (K+) 3.5 – 5.0 mmol/L
Chloride (Cl) 96 – 106 mmol/L
Phosphorus (PO4) 0.8 – 1.35 mmol/L
Calcium (Ca+2) 2.1 – 2.7 mmol/L
Magnesium (Mg+2) 0.63 – 0.94 mmol/L
Albumin (Alb) 35 – 50 g/L
Blood Urea Nitrogen (BUN) 3.0 – 7.0 mmol/L
Creatinine (Cr) 44 – 80 μmol/L
Total Cholesterol < 5.2 mmol/L

Sam’s Biochemical Data: Lab Values

Review Sam’s lab values in the table below. The “Notes” column indicates which values are outside of target range and explains how to correct calcium and magnesium when albumin values are <35g/L.

Sam’s laboratory values
[*] Indicates values outside the target range
Laboratory Value Sam’s Value Notes
Glucose (Random) 6.5 mmol/L N/A
Sodium (Na+) 135 mmol/L N/A
Potassium (K+) 3.8 mmol/L N/A
Chloride (Cl) 102 mmol/L N/A
Phosphorus (PO4) 1.1 mmol/L N/A
Calcium (Ca2+) *1.9 mmol/L
corrected = 2.24 mmol/L
Outside the target range

Correct when albumin is <35 g/L

Corrected calcium =
(normal albumin – abnormal albumin) × 0.02 + Ca2+ value

Corrected calcium for Sam:
(40 − 23) × 0.02 + 1.9
= 2.24 (normal)

Magnesium (Mg2+) 0.73 mmol/L
corrected = 0.81 mmol/L
Correct when albumin is <35g/L

Corrected magnesium =
(normal albumin – abnormal albumin) × 0.005 + Mg2+ value

Corrected calcium for Sam:
(40 − 23) × 0.005 + 0.73
= 0.81 (normal)

Albumin (Alb) *23 g/L Outside the target range

Albumin is <35g/L, requiring corrections for calcium and magnesium.

Blood Urea Nitrogen (BUN) *1.6 mmol/L Outside the target range
Creatinine (Cr) 56 μmol/L N/A
Total Cholesterol 3.3 mmol/L N/A


IV Solutions

Here is an overview of common IV solutions used in hospital.  IV solutions contribute calories and other nutrients, so they need to be considered when you are creating a nutrition care plan.

Common IV solutions
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Solution Kcal/L Composition/L
Normal Saline (0.9% NaCl) 0 Na – 154 mmol

Cl – 154 mmol

½ Normal Saline (0.45% NaCl) 0 Na -77 mmol

Cl – 77 mmol

D5W (5% Dextrose) 170 Dextrose – 50 g
D10W (10% Dextrose) 340 Dextrose – 100 g
5% Dextrose and 0.9% NaCl 170 Dextrose – 50 g

Na – 154 mmol

Cl – 154 mmol

⅔ and ⅓ (3.3% Dextrose and 0.3% NaCl) 112 Dextrose – 33 g

Na – 51 mmol

Cl – 51 mmol

Ringer’s Lactate 9 Na – 130 mmol

K – 4 mmol

Ca2+ – 1.4 mmol

Cl – 109 mmol

Lactate – 28 mmol

Dietary Data

Obtaining accurate dietary data can vary based on your patient (e.g.  family members present, patient’s cognitive ability, flow sheets or calorie counts, etc.), as well as the setting (e.g. inpatient compared to outpatient).

If possible, collect the following information:

  • Diet order(s): Important for a representation of daily intake while in the hospital (can include enteral nutrition & supplements).
  • Dietary recall: 24 hr recall (if recent admission or representation of food consumption in hospital), common eating patterns, or short-term and long-term representation of eating patterns or typical foods.
  • Calorie counts: Depending on the patient, you may order calorie counts to monitor/determine how much/ what they are eating in hospital.

Sam’s Dietary Data

Over the past 2 months, Sam’s diet consists mainly of fluids and small portion of bland foods (fruit, bread, rice, cereal) due to nausea, pain and loss of appetite.

Over the past 2 weeks (prior to hospital admission), Sam was not eating or drinking much due to feeling severely unwell, fatigued and having no appetite. Estimated caloric intake ~ 600 kcal per day.

Sam’s common foods or drinks:

  • Two cans of vanilla Ensure® Plus per day
  • Fruit juices, Gatorade, water, coffee, tea – reports drinking consistently throughout the day

Supplements: Vitamin D (1000 IU/day) and Calcium Carbonate (500 mg/day)

Current hospital diet order:

  • Clear fluids (on day 1 tolerating and consuming ~800 mL of water and juice) — RD to consult for progression.
  • Receiving IV ⅔ and ⅓ @ 100 cc/hour – provides 269 kcal/day and 122 mmol of Na and Cl
  • Practice calculating this using the IV solutions table provided earlier

Assessment summary

Summary of Sam’s Assessment Data

Review the final summary for Sam’s assessment data. In practice, it is good to have a summary of this information with you at all times and to keep track of the progression of your patient.

Summary of Sam’s Assessment Data
Area Key Data
Clinical Data
  • 42 year old male with Crohn’s disease – recent ileocecal resection resulting in removal of 70 cm of terminal ileum with temporary ileostomy.
  • Medications: prednisone (30 mg/day IV), metronidazole (500 mg IV), pantoprazole (40 mg IV)
  • Clinical documentation
    • Day 0 post-op: Patient NPO with ice chips, IV ⅔ and ⅓ started at 100 mL/hour (2400 mL/day), patient reports feeling nausea and fatigued, ostomy output was 200 cc.
    • Day 1 post-op: Patient switched to clear fluids, IV fluids running at the same rate, patient reports feeling better and is drinking + walking, ostomy output was 1200 cc.
  • Medical plan: monitor in hospital for 3-5 days (pending complications and tolerance), home once stable, plan to complete resection in 3 months.
Anthropometric and
Physical Assessment Data
  • Height = 186 cm, Weight = 65.9 kg (81.2 kg usual weight), BMI = 19.1 kg/m², 19.4% weight loss in 2 months (severe).
  • Moderate muscle wasting and subcutaneous fat loss.
Nutrition Requirements Data
  • Energy = 2,300 kcal/day (35 kcal/kg), Protein = 79 to 99 g/day (1.2-1.5 g/kg/day), Fluid = 2,300 mL/day (35 mL/kg).
Biochemical Data
  • Low BUN (1.6) and Albumin (23), electrolytes within range (monitor).
Dietary Data
  • History: poor appetite, diet consisting of mainly fluids over the past 2 weeks
  • Diet order: clear fluids (day 1:  ~800 mL of fluid consumed) – RD to progress
  • Supplements: Vitamin D (1000 IU/day) and Calcium Carbonate (500 mg/day)
  • Receiving IV fluids (2400 mL per day) providing 269 kcal and 122 mmol of Cl and Na
PART 1: ASSESS COMPLETE. Please take a few minutes to think about the assessment data collected. When you’re ready, move on to Part 2: Plan.



Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Preparation for Dietetic Practice Copyright © by Megan Omstead, RD, MPH is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.