{"id":150,"date":"2021-08-14T12:51:16","date_gmt":"2021-08-14T16:51:16","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/dietmods\/?post_type=chapter&#038;p=150"},"modified":"2022-03-07T23:59:51","modified_gmt":"2022-03-08T04:59:51","slug":"pn-evaluate","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/","title":{"raw":"Evaluate","rendered":"Evaluate"},"content":{"raw":"<h1>Evaluating the Nutrition Care Plan<\/h1>\r\nAfter you have implemented your nutrition care plan, you need to follow-up and evaluate it to ensure that it has been effective in addressing your patient's nutrition concerns. This can help you to decide on appropriate changes to make to the nutrition care plan moving forward.\r\n\r\nWhen evaluating your plan in a inpatient setting, you will need to gather updated information from the same key areas of nutrition concern that you identified in your initial assessment. This will include, but is not limited to: parenteral feeding delivery\/ tolerance, daily intake and outputs, laboratory values, medications, disposition, and any changes to the medical care plan. Also consider if PN is still indicated, or if your patient could transition to EN or an oral diet.\r\n<table class=\"grid\" style=\"height: 261px\"><caption>Questions to evaluate nutrition care plan effectiveness<\/caption>\r\n<tbody>\r\n<tr style=\"height: 17px\">\r\n<th style=\"height: 17px;width: 231.625px\" scope=\"col\"><strong>Common Nutrition Issues<\/strong><\/th>\r\n<th style=\"height: 17px;width: 676.625px\" scope=\"col\"><strong>Evaluate effectiveness of NCP<\/strong><\/th>\r\n<\/tr>\r\n<tr style=\"height: 70px\">\r\n<td style=\"height: 70px;width: 231.625px\">Parenteral Nutrition<\/td>\r\n<td style=\"height: 70px;width: 676.625px\">\r\n<ul>\r\n \t<li>Has the patient experienced any side effects or complications?<\/li>\r\n \t<li>Are they meeting their estimated requirements with the current plan? Does it need to reassessed?<\/li>\r\n \t<li>Is parenteral nutrition still warranted?<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 52px\">\r\n<td style=\"height: 52px;width: 231.625px\">Daily Intake and Output<\/td>\r\n<td style=\"height: 52px;width: 676.625px\">\r\n<ul>\r\n \t<li>Fluid balance?<\/li>\r\n \t<li>Volume of nutrition received?<\/li>\r\n \t<li>Changes in head to toe assessment?<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<td style=\"height: 17px;width: 231.625px\">Malnutrition<\/td>\r\n<td style=\"height: 17px;width: 676.625px\">\r\n<ul>\r\n \t<li>Has weight increased? Decreased?<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 35px\">\r\n<td style=\"height: 35px;width: 231.625px\">Electrolytes and Laboratory Work<\/td>\r\n<td style=\"height: 35px;width: 676.625px\">\r\n<ul>\r\n \t<li>Are the laboratory values normal?<\/li>\r\n \t<li>Are further replacements\/ supplements required?<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 70px\">\r\n<td style=\"height: 70px;width: 231.625px\">Medical Care Plan<\/td>\r\n<td style=\"height: 70px;width: 676.625px\">\r\n<ul>\r\n \t<li>Are there any changes to the medical care plan?<\/li>\r\n \t<li>Changes in medications that impact the nutrition care plan?<\/li>\r\n \t<li>Any updated laboratory work, tests, procedures or assessments?<\/li>\r\n \t<li>Disposition planning? Does this impact your nutrition care plan?<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\">Evaluating Poppy's Nutrition Care Plan<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<table class=\"grid\" style=\"height: 266px\"><caption>Outcomes of Poppy's nutrition care plan, by issue type<\/caption>\r\n<tbody>\r\n<tr style=\"height: 31px\">\r\n<th style=\"height: 31px;width: 185.688px\" scope=\"col\">Common Nutrition Issues<\/th>\r\n<th style=\"height: 31px;width: 639px\" scope=\"col\">Evaluate effectiveness of NCP<\/th>\r\n<th style=\"height: 31px;width: 454.625px\" scope=\"col\">Poppy's outcomes<\/th>\r\n<\/tr>\r\n<tr style=\"height: 63px\">\r\n<th style=\"height: 63px;width: 185.688px\" scope=\"row\">Parenteral Nutrition<\/th>\r\n<td style=\"height: 63px;width: 637.562px\">\r\n<ul>\r\n \t<li>Day 3 of PN administration, no complications, increase to 75%-100% of requirements<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 63px;width: 453.188px\">\r\n<ul>\r\n \t<li>Evaluate nutrition plan and patients medical status for safety of increase<\/li>\r\n \t<li>Monitor closely for refeeding syndrome or complications with increase<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 31px\">\r\n<th style=\"height: 31px;width: 185.688px\" scope=\"row\">Daily Input and Output<\/th>\r\n<td style=\"height: 31px;width: 637.562px\">\r\n<ul>\r\n \t<li>Urine output &gt; 2 L\/day (IV Lasix (furosemide))<\/li>\r\n \t<li>+5 L fluid balance<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 31px;width: 453.188px\">\r\n<ul>\r\n \t<li>Fluid overload \u2013 maintain fluid restriction in nutrition care plan<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 31px\">\r\n<th style=\"height: 31px;width: 185.688px\" scope=\"row\">Malnutrition<\/th>\r\n<td style=\"height: 31px;width: 637.562px\">\r\n<ul>\r\n \t<li>Only two days since initiation \u2013 no need for evaluation at this time. Can re-weigh patient to confirm decrease in total fluid balance if desired.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 31px;width: 453.188px\">N\/A<\/td>\r\n<\/tr>\r\n<tr style=\"height: 47px\">\r\n<th style=\"height: 47px;width: 185.688px\" scope=\"row\">Abnormal Electrolytes<\/th>\r\n<td style=\"height: 47px;width: 637.562px\">\r\n<ul>\r\n \t<li>Elevated: WBC, BG, Cr, BUN<\/li>\r\n \t<li>Low: Hgb, K, Mg<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 47px;width: 453.188px\">\r\n<ul>\r\n \t<li>Continue to monitor (up to 7 days)<\/li>\r\n \t<li>Liaise with team regarding replacements, if determined as necessary<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 63px\">\r\n<th style=\"height: 63px;width: 185.688px\" scope=\"row\">Medical Care Plan<\/th>\r\n<td style=\"height: 63px;width: 637.562px\">\r\n<ul>\r\n \t<li>Patient reports increased abdominal pain distension<\/li>\r\n \t<li>GI surgery team schedules OR \u2013 finds 20 cm segment of necrotic bowel in terminal ileum \u2013 25 cm resected, primary anastomosis<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 63px;width: 453.188px\">\r\n<ul>\r\n \t<li>Potential for postoperative ileus \u2013 need for assessment<\/li>\r\n \t<li>GI surgeon recommends continuing TPN for one week prior to trial of enteral feeding<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nPoppy is on day 3 of PN administration with no complications, therefore it would be appropriate to advance her PN solution to 75%-100% of her estimated nutrition requirements. It is important that we still monitor closely for refeeding syndrome and complications that may result with this increase.\r\n\r\nPoppy\u2019s fluid balance is +5 L, which is an improvement from +10 L and she has a urine output of &gt;2 L per day. Although Poppy is still considered fluid overloaded, she is moving in the right direction. For now, maintain fluid restriction in the nutrition care plan as per MD orders.\r\n\r\nPoppy\u2019s laboratory results reveal that her WBC, BG, Cr and BUN are elevated and her Hgb, K, and Mg are low. It would be important to liaise with the team regarding replacements for low K and Mg, and continue monitoring her laboratory values as PN volumes increase.\r\n\r\nLastly, Poppy continued to experience [pb_glossary id=\"2137\"]++[\/pb_glossary] abdominal pain and distension. Taking the CT abdominal results into consideration, the GI surgery team schedules an OR and finds a 20 cm segment of necrotic bowel in the terminal ileum resulting in a 25 cm small bowel resection. Post operatively, the GI surgeon recommends continuing TPN for one week and then to trial enteral feeding upon evaluation of Poppy\u2019s clinical status.\r\n\r\n<\/div>\r\n<\/div>\r\n<h1>Weaning PN<\/h1>\r\nThere are various strategies for weaning PN. Patients may transition from PN to enteral feeding or an oral diet. The oral diet may consist of various textures and oral supplements are also taken into consideration.\r\n\r\nHere is a general procedure for weaning PN for patients transitioning to enteral feeding:\r\n<ul>\r\n \t<li>PN may be weaned when patient is able to tolerate oral intake\/EN.<\/li>\r\n \t<li>PN should be reduced as oral intake\/EN improves. PN should be reduced by an amount that is equal to the calories and protein provided via oral intake\/EN.<\/li>\r\n \t<li>Calories counts can be used to assess adequacy of oral intake. Reduced oral intake can be expected if PN provides &gt; 25% kcal requirements.<\/li>\r\n \t<li>PN may be discontinued when patient is tolerating 50-75% energy and protein requirements via oral intake\/EN, unless impaired GI function precludes 100% absorption of nutrient needs.<\/li>\r\n \t<li>Some institutions do not gradually wean PN. PN is continued at goal rate and discontinued when the patient is receiving ~50% of their estimated nutrition requirements via enteral nutrition or oral intake.<\/li>\r\n<\/ul>\r\nPause here and consider how you may start a trial of enteral nutrition for Poppy.\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\">Weaning PN for Poppy<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nThis is what you could do to start a trial of enteral nutrition for Poppy:\r\n<ul>\r\n \t<li>Liaise with the GI surgery MD\/ICU team to ensure they agree with restarting EN.<\/li>\r\n \t<li>Re-evaluate Poppy\u2019s estimated nutrition requirements: energy, protein, fluid<\/li>\r\n \t<li>Complete a head-to-toe assessment<\/li>\r\n \t<li>If the team agrees to initiate EN, start conservatively to evaluate GI tolerance:\r\n<ul>\r\n \t<li>Example (\u201ctrickle feed\u201d): Isosource 1.5 @ 10 mL\/hour \u00d7 24 hours = 240 mL\/day<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li>Ask her RN to monitor closely for signs any of GI intolerance.<\/li>\r\n \t<li>If EN is well tolerated, decrease PN gradually as EN rate increases as described above. Review flow sheets or documented \u201cins and outs\u201d in Poppy\u2019s chart to assess PN &amp; EN volumes received. Use this information to avoid overfeeding and continue to meet her estimated nutrition requirements, as you adjust and transition to EN.<\/li>\r\n<\/ul>\r\n<strong>Considerations:<\/strong> absorption of nutrients is likely to remain adequate as a small portion of poppy\u2019s small bowel was removed (removal of 25 cm of ileum \u2013 vitamin B12 and bile salts absorbed in terminal ileum).\r\n\r\n<\/div>\r\n<\/div>\r\n<div>\r\n<h1>The Nutrition Care Process Model<span class=\"ez-toc-section-end\"><\/span><\/h1>\r\n<\/div>\r\n<div>\r\n\r\nAs you use the Nutrition Care Process Model and the learning from this case study as a guide throughout your patient care in practicum, please keep in mind that the process is dynamic, and not step-by-step as all cases are different. You are encouraged to complete the recommended readings for this module and continue to expand your learning in this clinical area of practice.\r\n\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n\r\n<span>PART 4: EVALUATE COMPLETE. Pause to reflect on the evaluation strategies discussed, and review the readings and resources in the following section for your information.<\/span>\r\n\r\nYou\u2019ve now completed the Parenteral Nutrition module. Please consider providing feedback through the embedded form in the next section.\r\n\r\n<\/div>\r\n<h1>Acknowledgements<\/h1>\r\nEmily Opperman, MSc, RD\r\n\r\nMichaela Kucab, MHSc, RD","rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 counter-hierarchy ez-toc-counter ez-toc-grey ez-toc-container-direction\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">Page Contents<\/p>\n<label for=\"ez-toc-cssicon-toggle-item-69e2edae9b522\" class=\"ez-toc-cssicon-toggle-label\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/label><input type=\"checkbox\"  id=\"ez-toc-cssicon-toggle-item-69e2edae9b522\" checked aria-label=\"Toggle\" \/><nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/#Evaluating_the_Nutrition_Care_Plan\" >Evaluating the Nutrition Care Plan<\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/#Evaluating_Poppys_Nutrition_Care_Plan\" >Evaluating Poppy&#8217;s Nutrition Care Plan<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/#Weaning_PN\" >Weaning PN<\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/#Weaning_PN_for_Poppy\" >Weaning PN for Poppy<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/#The_Nutrition_Care_Process_Model\" >The Nutrition Care Process Model<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/pn-evaluate\/#Acknowledgements\" >Acknowledgements<\/a><\/li><\/ul><\/nav><\/div>\n<h1><span class=\"ez-toc-section\" id=\"Evaluating_the_Nutrition_Care_Plan\"><\/span>Evaluating the Nutrition Care Plan<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<p>After you have implemented your nutrition care plan, you need to follow-up and evaluate it to ensure that it has been effective in addressing your patient&#8217;s nutrition concerns. This can help you to decide on appropriate changes to make to the nutrition care plan moving forward.<\/p>\n<p>When evaluating your plan in a inpatient setting, you will need to gather updated information from the same key areas of nutrition concern that you identified in your initial assessment. This will include, but is not limited to: parenteral feeding delivery\/ tolerance, daily intake and outputs, laboratory values, medications, disposition, and any changes to the medical care plan. Also consider if PN is still indicated, or if your patient could transition to EN or an oral diet.<\/p>\n<table class=\"grid\" style=\"height: 261px\">\n<caption>Questions to evaluate nutrition care plan effectiveness<\/caption>\n<tbody>\n<tr style=\"height: 17px\">\n<th style=\"height: 17px;width: 231.625px\" scope=\"col\"><strong>Common Nutrition Issues<\/strong><\/th>\n<th style=\"height: 17px;width: 676.625px\" scope=\"col\"><strong>Evaluate effectiveness of NCP<\/strong><\/th>\n<\/tr>\n<tr style=\"height: 70px\">\n<td style=\"height: 70px;width: 231.625px\">Parenteral Nutrition<\/td>\n<td style=\"height: 70px;width: 676.625px\">\n<ul>\n<li>Has the patient experienced any side effects or complications?<\/li>\n<li>Are they meeting their estimated requirements with the current plan? Does it need to reassessed?<\/li>\n<li>Is parenteral nutrition still warranted?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 52px\">\n<td style=\"height: 52px;width: 231.625px\">Daily Intake and Output<\/td>\n<td style=\"height: 52px;width: 676.625px\">\n<ul>\n<li>Fluid balance?<\/li>\n<li>Volume of nutrition received?<\/li>\n<li>Changes in head to toe assessment?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<td style=\"height: 17px;width: 231.625px\">Malnutrition<\/td>\n<td style=\"height: 17px;width: 676.625px\">\n<ul>\n<li>Has weight increased? Decreased?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 35px\">\n<td style=\"height: 35px;width: 231.625px\">Electrolytes and Laboratory Work<\/td>\n<td style=\"height: 35px;width: 676.625px\">\n<ul>\n<li>Are the laboratory values normal?<\/li>\n<li>Are further replacements\/ supplements required?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 70px\">\n<td style=\"height: 70px;width: 231.625px\">Medical Care Plan<\/td>\n<td style=\"height: 70px;width: 676.625px\">\n<ul>\n<li>Are there any changes to the medical care plan?<\/li>\n<li>Changes in medications that impact the nutrition care plan?<\/li>\n<li>Any updated laboratory work, tests, procedures or assessments?<\/li>\n<li>Disposition planning? Does this impact your nutrition care plan?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Evaluating_Poppys_Nutrition_Care_Plan\"><\/span>Evaluating Poppy&#8217;s Nutrition Care Plan<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<table class=\"grid\" style=\"height: 266px\">\n<caption>Outcomes of Poppy&#8217;s nutrition care plan, by issue type<\/caption>\n<tbody>\n<tr style=\"height: 31px\">\n<th style=\"height: 31px;width: 185.688px\" scope=\"col\">Common Nutrition Issues<\/th>\n<th style=\"height: 31px;width: 639px\" scope=\"col\">Evaluate effectiveness of NCP<\/th>\n<th style=\"height: 31px;width: 454.625px\" scope=\"col\">Poppy&#8217;s outcomes<\/th>\n<\/tr>\n<tr style=\"height: 63px\">\n<th style=\"height: 63px;width: 185.688px\" scope=\"row\">Parenteral Nutrition<\/th>\n<td style=\"height: 63px;width: 637.562px\">\n<ul>\n<li>Day 3 of PN administration, no complications, increase to 75%-100% of requirements<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 63px;width: 453.188px\">\n<ul>\n<li>Evaluate nutrition plan and patients medical status for safety of increase<\/li>\n<li>Monitor closely for refeeding syndrome or complications with increase<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 31px\">\n<th style=\"height: 31px;width: 185.688px\" scope=\"row\">Daily Input and Output<\/th>\n<td style=\"height: 31px;width: 637.562px\">\n<ul>\n<li>Urine output &gt; 2 L\/day (IV Lasix (furosemide))<\/li>\n<li>+5 L fluid balance<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 31px;width: 453.188px\">\n<ul>\n<li>Fluid overload \u2013 maintain fluid restriction in nutrition care plan<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 31px\">\n<th style=\"height: 31px;width: 185.688px\" scope=\"row\">Malnutrition<\/th>\n<td style=\"height: 31px;width: 637.562px\">\n<ul>\n<li>Only two days since initiation \u2013 no need for evaluation at this time. Can re-weigh patient to confirm decrease in total fluid balance if desired.<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 31px;width: 453.188px\">N\/A<\/td>\n<\/tr>\n<tr style=\"height: 47px\">\n<th style=\"height: 47px;width: 185.688px\" scope=\"row\">Abnormal Electrolytes<\/th>\n<td style=\"height: 47px;width: 637.562px\">\n<ul>\n<li>Elevated: WBC, BG, Cr, BUN<\/li>\n<li>Low: Hgb, K, Mg<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 47px;width: 453.188px\">\n<ul>\n<li>Continue to monitor (up to 7 days)<\/li>\n<li>Liaise with team regarding replacements, if determined as necessary<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 63px\">\n<th style=\"height: 63px;width: 185.688px\" scope=\"row\">Medical Care Plan<\/th>\n<td style=\"height: 63px;width: 637.562px\">\n<ul>\n<li>Patient reports increased abdominal pain distension<\/li>\n<li>GI surgery team schedules OR \u2013 finds 20 cm segment of necrotic bowel in terminal ileum \u2013 25 cm resected, primary anastomosis<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 63px;width: 453.188px\">\n<ul>\n<li>Potential for postoperative ileus \u2013 need for assessment<\/li>\n<li>GI surgeon recommends continuing TPN for one week prior to trial of enteral feeding<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Poppy is on day 3 of PN administration with no complications, therefore it would be appropriate to advance her PN solution to 75%-100% of her estimated nutrition requirements. It is important that we still monitor closely for refeeding syndrome and complications that may result with this increase.<\/p>\n<p>Poppy\u2019s fluid balance is +5 L, which is an improvement from +10 L and she has a urine output of &gt;2 L per day. Although Poppy is still considered fluid overloaded, she is moving in the right direction. For now, maintain fluid restriction in the nutrition care plan as per MD orders.<\/p>\n<p>Poppy\u2019s laboratory results reveal that her WBC, BG, Cr and BUN are elevated and her Hgb, K, and Mg are low. It would be important to liaise with the team regarding replacements for low K and Mg, and continue monitoring her laboratory values as PN volumes increase.<\/p>\n<p>Lastly, Poppy continued to experience <button class=\"glossary-term\" aria-describedby=\"150-2137\">++<\/button> abdominal pain and distension. Taking the CT abdominal results into consideration, the GI surgery team schedules an OR and finds a 20 cm segment of necrotic bowel in the terminal ileum resulting in a 25 cm small bowel resection. Post operatively, the GI surgeon recommends continuing TPN for one week and then to trial enteral feeding upon evaluation of Poppy\u2019s clinical status.<\/p>\n<\/div>\n<\/div>\n<h1><span class=\"ez-toc-section\" id=\"Weaning_PN\"><\/span>Weaning PN<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<p>There are various strategies for weaning PN. Patients may transition from PN to enteral feeding or an oral diet. The oral diet may consist of various textures and oral supplements are also taken into consideration.<\/p>\n<p>Here is a general procedure for weaning PN for patients transitioning to enteral feeding:<\/p>\n<ul>\n<li>PN may be weaned when patient is able to tolerate oral intake\/EN.<\/li>\n<li>PN should be reduced as oral intake\/EN improves. PN should be reduced by an amount that is equal to the calories and protein provided via oral intake\/EN.<\/li>\n<li>Calories counts can be used to assess adequacy of oral intake. Reduced oral intake can be expected if PN provides &gt; 25% kcal requirements.<\/li>\n<li>PN may be discontinued when patient is tolerating 50-75% energy and protein requirements via oral intake\/EN, unless impaired GI function precludes 100% absorption of nutrient needs.<\/li>\n<li>Some institutions do not gradually wean PN. PN is continued at goal rate and discontinued when the patient is receiving ~50% of their estimated nutrition requirements via enteral nutrition or oral intake.<\/li>\n<\/ul>\n<p>Pause here and consider how you may start a trial of enteral nutrition for Poppy.<\/p>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Weaning_PN_for_Poppy\"><\/span>Weaning PN for Poppy<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p>This is what you could do to start a trial of enteral nutrition for Poppy:<\/p>\n<ul>\n<li>Liaise with the GI surgery MD\/ICU team to ensure they agree with restarting EN.<\/li>\n<li>Re-evaluate Poppy\u2019s estimated nutrition requirements: energy, protein, fluid<\/li>\n<li>Complete a head-to-toe assessment<\/li>\n<li>If the team agrees to initiate EN, start conservatively to evaluate GI tolerance:\n<ul>\n<li>Example (\u201ctrickle feed\u201d): Isosource 1.5 @ 10 mL\/hour \u00d7 24 hours = 240 mL\/day<\/li>\n<\/ul>\n<\/li>\n<li>Ask her RN to monitor closely for signs any of GI intolerance.<\/li>\n<li>If EN is well tolerated, decrease PN gradually as EN rate increases as described above. Review flow sheets or documented \u201cins and outs\u201d in Poppy\u2019s chart to assess PN &amp; EN volumes received. Use this information to avoid overfeeding and continue to meet her estimated nutrition requirements, as you adjust and transition to EN.<\/li>\n<\/ul>\n<p><strong>Considerations:<\/strong> absorption of nutrients is likely to remain adequate as a small portion of poppy\u2019s small bowel was removed (removal of 25 cm of ileum \u2013 vitamin B12 and bile salts absorbed in terminal ileum).<\/p>\n<\/div>\n<\/div>\n<div>\n<h1><span class=\"ez-toc-section\" id=\"The_Nutrition_Care_Process_Model\"><\/span>The Nutrition Care Process Model<span class=\"ez-toc-section-end\"><\/span><span class=\"ez-toc-section-end\"><\/span><\/h1>\n<\/div>\n<div>\n<p>As you use the Nutrition Care Process Model and the learning from this case study as a guide throughout your patient care in practicum, please keep in mind that the process is dynamic, and not step-by-step as all cases are different. You are encouraged to complete the recommended readings for this module and continue to expand your learning in this clinical area of practice.<\/p>\n<\/div>\n<div class=\"textbox shaded\">\n<p><span>PART 4: EVALUATE COMPLETE. Pause to reflect on the evaluation strategies discussed, and review the readings and resources in the following section for your information.<\/span><\/p>\n<p>You\u2019ve now completed the Parenteral Nutrition module. Please consider providing feedback through the embedded form in the next section.<\/p>\n<\/div>\n<h1><span class=\"ez-toc-section\" id=\"Acknowledgements\"><\/span>Acknowledgements<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<p>Emily Opperman, MSc, RD<\/p>\n<p>Michaela Kucab, MHSc, RD<\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"150-2137\" hidden><p>Present Significantly<\/p>\n<\/div><\/div>","protected":false},"author":315,"menu_order":5,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-150","chapter","type-chapter","status-publish","hentry"],"part":110,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/150","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/users\/315"}],"version-history":[{"count":18,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/150\/revisions"}],"predecessor-version":[{"id":2257,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/150\/revisions\/2257"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/parts\/110"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/150\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/media?parent=150"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapter-type?post=150"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/contributor?post=150"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/license?post=150"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}