Denielle Saitta & Alyssa Schroeder

NCP
Renal & Nutrition Support
I.

Introduction: Patient Profile

Patient F is a 68 year old AA woman admitted to Neuro. Extensive medical issues
includes: abdominal wound dehiscence, acute renal failure, anemia, clostridium difficile
colitis, depression, diarrhea, deep vein thrombosis, electrolyte imbalance, H/O ischemic
bowel disease, hypertension, hypokalemia, ileostomy, intra-abdominal abscess,
leukocytosis, methicillin resistant staphylococcus aureus, pneumonia, respiratory failure
requiring intubation, systemic inflammatory response syndrome, protein-calorie
malnutrition, hypomagnesemia and septic shock Patient has a past surgical history of
exploratory laparotomy, ileostomy revision, I and D of wound dehiscence, tracheostomy,
and PEG tube in place. Her current nutritional issues include acute renal failure,
anemia, diarrhea, ischemic bowel disease, hypertension, hypokalemia, electrolyte
imbalance, and malnutrition.
II. Disease Process
Wound Healing:
Wound healing is a complex series of interactions that requires adequate blood and
nutrients provided to the site of injury. There are four phases of wound healing:
hemostasis, inflammation, proliferation, and remodeling. Nutrition plays a key role to
promote wound healing. The important nutrients include:
Vitamin A: enhances inflammation phase, stimulates immune response
Vitamin C: collagen synthesis, supports immune response, tissue antioxidant
Zinc sulfate: DNA synthesis, cell division, protein synthesis
Vitamin E: major lipid-soluble antioxidant in skin
Bromelain: only used post-surgery; reduces edema, bruising, pain, and healing
time; enhances inflammation response
Protein: prevents delayed healing and surgical complications
ASPEN Nutrition recommendations for wound healing:
Stage

Total Calories

Protein

Fluid

Stage I: persistent
redness or change in
color of skin

Maintenance: 30-35
kcal/kg

1.25-1.5 g/kg

> 30
ml/kg

Stage II: superficial

ulcer (blister,
abrasion, shallow
crater)

Slightly above
maintenance: 30-35
kcal/kg

1.25-1.5 g/kg

> 30
ml/kg

Stage III, IV: mildly

30 kcal/kg

1.25-1.5 g/kg

> 30-35

catabolic state
Stage III, IV:
moderate-severe
catabolic state

ml/kg
35-40 kcal/kg

1.5-2.0 g/kg

> 30-35
ml/kg

Tracheostomy:
A tracheostomy is a surgical opening made in the trachea to assist breathing. A
tracheostomy tube is placed surgically in the stoma. Usually performed to bypass an
obstruction, or to clean and remove secretions from the trachea and prevent them from
entering into the lungs, or to more easily and safely deliver oxygen to the lungs when
the patient is unable to breathe without assistance.
Nutritional implications: There are many complications related to the presence of a
tracheostomy tube, including the inability to speak or swallow normally. Patients with
tracheostomy tubes who are on mechanical ventilation are often at high risk for
aspiration. Frequently these patients require enteral nutrition. When it is safe for
patients to eat orally, the texture of the food often makes a difference. Work with an
SLP is often required.
PEG Tube & Nutrition Support:
Percutaneous endoscopic gastrostomy (PEG) is a procedure used by a physician to
insert a feeding tube through the skin and into the stomach using an endoscope. A
needle is used to puncture the abdominal wall into the stomach, the gastrostomy tube is
inserted into the stomach through the new opening. Advantages of PEG: outpatient
procedure without risk of anesthesia, longer-term feeding access, less expensive than
surgical insertion, reduced risk of tube displacement, and allows for bolus feeding.
Disadvantages of PEG: risk of irritation and infection for insertion site. Due to Patient Fs
tracheostomy a PEG tube was placed for enteral nutrition support.
Nepro with Carb Steady was chosen for Patient F due to patient respiratory function,
renal status/ dialysis, pertinent labs (low electrolytes, BUN, Creatinine, EGRF),
ventilation intubation.
Dialysis & Renal Function:
Dialysis is the removal of waste and extra chemicals and fluid from the blood to assist in
proper kidney function. Proper nutrition for acute renal failure is important for overall
health and quality of life. Adequate calories is essential for energy, weight
management, and help use protein for tissue repair. Prior to dialysis, low-protein diets
are recommended to limit the amount of waste products in your blood. Since starting
dialysis, protein is needed for muscle building, tissue repair, and immune protection.

Increased levels of sodium can cause thirstiness and fluid retention. Excess sodium and
fluid can cause edema, fluid weight gain, SOB, rise in BP, and increased work load on
the heart. Increased levels of Phos in diet will increase amount of Phos in blood.
Dialysis cannot remove all this Phos. Phos buildup causes Ca to be depleted from the
bones and can also cause Ca-Phos crystals to build up in joints, muscles, skin, blood
vessels, and heart. Potassium helps muscles and heart to function properly. Too much
or too little potassium in the blood can be dangerous.
III. Patient history:
Patient F. transferred from local hospital to SGA to receive treatment closer to family
members in the area. Patient appeared to be in septic shock with acute renal failure and
shortly after went into acute respiratory failure when arriving at previous hospital. Her
underlying etiology was ischemic bowel. The patient is on CVVHD due to acute renal
failure. She remained intubated throughout these procedures. She was put on
tracheostomy and ventilated that way after about a week. She was then weaned off of
CVVHD and underwent dialysis T, TH, and Sat. The patient was noted to have a very
large abdominal wound from her stump revision. They placed a PEG tube to introduce
nutrition for this patient.
On arrival to SGA, patient was on trach collar and stable. She stayed on dialysis T, TH,
and Sat. Wound care was consulted and was placed on a wound VAC with changes
approximately every other day.
Patient F. was seen for following B/S swallow evaluation. SLP assessed patients
swallow function with ice chips, thin water, nectar thick grape juice, and bites of
applesauce. Patient with delayed cough after thin liquid trials, very weak/nonproductive. No overt S/S aspiration present with ice chips, nectar, or puree trials. Patient
presents with higher risk for aspiration and decreased ability to clear airway.
IV. Course of hospital treatment N/A
V. Nutrition Care
a. Nutrition Assessment

Weight:
o 75 kg = 166 lb
o Weight changes likely due to fluid retention

Height:
o 165 cm = 65 in

BMI:
o ((166 lb)/((65 in)(65 in)) x 703 = 27.6 kg/m 2
o Overweight

Ideal Body Weight:

o 100 + 5(5) = 125 lb
o 166/125 = 133%

Labs:

o NA: 127 L
o K: 3.7
o CL: 92 L
o BUN: 67 H
o CREATININE: 3.9 H
o GLUCOSE: 144 H
o CA: 8.2 L
o P: 5.3 H
o ALBUMIN: 1.8 L
o WBC: 12.24 H
o RBC: 2.7 L
o HGB: 7.3 L
o PHOSPHORUS: 6.8 H
o HCT: 22.6 L
o EGFR: 11.46 L
Pertinent Medications
o Colace treating constipation
o Epoetin treating anemia
o Prevacid treating heartburn and acid reflux disease
o Senna treating constipation
o Diflucan - treating fungal infection
o Oxycodone - treating pain
o Percocet - treating pain
o Zosyn - treating bacterial infections
o Lactinex - treating digestion, preventing diarrhea, and symptoms of IBS
o Zyvox - treating bacterial infections
o Flagly - treating bacterial infections
Nutrition Needs:
o Needs estimated using: 75 kg
O Kcal: 1875 2250 kcal (25 30 kcal/kg)
o Protein: 113 - 150 g protein (1.5 - 2.0 g/kg for wound healing)
o Fluid: 1875 - 2250 ml (1 ml/kcal)
o Nutrition support: Nepro @ 45 ml/hr + Healthy Shot TID
KCAL: 2082 kcal
PROTEIN: 152 g
FLUID: 1320 ml per day (25 ml/hr free H2O per MD)

b. Diagnosis (PES) Statement

Increase nutrient needs related to wound healing as evidenced by abdominal wound 30
cm x 30 cm.
Altered nutrition related lab values related to acute renal failure as evidenced by
increased Phos (5.3) and Creatinine (3.1).
c. Intervention Plan & Implementation

 RECS:
Begin Nepro with Carb Steady at 15ml/hr increasing 10ml Q8H to goal rate of
45ml/hr running for 22 hr/day if medically appropriate
1,782 kcals/day, 80 g Protein/day, 720 ml free H2O
25 ml/hr free H2O or per MD
Suggest Healthy Shot TID to help reach protein needs required for wound
healing.
300 kcals/day, 72 g Protein/day
Vitamin C 500 mg TID and Zinc Sulfate 220 mg/day x 12 days to aid in wound
healing
d. Monitoring/Evaluation
RD will monitor TF tolerance, pertinent labs, wound healing, fluid status, weight, and
overall nutritional POC.

1.
2.
3.
4.

Goals:
Tolerate EN and provide >90% nutritional needs
Maintain weight status
Prevent/ correct nutrient deficiencies
Promote wound healing

e. Documentation
Completed
References:
Nahikian-Nelms, M. (2011). Nutrition therapy and pathophysiology. Belmont, CA:
Wadsworth, Cengage Learning.
The National Kidney Foundation. (n.d.). Retrieved May 17, 2016, from
https://www.kidney.org/
MacKay, D. & Miller, A.L. (2003). Nutritional support for wound healing. Alternative
Medicine Review 8(4), 359-377.