fsn429.SoapNote4 - mg/kg/min which is too high Generally we...

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SOAP note October 26, 2011/10:00 O. 55 YOWF Ht: 168.9 cm/66.5” Wt: 65 kg/143 # Kcal:gm N: 156.25 above nl BMI: 22.8 kg/m 2 nl IBW: 60 kg/132 # (92% IBW) mild deficit UBW: 72 kg/158.4 # (88%UBW) mild deficit 9.7% weight loss in the past 2 weeks. (severe) EER: 1900-2000 kcal/day (30 kcal/kg) Estimated protein requirement: 78 gm/day (1.2 gm pro/kg) Fluid Requirement: 2275 ml (35 mL/kg) A. (PES) Altered GI function related to perforated bowel/fistula closure and nausea and vomiting as evidenced by need for TPN. Pt has BMI of 22.8, which is considered normal. Her weight loss of 7 kg/15.4# weight loss is considered severe loss (>5%) since it is in a short amount of time (two weeks). Since she is unable to keep food in, her doctor orders TPN of 450 g dextrose, 60 g amino acids, and 100 g lipids on the first day. The amino acids are too low and the dextrose and lipids are too high. Risks associated with too high an amount of dextrose are hyperglycemia, hypertriglyceridemia, fatty liver, elevated carbon dioxide levels and electrolyte imbalances. This has a GIR of 4.8
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Unformatted text preview: mg/kg/min, which is too high. Generally we start with 1-2 mg dextrose/kg/min and work up to a goal of 4 mg/kg/min. P. Follow these guidelines: TPN needed for more than 2 weeks to allow for healing of perforated bowel/fistula closure. Goal: GIR (glucose infusion rate): 12917 mg= 3.31 mg/kg/min Recommended: Day 1: 2275 ml, GIR: 1.66 mg/kg/min, 7 % dextrose, 3.43 % AA concentration, 292.5 ml of 20% IL, 1423.5 kcals, 78 g protein Day 2: 2275 ml, GIR: 2.48 mg/kg/min, 10.5% dextrose, 3.43 % AA concentration, 292.5 ml of 20% IL, 1686.75 kcals, 78 g protein Day 3: 2275 ml, GIR: 3.31 mg/kg/min, 14% dextrose, 3.43 % AA concentration, 292.5 ml of 20% IL, 1950 kcals, 78 g protein TPN Breakdown: 312 kcals from protein 585 kcals from fat 1053 kcals from dextrose 310 g dextrose 14% dextrose concentration Follow-up in 2 weeks for weight check and diet assessment. Kim Chin, RD...
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