Nutrition Assessment 84 M admitted for CVA, with history of ETOH and little to no Intake for long time. In the first 36 hrs of admission, he remains aphasic and shows signs of dysphagia Diet: NPO PMH: liver Cirrhosis, HTN MEDS: heparin gtt, Plavix, Lopressor Ht: 70. Wt: 153# UBA: 180#. AST:180 ALT: 360 ALB:3.1. H/H: 10.1/31 151. 122.42 135 5.1. 24. 1.9 BMI: 21.94kg/m2 IBW: 166# %IBW:92.16% %UBW: 85% %Change:15% Est. needs: 1946-2085kcals/d (28-30kcal/kg) 83-97g protein (1.2-1.4g/kg) fluids: 2085ml(30ml/kg) Nutrition Diagnosis PES statement: Inadequate oral intake and swallowing difficulty RT dysphagia and ETOH use AEB signs of dysphagia, severe weight loss of 15% and low po intake Nutrition Intervention Nutrition Prescription: Nutren 1.5 @ 58 ml/hr to provide 2085Kcal, 83g protein and 973ml free H2O Goal: To meet nutrient needs via NDT Intervention/s: 1. Place NDT 2° aspiration risk 2. Initiate Nutren 1.5 at 25 ml/hr and increase 10ml Q6 hr to a goal rate of 58ml/hr 3. MVI 4. Consider Thiamine supplement 5. Social Work consult for ETOH Monitoring and Evaluation F/U with tolerance of formula in 24 hrs
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