VIDEO TO WATCH

Stan Johnson Simulation01 - YouTube

CASE STUDY: "I was in an accident and brokemy leg"

HPI:

47 y/o WM with no significant PMHx that was BIBA, s/p MVA with resulting left femoral fracture and is POD 1 for ORIF is found to have elevated glucose during observation and stabilization in the 300+ range on Q6HR FSG checks. His labs are negative for ketosis. He has not shown any signs or symptoms of hyperosmolar coma post operatively. HgbA1C is 13% and pt is unaware of a family history of diabetes. He denies blurry vision, nocturia and urinary frequency. He denies numbness or tingling or swelling in his extremities. His hospital stay has been uncomplicated.

Summary:

47 y/o WM with no significant PMHx that was BIBA, s/p MVA with resulting left femoral fracture and is POD 1 for ORIF and newly dx'd Type 2 DM with hyperglycemia.

Problem 1: s/p ORIF, POD 1, for left femoral fracture

Plan: Consult Ortho Surgery, Consult PT, DVT PPX, Tramadol APAP 37.5/325 mg tablets PO Q6HR PRN for 5 days.

Problem 2: Uncontrolled Type 2 DM without complications

Plan: Sliding Scale Insulin, FSG checks every 2 hours postprandial, AM fasting and at bedtime, CMP and UA every day, Consult Nutrition, Consult Endocrinology

Admit to Med Surgery Unit

Dx: 1. s/p ORIF of left femur, 2. Uncontrolled Type 2 DM without complications

VS Q6HR

Activities: ad lib with assistance if needed. Use crutches with ambulation. Leg dressing change after assisted shower.

Allergies: NKDA

Diet: 2000 kcal consistent CHO diet

Ins: IVF, NS at 50 mL per hour

Outs: toilet or urinal without output measure

Daily Weight

Labs drawn by Phlebotomy Tech, FSG checks by RN or CAN

PLEASE FOLLOW THIS STEP FOR THE ASSIGNMENT:

Nutrition Consult:

Assessment

• Diagnosis (medical) ex:

• Past Med. History

• Anthropometrics Include:

• Labs/ biochemical data: look for nutritionally relevant labs (vital signs are usually not relevant, use your clinical judgement)

• Medications

• NFPF ex:

• Diet Rx

• Social History:

• Diet History:

• Est. nutritional needs

oPRO

oKcal

• Est. Fluid needs

Diagnosis

• P: Problem
• E: Etiology:
• S: Signs/Sx

Intervention

• Pt education/counseling (include family members in edu. If applicable)

• Include referrals/ coordination of nutrition care

• Goals

Monitoring and Evaluation- The purpose is to assess the outcomes of your intervention and to see if the goals are being met. Also look at current health status and this will determine if you need to make any adjustments going forward.

Outpatient

Anthropometrics

• Lab values/ Biochemical data

• NFPF
• Monitor swallowing function
• Monitor appetite
• Muscle/fat wasting