Assignment task:
Complete a nutrition assessment. Three years later, Mr. Fernandez is taken emergently for a CABG x 4 due to 70% vessel occlusion. Today is admit day #1 and he is currently on the ventilator due to post-op respiratory distress and hypoxia. A nutrition consult is ordered. MIV is running at 100 mL/hour with D5W and 20 mEq of KCl. Unable to obtain a nutrition history from the patient but his wife reports that he hasn't been eating well for some time since he hasn't been feeling well. Past Medical History: Hypertension, dyslipidemia, depression. Has experienced an unintentional weight loss of 50 lbs. in the past 3 months - his wife reports "he just hasn't been hungry." Medications prior to admission: Lipitor, Lasix (80 mg/d), Lisinopril Current Medications: Aspirin, Lipitor, Plavix, Lasix, Lisinopril, Propofol @ 21 mL/hr Dietary Supplements: None Height: 5'8" Weight History: • 6 Months Ago: 225 lbs • 3 Months Ago: 204 lbs • Current Weight: 174 lbs Laboratory data: Na++: 134 (135-145) K: 4 (3.5-5) Cl: 97 (96-106) Phosphorus: 2.2 (2.5-4.5) HCO3: 25 (20-29) BUN: 11 (7-21) Cr: 1.5 (0.6-1.2) Magnesium: 1.5 (1.5-2.5) Gluc: 150 (70-99) Ca++: 7.5 (8.5-10.2) Alb: 2.9 (3.5-5.5) WBC: 11 (5-10) I/O: