Question

Patient: Mr. Rogers. Gender: Male Age: 79 4/4/2040 Setting: Medical Surgical Unit in Hospital. Pre-existing Conditions: Diabetic Type II, Chronic Leg Ulcers, Peripheral Vascular Disease, Stroke, and Aphasia.

Mr. Rogers is 79-year old male that came into the ER with complaints of Right lower leg pain. He was found to have cellulitis of his right calf. Patient states, “I know my leg wounds have been draining a lot lately, but for the last 2 days my leg feels inflamed and burning. I have been running a temperature and have fever/chills feeling.”

Upon assessment of his right leg, there is swelling, redness, and the temperature to the leg is hot compared to surrounding tissue.

His temperature is 101.9, His pedal pulse is strong. The drainage from the right leg is purulent, with a foul odor.

The health care provider orders an x-ray and Ultrasound for Mr. Rogers right leg. The diagnosis is cellulitis of his right lower extremity. The provider uses a skin marker to draw an outline of the redness. The patient is started on Zosyn and Clindamycin IV. The nurse established an IV site, draws his labs. His ESR is elevated, his CRP is elevated, and his WBC are 22,000.

Mr. Rogers is admitted to the hospital for IV antibiotics. While in the hospital the provider orders a diabetic diet, glucose checks, ac and hs, and dressing changes.

This am the nurse witnesses Mr. Rogers having difficulty swallowing his breakfast. The nurse alerts the MD and the MD orders a swallow study and NPO. Mr. Rogers fails his swallow study, showing he is aspirating liquids when he swallows. Knowing the importance of nutrition for wound healing, how could Mr. Rogers receive nutrition?

What do you think the Provider will order?

The Provider ordered for Mr. Roger to have a Naso-jejunum tube placed and to start tube feedings. The order to receive 2000 calories a day to maintain adequate calories for wound healing.

The tube feeding comes in 2000 ml bags, the diet order is: Tube feedings continuously for 24 hours. Free water flushes of 150ml every 4 hours.

What rate would you set the tube feeds to run at?

Who much free water would he receive in 24 hours?

When the tube feedings are started, the am PCA tells the nurse the patients’ blood sugar this am was 350. The nurse alerts the MD of the high blood sugar and orders for him to receive Novolog Sliding scale. Novolog 0-150 0 units 151-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units 400 or greater call MD. Mr. Rogers takes daily medications Metformin 500mg BID NPH 20 units every am Aspirin 81mg daily Metoprolol 25mg daily

As you are preparing his am dose of Insulin. How much Insulin do you give per the Sliding scale order?

Answer 1

The rate should set about 1.4ml/hr over 24 hours it should be enough to get the target intake.

As per the sliding scale we can gave 6 units of insulin meantime patient have the complaints of a dysphagia and aspiration tendency so the oral hypoglycemic agents may not be a suitable choice.