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Imagine that you are a nutrition assistant working at a pediatric rehabilitation center. This rehabilitation center
provides care for pediatric patients who are recovering from recent hospitalizations. This facility is considered
to be the bridge between critical care type hospitals and home care.
The supervising dietitian informed you that a new patient was admitted overnight from the nearby hospital and
is now recovering from a skin graft surgery due to a severe pressure ulcer (bed sore). Imagine that you are
asked to review the patient’s chart notes and provide a nutrition assessment summary along with
recommendations for a therapeutic diet or nutrition support (i.e. either enteral or parenteral nutrition with or
without an oral diet).
Patient information from the hospital medical chart:
Name: Cindy
Age: 6-year-old female
Height: 43 inches
Weight: 38 pounds
Admitting Diagnosis (Dx): Cerebral Palsy, bedridden, stage 3 pressure ulcer on sacrum, food allergy to eggs
Surgery: Skin graft performed to increase healing and reduce further infection risk.
Diet order: Thickened liquids and pureed foods with precautions due to dysphagia (swallowing deficiencies)
associated with CP. No eggs: Severe Egg Allergy.
Speech/Cognitive: Patient receives speech and swallowing therapy due to CP. Her speech and cognitive
abilities were reported to be around that of a 2-year-old.
Cindy normally resides at home with her family. She qualifies for state-funded home medical assistance due to
the CP diagnosis. She is bedridden and relies on the home health nursing assistants for care. Her parents
have three other children and involve her in as many family activities as possible, but the actual care is
provided by the in-home medical team. Cindy has had a gastrostomy feeding tube (G-tube) since she was just
a few months old. In recent years, it has only been used nocturnally if her oral intake of the pureed/soft diet
foods fell below the 50% mark for two or more meals. She received a specialized enteral formula that did not
have eggs as any source of the protein.
For many years, Cindy was cared for by the same team of nurses and nursing assistants, and she did not have
any major medical or nutrition-related problems. However, about 6 months ago, the state funded program
changed home care contract companies and a new company began to provide care. Cindy’s parents felt that
the care was sub-standard and reported it numerous times, but without any improvements. It was not until
Cindy’s quarterly check-up that these problems were identified. Her weight had dropped by 15% in just 3
months, her albumin was low, and her lean muscle mass and strength had decreased. Most alarmingly, she
had developed a pressure ulcer on the sacrum. The MD immediately admitted Cindy into the hospital.
Upon further investigation, the new home health company had been administering nocturnal tube feedings with
a formula that contained egg as one of the partial sources of protein. They thought that it was a comparable
substitute for the previous brand. Additionally, they had misread the original nutrition order to only give night
enteral feedings (via the G-tube) if her oral intake was insufficient. Until the issues were discovered, Cindy
went several months receiving a full night of tube feedings that provided a feeling of fullness to her. She also
was suffering from chronic diarrhea and associated malabsorption. Subsequently, she would not feel well
enough to eat the next day and the cycle repeated itself daily. She also started having many more nasal and
respiratory symptoms, which the new care providers explained away as being typical seasonal allergies. She
was prescribed an antihistamine. Her parents were unaware of the nocturnal tube feedings because the
nursing staff would run them about 8–10 hours while the patient was asleep.
Why was Cindy at risk for a pressure ulcer? What were some of the contributing factors, and why?
What are the symptoms of an egg allergy? Why do you think her allergy was not ever life threatening when she
was receiving the nightly tube feedings at home?
Take into consideration her multiple medical conditions of cerebral palsy, egg allergy, and recent pressure ulcer
surgery, and calculate her estimated calorie needs and protein needs.
Recommend an appropriate tube feeding formula brand name or type that has no albumin from egg protein (for
the days that she does not have adequate oral intake of her meals).
Appendix: Design a full-day meal plan for Cindy that includes pureed/soft foods. This diet needs to fully
address her CP-related chewing/swallowing challenges. Be sure to consider her protein needs for wound
healing promotion and future prevention, but without foods containing eggs or egg by-products. Oral protein
drink supplements can be considered. Include the total calories, carbohydrates, fats, protein, and any
micronutrients that are important in this case


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