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Undernutrition in a Multiple Sclerosis patient.

Undernutrition in a Multiple Sclerosis patient.

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Fifty two year old patient who was diagnosed with Multiple Sclerosis (MS) over 20 years ago. In October 2004, swallowing problems developed. Symptoms of her diagnosis include fatigues and therefore tires easily especially while eating. Patient had a shortfall of 500kcal, 29g protein and 725ml of fluid. Nutritional supplements were perscribed in order to meet the patients requirements.
Fifty two year old patient who was diagnosed with Multiple Sclerosis (MS) over 20 years ago. In October 2004, swallowing problems developed. Symptoms of her diagnosis include fatigues and therefore tires easily especially while eating. Patient had a shortfall of 500kcal, 29g protein and 725ml of fluid. Nutritional supplements were perscribed in order to meet the patients requirements.

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Published by: Undergraduate Awards on Sep 01, 2012
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12/17/2013

 
C Plac
ement Case StudyIntroduction:
Fifty two year old patient who was diagnosed with Multiple Sclerosis (MS) over 20years ago. The patient is currently residing in a nursing home in Belfast andtherefore this was a domiciliary visit. This patient was referred by her GP inSeptember 2008 due to weight loss.MS is a disease of the white matter of the central nervous system (CNS) affectingthe brain and the spinal cord. It is characterised by the degeneration and scarringof a layer of oligodendrocyte cells that surround the axon of a neurone, termed themyelin sheath (Figure 1 in appendices). The myelin sheath usually protects theneurone; however, in MS it is known the T-lymphocytes penetrate the blood-brainbarrier of the CNS to mount and autoimmune attack on the oligodendrocytes. As aresult, conduction of nerve impulses along the affected axon is impaired (Thomas,2007).A study carried out in Northern Ireland showed that the prevalence of MS was 168per 100,000. Female predominated (ratio 2.1:1) and the average age of onset was31.6 years. At any one time approximately 254 people in Northern Ireland have MS(Mc Donnell & Hawkins, 2000).
Social History:
Resident in a nursing homeMarried - good support from husband
Relevant Medical History:
Diagnosis: Multiple SclerosisOnset of symptoms: This patient was diagnosed with MS greater than 20 yearsago. In October 2004, swallowing problems developed. Speech deteriorated fromthe time following this. The patient currently has short term memory problemswhich have developed in the previous 3-4 years.Drugs: Table 1 in appendices. The patient experienced no side effects orcomplications with the medication.Medical History:Epileptic seizuresSwallowing problems secondary to MSShort term memory problems secondary to MSProne to pressure sores due to lack of mobility The memory problems and the swallowing difficulties have implementations onthe patients eating patterns. Therefore she eats slowly and finds it difficult tofinish meals.
 
Current episode of care:
Presenting problem: This patient became a resident in a nursing home in June2006. She is immobile and a wheelchair user. Symptoms of her diagnosis includefatigues and therefore tires easily especially while eating. She requires fullassistance with feeding as is at risk of choking due to swallowing difficulties. Thisalong with the patient’s short term memory problems makes feeding difficult andthe patient has therefore lost weight recently. The patient’s pressure sores havecurrently healed and extra care has been provided to prevent them returning. Timescale: This patient has been diagnosed with MS for greater than 20 years. Inthe previous 3 – 4 years this patient has presented with the side effects of thedisease, i.e. fatigue, bladder dysfunction, bowel problems, muscle weaknesstherefore causing immobility and potentially leading to the pressure sores,swallowing difficulties and cognitive difficulties resulting in memory problems andthe problems with feeding herself have therefore subsequently developed fromthe side effects.Monitoring: Table 2 in appendices. On liaising with the nursing staff, no concernedwas expressed over routine monitoring and all was recorded sufficiently in thepatient’s care plan.
Medical Treatment:
 The main medical concern of this patient is trying to prevent further progression of the MS and controlling the symptoms of the epileptic seizures. The patient hasbeen fully assessed by occupational therapy (OT) as she is wheelchair bound andat a risk of developing pressure sores. The wheelchair has been adapted with apressure relief cushion and the patient also has an air pressure mattress. She hasbeen fully assessed by speech and language therapy (SALT) andrecommendations are that she is commenced on a puree diet with yoghurtconsistency fluids. Further examination showed that she should be positionedcorrectly, have minimal distraction, feed with small amounts slowly and requiresfull assistance while feeding in order to reduce risks of choking.Biochemistry: This patient was stable and there were no concerns over unstableblood biochemistry therefore I was unable to obtain recent blood results for thispatient as they were not done on a routine basis.
Dietary Intervention:
Initial Assessment: Wednesday 15
th
October 2008Diet History: Table 3 in appendices. As the patient had short term memoryproblems, a diet history was obtained from the nurse in charge of the patient.Dietary intake was estimated to be ~1,180kcal, 39g protein and 1,600mls of fluid.Anthropometry: Figure 2 in appendices. As the patient was a resident in a nursinghome, weight and height were the only measurements taken for this patient.Other measurement such as waist circumference and skin fold thickness would
 
have been difficult to undertake due to the patients lack of mobility and beingwheelchair bound.Requirements: Figure 3 in appendices. A 15% activity factor was chosen as thepatient was taken out of bed daily to sit. Weight maintenance was chosen asalthough the patient had lost weight, her BMI was currently 23kg/m
2
. Nitrogen of 0.17g was chosen as although the patient was a risk of pressure sore, she hadcurrently no open wounds. As he patient was less than 60years, 35mls of fluid perkg was chosen.Shortfall: 500kcal, 29g protein and 725ml of fluidAims:
 To prevent further weight loss
 To prevent the development of pressure sores
 To increase fluid intakeDietary Regimen: Food fortification advice was provided to the nurse in charge of the patient and it was also recommended that they would use full cream milk asopposed to semi-skimmed milk for this patient. The nurse in charge was providedwith a food fortification sheet and a goal sheet (Figure 3 in appendices).As community dietetics is not contracted to one company for supplements, a trialof supplements has to be commenced when a patient is starting on supplement of at least 3 difference companies. The patient had a modified consistency diet;therefore the trial was very important in order for staff to determine whichsupplement they found the easiest for the patient to take when thickened. Ten of each of the following was trailed:
Fortijuce - the patient preferred juice flavoured supplements (300kcal, 12gprotein)
Ensure Plus Juce Style – the patient preferred juice flavoured supplements(300kcal, 12g protein)
Forticreme supplement would not have to be thickened, thereforeconvenient for staff (200kcal, 11.9g protein)
Fortimel – increased protein supplement without added extra of too manycalories (200kcal, 20g protein)
Fresubin Protein Energy increased protein supplement with extracalories(300kcal, 20g protein) The nurse was informed that the patient should receive two supplements per dayfor the trial which was to last one month.Ideally from the trial, in order to meet the patient’s requirements sufficiently, wewould have liked the patient and the staff to choose the Forticreme and one of themilky based supplements in order to meet protein requirements.

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