CASE STUDY PRESENTATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD

CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD
Airflow limitation usually progressive Abnormal inflammatory response of the lungs to noxious particles or gases Cigarette smoke is the most common cause It is predicted that by 2020, will have become the 3rd most common cause of death worldwide

Presenter: Vania Lederman
DIE 6935 – Special Topics in Dietetics The Nutrition Care Process Professor: Evelyn B. Enrione, PhD, RD

May be subdivided: emphysema and chronic bronchitis

Decramera, M et al. Systemic effects of COPD. Respiratory Medicine (2005) 99, S3–S10

CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD

CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD SYMPTOMS
EMPHYSEMA Dyspnea (shortness of breath) Most noticeable during physical activity As emphysema progresses, dyspnea occurs at rest CHRONIC BRONCHITIS

Healthy Bronchy Healthy Alveoli

Chronic Bronchitis Emphysema Alveoli are enlarged and destroyed Bronchi are red and swollen, and congested with mucous secretions

Chronic cough and sputum production The sputum is usually clear and thick As bronchitis progress infections occur more frequently Periodic infections can cause fever, dyspnea, coughing, production of purulent sputum and wheezing

CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD NUTRITIONAL COMPLICATIONS OF COPD
Nutritional wasting: low-energy intake and high-energy requirements Early satiety: decreased appetite ↑ expenditure: need 10x more energy for breathing Fatigue impairs desire to prepare food Changes in metabolism: result of inflammation, hypoxia, hypercapnia, nutritional deprivation, and pharmacologic therapy
BEE x 1.3 – 1.5 – maintenance BEE x 1.5 – 1.7 – anabolism CHO = 40-55% PRO = 15-20% LIP = 30-40%
• Decramera, M et al. Systemic effects of COPD. Respiratory Medicine (2005) 99, S3–S10 • Escott-Stump, S. Nutrition and Diagnosis-Related Care. 5.ed. 2002.

OVERVIEW OF THE CASE
Case: Chronic Obstructive Pulmonary Disease Pt: Stella Bernhardt DOB: 10/23 Age: 62 Sex: Female Occupation: Retired insurance agency office manager for independent

Household members: Husband, age 68. PMH of CAD. Ethnic background: Caucasian Referring physician: Debra Bradshaw, MD (pulmonology)

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OVERVIEW OF THE CASE
Chief complaint:

OVERVIEW OF THE CASE
Patient history:
Medical Dx: stage 1 COPD (emphysema) 5 years ago • Meds: Combivent (ipratropium bromide and albuterol sulfate) • PMH: Bronchitis and upper respiratory infections during winter • Smoker: 1 ppd for 46 years – has quit 1 year ago • Family hx: CA – mother, 2 aunts died from lung cancer

Pt refers that she is hardly able to do anything by herself right now. Even taking a bath or getting dressed makes her short of breath.

OVERVIEW OF THE CASE
Physical exam:
• General appearance: 62-years-old female in no acute distress • Vitals: Temp. 98.8ºF HR 92 bpm RR 22bpm BP 130/88

OVERVIEW OF THE CASE
Hospital course:
• Admitting dx: Acute exacerbation of COPD, increasing dyspnea, hypercapnia, r/o pneumonia • Tx plan: O2 1L/min via nasal cannula, O2 saturation 90-91% IVF D5 ½ NS with 20mEq KCL @ 75 cc/hr Corticosteroid -Methylprednisone: Solumedrol Antibiotic -Chephalosporin: Ancef Bronchodilator: Ipratropium bromide, Albuterol sulfate ABGs q 6 hours, CXR, sputum cultures and Gram stain

• Heart: Regular rate and rhythm; mild jugular distension noted • Extremities: 1+ bilateral pitting edema. No cyanosis or clubbing • Neurologic: Alert, oriented; cranial nerves intact • Skin: Warm, dry • Chest/lungs: Decreased breath sounds, percussion hyperresonant; prolonged expiration with wheezing; ronchi throughout; using accessory muscles at rest • Abdomen: Liver, spleen palpable; nontender, normal bowel sounds nondistended,

OVERVIEW OF THE CASE
Hospital course:
Pt dx: Acute exacerbation of COPD 2º to bacterial pneumonia Pt responded well to tx for the emphysema, however COPD has progressed Discharged: home O2 therapy, referred to an outpatient pulmonary rehabilitation program Discharge meds: Combivent + oral course of costicosteroids + Keflex (10-d) The Physician ordered a nutrition consult

OVERVIEW OF THE CASE
Nutrition history:
• Appetite is poor, fast satiety • Meal preparations are difficult • In the previous 2 days, she has eaten very little • Coughing has made eating difficult • Food doesn’t taste good, it has a bitter taste • 5 years ago she weighted 145-150lb, now she is 119lb, 5’3” • She didn’t weight herself for a while, but clothes are bigger, dentures fit loosely her family tells her how thin she has gotten • Avoids milk: “People say it will increase mucus production” • No previous MNT • No vit/min supplementation

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OVERVIEW OF THE CASE
Nutrition history:
• Usual Dietary intake: AM: Coffee, juice or fruit, dry cereal with small amounts of milk Lunch: Meat, vegetables; rice, potato or pasta. Pt eat small amounts Dinner: Soup, scrambled eggs, or sandwich. Drinks Pepsi throughout the day (3 12-oz cans)
Chemistry Labs Albumin Total protein Prealbumin Transferrin Sodium Potassium Chloride PO4 Magnesium Osmolality Total CO2 3.4 5.9 19 219 136 3.7 101 3.1 2.1 280 31 92 9 0.9 3.4 9.1 0.4

OVERVIEW OF THE CASE
Pt values Normal range 3.5-5.0 6.0-8.0 19-43 200-400 135-155 3.5-5.5 98-108 2.5-4.5 1.6-2.6 275-295 24-30 70-120 8-26 0.6-1.3 2.6-6.0 8.7-10.2 0.2-1.3 Units g/dl g/dl mg/dl mg/dl mmol/L mmol/L mmol/L mmol/L mmol/L mmol/Kg H2O mmol/L mg/dl mg/dl mg/dl mg/dl mg/dl mg/dl Hematology Labs WBC RBC HGB HCT SEGS BANDS LYMPHS MONOS EOS
ABG’s Labs pH pCO2 pO2 SO2 CO2 content Carbonic acid Base excess Base deficit HCO3
-

Pt values 15 4 11.5 35 83 5 10 3 1

Normal range 4.3-10 4-5 12-16 37-47 50-62 3-6 25-40 3-7 0-3

Units x 103mm3 x 106mm3 g/dl % % % % % %
Units

1d Pt values 7.29 50.9 77.7 92 31 2.4 3.6 24.7

3d Pt values 7.4 40.1 90.2 30.8 1.2 6.0 29.6

Normal range 7.35-7.45 35-45 ≥ 80 ≥ 95% 25-30 >3 <3 24-28

mmHg mmHg mmol/L mmol/L mEq/L mEq/L mEq/L

• 24h recall: ½ c coffee with nondairy creamer, few sips of orange juice, ½ c oatmeal with 1 tsp sugar, ¾ c chicken noodle soup, 2 saltine crackers, ½ c coffee with nondairy creamer, 32oz of Pepsi per day.

Glucose BUN Creatinine Uric acid Calcium Bilirrubin

NUTRITION CARE PROCESS
Diet Analysis
Calories Total Fat Saturated Fat Cholesterol Sodium Total carbohydrate Dietary fiber Sugars Protein Calcium Iron Caffeine

ASSESSMENT
Food / Nutrition History Data
Pt intake x needs ↓ ↓ ↑ ↓ ↓ ↑ ↓ ↑ ↓ ↓ ↓ ↑ Pt needs 1592 kcal 49.55g 15.93g 300mg 2400mg 218.98g 22.30g --43.18g 1200mg 8mg --Usual intake 1440 kcal 36g 28g 55mg 1220mg 248g 8g 134g 24g 30% 40% 93.24mg 24h recall 1100 kcal 27g 25g 5mg 1070mg 200g 2g 130g 6g 4% 10% 93.24mg

ASSESSMENT
Anthropometric Data
Chemistry Labs

ASSESSMENT
Biochemical Data
Pt values ↓ 3.4g/dl ↓ 5.9g/dl 19mg/dl 219mg/dl Albumin Total protein Prealbumin Transferrin

Age: 62y Ht: 5’3” = 160cm IBW: 115lb = 52.3Kg UBW: 145-150lb = 65.9-68.1Kg Usual BMI: 25.75 = overweight ABW: 119lb = 54.0Kg Actual BMI: 21.14 = healthy range ∆ wt: 20.66% since COPD dx 5 years ago

Na 136

Cl 101 K 3.7 ↑CO2 31

BUN 9 Cr 0.9

GLU 92

Hematology Labs WBC RBC HGB HCT SEGS BANDS LYMPHS MONOS EOS

Pt values
↑ 15x103mm3

ABG’s Labs pH pCO2 pO2 SO2 CO2 content Carbonic acid Base excess Base deficit HCO3-

1d Pt values

3d Pt values 7.4 40.1 90.2
↑ 30.8

Normal range 7.35-7.45 35-45 ≥ 80 ≥ 95% 25-30 >3 <3 24-28

Units

4x106mm3 ↓ 11.5g/dl ↓ 35%
↑ 83%

↓ 7.29
↑ 50.9

mmHg mmHg

↓ 77.7 ↓ 92
↑ 31

5% ↓ 10% 3% 1%

mmol/L mmol/L mEq/L mEq/L mEq/L

2.4
↑ 3.6

1.2 6.0

24.7

↑ 29.6

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ASSESSMENT
Physical Examination Data
Social history Head and neck Teeth: Poorly fitting dentures Skin Skin: dry Edema, peripheral: 1+ bilateral Vital Signs ↑ Temperature: 98.8ºF ↑ Respiratory Rate: 22 bpm Shortness of breath

ASSESSMENT
Client History Data
Physical activity, easy fatigue with increased activity; unable to achieve desired levels Medical/ Health history Chronic Obstructive Pulmonary Disease Upper respiratory infections or pneumonia Signs and symptoms Shortness of breath or dyspnea on exertion or at rest Meds and supplements Medications that cause anorexia: Albuterol sulfate

NUTRITIONAL ASSESSMENT MATRIX
PARAMETER Food/Nutrition Hx Data Change in way clothes fit Changes in appetite /taste Weight loss ↓ Albumin, serum ↓ Hemoglobin abnormal pCo2; pO2 Teeth: Poorly fitting dentures Skin: dry Physical Exam Data Edema, peripheral ↑ Respiratory Rate ↑ Temperature COPD Meds that cause anorexia NC 3.2 NI 2.1 NI 1.4 NI 2.1 NI 5.3 NI 51.1 NC 3.2 NI 5.1 NI 5.2 NI 55.1 NC 2.2 NI 1.4 NC 1.2 NI 3.1 NI 5.2 NI 51.1 NI 2.1 NC 2.2 NI 1.1 NC 3.2 NI 1.1 NC 3.2 NI 1.1 NC 3.2 NI 2.1 NDT

DIAGNOSIS RATIONAL
NI 2.1 – Inadequate Oral/Food Beverage Intake Definition Less than established reference standards or recommendations based on physiological needs ↑ nutrient needs due to prolonged catabolic illness NC 3.2 – Involuntary Weight Loss Decrease in body weight that is not planned ↑ nutrient needs due to prolonged catabolic illness Weight loss of 5% within 30 days, 7.5% in 90 days or 10% in 180 days Fever, ↑ heart rate, ↑ respiratory rate Normal or usual intake in face of illness Poor intake, change in eating habits, skipped meals, change in way clothes fit

Anthropometric Data

Etiology

Biochemical Data

Anthropometric

Weight loss

Physical Exam.

Dry skin

Food/Nutrition hx

Anorexia, change in appetite or taste

Client History Data

Client hx

Conditions associated with a dx or tx of catabolic illness Medications that cause anorexia

Conditions associated with a diagnosis or tx (COPD) Medications associated with weight loss

NUTRITIONAL DIAGNOSIS
PES STATEMENT
1.

INTERVENTION
FOOD AND/OR NUTRIENT DELIVERY MEALS AND SNACKS (ND-1)

(P) Involuntary weight loss (NC - 3.2) related to

Modify distribution, type, or amount of food and nutrients within meals or at specified time
GOALS Maintain actual body weight, recover plasma protein levels Decrease fatigue while eating Decrease early satiety Prevent fluid retention Prevent dehydration, which thickens mucus Decrease food-drug interaction MEANS BEE x 1.3 = 1530 Kcal PRO = 17% = 65g/d = 1.2g/Kg/d CHO = 48% = 183.6g/d LIP = 35% = 59.5g/d Use 6 small concentrated meals at frequent intervals Limit fluid intake with meals Limit salt intake, restrict Na and increase K intake Fluids = 30ml/Kg = 1620ml/d Decrease caffeine intake

(E) increased nutrient needs secondary to COPD as evidenced by

(S) 20% of weight loss since COPD diagnosis.

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INTERVENTION
2. NUTRITION EDUCATION INITIAL/BRIEF NUTRITION EDUCATION (E-1) Priority Modifications: Communicate relationship between nutrition and specific disease/health issue
GOALS Decrease food-drug interaction Avoid coughing spells Conserve energy during the day MEANS Provide knowledge: association between caffeine & bronchodilators Provide knowledge of caffeine high-content foods Avoid excessively hot or cold foods Encourage slow eating Give suggestions of foods that are easy to prepare Main meal early in the day to have more energy throughout the rest of the day Encourage rest periods before and after meals Encourage the patient to make small, attractive meals Overcome anorexia Explain how to concentrate protein and calories in small feedings Avoid distension from large meals or gaseous foods Ensure adequate flavor of foods Provide knowledge: no association between milk & mucus production Explaining the benefits of milk/Calcium intake Explain: relation between Ca, BMD, osteoporosis risk for post-menopausal women

INTERVENTION
3. COORDINATION OF NUTRITION CARE COORDINATION OF OTHER NUTRITION CARE (RC-1) CARE DURING

Collaboration / referral to other providers: Physical therapist

GOALS

MEANS

Schedule treatments to mobilize mucus 1 hour before and after meals to prevent nausea Improve ventilation before meals and overall physical Improve physical conditioning with planned exercises, especially conditioning to strengthen strengthening exercises respiratory muscles Make sure the oxygen cannula is worn during and after meals. Eating and digestion require energy, which causes the body to use more oxygen

Increase milk intake

MONITORING & EVALUATION
1. MEALS AND SNACKS (ND-1) Monitor: Tolerance to diet, food diary, body weight, presence of peripheral edema, Labs (ABG’s Labs, Alb, preAlb, H/H) Evaluate: Comparison of intake to estimated needs 2. INITIAL/BRIEF NUTRITION EDUCATION (E-1) Monitor: Pt understanding, sx of fatigue and shortness of breath, appetite Evaluate: Change of dietary habits 3. COORDINATION OF OTHER CARE DURING NUTRITION CARE (RC-1) Monitor: Sx of fatigue and shortness of breath, ABG’s Labs Evaluate: Improvements in fatigue while eating

DOCUMENTATION
ADIME FORMAT
A (Assessment): Review of data reveal a 62 year-old female with a medical dx of COPD with poor food choices comprised of high content of saturated fat, sugar and caffeine, although with insufficient caloric and micronutrient intake. Pt is 5’3”, 119lb, BMI 21.14, although pt has been loosing wt since COPD dx 5yr ago (145-150lb). Labs reveal low albumin and total protein and pre-albumin has borderline values. Pt presents shortness of breath and cough which impair food intake. D (Diagnosis): Involuntary weight loss (NC-3.2) RT increased
nutrient needs 2º COPD AEB 20% of weight loss since COPD diagnosis.

DOCUMENTATION
ADIME FORMAT
I (Intervention): Nutrition Prescription Meals
and Snacks (ND-1) Recommend 1530 kcal diet providing 65g of protein, 184g of CHO, 60g of fat and 1620ml of fluid/d. Limit sodium and caffeine intake. Eat small meals at frequent intervals. Initial/Brief nutrition education (E-1) Provide knowledge and tips to decrease drug-nutrient interactions, conserve energy during the day, prevent coughing spells, overcome anorexia and increase milk intake. Coordination of Other Care During Nutrition Care (RC-1) Referral to Physical Therapist to improve ventilation before meals and overall physical conditioning to strengthen respiratory muscles.

THANK YOU

QUESTIONS?

M (Monitoring): Tolerance to diet, food diary, body weight, presence of peripheral edema, Labs (ABG’s Labs, Alb, preAlb, H/H), pt understanding, sx of shortness of breath and fatigue while eating, appetite. E (Evaluation):Comparison of intake to estimated needs, change of dietary habits, and improvements in fatigue while eating

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