Mini Clinical Case Study

District One Hospital - Faribault, MN

Presented by: Lexi Brand, ISU Dietetic Intern, 2022
Presentation Outline
➢ Overview of Patient
➢ Medical History/Prior Hospitalizations
➢ Present Admission
➢ Physical Examination/Data/Imaging
➢ Chronic Obstructive Pulmonary Disease
➢ Gastroparesis
➢ General Progress & Physician Summaries
➢ Nutrition Assessment
➢ Medical Nutrition Therapy for COPD & Gastroparesis
➢ Discharge Nutrition Care Plan
➢ Prognosis
➢ Question & Answer
General Patient Information
Patients Initials: JH

Age, Height, Weight, BMI: 59 y/o, 5’9” (69”), 53.5 kg (117 lb), 17.41 kg/m2

Occupation: Works

Family Responsibility: Married

Date of Admission: 2/15/22

Attending Physician: Ahmad, Mirza Mujadil, MBBS

Unit: Med/Surg floor

Present Admission Background
JH was experiencing worsening shortness of breath, palpitations, coughing,
increased mucus production, migraines, abdominal pain, and vomiting upon
admission to the hospital. She was found to have acute hypoxic respiratory
failure secondary to COPD exacerbation. JH is not dependent on oxygen at
home, but was in need of it at the hospital. Had also been experiencing lack of
appetite.
Medical History
Current Problems: Past Health History:
➢ COPD exacerbation ➢ Graves disease
➢ Hypoxia ➢ Dyspepsia

➢ Emphysema ➢ Chronic Gastroparesis

➢ Palpitations ➢ Chronic COPD

➢ Migraines ➢ Tobacco use disorder

➢ Migraine disorder
➢ Vomiting
➢ Total R & L knee replacements
➢ Abdominal pain
Medical History Continued
Social History: Family Medical History:
➢ Alcohol use: No ➢ Breast Cancer - mother, aunt, sister
➢ Smoking status: Former ➢ Esophageal Cancer - father
smoker ➢ Rectal Cancer - sister
➢ Packs/day: ¾
➢ Start date: 10/10/1977
➢ Quit date: 1/10/2022
Current Medication List
➢ Albuterol-ipratropium
○ Combination inhaler
➢ Wellbutrin SR
○ Smoking cessation aid
➢ Restasis (Cyclosporine)
○ Graves disease dry eye
➢ Roflumilast
○ Decrease swelling in lungs
➢ Fluticasone
○ Reduce airway inflammation
➢ Diltiazem
○ BP & chest pain
➢ Dupixent (Dupilumab)
○ Improve lung function
➢ Doxycycline
○ Antibiotic for infection
➢ Levothyroxine
○ Treats hyperthyroidism
➢ Prednisone
○ Steroid to reduce lung inflammation
➢ Trazodone
○ Sleep aid
➢ Sumatriptan
○ Treat migraine headaches
Recent/Prior Hospitalizations
District One Hospital
Reason for Admission: COPD with acute exacerbation
Admission date: 1/10/2022
Discharge date: 1/12/2022
Pt symptoms: experiencing SOB, coughing, increased mucus production
Treatment: Starter pt on Azithromycin, IV steroids, and breathing treatment.
Increased oxygen to stabilize pt.
Physical Examination
Observations:
➢ Very brittle
➢ Evident temporal muscle wasting
➢ Hollowness of cheek bones
➢ Depleted/sunken orbital fat pads
➢ Chest had a cachectic appearance
➢ Apparent struggles with breathing
➢ Watery eyes due to Graves disease
Weight Data
Date 2/15/2022 2/14/2022 2/7/2022 1/142022 1/11/2022 1/10/2022

Weight (lb) 117 117 123 124 125 127

Weight (kg) 53.479 53.343 56.11 56.246 54.522 57.607

Significant Findings:
➢ Weight loss of 6 lbs (5%) in 1 week, from 2/7/2022 to 2/15/2022
➢ Weight loss of 10 lbs (8%) in 1 month, from 1/10/2022 to 2/15/2022
Imaging/X-rays
Volumetric helical thorax scan
Findings: Emphysema present. New
scattered nonspecific nodular infiltrates
are demonstrated in both lungs, most
notable in the lung bases. Calcification of
coronary artery plaque, noted that pt has
coronary artery disease.
Chronic Obstructive Pulmonary Disease (COPD)
➢ COPD is the slow progressive obstruction and inflammation of the airways.

➢ Group of diseases that contribute to COPD:

○ Emphysema
■ The air sacs of the lungs (alveoli) are damaged and enlarged causing
breathlessness
○ Chronic bronchitis
■ Long term inflammation of bronchial tube lining, and persistent cough
➢ Both conditions usually occur together
➢ Exacerbations during which become worse than usual day to day variations
Causes of COPD
➢ The main cause of COPD is cigarette/tobacco smoking
➢ Other causes of COPD:
○ Second hand smoke
○ Air pollution
○ Workplace exposure to industrial pollutants
➢ Genetic susceptibility:
○ In about 1% of those with COPD, the disease is caused by Alpha-1-antitrypsin
(AAt) deficiency
■ AAt deficiency is characterized by low levels of Alpha-1-antitrypsin, a protein
made in the liver and secreted into the bloodstream to protect the lungs
Symptoms of COPD
➢ Dyspnea ➢ Chest tightness

➢ Wheezing ➢ Lung hyperinflation

➢ Persistent cough ➢ Diminished breath sounds

➢ Sputum production ➢ Cyanosis in hypoxemic patients

➢ Increased breathing rate ○ Lack of oxygen in the blood

Complications Related to COPD
➢ Respiratory infections:
○ Those with COPD are more likely to catch the common cold, flu, and pneumonia
○ Respiratory infections can cause further damage to lung tissues
➢ Lung cancer:
○ Those with COPD are at a higher risk for developing lung cancer
➢ High blood pressure:
○ COPD can cause high blood pressure in the arteries that transport blood to the
lungs
○ Also known as pulmonary hypertension
➢ Heart problems:
○ Those with COPD are at a higher risk for heart disease and heart attack
○ COPD can put a lot of stress on the heart, making it work harder than normal
➢ Collapsed Lung:
○ Air leaks into the space between the lungs and chest wall
○ Lung collapses like a deflated balloon
Treatment of COPD
➢ Early and correct diagnosis of disease is key
➢ Quitting smoking is the most essential first step
➢ Four components of COPD disease management:
1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD status
4. Manage exacerbations
➢ Medications: bronchodilators, corticosteroids, combination inhalers, antibiotics
➢ Disease progression may require pulmonary rehab and oxygen therapy
➢ Advanced COPD may lead to surgical procedure such as lung transplant
Gastroparesis
➢ Gastroparesis is a gastrointestinal condition that affects the movement or
motility of stomach and intestine muscles, causing delayed gastric emptying.
➢ Occurs when the vagus nerve is damaged
○ The vagus nerve controls movement of food from the stomach through
the digestive nerve
○ Damaged vagus nerve results in food moving abnormally slow or
completely stops it from passing to the small intestine
➢ In most cases Gastroparesis is a chronic, long-term condition
Gastroparesis Etiology
➢ The most common cause of Gastroparesis is Diabetes
○ Also known as diabetic gastropathy
○ Usually attributed to autonomic neuropathy
○ Diabetes may damage the vagus nerve which controls stomach and intestine
muscles
➢ Other risk factors for Gastroparesis:
○ Hyper/hypothyroidism
○ Nervous system diseases
○ Abdominal or esophageal surgery
Symptoms of Gastroparesis
➢ Bloating ➢ Acid reflux

➢ Abdominal discomfort ➢ Weight loss

➢ Abdominal pain ➢ Lack of appetite

➢ Nausea ➢ Feeling full from small amounts

➢ Vomiting of food
General Progress
Nursing Summary - 2/15/2022
Active Problems: Ineffective gas exchange
Assessment/Interventions: Tachypnea, Increased wob, increased O2 needs.
Progress: increased O2 to 6L nasal cannula, continuous pulse oxygen (88-92% acceptable),
oxygen mask in room. RT called for assessment and treatment. Now saturating at 91%
Patient Goals for Next Shift: Improved gas exchange

Nursing Summary - 2/16/2022

Active Problems: Feelings of air hunger at times. O2 need.
Assessment/Interventions: Increased O2 to 5L most of day. Currently back down to 4L.
Added inhaler.
Progress: Breathing gradually progressing
Patient Goals for Next Shift: Sleep, monitor O2 sat/O2 needs
Review of Physician Summaries/Progress
Physician Hospital Summary - 2/16/2022
Pt is a 59 y.o. female with a history of COPD, Graves disease, palpitations and migraine who
presented acute hypoxic respiratory failure with COPD exacerbation. In the ED, she tested
negative for Influenza and COVID-19. EKG without any ischemic changes. CT chest done which
showed emphysema. Started on steroids and doxycycline. Albuterol and duonebs. Restarted
her advair. Started on Breo Ellipta. Goal SpO2 88-92%

Physician Progress Note - 2/17/2022

Follow up after Home O2 Assessment:
I have determined that the patient would benefit from home oxygen therapy after
assessment of the following: Oximetry test - exertional desaturation </= 88%
Nutrition Assessment Summarized
JH stated that prior to admission she had been aiming to eat 3 meals per day,
but was still eating a minimal amount. She explained that she often lacks
energy to cook meals, and has used boost supplements once a day in the past
to help increase intake. JH also claimed to mostly avoid eating processed and
packaged foods. Pt’s current eating patterns have not been helping her to
reach increased protein, energy, vitamin, and mineral needs related to her
chronic COPD. She has experienced continued unintentional weight loss, and
an inability to gain any back despite efforts. Through assessment it was
determined that malnutrition was a concern for this Pt case.
Malnutrition Criteria Screening:
Energy Intake: Acute Severe: </= 50% of estimated energy requirement for >/= 5 days
Interpretation of weight Loss: Acute severe: >2% in 1 week
➢ Body Fat Loss:
○ Orbital, Facial, Cheeks Region - Moderate to Severe
○ Upper Arm Region - Moderate to Severe
○ Ribs, Thoracic, Lumbar Regions - Moderate to Severe
➢ Muscle Mass Loss
○ Temporal Region - Moderate to Severe
○ Clavicle, Pectoral, Deltoid Regions - Moderate to Severe
○ Biceps, Triceps Regions - Moderate to Severe
Malnutrition Status: Severe malnutrition in the context of chronic illness
Diet Order/Nutrient Needs
Current Diet Order:
➢ Fiber Restricted Diet: < 13 grams/day
➢ Protein Supplement QD (1 per day):
○ Comfort menu smoothies
○ Ensure beverages

Nutrient Needs:
➢ Energy: 1605 - 1872 kcal/day (30-35 kcal/kg)
➢ Protein: 64 - 80 gm/day (1.2 - 1.5 gm/kg)
➢ Fluid: 1 ml/kcal/day
Nutrition Diagnosis (PES)
1. Unintended weight loss related to COPD exacerbation, increased energy expenditure,
poor appetite, and decreased food/beverage intake, as evidenced by weight loss of 5 lbs
or 5% in 1 week and a BMI of 17.41 kg/m2.

2. Unintended weight loss related to diagnosis of gastroparesis, GI discomfort, and lack of

appetite, as evidenced by weight loss of 5 lbs or 5% in 1 week and a BMI of 17.41 kg/m 2.

3. Inadequate oral intake related to SOB, fatigue, and inability to consume sufficient
energy/nutrients, as evidenced by < 50% of intake of estimated energy requirements for
> 5 days and severe malnutrition diagnosis in the context of chronic illness.

4. Increased energy expenditure related to increased energy requirements during COPD

exacerbation, as evidenced by patient’s heightened resting energy expenditure due to
respiratory distress and increased work of breathing.
Nutrition Intervention
1. Modified Diet: Fiber restriction
2. Medical Nutrition Supplements: Comfort menu smoothies or Ensure
3. Nutrition Education Provided:
a. COPD MNT
b. Gastroparesis MNT
c. Fiber restricted diet education
d. Protein content of foods

Nutrition Goals
1. Patient will consume >/= 50% of all meals and protein supplements
2. Pt will maintain current body weight of 117 lb and BMI of 17.4
3. Pt will consume meals without signs/symptoms of abdominal pain, vomiting, or discomfort
COPD MNT
Focuses:
➢ Maintaining, or restoring optimal nutrition status by food and beverage intake or
supplements
➢ Preventing continued weight loss, even in overweight patients
➢ Maintaining or restoring lean body mass

Intervention:
➢ Small, frequent meals and snacks to help compensate for shortness of breath and
possible limited oxygen supply to gastrointestinal tract.
➢ Food choices that are easy to chew, swallow, and digest with nutrients easily absorbed.
➢ Proper sitting posture along with sequencing of breathing and swallowing for eating, to
prevent aspiration.
Gastroparesis MNT
Focuses:
➢ Modify diet content and eating habits to limit the amount of work for the stomach
➢ Support faster and normal stomach emptying
➢ Reduce symptoms of bloating, abdominal pain, nausea, and vomiting

Intervention:
➢ Eat small, frequent meals 4-6 times per day
➢ Reduce intake of fiber and high fat foods to help prevent delayed emptying
➢ Consume protein-rich foods with meals and snacks
➢ Chew foods well before swallowing and eat slowly
➢ Avoid common foods that are more inflammatory to the GI system
Discharge Nutrition Care Plan
➢ Home oral nutrition supplement recommendation: 1-2 times daily
➢ Follow COPD and Gastroparesis MNT plans at home
➢ Get Gastroparesis symptoms under control through nutrition
recommendations
Prognosis
➢ Medical:
○ Continued smoking will likely lead to another COPD exacerbation.
○ This continued path may lead to development of lung cancer.
➢ Compliance with NCP:
○ Seems likely that Pt will comply with plan of care.
○ Pt asked to be provided with extra educational resources.
➢ Follow-up Plans:
○ Check on Pt ability to tolerate meals & supplements
○ Check on Pt symptoms related to COPD and Gastroparesis
What Would I Have Done Differently?
For this patient’s case I don’t think I would have done anything differently. I spent
time giving the patient information about the role that nutrition plays in the
various conditions she has. I believe that this patient was given the best tools to
support her health with nutrition, and sufficient care was provided.
References
1. Mayo Clinic. 2020. Diseases and Conditions: COPD. [online] Available at:
<https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679>[Accessed 18
February 2022].
2. Nutrition Care Manual. 2022. Pulmonary > Chronic Obstructive Pulmonary Disease (COPD). [online] Available
at:
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5538&lv2=22249&ncm_toc_id=22249
&ncm_heading=Nutrition%20Care [Accessed 18 February 2022].
3. Nutrition Care Manual. 2022. Gastrointestinal Disease > Gastroparesis. [online] Available at:
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=255703&ncm_toc_id=25570
3&ncm_heading=Nutrition%20Care [Accessed 19 February 2022].
4. International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition
Care Process. Third Edition.