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PATIENT CASE STUDY:

NUTRITION IMPLICATIONS AND


INTERVENTIONS
K ELCI M C H UGH
SPP D IETETIC I NTERN
U NIVERSITY OF K ENTUCKY
Statement of Purpose
1. Provide an overview on patient profile
2. Explain the disease background
3. Discuss the nutrition care process
Patient Profile
PERSONAL DATA PSYCHO/SOCIAL/ECONOMIC DATA

o Gender: Male o Occupation: Not on file


o Age: 63 o Home life: Lives by self
o Ethnicity: Non-Hispanic (Caucasian) o Education: Not on file
o Marital status: Divorced, 3 children
o Ethnic/religious considerations: Not on file
Patient Profile
MEDICAL HISTORY, PARTICULARLY IN RELATION TO STATUS OF THE DISEASE

Personal history of alcoholism COPD with acute exacerbation


Anxiety state, unspecified Abnormal stress test
Depressive disorder Chronic bilateral low back pain with bilateral
sciatica
Alcoholic cirrhosis of liver with ascites
Noncompliance
Personal history of tobacco use, presenting
hazards to health Acute respiratory failure with hypoxia
Chronic hepatitis Sepsis
Chronic ischemic heart disease, unspecified HCAP (healthcare-associated pneumonia)
Patient Profile
RECENT SURGICAL HISTORY FAMILY MEDICAL HISTORY

o Esophagogastroduodenscopy (EGD) with o Father: Heart disease, emphysema, cancer,


banding 8/3/2016 heart failure
o Esophagoscopy Biopsy 8/23/2016 o Mother: Hypertension
o Esophagogastroduodenscopy (EGD)
3/22/2018
Patient Profile
GENERAL

o Sleep: o Height: 5'7"


◦ Before admission- not on file
◦ Patient sedated since admission o Weight: 168 pounds

o Physical activity: o Weight history:


◦ Assumable minimal due to alcohol abuse and ◦ Admitted with symptoms of severe malnutrition
health condition upon arrival ◦ Recent weight trends appear be trending
upwards
o Appetite:
◦ Poor access to food before admission. Daughter ◦ Could be associated with increased fluid
reported minimal food in fridge retention from ascites
◦ May have been receiving most of their calorie
source from alcohol
Patient Profile
GI SYSTEM: DENTAL OR SWALLOWING
OTHER PROBLEMS AFFECTING FOOD INTAKE
PROBLEMS, DIGESTION, ELIMINATION
o History and current symptoms of o History of chronic alcohol abuse
gastroparesis o Factor in his malnourished state
o No evidence of active bleeding

o Patient never experienced a bowel


movement
o Nine-day length of stay

o No history of or current reports of chewing or


swallowing difficulties
Disease Background: Acute Respiratory
Failure with Hypoxia
o Acute, diffuse, inflammatory lung injury that can lead to increased pulmonary vascular
permeability, increased lung weight, and a loss of aerated tissue [1]
o Pathophysiology: Lung injury disrupting ability to regulate fluid, causing impaired gas exchange
and potential to increased pulmonary arterial pressure [2]
o Hypoxia: Decrease in arterial pressure of oxygen in the blood [1]
oEtiology: Pneumonia, sepsis and aspiration are the three most common causes [2]
Disease Background: Sepsis
o The body’s natural mediators to inflammation including phagocytic cells circulated in the blood
also become infected, creating a generalized infection away from the initial site of injury [3]
o Potential of organ failure [4]

o Pathophysiology: Likelihood of developing sepsis is higher for individuals who are alcoholics [2]
o Inferred lung tissue is being exposed to oxidative damage
o Glutathione concentrations in epithelial lining fluid decreases

o Etiology: Unclear
Disease Background: Pneumonia of Both
Upper Lobes
o Pathophysiology: Common lung infection caused by germs, such as bacteria, viruses, and fungi
o Etiology: Infectious organism
o Community acquired pneumonia can be the leading cause for respiratory failure [2]
o Pneumonia or sepsis?
Disease Background: Treatment of
Respiratory Failure
o Supplement with oxygen
o Medications for the infections causing acute failure
o Antibiotics or bronchodilators

o Intubation considered [5]


o Mechanical ventilation used as last step treatment

o Little information on nutrition treatment and interventions for respiratory failure [6]
o Decrease risk for aspiration

o Nutrition support [6]


o 35 calories per kilogram body weight and about 1.2 grams per kilogram of protein
o Immune-modulating enteral formulations used cautiously in patients with severe sepsis
o Fluid restricted, energy dense formula with acute respiratory failure
Disease Background: Chronic Hepatitis
o Cirrhosis of the liver is defined as late stage progressive hepatic fibrosis characterized by
distortion of the hepatic structure and formation of regenerative nodules
o Pathophysiology: Contraction of hepatitis C happens through blood exposure, typically drug use
or through sexual intercourse which can lead to hepatic decline especially with lack of
management [7]
o Etiology: Chronic hepatitis C infection and chronic alcohol abuse
Disease Background Treatment of
Cirrhosis
o Begin with alcohol withdraw - eliminating substance from diet
o Restoring adequate hydration status
o Thiamine and folic acid for chronic alcohol abuse
o Monitor refeeding related electrolyte labs
o Na, K, Ph, Mg
oAscites: Diuretics and/or paracentesis
o Monitor Na, K
o Hepatic encephalopathy: Improving predisposing conditions
o Sepsis
o Poor hydration
o Malnutrition related to altered electrolyte labs
o Synthetic disaccharides - lactulose and use of non-absorbable antibiotics [9]
Disease Background: Gastroparesis
o Delayed gastric emptying in the absence of a mechanical obstruction and exhibits chief
symptoms of nausea, vomiting, early satiety, bloating and upper abdominal pain
o Pathophysiology: Disruption in normal gut function - a complex process that requires
movements that coordinate sympathetic and parasympathetic nervous symptoms, neurons and
pacemaker cells within the stomach and intestinal cells
o Etiology: Idiopathic, diabetic or postsurgical related [10]
o Diagnostic Criteria
o Vomiting and possible bloating
o Exclude obstruction
o Scintigraphy
Disease Background: Treatment of
Gastroparesis
o Dietary modification
o Avoid non-digestible fibers
o Placement of NG tube

o Glycemic control
o Hydration [11]
o Pharmacological Interventions
Disease Background: Prognosis
o Poor
o Noncompliance to previous medical advice
o Worsening receptiveness to treatments
o Lack of ability to stay off the ventilator

o Ineffective interventions
o Feeding tolerance
o Bowel movements
o Mental status
Current Admission
DIAGNOSIS o Patient transported via ambulance
o Admitted with worsening shortness of breath in
Chronic hepatitis combination of cough with sputum
Acute respiratory failure with hypoxia o Unable to talk but could shake head

Severe sepsis o Reports 0.5 packs of cigarettes for previous 30 years


o Altered mental status related to encephalopathy
Pneumonia of both upper lobes due to
infectious organism o Chronic hepatitis associated with hepatitis-C and
alcohol abuse
o Appears with cachexia
o As experienced respiratory failure, secondary sepsis
and pneumonia determined
Current Admission
DIAGNOSTIC PROCEDURES WITH INTERPRETATION OF RESULTS

o 3/23 Nuclear medicine gastric emptying o 4/4 Single view abdominal KUB
study o Unremarkable bowel gas pattern
o Small calcification/calculi right upper quadrant
o Severely delayed gastric emptying consistent cholelithiasis
o NG tube extending to the gastric antral level
o 4/2 Renal Ultrasound o No bowel intramural gas evident
o Acute kidney injury
o3/30, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5 AP portable
o 4/4 CT head w/o contrast chest
o Endotracheal tube NG tube and right IJ central
o No acute intracranial abnormality venous catheter remain in place
o Heart size is normal
o No change in bilateral airspace disease with
effusions
Current Admission
TREATMENTS, INCLUDING MEDICAL, SURGICAL, THERAPIES

o Physical therapy, occupational therapy and o3/31 Thoracentesis


speech pathology o Pleural effusion left
o 3/29 Central Venous Catheter o4/1 Arterial line placement left radial
o Hypovolemia, need for frequent blood draws o Used to monitor blood pressure and samples for
and intubation procedure due to respiratory blood gas analysis
failure
Medications Drug-Nutrient Interaction
cefTRIAXone (ROCEPHIN) in sodium chloride May contain sodium.
Chlorhexidine (oral care) N/A
docusate (COLACE) N/A
folic acid (FOLVITE) N/A
heparin (porcine) N/A
hydrocortisone sod succinate (SOLU-CORTEF) N/A
pantoprazole (PROTONIX) Zinc supplementation may be needed in patients prone to zinc deficiency.
Current Prolonged treatment (≥2 years) may lead to malabsorption of dietary vitamin B12
and subsequent vitamin B12 deficiency.

Admission polyethylene glycol (MIRALAX)


sodium chloride flush
N/A
N/A
thiamine Ethanol may decrease thiamine absorption. Higher doses may be needed in patients
with history of ethanol abuse.
High carbohydrate diets may increase thiamine requirement.
Continuous Medications
NS infusion N/A
morphine in sodium chloride May cause GI upset.
MEDICATIONS FOR LAST 24 Ethanol: Alcoholic beverages or ethanol-containing products may disrupt extended
release formulation resulting in rapid release of entire morphine dose.
HOURS OF STAY Administration of oral morphine solution with food may increase bioavailability.
Take consistently with or without meals.

norepinephrine (LEVOPHED) In dextrose solution so provides extra calories and may effect blood sugar levels.

propofol (DIPRIVAN) Formulated in an oil-in-water emulsion. If on parenteral nutrition, may need to


adjust the amount of lipid infused. Propofol emulsion contains 1.1 kcal/mL. Soybean
fat emulsion is used as a vehicle. Formulations also contain egg phosphatide and
glycerol.
Edetate disodium, an ingredient of propofol emulsion, may lead to decreased zinc
levels in patients on prolonged therapy (>5 days) or those predisposed to deficiency
(burns, diarrhea, and/or major sepsis). Management: Zinc replacement therapy may
be needed.

PRN Medications
albuterol (PROVENTIL) N/A
Nutrition Care Process
NUTRITION ASSESSMENT ANTHROPOMETRICS

o Vent status Date Weight


4/5/18 168#
o Low BMI 4/4/18 164#
o 19.6 admission 4/3/18 151#
4/2/18 155#
o 24 final 3/31/18 148#
3/30/18 140#
o Nutrition risk Prior to Admission Weight History
3/23/18 142#
8/11/17 154#
6/06/17 154#
3/17/17 170#
Weight loss of 17.6% in the past year
3/30 3/31 4/1 4/2 4/3 4/4 4/5 4/6
Glucose 111 (H) 156(H) 182(H) 150(H) 150(H) 156(H) 147(H) 126(H)

BUN 17 38 (H) 56 (H) 69 (H) 80(H) 82 (H) 77 (H) 78 (H)


Creatinine 1.3 1.4 (H) 1.6 (H) 1.8 (H) 1.9(H) 1.9 (H) 1.7 (H) 1.7 (H)
Glomerular 56 51 44 38 36 36 41 41

Nutrition Care Filtration Rate

Process Sodium 131 (L) 132 (L) 133(L) 135(L) 137 138 140 142

Potassium 3.7 3.3 4.0 4.2 4.2 3.9 3.8 4.4


Chloride 96(L) 97(L) 103 105 105 110 113(H) 113(H)
Magnesium 2.0 2.0 2.1 2.0 2.1 2.0 2.0
Phosphorous 4.3 4.7 3.9 4.6 4.4 7.1 (H)

Carbon Dioxide 27 27 25 24 21 21 22 23
BIOCHEMICAL LABS
Calcium 8.3 8.4 8.3 8.4 8.6 8.3 8.4 8.6
Anion Gap 12
Albumin 2.5 (L) 2.1 (L) 1.9 (L) 2.0 (L) 1.8 (L) 1.8 (L) 2.1 (L)
Total Protein 5.3 (L) 5.4 (L) 5.4 (L) 5.8 (L) 5.4 (L) 5.4 (L) 5.6 (L)

SGOT-AST 28 25 26 24 23 26 25
SGPT-ALT 13 (L) 12 (L) 14 (L) 13 (L) 14 (L) 17 18
Alkaline 56 68 62 73 75 78 78
Phosphatase
Total Bilirubin 4.42 (H) 2.16 (H) 2.20 (H) 2.28 (H) 2.06 (H) 2.10 (H) 2.37 (H)

Lactic Acid 1.8


Nutrition Care Process
DIET HISTORY: 24 HOUR RECALL/FOOD FOOD SHOPPING, PREPARATION, MEALS
FREQUENCY AWAY FROM HOME
o No current diet history available o Previous admission 3/20: Visited by RD for heart
healthy diet instruction
o Receiving feedings through nasal o Patient reported not having good access to food
gastric/jejunal tube o Eats mostly fruit or deer meat when available
o Drinks fruit juice
o Documented by the health care team o Does not eat 3 meals per day
members that feedings were clamped on o Recent Admission: Daughter says he is able to
several occasions accomplish daily living tasks
o Does not appear to be doing well at home prior
o Rarely bathes
o Does not manage medications appropriately
o Neighbor helped with meals
Nutrition Care Process
FOOD/SHOPPING/COOKING HABITS MNT, DIET INSTRUCTION, OUTCOME

o Daughter reported patient's refrigerator o Congestive Heart Failure and heart healthy
being empty diet
o Seemed interested
o No money in his account
o Admitted poor access to food at home
o Bring food over, place in refrigerator and
show him where it was o No education during recent admission
o Still wouldn’t fix own meals
Nutrition Care Process
EVALUATION OF INTAKE, CURRENT ASSESSMENT OF LEVEL OF RISK

oFormula changed from Nutren 1.5 to o At nutrition risk


Peptamin 1.5 o Followed daily
o Gastric residuals occasionally >500cc o Signs of malnourishment
o Nasogastric tube advanced postpyloric o Monitored refeeding syndrome

o Exceeded 30 cc/hour once o Intubated through entire length of stay


o Appeared to have poor tube feed tolerance
o Never able to advance to goal rate
Nutrition Care Process
MACRONUTRIENT NEEDS NUTRITION DIAGNOSIS

o Inadequate energy intake related to vent


Equation (3/30) Estimated Needs status as evidenced by npo without nutrition
Mifflin St. Jeor 1662 calories support at this time.
Penn State 2003b 1776 calories o Malnutrition related to chronic illness, food
35 calories/kg 1925 calories
insecurity, alcohol abuse as evidenced by
patient report of limited food access,
1.2 g protein/kg 66 grams
estimated <50% needs >1 month, severe
Fluid Per MD temporal/orbital muscle wasting.
Nutrition Care Process
NUTRITION INTERVENTION/CARE PLAN

o 3/30 - Goal is to minimize npo status oMonitoring bowel function


o Requested magnesium/phosphorous levels to o Initiate feed of fiber free formula overnight
be added on to labs with slow progression towards goal rate
o Nutren 1.5 @ 20cc/hour rate
oMonitor electrolyte labs for refeeding risk
o Monitor per tube feed order set
o Thiamine ordered for malnutrition due to
alcohol abuse o Place order for addition of protein modular
tomorrow
o Assess abdomen/ascites
Nutrition Care Process
FOLLOW UP 3/31 FOLLOW UP 4/2

o Failed spontaneous breathing trial this AM o Tube feed was at goal rate
o Continue on tube feed o Placed on hold 1900cc of emesis

oTolerating tube feed regimen o Discussed possible NG tube advancement


postpyloric
o Discussed with nurse to slowly advance feeds
10cc every 12 hrs to goal of 45cc/hr o Refeeding labs WNL

o Refeeding labs WNL o Followed up with tube feed in afternoon – still


clamped
o NG confirmed per x-ray o Checked residuals with nurse and restarting with
Peptamin 1.5 @ 20cc
o Checked abdomen/ascites
o No significant changes
Nutrition Care Process
FOLLOW UP 4/3 FOLLOW UP 4/4

o Tube feed delivered on night shift o Possible extubation


o Tube remained clamped o Discussed keeping NG tube
o Discussed starting Peptamin 1.5 @ 20cc/hr o Residuals 600cc – tube clamped
o Day shift nurse resume feeds of Peptamin 1.5 @
o Consider NG advancement postpyloric 30cc/hr
oDiscussed meds for bowel movements o Suggested NG advancement postpyloric
(reglan, tap water enema) o Tap water enema ordered – not documented
oContinue monitoring refeeding labs o APRN placed new orders for KUB, enema,
colace, miralax
o Abdomen increasingly distended, more firm
o Wt up 13# overnight and hands edematous
Nutrition Care Process
FOLLOW UP 4/5 FOLLOW UP 4/6

o Feeds on hold from continued residuals o Tube feeds d/c


o Discussed discontinuing residual checks
o Per chart review, patient deceased
o NG advanced postpyloric confirmed x-ray

o Discussed TPN as option


o No bowel movements
o Refeeding labs WNL
o Followed up w/ feeds in afternoon – patient
terminally extubated
o Remain available if consulted
Summary
o Patient admitted with chronic hepatitis, acute respiratory with hypoxia, severe sepsis and
pneumonia of both upper lobes due to infectious organism
o Screened out for vent status, low BMI and nutrition risk score
o Followed daily

o Severely malnourished
o Wt loss, muscle wasting, cachectic

o Tube feeds never reached goal rate


o Changed formula, advanced tube, meds for gastroparesis and bowel function

o Prognosis worsened with LOS


o Interventions to support feeding, bowel movements and mental status where becoming ineffective
References
1. Siegel, M.D. (2017). Acute respiratory distress syndrome: Clinical features and diagnosis in adults. UpToDate.
2. Siegel, M.D. (2018). Acute respiratory distress syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults. UpToDate.
3. Neviere R. (2016). Pathophysiology of sepsis. UpToDate.
4. Neviere, R. (2018). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentations, diagnosis and prognosis. UpToDate.
5. Allen, G.B. (2018). Invasive mechanical ventilation in acute respiratory failure complicating chronic obstructive pulmonary disease. UpToDate.
6. Taylor, B. E., McClave, S. A., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C. S., Compher, C. (2016). Guidelines for the
Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American
Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Critical Care Medicine, 44(2), 390-438.
7. Chopra, S. & Pockros, P.J. (2017). Overview of the management of chronic hepatitis C virus infection. UpToDate.
8. Goldberg, E. & Chopra, S. (2016). Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis. UpToDate.
9. Goldberg, E. & Chopra, S. (2017). Cirrhosis in adults: Overview of complications, general management, and prognosis. UpToDate.
10. Camilleri, M. (2016). Gastroparesis: Etiology, clinical manifestations, and diagnosis. UpToDate.
11. Camilleri, M. (2017). Treatment of gastroparesis. UpToDate.