rebekah vukovich dietetic intern case study. introduction to patient past medical history primary...
TRANSCRIPT
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Rebekah Vukovich Dietetic Intern
CASE STUDY
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Introduction to patientPast medical history Primary diseases/conditions Short bowel syndrome Patient’s current hospital admissions
Nutrition Care Process
OUTLINE
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Female Age: 63Weight:
First admission: 44kg Second admission: 49kg 28% wt. loss in past 10 months
Height: 152.4 cmBMI: 18.9 (first admission) Social history: Married, retired, previously
residing in extended care facility, home health care
Primary problem: Multiple abdominal surgeries with complications, malnutrition, long-term TPN
INTRODUCTION
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Partial gastrectomy RNY gastrojejunostomy Colostomy G-tube GI bleed GERD Ulcers HTN Tracheostomy (December) MI COPD Depression CAD TIA Cardiac stents Rheumatoid arthritis
PAST MEDICAL HISTORY
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3/2011 Cardiac arrest, myocardial infarction
6/2012 Perforated duodenal ulcer, peritonitis, graham patch over ulcer
7/2012 Small bowel obstruction
3/2014 Hematemesis, hiatal hernia, chronic gastritis, gastric ulcer
5/2014 GI bleed, hiatal hernia, gastric ulcer
7/2014 Upper GI bleed, peptic ulcer, anemia, partial gastrectomy, RNY
gastrojejunostomy, G-tube placed10/2014
Chronic antral ulcer, gangrene, colectomy, ileostomy12/2014
Hyperkalemia, dehydration, AKI
PREVIOUS HOSPITAL ADMISSIONS
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Open sores or lesions, disrupt mucosal integrity Gastric ulcer Esophageal ulcer Duodenal ulcer
Causes: Stomach acid Helicobacter pylori infection Long-term NSAIDs use
Symptoms: Burning stomach pain Starts between meals or during the night May come and go, duration varies Less common: N/V, belching, poor appetite, weight loss
PEPTIC ULCER
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Complications Bleeding Perforation Obstruction
Treatment Worsen if not treated Acid-suppressing medication Antibiotics Surgery
Nutrition Therapy Alcohol Coffee and caffeine Spices Probiotics Omega 3, 6
PEPTIC ULCERS
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Billroth II Due to recurrent GI bleeds Chronic antral ulcer Procedure Nutritional complications
Obstruction, dumping, abdominal discomfort, diarrhea, weight loss, impaired digestion and absorption
Micronutrient defi ciencies: iron, calcium, Vit. D, ribofl avin, folate, Vit. B12
Diet Avoid: concentrated sweets Lactose Small, frequent meals Lying down after meals Emphasize protein and fat Fiber
GASTRECTOMY WITH RNY GASTROJEJUNOSTOMY
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Anatomy Diet recommendations:
High-calorie high-protein Low residue Foods that cause gas and odor
Malabsorption Bile acid Fat Vitamin B12
Increased loss Fluid Sodium Potassium
ILEOSTOMY
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>40-50% small intestine removed Particularly ileum and ileocecal valveLoss of small bowel absorptive area Complications
Diarrhea, dehydration, steatorrhea, weight loss, muscle wasting, bone disease
Malabsorption with loss of absorptive areaPrognosis:
Adaption of remaining bowel Length of residual bowel Ileocecal valve Small and large bowel continuity
SHORT BOWEL SYNDROME
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Post-op feedings If >1/2 removed, start TPN Elemental formula MCT triglycerides 6-10 small meals/day
Supplements/Medications Initially, control hydroelectrolitic
disturbances/rehydrate PN started earlyPN essential for long-term survival
SHORT BOWEL SYNDROME
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Long-term TPN Complications Systemic recurrent infections (vein catheter
contamination), thrombosis of two or more central veins, and hepatic malfunction
Satisfactory results with the use of EN To reduce/eliminate PN
Antimotility agents Oral diet: iso-osmolar, hypercaloric, fractionated
form, addition of soluble fibers Restriction of lipids, lactose, and calcium oxalate. Oral rehydration Vitamin/mineral supplement
DIET AND SHORT BOWEL SYNDROME
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Long-term retrospective clinical study10 patients with severe SBS after intestinal surgery
resection No chronic conditions Examined every 12 months Measured: body weight, height, BMI, basal energy
expenditure, percentage of involuntary loss of usual body weight (%UWL), fat-free mass, fat mass, total protein, albumin, total lymphocyte count
Calculated home parenteral nutrition (HPN) and home enteral nutrition (HEN) provided
RESEARCH STUDY
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Signifi cant and progressive increase in %UWL 20% of body weight loss by the end FFM and FM signifi cant decrease Serum albumin, total protein, and total lymphocyte count
did NOT change signifi cantly HPN withdrawn in 8 patients (permanently in 5, and
temporarily in 3) Most frequent complications: infection from central venous
catheter (at least 1x in each patient, 30 total instances) Bone disease in 7 pt., deep vein thrombosis in 3 pt., chronic
calculous cholelithiasis in 5 pt. Bone disease: use of cyclic HPN, may contribute to urinary calcium
loss All patients survived for 2 years, seven for 5 yrs., and six for
7 years of more
RESULTS
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References a study of 124 patients with SBS, survival of 94% at 1 year, 86% at 2 years, and 75% at 5 years Death rate: 22% r/t HPN
Duration of PN correlates significantly with length of RSB (length of the residual small bowel after the Treitz angle)
Long-term Enteral Nutrition + Oral Intake achieved the minimal energy requirement at only 2 periods of the study
Inability to use EN exclusively in severe SBSPatients who reduced PN, survived for longer periodsUse of HEN + OI reduced complications of prolonged
PN
RESULTS
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Slow and progressive introduction of oral diet Control electrolytes No benefit to restricting lipids and oxalate if there is
no colon Intestinal absorption up to 50% in SBS Hypercaloric: 1.5-2.0 of BEE
Factors impairing intake: bacterial overgrowth, nausea, flatulence, poor appetite, fear of eating outside the home
Consider intermittent use of PN throughout the year.
NUTRITION RECOMMENDATIONS FROM STUDY
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IV fluidsTPN M/VLasix Novolog LipitorFiberCon Lomotil Imodium Protonix Zofran Codeine Sulfate
ADMISSION 1 MEDICATIONS
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Test Value Normal Range
Hemoglobin 10.4 g/dL 11.6–14.8 g/dL
WBC 15.6 K/mm3 3.8-10.4 K/mm3
Glucose 173 g/dL 60-110 mg/dL
Sodium 132 mmol/L 137-145 mmol/dL
Phosphorus 3.1 mg/dL 3.6–5.0 mg/dL
Free Triiodothyronine
2.26 pg/mL 2.77–5.27 pg/mL
ADMISSION 1 LABS
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Severe sepsis due to abdominal abscess, complicated by septic shock r/t recent removal of duodenostomy tube
Advanced COPDRight lower quadrant fluid collectionAcute abdominal pain r/t mesenteric edemaPeritonitisLeukocytosisHypertension Treatment:
Guided drainage IV fluids IV antibiotics Oxygen
PRESENT MEDICAL STATUS AND TREATMENT
ADMISSION 1
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Surgeon recommends complete bowel shut down and rest with minimum 2 weeks of TPN for malnutrition and duodenal leak.
Diet History: soft diet at nursing homeWeight History: Admission 44kg (22% in <3 months;
severe) 12/2/14 41.8kg 10/23/14 56.5kg 3/8/14 61.3kg
Nutrition-Focused Physical Assessment: Orbital Triceps Temporal Clavicle Shoulders Interosseous Hand-grip strength
ADMISSION 1NUTRITION ASSESSMENT
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Diet order: Clear Liquids, NPO, TPNNutrition Needs:
Calories: BMR = 917; stress factor 1.4 (sepsis) = 1375 Protein: 1.2-2.0g/kg (sepsis, catabolic) = 52-88 Fluid: 30 ml/kg = 1200 ml/d
TPN: Clinimix 5/15 2L w/ 500 ml 20% lipids providing 1920 kcal and 100 gm
protein 1320mL w/ 250 ml 20% fat emulsion, providing 1437kcal
(104%) and 66g protein (75-127%)Nutrition Diagnosis: Malnutrition r/t chronic illness of
sepsis and altered GI function as evidenced by 22% wt. loss past 3 months, poor grip strength, subcutaneous fat loss, muscle atrophy and poor po intake for 3 days which meets the parameters for severe protein-calorie malnutrition (PCM).
ADMISSION 1NUTRITION ASSESSMENT
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WeaknessHyponatremia Acute respiratory failureLeukocytosis UTI Sepsis
Polymicrobial septicemia Fungal septicemia
Short bowel syndrome Treatment
Normal saline Antibiotic 2 units packed red blood cells
PRESENT MEDICAL STATUS AND TREATMENT ADMISSION 2
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Fatigue and weakness past 2 weeksTrigger: poor po >5 days and 10# wt. loss in past 6
months Weight: admission 49kg, Discharge 62.2kg I>O Diet history: since previous discharge
Regular diet: 2-3 meals/day Steak, potatoes, chicken, fish, mac & cheese, hamburger,
yogurt, oatmeal, pudding. No cottage cheese. Denies GI discomfort.
Eating less past 2 weeks Stated she was drinking adequate fluids (ginger-ale,
Pedialyte, Powerade, popsicles) TPN: 1320 ml with 250 ml 20% lipids
ADMISSION 2NUTRITION ASSESSMENT
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Nutritional Needs: Calories: RMR = 971, stress factor 1.3 (infection, hx COPD)
= 1262 Protein: 1-1.3 g/kg (potential malabsorption, infection,
chronic illness) = 49-74 g Fluid: 30ml/kg = 1470 ml
Current diet: Purred diet, Clear Liquids, Full Liquids TPN: Clinimix 5/15 1320 ml w/ 250 ml 20% lipids,
which provides: 1437 kcal (114% of estimated needs) and 66 g protein (90-135% of estimated needs).
NUTRITION ASSESSMENT
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Diagnosis Inadequate oral intake r/t poor appetite and fatigue as
evidenced by reported poor po intake >5 days. Intervention
Meals and Snacks: Encourage small, frequent meals. Decrease amount of fluid consumption with meals, have fluids between meals.
Nutrition Support: Continue TPN Supplement: Place order for Ensure TID.
Monitoring and Evaluation Meals and Snacks: Monitor for intake and tolerance. Nutrition Support: Monitor for tolerance and order change. Supplement: Monitor for consumption and need for lower-
sugar formula Anthropometrics: Maintain wt. +/- .5 to 1kg of admission wt. Biochemical: Monitor Hgb, Hct, sodium, BUN, glucose, and
iron.
ADMISSION 2NUTRITION CARE PROCESS
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Two weeks of therapy for bacteremia and fungemia.
Long-term TPN Home health care
DISCHARGE
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Questions?
THANK-YOU!