Introduction to Patient

Case
81 year old female
66in., 104lbs, BMI 22.59 (underweight
for age)
Admitted for hip fracture January 28th
History of inclusion body myositis x20
years, vertigo, hemorrhoid surgery,
cholescystectomy
Lives with husband, has caregiver M-F
Introduction to Patient
Case
January 29
th

Hip Surgery
Nutrition Assessment CIB supplement
January 30
th

NDD2/Honey Liquids, chocolate milkshake w/ beneprotein supplement
Swallow Evaluation Zenkers Diverticulum
February 1
st

NDD1/thin liquids, chocolate ensure BID
February 4
th

NDD3/Thin Liquids, chocolate ensure BID
February 5
th
-7
th

Calorie Count 1
Pressure Ulcer Development
DVT Dx
February 2
nd
-10
th

Calorie Count 2
3lb weight loss
February 13
th

NG-tube placement failure
February 14
th

G-tube placement
February 16
th

Discharge

Calorie Count
CALORIE COUNT 1
2/5= 870kcal (54% total kcal needs), 34g pro (49% total pro
needs)-majority of kcals from ensure
2/6= 760kcal (48% total kcal needs), 21g pro (30% total pro
needs)-majority of kcals from ensure, pt found to be sneaking
cheese snack crackers and dry honey nut cheerio cereal in
between meals
2/7 =1440 (90% total kcal needs), 53g pro (76% total pro
needs)-majority of kcals from ensure
CALORIE COUNT 2
2/8=1200kcal (75% total kcal needs), 40g pro (59% total pro
needs)-majority of kcals from ensure
2/9=640kcal (40% total kcal needs), 19g pro (27% total pro
needs)-majority of kcals from ensure
2/10=720kcal (45% total kcal needs), 24g pro (34% total pro
needs)-majority of kcals from ensure, 3lb wt loss

Etiology and Pathophysiology

Malnutrition
Pressure Ulcer, Weight Loss
Zenkers Diverticulum
Hip Fracture, DVT
Advanced Age, IBM, Underweight, Dysphagia
Medical List of Concerns
Hip Fracture
Inclusion Body Myositis
Deep Vein Thrombosis
Dysphagia and Zenkers Diverticulum
Pressure Ulcer
Malnutrition

Hip Fracture
Inclusion
Body
Myositis
Deep Vein
Thrombosi
s
Zenkers Diverticulum
http://www.youtube.com/watch?v=XnDp0BOFzOs
Pressure
Ulcers
Malnutrition
Nutrition Practice
Guidelines
Dysphagia/Zenkers Diverticulum
Pressure Ulcers
Malnutrition
Dysphagia
Nutrition care plan developed on:
finding safest food and liquid consistencies
determining the patient's needs
food preferences
addressing underlying medical, psychological,
or social factors

Goal = provide adequate oral and fluid
intake to maintain healthy weight, prevent
deficiencies, and support independent
eating behaviors

National Dysphagia Diet

National Dysphagia Diet:
Food Consistencies/Levels
Level 1: Dysphagia Pureed
For moderate to severe dysphagia. The diet consists of pureed, homogenous, and cohesive foods.
Foods should be pudding like. Any food that requires bolus formation, controlled manipulation, or
chewing should be excluded.
Level 2: Dysphagia Mechanically Altered
For mild to moderate oral and/or pharyngeal dysphagia. This level consists of all foods from Level
1, plus foods that are moist, soft-textured, and easily formed into a bolus. Pieces can be no larger
than one-quarter inch. This is a transition level from pureed texture to more solid foods and some
ability to chew is required. The ability to tolerate mixed
textures at this level will be individualized.
Level 3: Dysphagia Advanced
For mild dysphagia. This level consists of most textures except very hard, sticky, or crunchy foods.
Foods should still be moist and in bite-size pieces at the oral phase of the swallow, more
chewing ability is required.
Level 4: Regular Diet
All foods allowed, as tolerated.
National Dysphagia Diet
Liquid Consistencies
Thin No alteration
Nectar-like
Slightly thicker than water; the
consistency of un-set gelatin
Honey-like A liquid with the consistency of honey
Spoon-thick
A liquid with the consistency of
pudding
CONDRADICTIONS???
Pressure Ulcers
Pressure Ulcers
Calories
Agency for Health Care: 30-35kcal/kg/day
European Pressure Ulcers Advisory Panel: 35-
40kcal/kg/day
Protein
European Pressure Ulcer Advisory Panel: 1.0-
1.5g/kg/day
Vitamin/Minerals
Multivitamin in those with deficiencies
Amino Acids Arginine and Glutamine???
Oral Liquid Supplements???


Malnutrition

Three typical etiologies:
Acute Illness/Injury: Severe acute inflammation
Chronic Illness: Mild to moderate chronic inflammation
Social/Environmental Circumstances: without inflammation

Six characteristics:
Weight loss
Insufficient energy intake
Loss of subcutaneous fat
Loss of muscle mass
Localized or generalized fluid accumulation
Diminished functional statusmeasured by hand-grip strength

Malnutrition
Long-Term Tube Feeding
According to A.S.P.E.N. when an enteral
tube feed will continue for more than
four weeks: nasogastric or gastrostomy
tube
The Dietitians job:
calculating nutritional needs
choosing the proper formula
determining initiation and goal rate
monitoring and evaluating tolerance
Estimating Needs
Calories:
Mifflin St. Jeor
Harris-Benedict equations
adjustments for confounding medical conditions
and clinical judgment

Protein:
Institute of Medicine
Adults: 0.8-1.0g/kg/day
Elderly: 1.0-1.2g/kg/day
Fluid
30ml/kg/day
Minimum 1500ml/day


Long-Term Tube Feeding
Formula
Polymetric Standard
Addition of fiber???
Type of Feeding
Continuous
Intermittent
Bolus
Initiation/Goal Rate
No current guidelines clinical judgment
Monitor/Evaluation
Intake/Output and Bowel Movements DAILY
Weight WEEKLY
Labs MONTHLY
Placement and Residuals AS NEEDED

Discussion
USE PUBLISHED GUIDELINES TO
FORM NUTRITION CARE PLAN
Nutrition Interventions
Oral Liquid Supplements
National Dysphagia Diet
Long-Term Tube Feed




Oral Liquid Supplements
Oral Liquids Supplements Used:
Carnation Instant Breakfast
Chocolate Milkshake w/ Beneprotein
Ensure
Reasons:
Underweight
Increase calories/protein to prevent further weight loss
and malnutrition
Hip Facture
Promote healing
Dysphagia
Tolerable way to increase daily oral intake
Pressure Ulcer
Increase calories, protein, vitamins/minerals to promote
healing

National Dysphagia Diet
NDD Used:
NDD3/Honey Liquids
NDD1/Thin Liquids
NND2/Thin Liquids
Reasons:
Dysphagia
Zenkers Diverticulum (not a candidate for
surgery)
Increase oral intake to meet estimated daily needs
Prevent further weight loss/wasting
Malnutrition Diagnosis
ADA and A.S.P.E.N. Criteria
Etiology
Acute illness/injury
Hip Fracture
Characteristics
Weight loss
3lbs in 2 weeks
Insufficient energy intake
<50% energy intake compared to estimated needs for
>5 days
Localized or generalized fluid accumulation
Right Leg DVT edema/swelling




Long-Term Tube Feeding
Estimate Needs
Calories: Mifflin St. Jeor x 1.3
Protein: 1.0-1.2g/kg/day
Recommendations for elderly
Higher then usual to promote healing from hip fracture and pressure ulcer
Fluid: 25-30ml/kg/day
Formula Selection
Jevity 1.2
Polymetric Standard formula with addition of protein
Type of Feed
Bolus
Mimics normal meal/snack lifestyle
Allows for pleasure feeds
Initiation/Goal Rate
Clinical judgment
Monitor/Evaluation
Initial
Residuals <500 (ASPEN guidelines), normal abdominal distention, no
signs/symptoms of edema, adequate I&Os, all electrolytes, BUN, creatinine,
phosphorus, magnesium, calcium and glucose lab values within normal limits, normal
stool output/consistency, minimal weight fluctuation
Long-Term Tube Feeding
Formula: Jevity 1.2
Feeding Type: Bolus
Initiation: 140ml/hr for first 2 feedings
Goal Rate: 280ml/hr 5x/day
Provides:1680kcal, 78g pro, 1128ml free
fluid
Flushes: 50ml before and after each
bolus
Provides total of 1700ml/day
Conclusion/Recommendations
Malnutrition = primary concern for RD
Long-term tube feeding necessary
Goal of nutrition support not only to
provide sufficient means of nutrition, but
to also improve quality of life.
The bolus feeds was a way for the patient to
fulfill their physiological need of nutrition,
while the option of pleasure feeds would
fulfill the psychological need of smell, taste,
fullness, and satisfaction
References
1. Johnsen C, East JM, Glassman P. Management of malnutrition in the elderly and the appropriate use of commercially
manufactured oral nutrition supplements. The J ournal of Nutrition & Aging. 2000; 4(1):42-46.
2. Causes of malnutrition. Nestle Nutrition Institute Website. http://www.mna-elderly.com/causes_of_malnutrition.html.
Updated 2014. Accessed March 2014.
3. Cox FM, Verschuuren JJ, Verbist BM, Niks EH, Wintzen AR, Badrising UA. Detecting dysphagia in inclusion body
myositis. J ournal of Neurology. 2009; 256: 2009-2013.
4. Hip fractures. American Academy of Orthopaedic Surgeons Website.
http://orthoinfo.aaos.org/topic.cfm?topic=A00392. Reviewed April 2009. Accessed March 2014.
5. Myint MWW, Wu J, Wong E, Chan SP, To TSJ, Chau MWR, Ting KH, Fung PM, Au, KSD. Clinical benefits of oral
nutritional supplementation for elderly hip fracture patients: A single blind randomized controlled trial. Age and
Ageing. 2013: 42: 39-45.
6. Inclusion-body myositis. Muscular Dystrophy Association Website. http://mda.org/disease/inclusion-body-myositis.
2014. Accessed March 2014.
7. Inclusion-body myositis. The Myositis Association Website. http://www.myositis.org/learn-about-myositis/types-of-
myositis/inclusion-body-myositis. Updated March 2012. Accessed March 2014.
8. Deep vein thrombosis. MayoClinic Website. http://www.mayoclinic.org/diseases-conditions/deep-vein-
thrombosis/basics/definition/con-20031922. January 2013. Accessed March 2014.
9. Dugdale DC, Zieve D, Black B, Wang N. Deep venous thrombosis. MedlinePlus website.
http://www.nlm.nih.gov/medlineplus/ency/article/000156.htm. Updated January 2013. Accessed March 2014.
10. DVT prevention and management. The Coalition to Prevent Deep-Vein Thrombosis Website.
http://www.preventdvt.org/management/dvt-diet-nutrition.aspx. Updated February 2013. Accessed March 2014.
11. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: Management and nutritional considerations.
Clinical Interventions in Ageing. 2012; 7: 287-298.
12. Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: Exploring different treatment options. Acta
Otorhinolaryngologica Italica. 2013; 33: 219-229.
13. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (zenker's diverticulum). Postgrad Medical J ournal. 2001; 77: 506-
511.
14. Klockars T, Sihvo E, Makitie A. Familial zenker's diverticiulum. Acta Oto-Laryngologica. 2008; 128: 1034-1036.
15. Egea AH, Delgago LP, Galve GT, Larpa MG, Aldea CO, Garcia AO. Treatment of zenker's diverticulum: Comparison of
techniques. Acta Otorrinolaringol Espanola. 2013; 64(1): 1-5.
16. Vogelsand A, Schumacher B, Neuhaus H. Therpay of zenker's diverticulum. Deutsches Arzteblat International. 2008;
105(7): 120-126.
17. Bedsores (pressure ulcers). MayoClinic Website. http://www.mayoclinic.org/diseases-
conditions/bedsores/basics/causes/con-20030848. March 2014. Accessed March 2014

References
18. Gruen D. Wound healing and nutrition: Going beyond dressings with a balanced care plan. J ournal of the American
College of Certified Wound Specialists. 2010; 2: 46-49.
19. Collins CE, Kershaw J, Brockington S. Effect of nutritional supplement on wound healing in home-nursed elderly: A
randomized trial. Nutrition. 2005; 21: 147-155.
20. Wellman NS, Kamp BJ. Nutrition in aging. In: Mahan LK, Escott-Stump S, ed. 12. Krause's Food & Nutrition
Therapy. St. Louis, Missouri: Saunders Elsevier; 2008: 286-305.
21. Malnutrition. American Academy of Nutrition and Dietetics Nutrition Care Manual Website.
http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=109585&highlight=malnutrition. 2014. Accessed
March 2014.
22. Dysphagia. American Academy of Nutrition and Dietetics Nutrition Care Manual Web Site.
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=22679&lv2=255550&ncm_toc_id=255550&nc
m_heading=Nutrition%20Care. 2014. Accessed March 2014.
23. Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of older people consuming a
texture modified diet with a normal hospital diet. J ournal of Human Nutrition Dietetics. 2005; 18: 213-219.
24. Germain I, Dufresne T, Gray-Donald K. A novel dysphahia diet improveds the nutrient intake of institutionalized
elders. J ournal of American Dietetic Association. 2006; 106: 1614-1623.
25. Pressure ulcers. American Academy of Nutrition and Dietetics Nutrition Care Manual Web Site.
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5546&lv2=16668&ncm_toc_id=16668&ncm_h
eading=Nutrition%20Care. 2014. Accessed March 2014.
26. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,
Protein, and Amino Acids (Macronutrients). Washington, DC: National Academies Press; 2005.
27. Campbell WW, Crim MC, Young VR, Joseph LG, Evans WJ. Effects of resistance training and dietary protein intake
on protein metabolism in older adults. American J ournal of Physiology. 1995; 268: E1143-E1153.
28. Reddy M, Sudeep SG, Kalkar SR, et al. Treatement of pressure ulcers: A systematic review. J AMA. 2008; 300(22):
2647-2662.
29. Williams JZ, Barbul A. Nutrition and wound healing. Surg Clin North Am. 2003; 83: 571-596.
30. Dorner B, Posthauer ME, Friedrich EK, Robinson GE. Enteral nutrition for older adults in nursing facilities. Nutrition
in Clinical Practice. 2011; 26(3): 261-272.
31. American Dietetic Association Evidence Analysis Library. Available to members at: www.adaevidencelibrary.com.
Accessed March 2014.
32. Enteral nutrition. American Academy of Nutrition and Dietetics Nutrition Care Manual Website.
http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255292. 2014. Accessed March 2014.
33. Schneider SM, Girard-Pipau F, Anty R, et. al. Effects of total enteral nutrition supplemented with muli-fibre mix on
fecal short-chain fatty acids and microbiota. Clinical Nutrition. 2005; 28:2267-2279.