Case Study

Rachel Brown
Keene State College Dietetic Intern
November 2016
 Introduction
Patient: MJ, 52 year old Male
Medical Diagnosis:
- Acute Bronchitis
- Chronic Aspiration in the setting of vocal cord
squamous cell carcinoma status post radiation
therapy
- Hypokalemia
 Medical Course
- Bronchitis started on azithromycin (antibiotic)
- Acute renal failure receiving IV hydration
- Patient determined to be fairly bronchospastic receiving
steroids (prednisone) and antibiotic coverage
- After choking observed Augmentin (antibiotic for
infection in the airways) to cover aspiration
- Hypokalemia given potassium chloride bolus
Primary Diagnosis

http://www.webmd.com/lung/understanding-bronchitis-basics
 Acute Bronchitis
- Acute inflammation of the bronchial tubes lining
- Symptoms include productive cough, prolonged cough,
and wheezing while breathing
- May result from viral or bacterial infections (most likely
viral) and exposure to substances that irritate the lungs
such as tobacco smoke or air pollution
- Suspected to be related to chronic aspiration related to
cancer in the throat
 Acute Bronchitis
- Leads to decreased ability to breath due to swelling of the
respiratory tract
- Can lead to a bacterial infection in the airway in addition to
the the viral infection
- If persists for more than 3 months, it becomes a chronic
bronchitis, otherwise known as a form of chronic obstructive
pulmonary disease (COPD)
- Constant productive coughing and wheezing can cause
decreased intake because of lack of swallowing comfort in
the throat
- Can lead to malnutrition
 Treatment of Bronchitis
- Usually goes away on its own (since its most likely a viral
infection)
- If suspected to have a bacterial infection forming with it,
antibiotics are prescribed
- Steroids are given to reduce inflammation of the airway
- Inhalers can be given to help open up airway
- Supplemental oxygen can be provided to help air flow
 Acute Renal Failure
- A sudden episode of kidney failure where the kidneys are
unable to filter the blood as usual
- Build up of waste products in the blood (Creatinine and
BUN)
- Difficult for the kidneys to create a proper balance of fluid in
the body
- Caused by decreased blood flow to the kidneys, damage to the
kidneys, or a blocked urinary tract
- In more serious cases, this build up of waste could effect the
other organs in the body through acidosis
 Acute Renal Failure
Further complications include:

- fluid build up in the lungs (causes shortness of breath)

- muscle weakness from electrolyte imbalance

- heart complications from elevated potassium and other

electrolytes

- Permanent damage to the kidneys that can require dialysis

Treatment of Acute Renal Failure
The problem that causes the acute kidney failure needs to be
treated for the kidneys to recover:

- If blood flow to the kidneys is limited, then the patient is

given fluids to increase blood flow

- If the kidneys are damaged, then the cause of damage is

treated

- If the urinary tract is blocked, then the blockage needs to be

removed/ treated

Treatment is very individual based on the patients situation

Cancer in the Throat

http://www.cancerbox.org/category/info
 Squamous Cell Carcinoma of
the Vocal Cords
Cancer of the Vocal Cords
- Biggest risk factor is tobacco use
- Symptoms include painful swallowing, a development of a
mass in neck, and a hoarseness in voice
- Treatment options include either surgery, chemotherapy,
radiation, or a mix of these interventions
- Increases calorie and protein needs due to changes in
metabolism
 Radiation Therapy
- Treatment option for laryngeal cancers that has the
benefit of no resection of the normal anatomy of the
throat and organs

- May have the side affects of trouble swallowing, loss of

taste, dry mouth (related to damage to the salivary
glands), and painful sores in the mouth and throat (will
heal when radiation has stopped)

https://hpvthroatcancer.wordpress.com/tag/radiation-therapy-for-throat-cancer/
 Other Treatment Options
Chemotherapy
- Medication that targets fast multiplying cells
- Can lead to an impaired immune system and increased
nausea/vomiting
Surgery
- Physical removal of a part of the cancer area
- May result in the loss of anatomy in the head that can change
the patients ability to swallow, speak, or perform other
functional tasks
 Nutrition Care for Patients
- Dietitians at Concord
- The Role of the Dietitian in the Hospital
- Assessment
- Needs
- Diagnosis
- Intervention
- Monitoring and Evaluation
 Concord Hospital
An acute care hospital in
Concord, New Hampshire
- contains 295 beds
- 6 floors that include
cardiac, pulmonary,
surgical, medical,
pediatrics/family place,
http://www.yeatonassociates.com/featured-
projects/healthcare/concord-hospital.html intensive care, behavioral
health, and emergency
department
Dietitians at Concord Hospital
- Work closely with other
health care professionals to
provide the best care for
patients
- Attend rounds/discharge
planning/huddle sessions to
help gather information
about patients
- Keep up to date with the
newest information to keep
the highest Standards of
Practice http://www.spauldingbrick.com/portfolio/concord-hospital
 Role of the Dietitian
- Screen and Assess Patients at high risk for Malnutrition

- Perform a Nutrition Focused Physical Examine

- Determine Malnutrition/ Malnutrition Severity

- Define the Nutritional Diagnosis

- Develop a Nutrition Intervention

- Follow up to Monitor and Evaluate Intervention

- Change or Continue Intervention based on Evaluation

 Assessment
Height: 5ft 6in (66 inches) Prior to Admission Diet History:
- decreased intake for 3 months due to
Weight: 65.1 kg standing pain and difficulty while swallowing
post radiation therapy
BMI: 23.2
Current Diet History:
Labs to Note: - ate 90% of breakfast the morning
before, but choked on foods and
BUN 42 (7-20) drinks now NPO for aspiration risk
Creatinine 2.86 (0.6- Previous weights:
1.2) - 73.6 kg (standing) one month prior
from out patient visit, making him
Potassium 3 (3.5-5.0) have a 12% weight loss in one
month
 Nutrition Risk
3 points for Impaired Nutrition Status

- 12% weight loss in one month

1 point for Disease Severity

- Oncology patient

Total of 4 points = High Nutrition Risk

 Nutrition Focused Physical
Assessment
Findings
- Moderate muscle wasting in scapula, temporalis,
and clavicle
- Mild orbital subcutaneous fat loss
 Nutrition Needs
Calories (from ASPEN Guidelines)
30-35kcal/kg - for cancer, higher energy needs

Protein (from ADA Guidelines)

1.0-1.5 grams of protein/kg increased needs for cancer

Recommendation
1,950-2,280 kcals/day

65-98 grams of protein/day

 Malnutrition Orders
Written by the RD, but signed by the hospitalist/ primary care
provider
Orders included
- 12% weight loss in one month
- >= 1 months intake <= 75% of total estimated energy
requirements
- Moderate muscle wasting in scapula, temporalis, and
clavicle
- Mild orbital subcutaneous fat loss
Patient diagnosed with Severe Protein Calorie Malnutrition
 Nutrition Diagnosis
Inadequate food/beverage intake related to
cancer of the vocal cords post radiation therapy
as evidenced by poor intake, difficulty
swallowing, and unintentional weight loss.

Handout on Radiation Therapy and Head and Neck Cancers

https://www.mskcc.org/pdf/cancer-care/patient-education/radiation-
therapy-head-and-neck-what-you-need-know-about-swallowing
 Intervention
Awaiting diet advancement and SLP recommendations
post Video Fluoroscopic Swallowing Study (VFSS), also
known as modified barium swallow.

If patient is unable
to swallow, will
consider starting
Enteral Feeding.

http://www.kumc.edu/school-of-medicine/otolaryngology/clinical-specialties/voice-and-swallow-
disorders/swallowing-disorders.html
Monitoring and Evaluation
Anthropometrics
- Weight Changes, new weight post hydration
Biochemical
- Potassium level
Clinical
- VFSS result and diet advancement
Diet
- PO intake and tolerance when diet advances
Modified Barium Swallow

https://jessbrantnerwvudietetics.wordpress.com/2014/02/11/modified-barium-swallowing-test/
 Outcomes
Patient aspirated thin liquids (silent aspiration)
Patient did not aspirate honey liquids
Patient aspirated on the juice of a clementine
Patient did not aspirate on pudding

SLP consistency recommendation:

National Dysphagia Diet 2, Honey Liquids
 National Dysphagia Diet 2
with Honey Liquids
NDD2
Soft, moist foods that require little chewing
Regular food needs to be modified to be easier to chew and swallow
http://www.swallowingdisorderfoundation.com/wp-
content/uploads/2011/06/mech-altered-breakdown.pdf

Honey Liquids
All liquids need to have the same honey-thick consistency for safe
swallowing
https://patienteducation.osumc.edu/documents/thickened-liquids.pdf
 Medical Course
- Improved bronchitis with antibiotics and steroids

- Renal dysfunction improved with rehydration

- Creatinine and BUN levels improved

- Bolus of potassium chloride

- Potassium level improved

- Will discharge with new diet and added augmentin,

azithromycin, ventolin, and prednisone to medication list
 Assessment #2
New post-hydration weight: 66.9 kg standing
(weight loss actually only 6.7 kg, 9% in 1 month but still significant)
Labs
- BUN: 16 (7-20)
- Creatinine: 1.3 (0.6-1.2)
- Potassium level: 3.5 (3.5-5)
Patient now with new diet of NDD2 with honey liquids.
- Needs education on new diet
 Diagnosis #2
Food and nutrition related knowledge deficit
related to NDD2 diet and honey liquid
recommendation as evidenced by the patient
requesting information on their diet.
 Intervention #2
Provided comprehensive (>15min) nutrition education
Topic:
NDD2 diet and honey liquids
Materials provided:
Provided RD contact information and education handout
Goal:
Increase Knowledge
Monitoring and Evaluation
#2
Will monitor and evaluate
- PO intake and tolerance of new diet
- Potassium Level
- Weight Changes
- Verbal Understanding of Diet Education
 Conclusion
- If patient tolerates new diet without aspiration, then he will
discharge today

- Patient was discharged that afternoon

- Patient will follow up with an out patient SLP for further diet
advancement
Questions?
 References
http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/acute-bronchitis/

http://www.cancer.org/cancer/laryngealandhypopharyngealcancer/detailedguide/laryngeal
-and-hypopharyngeal-cancer-treating-radiation

https://www.kidney.org/atoz/content/AcuteKidneyInjury

https://www.mskcc.org/cancer-care/patient-education/radiation-therapy-head-and-neck-
what-you-need-know-about-swallowing

http://lungcancer.ucla.edu/adm_lung_bronchitis.html

http://www.mayoclinic.org/diseases-conditions/kidney-failure/basics/complications/con-
20024029

http://leader.pubs.asha.org/article.aspx?articleid=2292328

https://patienteducation.osumc.edu/documents/thickened-liquids.pdf