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CMC Clinical Case

Study
Jaclyn Schermer
Keene State College Dietetic Intern
June 2017
About Catholic Medical Center
Was founded in 1858

11 units with variable amounts of beds


in each
Example: Cardiovascular surgical unit

NH first open heart surgery in 1978 and


is leader in cardiovascular services

2002 was the first New England hospital


to use robotic surgical system for minor
surgeries
Role of the Registered Dietitian at CMC
Medical nutrition therapy

Assess nutritional needs based on the


standards of care.

Consults, triggers, risk

Educate patients on nutrition

Provide supplements to patients to


increase nutrition for healing

Oral, TPN, tube feed, etc

Calorie counts, calculate requirements,etc

Participate in rounds for discharge and medical


Introduction to Mrs. M

She is 64 yo, she is married, she lives at home with her husband who is her
primary caregiver when she is at home.

Has been consistently in and out of the hospital since cancer diagnosis in
April of 2016

Family hx: Colon cancer, DVT

Was admitted to CMC on May 13th from a rehabilitation center due to


abdominal pain, COPD exacerbation, and chronic respiratory failure.

Focus of case study will be on Mrs. Ms malnutrition


2016 Sypmtoms diagnosis Weight /BMI Treatment Other

April Bloody stools Rectal 113 lbs, BMI Chemo and COPD
Unintentional cancer 16.5 radiation symptoms
Weight loss malnutrition

July/August Severe Rectal 100lbs, BMI d/c treatment Regular diet


diarrhea cancer 14.9 from but chooses
malnutrition personal lactose free
choice
December Anxiety, SOB Rectal Wt 98 lbs, Loop TPN
cancer BMI 14.5 ileostomy temporarily
Ileus with bowel due to ileus
COPD resection And regular
diet as
tolerated

Information acquired from Sunrise charting system


Loop Ileostomy
What it is: when a piece of the ileum is
surgically placed into an opening made in the
abdomen.

Benefits: helps bowel rest for healing, pt will be


able to resume most normal functions

Nutrition risks associated: decrease urine


output electrolyte imbalance, dehydration,
nausea, diarrhea, severe skin irritation
2017 Symptoms Diagnosis Weight/ Treatment other
BMI

January Weakness COPD 81 lbs, BMI 12 TF promote Ileus healed up


Weight loss Hyponatremia in December
COPD malnutrition
exacerbation

March Liquid ostomy malnutrition 108 lbs , BMI Continued on Admitted into
output 15.4 promote TF, on rehab for
regular diet as stability for
tolerated, ileostomy
unjury reversal
supplement w/
lactaid
Ostomy Output

Risks of liquid output: dehydration, electrolyte imbalance, fatigue

Liquid ostomy output is typically treated with TPN

Goal for ostomy output is between 500-1500 ml/day


April 2017 Symptoms diagnosis Weight/ BMI Treatment Other

April 6th Weight loss Acute 115 lbs Colostomy


Weakness respiratory BMI 17 Takedown loop
failure ileostomy
April 11th Change in Acute No new weight Redo small
ostomy output respiratory or BMI bowel
consistency, failure anastomosis

April 13th SOB Pleural effusion No new weight Underwent


Myopathy or BMI thoracentesis

April 18th Abnormal Anastomotic No new weight Small bowel Placed in rehab
drainage in leak, iron def. or BMI resection with when stabilized
stoma anemia ileostomy due on 24th
anastomotic
leak.
May 2017 Medical diagnosis
Medication Reasoning
Dilaudid Pain management
Medical
Lyrica Nerve and muscle pain
diagnosis: Pt
Prednisone Inflammation and COPD
admitted from
Furosemide Fluid accumulation
rehab with chronic
Protonix Decrease reflux
respiratory failure,
Ferrous sulfate p/o low iron
abdominal pain,
and COPD Diclyclomine IBS symptoms
exacerbation. Methocarbamol Muscle relaxant
Buprenorphine Pain management
Megace Cachexia
Admission Labs May 13th

Lab Value Lab Value

Hemoglobin 8.8 Glucose 119


Hematocrit 28.9 Calcium 8.1

Albumin 1.8 BUN/Creat Ratio 150


Sodium 135 Magnesium 1.9
Potassium 3.8 Phosphorus 2.6
Chloride 99 Total protein 5.8
Carbon dioxide 31 AST 42
BUN 27 Alk Phos 121
Creatinine 0.18 ALT 92
Nutrition Assessment: 5/13 (information from Sunrise)
Anthropometric Data: Admit weight of 99 lbs which is down 15 lbs in 5 weeks, 5 ft 9
inches, BMI 14.6

Pt has Dentures

Appears: cachectic, generalized muscle wasting, generalized wasting fat stores

Previous diet instruction: Calorie counting, low fiber, 2 g sodium diet, 2000 ml
fluid restriction, Eating Your Way to a Healthy Heart

Current diet order- regular as tolerated, low lactose per pt request

Recent food recall per pt: oatmeal w/ brown sugar (50%), (50%) tapioca
pudding, (25%) grilled cheese, (40%) cordon blue
Nutrition Assessment Review of Labs from 5/13:
Lab Measuring Value
Albumin Protein made by liver to keep fluids from 1.8 g/dL (low)
(Mal.) leaking out of blood . Measures amount of
protein in clear part of blood.
AST Enzymes in the blood 42 (ok)

ALT Enzymes in the blood 92 (high)

Alk Phos Enzymes in the blood 121 (high)

Total protein Measures the amount of protein found in fluid 5.8 (low)
(Mal) portion of blood
Hemoglobin Tests the total amount of Hgb in the blood 8.4 (low)
(Mal.) which transports O2 and CO2
Medications with Nutritional Importance:

prednisone (inflammation, COPD): may cause Na retention and suppress


immune system

Furosemide ( fluid accumulation): may cause electrolyte imbalances

Protonix ( decrease reflux): may cause decrease serum magnesium

Ferrous sulfate ( p/o low iron): improve iron in the blood

Megace (cachexia): stimulate appetite


Nutrition Diagnosis

Malnutrition (NI-5.2) r/t malignant neoplasm of rectum and COPD


exacerbation AEB BMI 14.6, Wt of 98.8lbs, severe muscle mass and
fat store depletion, low albumin and prealbumin, and severe wt loss.
Pathophysiology of Malnutrition

Malnutrition- lack of proper nutrition

Causes: inadequate intake, increased energy requirements,


inadequate absorption of nutrients, increases nutrient losses,
inadequate nutrient utilization, presense of chronic conditions
Primary/Secondary Systems Impacted by
Malnutrition

subcutaneous tissues: decrease in these tissues mainly face, legs,


and arms

Extremeties: fluid accumulation mainly in distal extremeites

Skin: may become hyperpigmented and dry

Nail: ridged nails

Hair: may become more brittle and thin


Statistic on Malnutrition
- 1 in 3 patients that stay in the hospital are malnourished

- Malnutrition is the number one risk to health worldwide.

- Patients discharged after a malnutrition diagnosis is five times more likely to


result in death.
Review of Weights Up until May 13th
Month and Year Weight BMI

April 2016 113 lbs 16.5

July/August 2016 100 lbs 14.9

December 2016 98 lbs 14.5

January 2017 81 lbs 12

March 2017 108 lbs 15.4

April 2017 115 lbs 17

May 2017 99 lbs 14.6


Progression of Malnutrition
Mrs. M and Diagnosis of Malnutrition Based
on ASPEN Guidelines
Severe Malnutrition Chronic Illness
Greater than 5%/1 month
Greater than 7.5%/3 months
Weight Loss
Greater than 10%/6 months
Greater than 20%/1 year
Less than or equal to 75% for greater than or equal to 1
Energy Intake
month
Body Fat Severe Depletion
Muscle Mass Severe Depletion
Fluid Accumulation Severe
Grip Strength Measurably Reduced
Alb less than 2.5 g/dl
Labs
PAB less than 10mg/dl
Malnutrition and Mrs. M

Cancer: decreased appetite, excessive diarrhea (d/c chemo/radiation),


decreased absorption of nutrients, increased inflammation, weight loss due to
decreased PO intake, increased energy expenditure, muscle loss, weakness,
eating fewer kcals

COPD: increased protein/energy expenditure, poor appetite, decreased


respiratory strength, fatigue

Multiple Operations: fatigue, increase protein/energy requirements,


weakness, decreased immune system function
MNT Recommendations for Malnourished
National Cancer Institute/ American Cancer Society Similarities:

Small frequent meals/snacks, consume high kcal and protein, meal


replacements if needed, enteral or parenteral nutrition support

Differences:

American cancer society says avoid liquid with meals

National cancer institute says enteral nutrition support if patient is


malnourished and anticpated to have inadequate ingestion or
absorption for 7+ days
Intervention: Day 1

Energy needs: 1700-1900 kcal/d( 37-42 kcal/kg), 80-90 g/d( 1.7-2 g/kg), 1900
mls fluid( 1 ml/kcal)

Nutrition Support: TPN cant have lipids due to elevated liver enzymes: Provides
1385 kcals and 114 grams Protein

Recent food recall: oatmeal w/ brown sugar (50%), (50%) tapioca pudding, (25%)
grilled cheese, (40%) cordon blue
Intervention: Day 1

TPN 24hr providing 1385 kcal and 114 grams protein, added unjury
frappes TID

TPN (TPN provided D70 390 ml, AA15 760 ml)

Unjury Frappe: 100 kcal/cc, 21 gm per scoop

Based on wt of 44.9 kg , needs 1700 kcal-1900 kcal per day(


37kcal/kg-42 kcal/kg)), 80-90 gms protein( 1.7- 2g/kg), 1900 ml
fluid ( 1 ml/kcal)
Intervention: Day 1

TPN without lipids ( D70 390 ml, AA 15 760 mls) due to elevated
liver enzymes 24 hours a day at 75 mls/hr

Unjury frappes with lactaid TID

Monitor PO intake, acceptance of supplement, weight, ileostomy


output, and changes in status.

We prioritized getting her nutrition the most to gain weight. So we


were mainly prioritizing weight gain. Then we prioritized PO intake.
Next we considered the LFT labs to add back in the lipids to the TPN.
Goals for A.M: Day 1
Goals:

Maximize PO intake, increased PO intake so we can decrease


dependence on TPN

Meet 100% of nutrient needs for at least 3 consecutive days


before TPN adjustment

Have ileostomy output in proper range ( 800-100 cc/day)

Weight gain and increased BMI: 1-2% body weight increase

Increased liver function ( improvement in LFT labs)


Days 2- 4 (5/14-19)
d/c furosemide on 5/16

Palliative care consult 5/16, pt given 3 months to live

Remain on TPN providing 1385kcal and 114 gram protein (lipid free)

LFTs remain elevated (5/13): AST 42, ALT 92, alk phos 121

Tolerating unjury supplements and taking small amounts of solids

Three day calorie count in progress and incomplete

Abdominal wound care consult and stoma check ordered, wound identified
Day 8-9 (5/23-24)
Requested MD to have new LFT labs drawn (been 10 days since updated)
and wt from the nurse on standing scale

Questioned if liver enzymes were improved enough to add lipids back into
TPN

Ileostomy output around 1600mls which was higher than 800-1000 cc/d

Risks associated with high ileostomy output: dehydration, electrolyte


imbalances

PO intake improving, COPD at baseline

Albumin 2, AST 35, ALT 140, alkphos 159


Day 10-11 (5/25-26)

Wt of 105 lbs (+6 lbs since admission from RMU)

Meeting 89% PO intake and 72% protein low end needs based on
calculated calorie count.

TPN remains the same which provides 1385 kcals and 114 grams
Protein

Continue calorie count


Day 14-16 (5/29- 5/31): Adjusted Intervention
Albumin 2.1, AST 27, ALT 101, Alk phos 121

d/c shakes and add unjury powder to food instead

MD okayed adding lipids back into TPN

Plan to monitor liver enzymes and begin pt on cyclic TPN due to PO intake progress

Plan to begin cyclic TPN: D70 260 ml, AA15 510 ml, L20 130 mls (1185 kcal and 76.5
g protein)

Continue calorie count, placed on Imodium due to diarrhea. A person with an


ileostomy can have imodium as long as it isnt a pill that is coated, as that may come
out whole. Recommend liquid antidiarrheal medications.
Day 18 (6/2)
Liver enzymes improving: AST 26, ALT 76, Albumin 2.3

PO intake is fairly good, pt consuming ~1600 kcal and 86 g protein

Continues on TPN cyclic at night

Rt rib pain, positive for rib fracture and given toradol

Was denied to rehab and cant go to SNF due to TPN.

Discussed in multidisciplinary meeting talk of sending pt home with


wound vac and cyclic TPN. Help set up VNA services.
Reassessment of Labs: 6/2
Lab Value Lab Value

Hemoglobin 9.4 Glucose 91


Hematocrit 30.8 Calcium 7.8

Albumin 2.3 BUN/Creat Ratio 96


Sodium 139 Magnesium 1.9
Potassium 4.0 Phosphorus 2.6
Chloride 106 Total protein 5.5
Carbon dioxide 28 AST 26
BUN 24 Alk Phos 126
Creatinine 0.25 ALT 76
Evaluation and Reassessment: Labs
Lab 5/13 5/24 5/29 6/1

Albumin 1.9 2 2.1 2.3

AST 42 35 27 25

ALT 92 140 101 65

Alk. Phos. 121 159 121 127


Evaluation and Reassessment: Weight

Weight 5/12 5/13 5/19 5/26 5/30

Pounds 99 129 114 105 107


( fluid (diuresing)
overloaded)

Updated Medications List: Prednisone, Protonix, Dilaudid,Ferrous


Sulfate, Cymbalta, Duoneb inhalation, Nitroglycerin
Adjustment and Re-evaluation:Medications
Medication Reasoning Discontinued/Active
Dilaudid Pain management Active
Lyrica Nerve and muscle pain d/c 5/19
Prednisone Inflammation and COPD Active
Furosemide Fluid accumulation d/c 5/16
Protonix Decrease reflux Active
Ferrous sulfate p/o low iron Active
Diclyclomine IBS symptoms PRN
Methocarbamol Muscle relaxant PRN
Buprenorphine Pain management PRN
Megace Cachexia Pt chose to d/c 5/14
New Medications
Medication Reasoning Began
Mylicon Flatulence PRN 5/20
Dakin Solution Abdominal wound cream 5/16
Today was my last day of my Clinical
rotation, it is unknown to me how the pts
case progressed. Patient likely to continue
nutritional care based on CMC standards of
care.
Evaluation/Reassessment Summary/Recap
Increased PO intake over the course since admission

Improved liver function with liver enzyme ranges decreasing, as


shown on chart on previous slide

transition from 24 hour TPN to cyclic at night, tolerating

increased weight +7% in 1 month

RD impacts: helped encourage PO intake, monitor TPN/calculate,


calorie counts/nutrient analysis, improve weight
Thank you!
Resources

http://www.ostomy.org/Ostomy_Information.html#ileostomy
https://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq
http://www.gainhealth.org/knowledge-centre/fast-facts-malnutrition/
https://www.nutritioncare.org/Press_Room/2013/One_in_Three_Hospitalized_Patients_is_
Malnourished;_Experts_Call_for_Better_Diagnosis_and_Treatment/

R E Black, L H Allen, Z A Bhutta, et al (2008) Maternal and child undernutrition: global and
regional exposures and health consequences, The Lancet, 2008, Jan 19, 371 (9608), 243-
60.

Snider JT, Linthicum MT, Wu Y, LaVallee C, Lakdawalla DN, Hegazi R, et al. Economic
burden of community-based disease-associated malnutrition in the United States. JPEN J
Parenter Enteral Nutr. 2014;38(S2):77S-85S.

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