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Whitney Miller

Jennifer Crumm

Chelsi Cardoso

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Introduction, Meet Mrs.M 64 year old Cuban-American Admitted to the ER with a Dx of DVT (deep

vein thrombosis) in her right leg andhyperglycemia

This is her fifth admission in the last year.Long standing MH that includes:Type 2 diabetes mellitusPVD (peripheral vascular disease)Retinopathyneuropathynephropathyhypertensionand S/P MI (status post myocardial infarction).

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Anthropometrics

Height: 53 (1.6 m)Weight: 252 lbs (115 kg)

IBW: 100 lbs. for 1st 5 ft. + 5 lbs. foreach additional inch = 115 lbs.

%IBW: 252 lbs/ 115 lbs. = 219%

BMI: kg/m2 = 115 kg / 2.56 m2

44.8 kg/m2 => Class III, morbidlyobese

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Medications

HeparinAnticoagulant

Hyperkalemia

InsulinUsed to keep diabetes under control

Depletes magnesium, potassium, and phosphate

in blood

Potassium SupplementsInsulin can deplete levels in blood, so

supplement to keep levels normal

Contradiction with Heparin

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Medications

Phosphorus SupplementsTake because insulin can deplete levels in

blood

Avoid if have kidney issues

ReglanUsed to treat slow gastric emptying in

people with diabetesCauses nutritional side effects

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Lab Values andInterpretations

Basic Metabolic PackageTEST RESULT REFERENCE

UNITSTEST RESULT REFERENCE

UNITS

Glu (H) 203 mg/dl 70-110 mg/dl Na 144 mEq/L 136-145mEqu/L

BUN (H) 27 mg/dl 6-20 mg/dl K (L) 3.1mEq/L 3.5-5.2

mEq/LCr (H) 1.2 mg/dl 0.6-1.1 mg/dl Cl 98 mEq/L 96-

106mEq/L

Ca 9.1 mg/dl 8.8-10.0mg/dl

Mg 1.9 mEq/L 1.8-2.6mEq/L

Ser alb 3.7 g/dl 3.5-4.8 g/dl P 4.4 mg/dl 2.7-4.5 mg/dl

Elevated glucose indicates diabetes and

Elevated BUN and creatinine levels indicate kidney disease

The low potassium levels could be caused by K+-losing diuretics used to treat

hypertension

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Lab Values

CBC

TEST RESULT REFERENCE UNITS

TEST RESULT REFERENCE UNITS

Hgb 13 g/dl 12-16 g/dl WBC 6.8 x 103/ l 4.5-10.5 x103/cells/mm3

Hct 39 % 36-48 % % Lymph 25 % 25-40 % of total WBC

RBC 4.6 x 106 / 3.6-5.0 x106/L

MCH 28 pg/cell 26-34 pg/cell

MCV 85 m3 82-98 m3 MCHC 33 g/dl 32-36 g/dl

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Hospital Course

Treated with I.V. heparin therapy,

insulin, potassium and phosphorus

supplementation repeated as necessary,

bed rest, and 1000 kcal, 2 g Na diet,with a protein intake not to exceed .7 g

per kg IBW.

Progressed well on treatment and clotresolved.

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Continued

As preparing for d/c, developed newsymptoms:N/V to a degree such that an N/G tube

placedAbdomen extended and hard to touch but

her BS (bowel sounds) decreased=> eithergastric ileus or obstruction

Physicians to R/O (rule out) a SBO (smallbowel obstruction) soesophagogastroduodenoscopy conductedwith negative results.

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Continued

Gastric emptying time delayed: Venography studies indicated ischemia of the

gastric arteries slowing down blood supply to

stomach causing decrease in gastric functioning,termed as gastroparesis 2 to diabetic

gastrovasculitis.

GI tract function beyond stomach:

PEJ performed and feeding tube placed.MD prescribed Reglan to aid in gastric emptying

when pofeedings resumed.

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Nutrition History

Fried plantains, dried blackbeans, chick peas, yams,french fries, vegetablescooked with animal fat, orlard, sugar is added tomany things like coffee, or

vegetables. When she watches her

son bowl she eats a largehamburger, fries, andsoda. After she eats thatshe may drink a few beers.

She lives with her son whois an obese cook and hemakes whatever shewants.

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Nutrition Diagnosis

The Third step of the NCPNutrition intervention with Medical Nutrition Therapy

(MNT)

PES #1: Excessive energy intake (P) related toeating fried and high sugar foods (E) as evidence by

diet history including fried plantains, french fries,vegetables cooked in lard, regular soft drinks andcoffee with sugar (S).

PES #2: Inadequate calories and incorrect proteinrequirements (P) related to a increased

requirements (E) as evidenced by enteral formulameeting 45% of estimated energy and 81% ofestimated protein needs(S).

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Intervention: NutritionEducation Intervention plan: nutrition education

regarding diets focused on diabetes,kidney disease, and hypertension.

First, the main need is to lose weight,since all of her problems stem fromobesity.ADAs position

If she is able to loose weight and herhypertension is still high, then DASHKidney issues need to be watched

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Continued

She needs to continue to monitor her

blood glucose throughout

Also, important to incorporate some

physical activity in her lifeWalking would be appropriate for her

condition

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Intervention: Revised MealPlan

Instead of having so manyfried foods she should justincorporate different cookingmethods.

Instead of putting sugar onfoods she could substitutesugar with a low caloric

artificial sweetener. When she goes to watch her

son bowl, she shouldprobably eat before shegoes so she isnt tempted toeat the foods at the bowlingalley.

In helping her with her diet,her son should be morerestricting on the foods hecooks for her.

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Intervention: EnteralFeeding Standard Enteral

Formula: 1000 kcals, .7 g

protein/kg body weight 1000 kcals/ 1 kcal/ml =

1000 mL/ 24 hr = 41.7mL/hr => 40 ml/hr x 24 hr= 960 mL x 960 kcal

40 g protein/L x .96 L =38.4 g protein

Appropriate EnteralFormula: Peptamen, kcal/mL: 1.00,

40g protein/L, 127 gCHO/L, 39 g lipids/L, 270mOsm/kg water, volumeto meet RDI in mL: 1500.

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QUESTIONS???