Joyce L. Hornick Dietetic Intern University of Maryland,
College Park January 4, 2012 2012 by Joyce L. Hornick,
http://joycehornick.com/
Slide 2
Case Report: General Information MH: 44 yo AA Female Admitted
10/22/11 for slurred speech and difficulty ambulating Height 5 2
(157.48 cm) Weight 149 lbs (67.8 kg) Diagnosed with acute
cerebellar ataxia infarction Received treatment for 18 days
Discharged to nursing home facility 11/8/11
Slide 3
Case Report: Social History Living with sister PTA Sister took
care of medical and nutritional needs Not employed due to: Limited
physical abilities Multiple medical issues Presumed to be on
disability-related insurance coverage
Slide 4
Case Report: Medical/Surgical Data Past Medical History: Type 2
Diabetes Mellitus (DM2) Hypertension (HTN) End Stage Renal Disease
(ESRD) with hemodialysis 3 times per week x 2 years Cerebrovascular
Accident (CVA) Human Immunodeficiency Virus Disease (HIV) Hepatitis
C
Slide 5
Case Report: Medical/Surgical Data Medications: Heparin (blood
clotting) PhosLo (phosphate control) Rena-Vite (renal-specific
multivitamin) Sensipar (hyperparathyroidism) Sustiva (HIV) Epivir
(HIV) Catapres/clonidine (HTN) No DM medications
Slide 6
Case Report: Medical/Surgical Data Relevant Information about
MH PTA: 10/19/11: Missed hemodialysis appointment. 10/20/11: Family
noticed difficulty ambulating. 10/21/11: MH unable to have
dialysis. At FSH, fistula blocked and staff attempted to
unblock.
Slide 7
Case Report: Medical/Surgical Data Relevant Information about
MH Following Admission: 10/22/11 (Day 1): Admitted for right side
weakness, confusion, and cognitive decline. No chest pain,
shortness of breath, nausea, vomiting or diarrhea. Examinations
scheduled to r/o CVA, Encephalitis, and/or infection. Family
reported that MH had been slow to respond and/or talk for the
previous three weeks.
Slide 8
Case Report: Tables Laboratory Results: Appendix A List of
Medications: Appendix B Vitamin Supplements: As listed in Appendix
B, MH was taking Rena-Vite, as recommended for dialysis
patients.
Slide 9
Case Report: Nutritional History Nutritional history
unobtainable due to: non-verbal state cognitive decline Family
reported normal appetite/intake until Thursday PTA. MH ate very
little by mouth/refused to eat throughout admission. No known food
allergies.
Slide 10
Case Report: Nutritional History Weight parameters: Ideal Body
Weight (IBW) = 50 kg Percent of IBW = 136% Body Mass Index (BMI) =
27.34 BMI = overweight
Slide 11
Case Report: Nutritional History Estimated Nutritional Needs:
Source Kcal requirements Protein requirements Fluid requirements
Union Memorial Hospital standards Based on 120- 160% IBW = 20-25
kcal/kg = 1356- 1695 Based on a patient on hemodialysis = 1.2-1.4
g/kg = 81-95 Based on 1000 mL + urine output due to patient on
hemodialysis NCM Based on a patient < 60 yrs on hemodialysis, 35
kcal/kg = 2373 Stage 5 CKD, on hemodialysis = > 1.2 g/kg= >
81 Stage 5 CKD, on hemodialysis = urine output plus 1,000 mL
Slide 12
Case Report: Nutritional History Nutrition Care Process,
Initial PES: (NI-2.1) Inadequate oral intake related to diet order
and current mental status as evidenced by NPO for 3 days (1).
Goals: Honor familys wishes concerning patient support options.
Nutrition recommendations available if family reconsiders feeding
options or if MHs mental status improves.
Slide 13
Case Report: Nutritional History Nutrition Care Process,
Updated PES: (NC-1.1) Swallowing difficulty related to history of
CVA and acute cerebellar ataxia infarction as evidenced by PEG tube
feeding as primary source of nutrition (1). Family reversed
decision. Goals: Meet estimated nutritional needs via PEG at goal
rate. Recommendations made to monitor TF tolerance and
electrolytes.
Slide 14
Case Report: Hospital Course of Patient Medical Treatment:
10/22/11 (Day 1): Given Heparin due to suspected CVA Initial lab
results: elevated BUN (66 mg/dL) and creatinine (8.19 mg/dL)
elevated finger stick blood glucose level (176 mg/dL)
Slide 15
Case Report: Hospital Course of Patient Medical Treatment:
10/23/11 (Day 2): CT scan performed with no intracranial mass
and/or hemorrhage noted. Cultures for bacterial infection negative.
Passed SLP bedside swallow test. Diet order: medium carbohydrate
diabetic diet, with minimal intake.
Slide 16
Case Report: Hospital Course of Patient Medical Treatment:
10/25/11 (Day 4): Awake and slight improvement in mental status.
Diet order: med. carbohydrate diabetic diet, minimal intake.
10/26/11 (Day 5): Brain MRI indicates acute cerebellar ataxia
infarction. Diet order: NPO
Slide 17
Case Report: Hospital Course of Patient Medical Treatment:
10/28/11 (Day 7): Initial nutrition assessment performed. All oral
medications discontinued. Intravenous fluid support of 40 mL/hour
for general hydration. Family states DNR/DNI. 10/29/11 (Day 8):
Right arm fistula to be used for next hemodialysis treatment.
Slide 18
Case Report: Hospital Course of Patient Medical Treatment:
10/31/11 (Day 10): Case manager to meet with family to review
choices and goals of care. 11/1/11 (Day 11): Family changes
position and now wants aggressive care. Orders for PT/OT evaluation
and PEG placement placed. SLP efforts with nectar and puree were
unsuccessful.
Slide 19
Case Report: Hospital Course of Patient Nutritional Care:
11/2/11 (Day 12): MH remains nonverbal and non-responsive. PEG
placed with no complications or post-operative issues. TF
recommendations: Nepro at 15 mL/hr, increasing by 10mL every 4
hours to a goal rate of 35 mL/hour (providing 1512 kcals, 68 g
protein, and 613 mL water) 225 mL water flushes every 6 hours Add
one packet of Juven with one water flush to provide an additional
70 kcals and 7 g protein Additional recommendations include
monitoring electrolytes.
Slide 20
Case Report: Hospital Course of Patient Nutritional Care:
11/3/11 (Day 13): MH receiving Nepro at goal rate of 35 mL/hour,
with 1 packet of Juven and 225 mL water flushes every 6 hours.
Recommendations include: Continue TF at current rate with flush
Replace Juven with 1 oz. ProSource (providing additional 60 kcals
and 15 g protein) Continue to monitor electrolytes 11/5/11 (Day
15): Physicians prescribed potassium chloride due to low potassium
blood level (3.1 mEq/L).
Slide 21
Case Report: Hospital Course of Patient Nutritional Care:
11/7/11 (Day 17): MH tolerating TF of Nepro at goal rate of 35
mL/hour, with 1 oz. ProSource and 225 mL water flushes every 6
hours. SLP determines MH at risk for silent aspiration with trials
of nectar liquids and puree via spoon. Based on SLP evaluations,
diet order changed to allow full liquid, honey thick when MH is
sufficiently aware/awake. Goals include: TF tolerance Monitoring
SLP efforts to advance oral diet.
Slide 22
Case Report: Hospital Course of Patient 11/8/11 (Day 18): MH
discharged to nearby nursing home. Lab values for BUN and
creatinine remained elevated throughout stay. Phosphorus
fluctuated, but was typically elevated. Magnesium was elevated, but
brought down to normal limits approximately half way through course
of treatment. Blood glucose levels were elevated, brought under
control, and became elevated again prior to discharge.
Slide 23
Case Report: Hospital Course of Patient Discharge instructions
included: Hemodialysis via the AV port Continued PEG feeding Honey
thick liquids when sufficiently oriented to safely drink
Slide 24
Case Report: Hospital Course of Patient Discharge medications
included: Aspirin (blood clotting) Catapres/clonidine (HTN)
Pravachol (HLD) PhosLo (phosphate control) Rena-Vite
(renal-specific multivitamin) Sensipar (hyperparathyroidism)
Sustiva (HIV) Epivir (HIV) Ziagen (HIV) Bactrim (antibiotic) No DM
medications
Slide 25
Case Discussion: Medical Considerations Develop long-term care
options and goals. Prognosis of acute cerebellar ataxia infarction.
Limit extension of existing stroke. Provide rehabilitation efforts
with medication. Prevent future ischemic events using risk-factor
reduction treatments. Control HTN and DM2 via oral diet/medication
therapy (4). Restrict sodium, fluid, potassium for ESRD/CKD control
(5). MHs ESRD/CKD requires continued hemodialysis to control HTN
and loss of renal function (5).
Slide 26
Case Discussion: Nutritional Considerations Metabolic and
gastrointestinal complications must be monitored (6). A.N.D.
specific guidelines to maintain electrolyte balance for
hemodialysis. Comparison of Nutrition prescription, Nutrition Care
Manual of A.N.D. (7) with Nepro (8) recommendations.
Slide 27
Case Discussion: Nutritional Considerations NutrientNCM
(7)Nepro (8) Energy (kcals)23731512 Protein (g) > 8183*
Sodium1-3 g890 mg Potassium2-3 g890 mg Phosphorus (mg)800-1000603
Calcium< 2 g890 mg Vitamin B6 (mg)27.1 Vitamin B12 (mcg)38.2
Vitamin C (mg)60-10090 Vitamin E (IU)1582 Folate (mg)10.9 Zinc
(mg)1523 *Includes Proscource All other water-soluble vitamins
follow the DRI. Vitamin D and Iron, individualized for each
patient. MH also taking Rena-Vite (contains B vitamins, vitamin C,
folic acid, and biotin)
Slide 28
Case Discussion: Implications of Findings to the Practice of
Dietetics Ultimate goals: All nutrition oral Control of HTN, DM2,
and HIV Prevention of future CVAs Prognosis of attaining goals
unknown Long-term tube feeding vs. palliative care
Slide 29
Case Discussion: Implications of Findings to the Practice of
Dietetics Clinical literature review by Plonk. Evidence-based
recommendations for PEG placement in only four medical conditions.
Included acute stroke with dysphagia (9). The study did not look at
co-morbidities in conjunction with acute stroke with dysphagia.
Looked at ethical placement of PEGs avoidance of end-of-life
discussions.
Slide 30
Case Discussion: Implications of Findings to the Practice of
Dietetics FOOD trials data (10). Studies of statistical trends and
PEG placement and CVA patients (11). Prognosis regression in
medical care (12). Syndromes of adverse outcome for geriatric
patients (12). Future decisions about MHs care.
Slide 31
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