Transcript Slide 1

Joyce L. Hornick
Dietetic Intern
University of Maryland, College Park
January 4, 2012
© 2012 by Joyce L. Hornick, http://joycehornick.com/
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
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
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
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
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.
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.
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.
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.
Case Report: Nutritional History
Weight parameters:
 Ideal Body Weight (IBW) = 50 kg
 Percent of IBW = 136%
 Body Mass Index (BMI) = 27.34
 BMI = overweight
Case Report: Nutritional History
Estimated Nutritional Needs:
Source
Kcal
requirements
Protein
requirements
Fluid requirements
Union
Memorial
Hospital
standards
Based on 120Based on a patient on
160% IBW = 20-25
hemodialysis = 1.2-1.4
kcal/kg = 1356g/kg = 81-95
1695
Based on 1000 mL + urine
output due to patient on
hemodialysis
NCM
Based on a
Stage 5 CKD, on
patient < 60 yrs
hemodialysis = > 1.2
on hemodialysis,
g/kg= > 81
35 kcal/kg = 2373
Stage 5 CKD, on
hemodialysis = urine
output plus 1,000 mL
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 family’s wishes concerning
patient support options.
 Nutrition recommendations available if
family reconsiders feeding options or if
MH’s mental status improves.
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.
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)
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.
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
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.
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.
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.
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).
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.
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.
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
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
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).
 MH’s ESRD/CKD requires continued hemodialysis to control
HTN and loss of renal function (5).
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.
Case Discussion: Nutritional Considerations
Nutrient
NCM (7)
Energy (kcals)
2373
Protein (g)
> 81
Sodium
1-3 g
Potassium
2-3 g
Phosphorus (mg)
800-1000
Calcium
<2g
Vitamin B6 (mg)
2
Vitamin B12 (mcg)
3
Vitamin C (mg)
60-100
Vitamin E (IU)
15
Folate (mg)
1
Zinc (mg)
15
*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)
Nepro (8)
1512
83*
890 mg
890 mg
603
890 mg
7.1
8.2
90
82
0.9
23
Case Discussion: Implications of
Findings to the Practice of Dietetics
 Ultimate goals:
 All nutrition oral
 Control of HTN, DM2, and HIV
 Prevention of future CVA’s
 Prognosis of attaining goals unknown
 Long-term tube feeding vs. palliative care
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 PEG’s – avoidance
of end-of-life discussions.
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 MH’s care.
References
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Acute Cerebellar Ataxia. Medline Medical Encyclopedia. Source: http://www.nlm.nih.gov/medlineplus/ency/article/001397.htm.
Posted 2/5/11. Accessed: December 19, 2011.
Ovbiagele, B., MD, MSc and Nath, A., MD. Increasing incidence of ischemic stroke in patients with HIV infection. Neurology.
http://www.neurology.org/content/76/5/444. Accessed January 2, 2012.
Winkler, S., Pharm.D., BCPS. Cerebrovascular Disease. University of Illinois at Chicago. 1998.
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Accessed: December 26, 2011.
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Kearney, C., MD. Palliative Care and Nutrition. A PowerPoint presentation dated 3/4/11.
End Stage Renal Disease. American Kidney Fund. Source: http://www.kidneyfund.org/kidney-health/kidney-failure/end-stage-renaldisease.html. Posted 2/11/08. Accessed: December 19, 2011.
Full Code. Patient friendly definitions. California Pacific Medical Center. Source: http://www.cpmc.org/services/ethics/faq.html.
Accessed: December 19, 2011.
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