Transcript Case Study Presentation - Whitney Houser's Professional

Whitney Houser
KSC Dietetic Intern
February 6th 2013
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The role of the RD is to assess nutrition status as
hospital stay continues, monitor bowel function,
PO, appetite, assess needs (nutrition and
educational), provide education, provide referral
as needed (suggest consult, outpt. f/u) encourage
appropriate intake.
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Diet techs are responsible for all moderate to low
risk patients.
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Formerly known as Margaret Pillsbury General hospital
opened its doors in 1891.
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It grew into Concord Hospital by 1946.
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114 acres, 2,650 staff members, 352 medical hospital
staff with 235 staffed beds.
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Serving nearly 18,000 patients per year
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Mission Statement: “Concord Hospital is a charitable
organization which exists to meet the health needs of
individuals within the communities it serves.”
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Baby friendly hospital
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Nearly 40 specialties and subspecialties, particularly
known for: cardiovascular care, urology, cancer care,
orthopedic surgery and women’s health.
86yo male, admitted 01/21/13.
Admission Dx: Muscle invasive bladder cancer
Procedure: Open radical cystectomy with ileal conduit, urinary diversion.
Social Hx: Retried geologist, WWII vet: worked all over the world from oil
fields in Texas, mines in Colorado, all the way to Africa. Pipe smoker, light
drinker. Lives with wife of 20yr who has metastatic breast cancer. Enjoys
spending time with grandchildren.
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Height: 5’ 5”
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Weight: 61kg (134lbs)
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UBW: 51kg (1yr ago: 7% loss)
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BMI: 22.4
• Prostate Cancer, s/p combination external beam and
interstitial seed implant
• Incontinence
• Macrocytic anemia
• Hernia repair
• Memory loss
• Mild dementia
• Hyperlipidemia
• COPD w/o exacerbations
• Lung nodules
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Microscopic Dx: Two bladder biopsies revealed soft tissue
density within left bladder base, extending into trigone. Right
posterior smooth muscle, left walls and surrounding lymph
nodes biopsied and benign.
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Pre-op workup revealed he was safe for surgery, despite age.
Question of waiting vs surgery vs palliative. Pt opted for surgery
to “be there for his wife.”
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Per surgeon: Opted for open surgery vs robotic because of
previous radiation therapy to prostate and scar tissue build up.
Prior to Admission
Vitamins/Minerals:
 B12 (for macrocytic anemia)
 B6
 Glucosamine (for osteoarthritis, osteoporosis)
 Vit. C
 Vit. A
 Lutein (beneficial in preventing the progression of age related macular degeneration)
 Calcium/Vit. D (for osteoarthritis, osteoporosis)
 Other antioxidants (for macular degeneration—recommended by his eye doctor)
In Hospital
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Heparin (for DVT prophylaxis)
Zofran and Reglan (for nausea)
Epidural for pain mgt (4cc/hr, demand dose 2cc)
B12
Vit. D/Ca
Significant labs upon admit (01/21/13)
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BUN 22
Ca 7.8
HH 10.9/33.2
MCV 99
Estimated Needs
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1,600kCal (Mifflin x 1.3)
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73-86g Pro (1.2-1.4g/kg)
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1,528ml fluid (25ml/kg)
Cancer is a disease characterized by uncontrolled
proliferation of cells.
3 Types of Bladder Cancer
• Urothelial carcinoma
• Squamous cell carcinoma
• Adenocarcinoma
1 in 42 men and women will be diagnosed
with bladder cancer within their lifetime
-National Cancer Institute
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Age
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Race
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Gender
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Medical history (Family, Personal)
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Lifestyle factors
(Cleveland Clinic, 2013)
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50% of bladder cancer incidences is
related to tobacco smoking
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20-25% from long-term workplace
exposure to toxins
Pathophysiology
 Carcinogens are filtered from the
bloodstream through the kidneys and
eliminated from the body via urine.
 Inner cellular lining of bladder is exposed to
these carcinogens while they sit in the urinary
storage waiting for elimination.
 Cellular exposure over time can lead to
genetic mutation and subsequent
carcinogenesis.
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Hematuria
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Pain during urination
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Frequent night time urination
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Urge without ability to pass urine
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Unexplained appetite loss
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Unintentional weight loss
Diagnosed via cystoscope , followed by bladder biopsy.
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Most bladder cancers are noninvasive, easily treatable.
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Cancer typically begins in urothelium lamina propria
(muscle) perivesicle fat
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When it becomes muscle invasive, it is likely to metastasize to
surrounding organs.
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Most commonly metastasizes to lungs, liver.
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High recurrence rate of 50-80%: Related to high grade nature of
tumors.
(National Cancer Institute)
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Surgery: non-invasive, invasive
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Chemotherapy: Adjuvant therapy
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Palliative care & Pain management
(The Nature Clinical Practice Urology)
1. Piece of
terminal ileum
is surgically
removed.
2. Piece is
reattached to the
ureters and a
stoma is created.
3. Stents are attached to
ureters which carry urine
through the stoma into a
urostomy collection
pouch.
The Journal of Urology, 1992:
“Since intestine was not meant to serve as either a conduit or storage vehicle for
urine, the use to which it is put in urology, numerous complications may occur in the
short and long term…the duration that the intestinal segment has been in the
urinary tract has also been suggested as a determinant of solute absorption. It has
been suggested that the activity of transport processes diminishes with time.”
Advances in Urology, 2011:
“ The duration of contact between urine and bowel, the segment and length of bowel
used are factors that determine the nature and grade of metabolic effects…In the
bowel, sodium is secreted in exchange of hydrogen and bicarbonate is secreted in
exchange of chloride. In parts of bowel that are exposed to urine, ammonia,
ammonium, hydrogen, and chloride are reabsorbed as well. As a consequence, the
presence of an ileal and/or colonic urinary diversion always implies a chronic acid
load.”
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Diarrhea
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Malabsorption
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Hyperchloremic metabolic acidosis is baseline
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B12 deficiency
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Bone loss
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Issues surrounding pre-existing renal insufficiency
Why the ileal segment?
According to Nutritional Issues in Gastroenterology from the University of Virginia
Medical School: “It has good mobility with relatively long and anatomically constant
vessels, the caecum rarely has diverticula, easy harvesting and reanastomosis.”
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Maintain adequate energy and protein intake
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Avoid dehydration
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B12 supplementation
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Increased dietary fiber intake; cholestyramine meds.
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Oral sodium bicarbonate
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Calcium/Vit D supplementation
Nutrition Status: PTA
 Intake variable
 Appetite poor
 Wife ‘forced’ him to drink Ensure
 Per Pt: Supplements killed appetite
 Diarrhea: Wife tried to increase fiber,
unsuccessful
 Unintentional wt loss
Jan 21:
Jan 22:
Admission
Initial Nutr. Meeting
• NG tube for suction
• 5% dextrose in lactate ringers
(100ml/hr)
• 2-JP tubes for drainage
• Braden 19
• Morphine PCA
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NPO
Pt confused post-op
Wt, diet hx from wife
Decreased urine output
IV bolus x 3
Decreased strength, mobility
Hungry, may chew gum
Conduit lessons today, RN
Jan 24:
Jan 25:
#2 Nutr. Meeting
#3 Nutr. Meeting
NPO
Not chewing gum as advised
N/V
n/d, tender
Stoma teachings today, RN
Sodium 135
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NPO
Nutr support if no diet adv.
IVF 125ml/hr
Gas pain relieved
BG 129
Jan 23
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NPO
Abd t/d
Low urine output
High JP output
Gas pain
Epi removed, leaking
BG 130
Jan 26
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Constipation
NPO x 6
Suppository given w/ effect
Urine neg. for creatinine
Jan 27:
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Jan 28:
Diet Adv. To Clears
BM
No gas
50% breakfast noted
High JP output
Chloride 108
BUN 6
Ca 7.2
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Diet Adv. To Fulls
BM—very small
Gas
100% breakfast/dinner
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Jan 29:
Jan 30:
#4 Nutr Meeting
#5 Nutr. Meeting
Diet Adv. To Reg.
Supplements started
100% B/L
Nt/d
Cal Count started
64% kcal needs met
67% pro needs met
Jan 31:
Final Nutr. Meeting
• <15 min High calorie/pro education with pt and wife
• Pt discharged
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57% kcal needs met
54% pro needs met
s/nd
IVF d/c
Goals: Await diet adv., transition to PO, increase intake, meet needs, increase knowledge.
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Encouraged gum chewing to stimulate bowel
(Journal of Gastrointestinal Surgery, 2009)
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Emphasized importance of adequate fluid intake upon diet adv.
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Recommended whole milk at meals
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Encouraged intake through supplementation
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Ordered Calorie Count to gauge intake, need for nutr. Support
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Provided high cal/pro nutrition education to pt and family
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PO
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Appetite
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Bowel function
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Reassess needs as appropriate
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Educational needs met: conduit lessons, high cal/pro education, follow up
materials and RD number given.
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Nutritional needs met: Progressed to a regular diet, meeting over 50% of
needs after NPO x 6.
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Discharged home w/o VNA at pt’s wife request
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Stenzl A, Cowan C N, De Santis M, et al. The Updated EAU Guidelines on Muscle-Invasive and Metastatic Bladder
Cancer. European Urology. 2009; (55): 815-825. http://eu-acme.org/europeanurology/upload_articles/Stenzl.pdf.
Accessed February 1, 2013.
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Said N, Sanchez-Carbayo M, Smith S C., Theodorescu D. RhoGDI2 Suppresses Lung Metastasis in Mice by Reducing
Tumor Versican Expression and Macrophage Infiltration. J Clin Invest. 2012; 122(4): 1503-1518.
http://www.sciencedaily.com/releases/2012/03/120312140246.htm . Accessed February 1, 2013.
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Gakis G, Stenzl A. Ileal Neobladder and Its Variants. European Urology Supplements. 2010; (9): 745-753.
http://eu-acme.org/europeanurology/upload_articles/Georgios%20Gakis,%20Arnulf%20Stenzl.pdf. Accessed
February 3, 2013
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Up-to-date website. http://www.uptodate.com/contents/bladder-cancer-treatment-non-muscle-invasivesuperficial-cancer-beyond-the-basics. Bladder cancer treatment; non-muscle invasive (superficial) cancer (Beyond
the Basics). O’Donnell, Michael A. MD, FACS. Accessed February 2, 2013.
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Taylor, J. Kuchel, G. Vega, C. Bladder Cancer in the Elderly: Clinical Outcomes, Basic Mechanisms, and Future
Research Direction. Nat Clin Pract Urol. 2009; 6(3). http://www.medscape.org/viewarticle/589047. Accessed February
3, 2013.
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Memorial Sloan-Kettering Cancer Center website. http://www.mskcc.org/cancer-care/adult/bladder/diagnosistreatment-msk. Accessed February 2, 2013
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American Society of Clinical Oncology, website. http://www.cancer.net/cancer-types/bladder-cancer/symptomsand-signs. Accessed February 3, 2013.
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Van der Aa F, Joniau S, Van Den Braden M, Van Poppel H. Metabolic Changes after Urinary Diversion. Advances in
Urology. 2011. Article ID 764325. http://www.hindawi.com/journals/au/2011/764325/ Accessed February 3 2013.
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Rodriquez K, Albright M. The Use of Chewing Gum to Prevent Post-Operational Ileus in the Open Abdominal Surgical
Adult Patient on a Post-Operative Unit: A Literature Review. Gastro Surg Unit, Oschner Med Cnt.
http://academics.ochsner.org/uploadedFiles/Research/Nursing/rodriguezposterEBP.PDF
Accessed: February 2 2013.
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Steinberg G, Katz M. Bladder Cancer, website. http://www.emedicinehealth.com/bladder_cancer/article_em.htm.
Accessed February 1, 2013.
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Stein J, Lieskovsky G, Cote R, Groshen S, et al. Radical Cystectomy in the Treatment of Invasive Bladder Cancer:
Long-Term Results in 1,054 Patients. J Clin Oncology. 2001. (19): 666-675.
http://jco.ascopubs.org/content/19/3/666.short Accessed February 3 2013.
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Davis-Dao C, Henderson K, Sullivan-Halley J, Ma H. et al. Lower Risk in Parous Women Suggests That Hormonal
Factors Are Important in Bladder Cancer Etiology. Cancer Epidemiological Biomarkers Prev. 2001; (20): 1156.
http://cebp.aacrjournals.org/content/20/6/1156.short. Accessed February 2 2013.
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Kaufman D, Shipley W, Feldman A. Bladder Cancer. The Lancet. 2009; 374 (9685): 239-249.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60491-8/fulltext. Accessed February 3, 2013.
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Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology Reference Manual: Standardized
Language for the Nutrition Care Process. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013: 415.
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Escott-Stump, Sylvia. Nutrition and Diagnosis-Related Care. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins, a
Wolters Kluwer business. 772-774.
The patient content of this case study was gathered from Horizon Clinical EMR, H/P, therapy notes, preop consult notes and directly from the patient care team (RN, MD, social work, RD).