Transcript Patient Presentation

Patient
Presentation
By Kara LeClair
Patient Basics and Social
Hx
• Age: 96
• Sex: F
• Antrhotpometrics:
• Ht: 61”/155 cm
Wt: 144 lbs/65kg
• IBW: 105 +/-10%(115.5-94.5lbs)
%IBW: 137%
%UBW: 100%
• BMI: 27.2 - overweight
UBW: current
• Social Hx:
• Pt. lives on her own in a senior housing apartment.
• Her son lives close by and her family is very involved in her.
Medical Hx
• Diagnosis: Colon Cancer
• Pt was admitted with UTI with sepsis, led to
discovery of colon obstruction and distention
• PMHx:
• aortic stenosis, iron deficiency anemia,
diverticulosis, elevated cholesterol, HTN, kidney
stones, CHF
Treatments
• Past medical: Partial nephrectomy
• Left hemicolectomy – colon
resectioning (3/31)
• CT scan: mass lesion at descending and
sigmoidal colon junction
• Blood transfusion post op. (4/1)
• Nasogastric tube inserted twice post
op – pulled out by pt. both times
MNT for Hemicolectomy &
Colostomy
• Colon Cancer and Diverticulitis
• High-fiber diet
• 25 g/day
• Adequate hydration
• Colostomy
• Odorous stool formation may concerning for patients
• These foods include: legumes, onions, garlic, cabbage,
eggs and fish.
• HTN, CHF
• DASH Diet – low sodium
Diet Order
• Current Diet Order: NPO
• Path of recovery: Pt. will progress to clear
liquids, soft foods, low fiber diet and then
gradually increase fiber intake to 25 g/day
• Before Surgery: 2 gram Na restriction
Pertinent Medications
• Current Medications:
• Lasix: diuretic – post op.
• Levaquin: antibiotic – UTI/sepsis
treatment
• Lovenox: anticoagulant – post op.
• Flagyl: antibiotic IV – UTI/sepsis
treatment
• Prior to admission pt. was taking only
aspirin each day
Pertinent Labs
• Lasix use:
• Serum Potassium (N)
• Mg (N)
• Iron deficiency Anemia:
•
•
•
•
•
MCH (L)
RDW (H)
RBC (L)
HGB (L)
HCT (L)
PES
• Pt. has inadequate energy intake related to
colectomy on 4/1/15 as evidenced by no bowel
movement since surgery.
Nutritional Education
• Pt. is currently NPO, which requires no education.
• Upon return to normal diet, focus emphasis on:
• Reduced sodium diet, such as added salts to food
• Increase fiber; may use supplement such as Metamucil
• Adequate energy intake
• Supplementation with Ensure Plus – normal intake only
50-75%
• Diet order once recovered:
• Increased fiber intake (at least 25 g/day), no added salt
and supplement Ensure Plus TID
Caloric and Macro
Nutrient Requirements
• Total Calories:
• 25 kcal/kg for patients >65= 1,625kcal
• Mifflin St. Jeor: (9.99*65)+(6.25*155)-(4.92*96)161= 1,929*1.2 (AF)*1.2 (IF) = 1,418kcal
• Protein Requirements:
• 1.5g protein g/kg/day = 98 grams/day
• Fluid Requirements:
• 30 mL x 65 kg = 1,950 mL/day (~65 oz)
Sample Menu
• Breakfast:
• 1 small banana
• 5.3 oz greek yogurt
• Snack:
• Ensure Plus, 8 oz
• Lunch
• ½ egg salad sandwhich on
WW
• 1 apple, sliced
• Ensure Plus, 8 oz.
• 20 oz water throughout
afternoon
• Dinner:
• 4 oz. grilled chicken, 1/3 cup WW
pasta with lite tomato sauce, 1
cup steamed kale
• 12 oz water w/ Metamucil
• Evening:
• Ensure Plus, 8 oz.
• Total Calories: 2,140kcal
• Carbs: 1,211g Protein: 82g Fat:
44g Na: 1,000mg K: 1,560 mg
Fluid: 62 oz
Intervention
• Food and/or Nutrient Delivery
• Whoever prepares the meals for the pt should be educated on a no added salt
and increased fiber diet
• High in potassium and magnesium (if still on Lasix)
• Due to the patients past medical history of iron deficiency, blood loss (indicated
by the blood transfusion) and lab values for RDW, HCT, HGB and RBC it may be
beneficial to add an iron supplement.
• More blood work should be done after the blood transfusions are completed to
see if this supplementation is warranted.
• Coordination of Nutrition Care
• This decision will be based on how well the patient recovers.
• Full recovery: she should be able to return to her senior housing.
• Limitations in recovery, or requires a more specialized diet: (remains on Lasix)
her diet may require more attention, at which point her dietary needs must be
addressed with whoever prepares her meals.
• If she is responsible for cooking for herself, there should be a plan set in place
for someone to check on her regularly to make sure she is adhering to the diet
and consuming enough potassium and magnesium.
Additional Treatment
• The family should seek advice from an
oncologist and decide whether or not she will
receive additional treatment for the colon
cancer.
Monitor & Evaluate
• Food/Nutrition Related Outcomes:
• Pt. will progress to a normal diet with the return of bowel sounds, and
consume 75% of each meal, along with three Ensure Plus supplements
and one serving Metamucil or other fiber supplement as tolerated daily.
• Biochemical Data Outcomes:
• Increase MCH, RBC, HGB, HCT & decrease RDW by taking an iron
supplement as directed.
• Other altered lab values are likely influenced by infection or stress of
surgery and should return to normal limits as she recovers.
• Keep an eye on serum K & Mg with the use of Lasix.
• Anthropometric Outcomes:
• Pt. should aim to maintain her weight.
References
• Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L.
Raymond, and Marie V. Krause. Krause's Food
& the Nutrition Care Process. St. Louis, MO:
Elsevier/Saunders, 2012. Print.
• http:www.myfitnesspal.com
• Pronsky, Zaneta M., and Jeanne P. Crowe. Food
Medication Interactions. Birchrunville, Penn.:
Food-Medication Interactions, 2010. Print.
• *All images obtained from Google search engine
Questions