Cheryl Gregory February 18, 2013

Case Study #1: Upper GI

C.D. is a 74yr old female who was diagnosed with Alzheimers 5 years ago. She now requires 24 hr care and needs assistance with most activities including bathing, toileting, dressing, and eating. She is ambulatory, and enjoys walking around the care home in which she resides. She has had increasing difficulty with chewing and swallowing lately, and her family says shes lost her appetite and thirst; she doesnt even want her favorite foods anymore and she barely drinks anything all day. Family says that she chokes on dry, hard foods but seems to tolerate moist, softer foods well. She has been complaining of severe heartburn and throat pain, and her givers report dark-colored blood in her stool for the past week. They estimate shes lost a few pounds every month for the past year. Height: 53 Weight history: Usual adult weight 150# (I year ago), current weight 120# Her family estimates that shes lost a few pounds every month for the past year. Past medical history: GERD, arthritis in hands, lactose intolerant Labs:
Labs Sodium, Ser/Plas Potassium, Ser/Plas Chloride, Ser/Plas CO2, Ser/Plas Urea Nitrogen,Ser/Plas Creatinine, Ser/Plas Glucose, Ser/Plas Anion Gap Calcium, Ser/Plas Phosphorus, Ser/Plas Total Bilirubin AST (SGOT), Ser/Plas ALT (SGPT), Ser/Plas Alk P'TASE, Total, Ser/Plas Albumin, Ser/Plas Protein, Total, Ser/Plas Globulin Magnesium, Ser/Plas Reference Range Latest Range: 135-145 mmol/L Latest Range: 3.5-5.5 mmol/L Latest Range: 96-109 mmol/L Latest Range: 20-30 mmol/L Latest Range: 5-25 mg/dL Latest Range: <1.2 mg/dL Latest Range: 70-100 mg/dL Latest Range: 5-15 mmol/L Latest Range: 8.5-10.5 mg/dL Latest Range: 2.5-4.5 mg/dL Latest Range: <1.4 mg/dL Latest Range: <40 U/L Latest Range: <60 U/L Latest Range: <130 U/L Latest Range: 3.5-5.0 g/dL Latest Range: 6.0-9.0 g/dL Latest Range: 2.0-5.0 g/dL Latest Range: 1.8-2.4 mg/dL 2/5/2012 06:55 151 3.7 102 25 17 1.5 HIGH => musc loss 98 11 8.9 3.8 0.5 27 36 84 3.5 6.0 2.5 1.9

24 hr diet recall: Breakfast-1/2c applesauce, 1/2c coffee 3 bites of buttered toast Lunch-1/2c orange juice, 1/2c jello, 1/2c. of chicken noodle soup Dinner-few bites meatloaf, c mashed potato with gravy, 1/2c tea

1. (5 pts) C.D. gets admitted to your hospital for failure to thrive. She is NPO x2 days for testing which reveals dehydration, GERD, PUD and advanced Barretts Esophagus. She is swallowing thin liquids well. In morning rounds, the doctors ask you which diet to put her on. What do you recommend and why? C.D. has been NPO for 2 days, so to minimize GI stimulation and to help re-hydrate, she should start with a clear liquid diet. If C.D. is able to handle the clear liquid diet for two to three days she should move to a lactose-free full liquid diet with restrictions on high osmolality fluids (such as prune juice). Because C.D. is lactose intolerant, neither the clear liquid nor the full liquid diet will be nutritionally adequate. The ultimate goal will be to move C.D. to a NDD-1 diet, Dysphagia Pureed diet, because C.D.s dysphagia, difficulty chewing and swallowing, is fairly advanced as demonstrated by her ability to eat only a few bites of meatloaf. If C.D. handles the NDD-1 diet, a Dysphagia Mixed diet may be tested. To help minimize her GERD and PUD symptoms, she should have small frequent meals and keep a raised head of bed following meals. She should avoid foods that increase acid secretion in the stomach such as caffeine, coffee, spearmint, pepper, and alcohol. She should also avoid high fat foods that can prolong stomach stimulation. Doctors should consider Iron, Ca++, Vit D, and Vit B12 supplements because iron is lost through the blood in her stool and patients with GERD are at risk for Ca++, Vit D and Vit B12 deficiencies. 2. (5 pts) The family of C.D. keeps bringing food in that is not recommended on the diet you had ordered for her. You set up an appointment with the family to discuss foods allowed/not allowed on her current diet order. What do you tell them? Include a list of 3 foods allowed, and 3 foods not recommended. Three foods allowed: 1. Pureed or broth soups 2. Mashed potatoes 3. Soft foods, such as applesauce, pureed carrots etc. Three foods not recommended: 1. Black tea or peppermint tea because the caffeine and peppermint can stimulate acid secretion irritating the stomach. 2. Fried eggs, because the texture is too difficult to chew and swallow. 3. Spicy foods, because the pepper and spices stimulate acid secretion. 3. (20pts) RNs notice CD eats very small amounts for 2 days and so you perform a calorie count. It indicates that she is eating 500kcals, 15gm protein and 750ml of fluid (average). The patient is scheduled for an esophagectomy tomorrow, and the doctors inform you she will need to be NPO for more than a week. You recommend the following tube feeding regimen (show your work!): Calorie need (include dosing weight, activity/stress factor): Height: 53 = 160cm UBW: 150lbs = 68.04kg CBW: 120lbs = 54.43kg BMI: 54.43/(1.6) = 21.3 = healthy range CDs current body weight will be used as the dosing weight because she is in a healthy BMI range, whereas her usual body weight correlates with an overweight BMI. Harris Benedict Equation: Acitivity Factor = 1.2 because CD is hospitalized and although normally ambulatory, she will be bed ridden following surgery Injury Factory = 1.3 because CD will undergo surgery. [655.1 + 9.6(54.43) + 1.9(160) - 4.7(74)] x 1.2 x 1.3 = 1768.77 = ~ 1800 kcal/day

Protein need: Normal Protein Need: 0.8 g/kg/day C.D. is experiencing GI bleeding, is elderly, and will undergo major surgery. Therefore, her protein needs will be increased. C.D. Protein Need: 1.2g /kg/day x 54.43 kg = ~ 65 g/day Fluid need: Normal Fluid Need: 1ml/kcal/day 1ml/kcal x 1768.77 kcal/day = 1768.77 ml/day 24 hr/day = ~75 ml/hour 75 ml/hr x 24 hr/day = 1800 ml/day *Please answer the questions and explain your rational for the following: Feeding tube site placement: Jejunostomy tube will placement will bypass the esophagus and stomach. Bypassing the stomach will help minimize GERD and PUD symptoms. A naso or oro tube placement is not recommended after the esophagectomy because the tube would irritate the esophagus. Parenteral nutrition is not recommended because C.D.s gut is still functioning and the jejunostomy will help maintain normal gut flora and function. Formula (choices: Jevity 1.2, Jevity 1.5, TwoCalHN, or Peptamen 1.5) Jevity 1.2 meets C.D.s nutritional requirements the best, is lactose free, and has a moderate osmolality. Volume: 1800kcal / 1.2kcal/ml = 1500ml 1500ml / 24hr = 62.5 ml/hr = 60 ml/hr 60ml/hr x 24 hr = 1440ml/day Kcal requirements met: 1440ml x 1.2kcal/ml = 1728 kcal Protein requirements met: 55.5g prot/L x 1.44L = 79.92 g prot Fluid requirements met: 1800ml needed 1440ml = 360ml additional fluid 450 mOsm/kg Rate (initial and goal rate): Begin with Jevity 1.2 at 20ml/hr, increase rate by 20ml/hr every 8 hours, to reach goal rate of 60ml/hr. 4. (20pts) C.D. is tolerating your tube feed formula very well, however during the esophagectomy surgery, it was discovered that her GERD and PUD were much more severe than anticipated. She is scheduled to have a roux-en-y to help correct her GERD and PUD. The doctors estimate that shell need to be completely NPO (no TFs either) for ~5days, and want to feed her via parenteral nutrition. C.D. has peripheral lines and a PICC line. Her labs are now normal, and she does not have any fluid limitations. PPN or TPN? Explain your reasoning, giving two examples of pros and cons of each delivery method. TPN: Pros: The use of larger central veins allows for higher osmolality solutions. Drugs may be administered simultaneously with nutrition.

Cons: Only a few meds at a time may be administered. The central access increases the risk of systemic infections. PPN: Pros: Decreased risk of systemic infections associated with TPN. Does not involve a surgical procedure to place the line. Cons: Requires use of low osmolality formulas and fluid levels are restricted by vein capacity, therefore, formulas cannot meet nutritional needs (ex. max. 12.5% dextrose, max. 5% amino acids) and supplemental nutrition is necessary. PPN is only for short term nutrition support. TPN is the preferred choice because a PICC line has already been placed so no additional surgery is necessary. With higher osmolality solutions, TPN will allow C.D. to meet more of her nutritional needs than PPN would. Also, because C.D. is elderly her peripheral veins may be difficult to locate and may be susceptible to collapsing with the use of PPN. Please provide your final PN recipe (show all steps!): Nutrient Needs (female pt, 74 yrs, 54kg): 1800 kcal/day, 65 g prot/day, 1800 ml H2O/day 1. Fluids: 1800ml/day / 24hr/day = 75 ml/hr 75 ml/hr x 24 hr/day = 1800ml/day total volume 2. Prot Reqs: 65g/day/1800ml = 3.61 % prot = 3.5% prot 3. Kcal from prot: 3.5% x 1800ml x 4kcal/g = 252 kcal prot/day 4. Kcal from CHOs: 1800 kcal x 50% = 900 kcal CHOs/day Grams of CHOs: 900kcal / 3.4kcal/g = 264.7g CHO 5. Dextrose conc.: 264.7g / 1800ml x 100% = 14.7% = 15% Dextrose 6. kcal from fat: 1800kcal 252kcal 900kcal = 648kcal fat/day 7. Lipid solution: 500ml @ 10% = 550kcal 8. D15%, AA3.5% @ 75ml/hr plus 500ml of 10% lipids Prot: 252kcal/4kcal/g = 63g prot CHO: 1800ml x 15% = 270g CHO x 3.4kcal/g = 918 kcal prot Kcal: 252kcal prot + 918kcal CHO + 550kcal lipid = 1720kcal total (14.7% prot, 53.4% CHO, 32% fat) 9. CHO & Lipid check: 270g CHO x 1000ml/l / 54kg/1440min = 3.5mg of cho/kg/min Okay, because less than 5mg/kg/min 550kcal lipid / 9kcal/g = 61.1g lipid / 54kg = 1.13g lipid/kg Okay, because less than 2g/kg 10. Vit & Minerals: Doctors should still consider Iron, Ca++, Vit D, and Vit B12 supplements. C.D. should be given 1800ml of D15%, AA3.5% @ 75ml/her plus 500ml or 10% lipids.