Download Ulcerative Colitis and Colectomy

ULCERATIVE COLITIS
Brittney Hudson
Patient Profile


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KV 18 y.o. male
Just moved to Provo, Utah
Mother, father, 3 brothers
Plays football
Medical History

Ear tubes
Disease Progression





Bloody diarrhea x 3 months
June 2011 – 12-14 times/day
Fatigue
Decreased appetite
Lost 10-15 pounds
Diagnosis


Colonoscopy – July 2011
Ulcerative Colitis
Inflammatory Bowel Disease

Autoimmune, chronic inflammatory condition of the
gastrointestinal tract
Ulcerative
Colitis
Crohn’s
Inflammatory
Bowel
Disease
Etiology




Immune System
GI System
Genetics
Environmental Factors
Pathogenesis
Intestinal
flora, diet, etc.
Inflammatory
response
GI tissue
damage
occurs
Body can’t
suppress
immune system
Signs and Symptoms







Abdominal pain
Diarrhea
Nausea
Vomiting
Osteopenia
Dermatitis
Hepatobiliary complications
Disease effect on Nutrition
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Weight loss
Electrolyte imbalances
Anemia
Malabsorption
Food allergies or aversions
Fear of eating
Self-imposed dietary restrictions
General Treatment Recommendations


Induce and maintain remission of disease
Corticosteroids
 Anti-inflammatory
agents
 Immunosuppressive agents


Colectomy
Ileostomy
Beginning Treatments



Prednisone
Constantly changing doses
Unresolving symptoms
Drugs/Medications
Medication
Purpose
Prenidsone
Anti-inflammatory and
Immunosuppressive
Methotrexate
Immunosuppressive
Remicade
Anti-inflammatory and
Immunosuppressive
Zofran
Nausea
Side Effects of Prednisone



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

Weight gain
Acne
Hyperlipidemia
Hypertension
Osteopenia
Joint pain
Procedures

Colectomy with ileostomy placement on September
25, 2012
Diet before Colectomy



Poor
Didn’t feel like eating
Elemental formula – Neocate Jr
Diet after Colectomy


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TPN and clear liquids – small bowel obstruction
Lost 25 pounds
Taken off TPN due to hepatitis – October 18, 2012
ALT - 482 U/L (10-40 U/L is normal)
AST - 200 U/L (15-45 U/L is normal).
UVRMC


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Admitted on October 25, 2012
Dehydration
Weight Loss and Malnutrition
Intractable nausea
Malnutrition

When nutritional reserves are depleted or nutrient
intake is inadequate to meet the body’s daily
metabolic needs.
Signs and Symptoms



Weight loss
Protein wasting
Fatigue
Refeeding Syndrome

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When patients are moderately or severely
malnourished
Tissue growth
Not enough electrolytes
Fluid overload
KV’s Treatments

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NJ tube feeding was started
Ate sparingly
Ileostomy takedown
NJ tube feeding started again
KV pulled it out
TF replaced
KV vomited it out
TPN started
Psychiatric Counseling
Drugs/Medications
Medication
Purpose
Prenidsone
Anti-inflammatory and
Immunosuppressive
Cyproheptatdine (Periactin)
Appetite stimulator
Zofran
Nausea
Calcium
Supplementation
Magnesium
“
Potassium
“
Sodium
“
Zinc
“
Multivitamin
“
Nutrition Assessment
Food/Nutrition Related History


Unremarkable before diagnosis
After diagnosis: poor appetite, anxiety
Diet
Clear Liquid
Regular
Full Liquid
Clear Liquid
NPO
Regular
NPO
Regular
Clear Liquid
NPO
Regular
NPO
Regular
Start
11/5
11/4
11/3
11/1
10/31
10/29
10/29
10/28
10/27
10/27
10/26
10/26
10/25
Food/Nutrition Related History
Diet
Start
3 L standard TPN with
20% lipids 2 times per
week
11/6
Peptamen AF 10 mL/hr
11/3
Peptamen AF 50 mL/hr
10/28
Peptamen AF 35 mL/hr
10/27
Anthropometrics
Height: 5’8”
Weight
190
180
Pounds

170
160
150
140
130
120
Weight
Biochemical Data
Magnesium
2.5
2
m 1.5
E
q
/
L 1
0.5
0
Magnesium
Biochemical Data
Phosphorus
6
5
4
m
g
/ 3
d
L
2
1
0
Phosphorus
Biochemical Data
Potassium
5
4.5
4
m 3.5
E
q 3
/
L 2.5
2
1.5
1
0.5
0
Potassium
Biochemical Data
Albumin
6
5
4
g
/
3
d
L
2
1
0
Albumin
Nutrition Focused Physical Findings
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Attentive and cooperative
Respiratory and cardiovascular systems normal
Abdomen was soft, non-tender, active bowel sounds
No rashes or legions
OK muscle tone
Comparative Standards
Calories
Kcals
1775 – 2130
Protein
kcals/
kg
gm
gm/kg
25-30 85 - 107 1.2 – 1.5
Fluid
mL
mL/kg
Based On
2840
40
Actual Body
Weight (71 kg)
Nutrition Diagnosis

Inadequate oral intake related to
nausea/vomiting/dehydration as evidenced by
weight loss of 30 pounds the past two months.
Nutrition Intervention

Problem


Long-Term Goal


Inadequate oral intake related to
nausea/vomiting/dehydration as evidenced by weight loss
of 30 pounds the past two months.
Increase oral intake to the point where the patient will be
able to consume enough to meet estimated needs without
the use of PN or EN.
Short-Term Goal

Have patient consume 10-15% of calories through oral
intake and gradually increase to keep the gut stimulated.
Specific Intervention and Client
Objectives
1. Intervention: Food and/or Nutrient Delivery
a. Patient switched between a clear liquid, full liquid and
regular select diet throughout his hospital stay
depending on his tolerance. A select diet means he was
able to call down and order food when he felt like it.
Objective: Patient will call down and order something from
room service everyday.
Specific Intervention and Client
Objectives
2. Intervention: Nutrition Education
a. Review nutrition relationship to his disease
Objective: Patient will be able to explain the effect his
disease and health status has on his nutritional status.
b. Recommended modifications
Objective: Patient will be able to explain how to best increase
his oral intake (i.e. eat one thing and see how his body
reacts so he can figure out if any certain foods cause a
bigger problem for him than others).
Nutrition Diagnosis

Altered GI function related to ulcerative colitis and
colectomy as evidenced by need for TPN and/or
EN.
Nutrition Intervention

Problem


Long-Term Goal


Altered GI function related to ulcerative colitis and
colectomy as evidenced by need for TPN and/or EN.
Discontinue TPN and/or EN as soon as patient is able to
consume most of his estimated calories by mouth.
Short-Term Goal

Provide enough calories and protein through TPN and/or EN
to meet his estimated needs while avoiding refeeding
syndrome.
Specific Intervention and Client
Objectives
1. Intervention: Food and/or Nutrient Delivery
a. Patient was started on Peptamen AF after being
admitted to UVRMC.
Objective: Patient will receive adequate calories and protein
to meet his needs and not have any issues with the feeding
tube.
Objective: Will be infused at 50% (35mL/hr) of needs on Day
1, 75% (50 mL/hr) of needs on Day 2 and 100% (70
mL/hr) of needs on Day 3. Target infusion rate of Peptamen
AF at 70 mL/hr will provide 1660 mL, 2015 kcals, 126 g
protein and 1344 mL free fluid which meets his needs.
Specific Intervention and Client
Objectives
b. Patient was started on TPN after his feeding tube was
dislodged because of vomiting.
Objective: Patient will be able to tolerate TPN better than EN.
Objective: Standard TPN will be infused 2.5 L/day and 20%
lipids 2 times/week providing 2060 kcal and 100 g protein
which will meet KV’s estimated needs.
Specific Intervention and Client
Objectives
2. Intervention: Nutrition Education
a. Purpose of the nutrition education
Objective: Patient will be able to explain the purpose of
enteral nutrition and parenteral nutrition and the role it will
play in his recovery.
b. Survival Information
Objective: Patient will be able to explain how he will be able
to wean off of EN and/or TPN (i.e. tolerance to oral intake
and adequate oral intake). He will also explain his role in the
process (i.e. being willing to try foods and not being anxious
about it).
Nutrition Monitoring and Evaluation
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
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PO intake
Refeeding syndrome
Tolerance of EN and TPN
Appropriateness of Care

Pretty appropriate
 Multiple
doctors
 Back and forth
 Difference of opinions
 Dietitian not consulted each time
 TPN not lowered when LFTs started increasing
Discharge

To home on TPN
References
(1) American Dietetic Association. Nutrition Care Manual.
http://nutritioncaremanual.org/index.cfm.
(2) Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th ed. St. Louis: Saunders
Elsevier; 2008.
(3) Mayo Clinic. Prednisone and other corticosteroids.
http://www.mayoclinic.com/health/steroids/HQ01431
(4) Medline Plus. Methotrexate.
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682019.html#side-effects
(5) Web MD. Drugs &Medications. http://www.webmd.com/drugs/drug-16554Remicade+IV.aspx?drugid=16554&drugname=Remicade+IV
(6) Pagana KD, Pagana TJ. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th ed. St. Louis:
Mosby Elsevier; 2010.
(7) Periactin Side Effects. http://www.drugs.com/sfx/periactin-side-effects.html
(8) Utah Valley Regional Medical Center Standards of Care
(9) The American Dietetic Association. International Dietetics & Nutrition Terminology Reference
Manual. Chicago: American Dietetic Association; 2011.