Download File - Maureen Donah, rd

L.M. 52 y.o. female
Maureen Donah 2013 Sodexo Southcoast Dietetic Intern
Past Medical History
COPD
 Type 2 Diabetes
 Hyperlipidemia
 Obesity
 Fibromyalgia
 Hx of recent UTIs
 Kidney Stones
 Irritable Bowel Syndrome
 Depression

L.M. was admitted 1/8/13
Caucasian
 5’0” 212# (stated)
 BMI 41.4
 Social Hx: patient doesn’t drink alcohol
and used to smoke in the past

140
99
4.3
27
16
1.1
186
Emergency Room
In the ER L.M. presented
with left-sided flank pain
 CAT scan showed UPJ stone
with hydronephrosis and
diverticulitis


Hydronephrosis is the
swelling of the kidney due to
a back up of urine.
http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm
Procedure 1/9/13

Pre-op dx: ?colovesical fistula (due to air
in the bladder) and left proximal ureteral
stone
◦
◦
◦
◦

Cystoscopy
Fistulogram
Left retrograde pyelography
Left ureteral stent placement
Post-op dx: Left proximal ureteral stone
and colovesical fistula confirmed
The Plan
The pt was treated with IV antibiotics, IV
fluids, and IV narcotics
 1/11/13 pt started clear liq diet and
tolerated well and was adv to a DM diet
 Pain was off and on and was better
controlled with p.o. medications
 1/12/13 pt was d/c home

The Plan
The pt was told to follow up with primary
doctor within 5-7 days
 Follow up with GI for colonoscopy after
antibiotic is finished
 Follow up with surgery in 2-3 weeks

Re-admitted 1/25/13
Left flank pain
 Diarrhea and vomiting PTA

139
101
4.3
27
11
189
1.0
Started DM 1800cal dt 1/26/13-2/1/13
with fair to poor intake
RD Assessment 2/4/13
5’0” 212# (Stated) BMI 41.4
 Adj. body wt: 128#/58kg

Kcals 1450-1750 (25-30 kcals/kg)
 Protein 69-76g
(1.2-1.3g/kg)
 Fluid 1750mL
(30mL/kg)

On full/clears since 2/1/13 with fair intake
 Prep for surgery

2/5/13 Surgery
Dx: Sigmoid diverticulitis with colovesical
fistula
 Laparotomy with sigmoid colon resection
and repair of colovesical fistula

Nutrition after Fistula Repair
NPO 2/5-2/8
 Started clear liquid 2/9-2/10

◦ Not tolerating clears, episodes of vomiting

NPO 2/11-2/13
2/13/13 POD#8
Anastomotic leakage
 Confirmed by a barium enema
 Procedure: Diverting loop ileostomy

Nutrition after Ileostomy

Nutritional Needs (58kg)
◦ Kcals 1450-1750 (25-30kcals/kg)
◦ Protein 75-87g (1.3-1.5g/kg)
◦ Fluid 1750mL (30mL/kg)
IVF D5 ½ NS + 20mEq KCl
 Diet advance to clear liquids 2/13
 Diet advance 2/14 to diabetic diet for
breakfast only
 L.M. not tolerating, vomiting continues

The Plan
Patient not tolerating liquids at all
 In 2 weeks L.M. had 2 surgeries and was
NPO for 7 days and received 7 days of
liquid trays
 With this minimal nutrition the plan was
to start TPN - Central line 2/15/13
 Pt at refeeding risk!

◦ Potassium 3.7
◦ Magnesium ?
◦ Phosphorous ?
Nutrition Support (TPN) 2/15
Day 1 custom bag 1,000mL/day 50g AA,
100g dextrose, no lipids due to shortage
 IVF (D5 ½ NS) kept at 100mL/hr will
decrease by day 2 per PA

Day 2 TPN 2/16/13
2,000mL/day 80g AA, 175g dextrose, no
lipids, 20 units insulin
 IVF switched to Normal Saline
 IVF decreased to a combined rate with
TPN to 100mL/hr

◦ Potassium 3.1
◦ Magnesium 1.7
◦ Phosphorous 1.9
Day 3 TPN 2/17/13
TPN at goal: 1,800mL/day 85g AA, 160g
dextrose, 25 units insulin
 IVF (NS) at combined rate of 100cc/hr
 To provide 884 kcals/day
 Only meeting 55% of calorie needs

◦ Potassium 3.1
◦ Magnesium ?
◦ Phosphorous 1.6
Day 4 TPN 2/18/13

1,800mL/day 85g AA, 160g dextrose, no
lipids, 35 units insulin
◦ Potassium 3.2
◦ Magnesium 2.3
◦ Phosphorous 2.3
◦ Pt now not passing gas and has hypoactive
bowel sounds
2/18/13
Vomited
 KUB showed multiple dilated small bowel
loops, consistent with a small bowel
obstruction.
 Started NGT to LWS 1500cc output

Day 5 TPN 2/19/13
1,800mL/day 85g AA, 160g dextrose, 50g
lipids, 45 units insulin
 To provide 1334kcals, meeting ~83% of
calorie needs
 NGT to LWS 2550cc output

◦ Potassium 3.3
◦ Magnesium 2.3
◦ Phosphorous ?
Day 6 TPN 2/20/13
1,800mL/day 85g AA, 160g dextrose, no
lipids, 55 units insulin
3000c output
 NGT to LWS 3000cc

◦ Potassium 3.3
◦ Magnesium 2.2
◦ Phosphorous 4.3
*Pt was weighed for the first time today! 5’0” 192.5# (Standing Scale)
BMI 37.5 Down 19.5# since admission
Gastric Secretions
Production and composition of gastric
secretions varies. Daily estimates ~1-3L
 ~1liter saliva and ~2 liters gastric
secretions: ~3 liters total
 The electrolyte composition of each liter
is estimated at 20-100mEq sodium, 50160mEq chloride, and 5-15mEq potassium

Johnson ML. Gastric Secretions: Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18.
Gastric Secretions
Date
2/18
2/19
2/20
NGT output
1500cc
2550cc
3000cc
Chloride
92 (L)
92 (L)
93 (L)
34
36 (H)
37 (H)
Bicarbonate
* No blood gas labs taken
pH
Metabolic
Acidosis
Metabolic
Alkalosis
Respiratory
Acidosis
Respiratory
Alkalosis
PCO2
HCO3-
Differential
Diabetes, renal
failure,
increased acid
production
Normal or
decreasing
Vomiting,
increased NGT
output,
administration
of alkaline
solutions
Normal or
increasing
Normal or
increasing
Obstruction,
pneumonia,
mediastinal
disease
Normal or
decreasing
Anemia, CHF,
exuberant
mechanical
ventilation
Day 7 TPN 2/21/13
1,800mL/day 85g AA, 160g dextrose, 50g
lipids, 60 units insulin
 NGT to LWS 1500cc output
 Started to pass flatus but still hypoactive
bowel sounds
 KUB still seeing multiple dilated loops

Day 8 TPN 2/22/13
1,800mL/day 85g AA, 160g dextrose, no
lipids, 60 units insulin
 Started clear liquid diet
 NGT clamped for 3hrs then LWS for 1hr
 NGT to LWS 2250cc output
 Pt was given MOM (30mL) q2h while
awake

TPN Continues
Pt continued on clear liquid diet and TPN,
with fair PO intake
 SBO resolving 2/25/13 per KUB
 Diet advanced to full liquid on 2/27/13
with good intake
 Lunch on 2/28/13 diet advanced to soft
easy to chew and TPN d/c’d

Cleared for Discharge
Pt was tolerating soft diet with fair intake
and supplements.
 Pt was discharged home with VNA on
3/2/13
 Pt was told to follow up with surgery for
barium enema as an outpatient and
eventually reverse her ileostomy

Re-admitted on 3/6/13
Abdominal pain and minimal output from
ileostomy.
 Low sodium of 122 on admission
 Hyponatremia resolved after hydration
 Electrolytes were stable and she was
tolerating a full diet.
 D/c’d home 3/12/13

Re-admitted 3/20/12
Fatigue, nausea, and abdominal pain
 Found to have another low sodium on
admission of 129
 Pt was hydrated and stable
 D/c’d home on 3/22/13
 Still follow up with surgery regarding
ileostomy

Re-admitted 3/25/13
Nausea, vomiting, and abdominal pain
 Pt vomiting and unable to keep any food
or fluids down
 Pt was again found to be dehydrated
 Sodium on admission 132
 Pt was given fluids and tolerated diet
 D/c’d 3/31/13 to nursing home facility

References
Johnson ML. Gastric Secretions:
Physiology During Loss and Suggestions
for Replacement. Support Line.
2012;34(6);13-18.
 Medline Plus. Hydronephrosis. (2013).
http://www.nlm.nih.gov/medlineplus/ency/ar
ticle/000506.htm
