Download Exam Case Study - Advanced Nutrition II

Lili Rosenberg
Final Examination – Advanced Nutrition II
Mr. R. was admitted as an emergency from a nearby nursing home. His nursing home records indicated
he was 86 years old and had a history of heart disease, diverticulosis, and frequent bouts of
constipation. His medications included lasix and digitalis. Measured height was 5'5", weight 125
pounds. temperature 102 oF and BP 147/102.
Physical examination revealed a frail, poorly nourished man in acute distress with left lower quadrant
abdominal pain, muscle spasm and rebound tenderness. Despite frequent coughing, his lungs were
grossly normal. His lower torso and legs were covered with hyperkeratotic follicles; some were
surrounded by red halos and appeared infected. Cracks at the corners of his mouth resembled cheilosis
and seborrheic dermatitis was observed around the folds of his nose. His teeth were in poor repair and
appeared loose. He complained that his poor dental health and pain in the corners of his mouth
prevented him from chewing his food.
The differential diagnosis included acute colonic diverticulitis with risk for rupture, sepsis and shock. He
was started on preoperative broad spectrum antibiotics and IV fluids and admitted for observation.
Diet records indicated that his diet consisted largely of mashed potatoes, canned soups and soft
desserts, especially rice pudding. He took his coffee with cream and 6 sugars per cup. He had difficulty
with his vision, particularly at night. The facility also reported that Mr. R. smoked about 1 pack of
cigarettes a day and was thought to keep alcohol in his room. A psychiatric evaluation had been
scheduled, since Mr. R. had recently become very depressed and appeared mentally confused. He was
also combative at times. Medications included lanoxin and lasix as well as 6 aspirin per day for joint and
foot pain. Anthropometric measures indicated that his triceps skinfold was 9.9 mm, his arm
circumference was 20.5 cm and his muscle circumference was 15.2cm. Transferrin was 170 mg/dl and
serum albumin was 2.2 gm/dl. Mean induration response to an anergy panel was 2.6 mm**.
On day 2, Mr. R. underwent surgery to remove a section of infected bowel. Additional post-surgery
antibiotics were added to the IV fluids (D5W and electrolytes). He did not fully recover from anesthesia
and remained confused and aggressive for at least a week. On day 4, Mr. R. developed bacterial
pneumonia, but his temperature rose only to 39 C. He was put on Warfarin to reduce the possibility of
post-surgical coagulation. The antibiotics were again changed to treat the organisms isolated. He was
transferred to the ICU.
He developed ventricular arrythmia and his heart medication was increased to compensate. He had
gained 6 pounds since surgery; in/out charts revealed that he was retaining fluid. The petechiae and
ecchymosis on his extremities had now become more confluent and he complained of severe pain in
both legs. The pain was so severe that he kept removing the bed-covers from his legs. On day 6 he
developed melena and hematemesis.
His hematocrit dropped to 20% and he was given two units of blood and prescribed iron supplements.
On day 10 his stitches were removed, revealing that the wound had not healed. He also had developed
pressure sores on his buttocks and special pads were used to lessen pressure.
Blood values on day 10 revealed hypertriglyceridemia (1000 mg/dl) hyperglycemia (350 mg/dl) and a
cumulative negative nitrogen balance over the 10 days of 60 grams nitrogen loss. The Blood Urea
Nitrogen (BUN) was elevated as were lactate and pyruvate values.
Exam Questions
1.
What is your nutrition-focused assessment of this patient? Include anthropometric indices, protein
and energy requirements.
86y/o male, 5’5(1.65m); 125lbs(56.8kg)
BP: 147/102 (elevated) Temp: 102 oF (fever)
BMI: 56.8/2.72 = 20.8 (normal)
IBW: 136 +/- 10% = 122.4 - 149.6LBS
%IBW: 92%
Transferrin:170 mg/dl (nl: 215-365mg/dl) (Ciccone 1294)
Serum Albumin was 2.2 gm/dl (nl: 3.2-4.6mg/dl) (Ciccone 18) <2.4 is severe undernutrition. (Merck, PEU)
Triceps skinfold was 9.9 mm
Arm circumference was 20.5 (average is ~32cm) and his muscle circumference was 15.2cm (mean is
26.8cm). (Merck, PEU) Mean induration response to an anergy panel was 2.6 mm.
PNI % = 158 - 16.6 (ALB) - 0.78 (TSF) -0.20 (TFN*) -3.88 (DH)
PNI % = 158 - (16.6x2.2mg/dl) - (0.78 x 9.9) - (0.20x170) - (3.88x2.6) = 67.67% (High risk of post-operative
complications.)
Energy and protein requirements for height and weight:
Energy (Harris-Benedict):
No or low ambulation expected due to arrival from nursing home.
1.2 x BMR = 66.5 + ( 13.75 x weight in kg ) + ( 5.003 x height in cm ) – ( 6.755 x age in years )
BMR: 66.5 (13.75 x 56.8) + (5.003x165) - (6.755 x 86) = 1092
EER: 1310.5
Protein: (0.8 - 1.0) Range: 45.44 - 56.8g/kg
PMH: heart disease, frequent bouts of constipation, diverticulosis
Medications: Lasix (diuretic), Digitalis (heart failure), Lanoxin, Aspirin
Medical Dx: Acute colonic diverticulitis with risk for rupture, sepsis and shock.
Current diet: Mashed potatoes, canned soups, soft desserts (rice pudding), possibly alcohol. Coffee with
6 sugars.
C / O: Left lower quadrant pain. Secondary: Dental pain, depression, confusion, poor night vision,
cheilosis, seborrheic dermatitis.
Assessment: Appears poorly nourished and frail despite adequate energy intake as evidenced by BMI.
He is underweight per % IBW. Poor dental health and oral pain, and constipation may be causing poor
po intake.
Protein intake is extremely low as evidenced by serum albumin, frailty, poor wound healing and dietary
records.
Night blindness is an early symptom of vitamin A deficiency, which is likely given a diet lack in animal
protein and leafy greens. The lesions on his skin are also a possible indicator of vitamin A and/or C
deficiency. Ocular problems could also be a sign of thiamin deficiency. Thiamin deficiency could explain
his confusion as well as increased lactate production.
Cheilosis and Seborrheic dermatitis are found with riboflavin deficiency.
Pressure sores, indicate low protein, vitamin C and zinc.
Loose teeth, petechiae and ecchymoses are signs of vitamin C deficiency.
Displays many symptoms of scurvy.
May have hypogeusia due to low Zinc, which is causing the intake of excessive sugar in coffee.
2.
List at least five important pieces of information not pertaining to diet that may impact on your
diagnosis and management of the patient that you would want to elicit in an interview.
3.
-
Alcohol intake
-
Level of mobility, ataxia?
-
Smoking
-
N/V/D/C and GI distress - is constipation current?
-
Height and weight changes
-
Dietary supplements
-
Difficulty swallowing
-
Injury
-
Memory loss
-
Appetite changes
-
Flavor/Smell changes
What would you advise this patient about his consumption of alcohol, margarine, canned soup?
-
Alcohol will lead to further nutritional deficiencies that will further weaken his muscles and
bone and promote further cardiac distress. Alcohol can cause deficiency of riboflavin, biotin,
thiamin
-
Margarine with trans fats should be avoided to prevent CVD. Margarine that is fortified with
vitamin D can promote calcium absorption and increase bone density.
-
Canned soup is typically high in sodium and low sodium versions should be sought out given his
hypertension and history of heart disease. In addition, any vegetables in canned soup may be
compromised due to cooking. Many nutrients, such as thiamin, riboflavin and magnesium, and
vitamin C are water soluble and lost in cooking fluid.
4.
What is your assessment of the following symptoms? What are there nutritional implications?
·
Dermatitis and joint pain. - Joint pain can result from low BMD or low Vitamin C. Dermatitis
likely as a result of low vitamin C, protein, and water soluble vitamins.
·
hyperkeratotic follicles with red halos - This is a sign of Vitamin C deficiency.
·
dental status - Can result in poor PO intake and malnutrition. May result from vitamin C
deficiency causing gum damage.
·
poor night vision - Can be due to poor vitamin A or thiamin levels
·
mental state on admission - nutritionally attributable to low thiamin or vitamin C if no
neurologic disease present. PEU also causes altered mental state.
5.
What nutrient risks would you expect on admission from prior use of cigarettes? alcohol? lanoxin
and lasix? aspirin?
-
Smoking can increase risk of osteoporosis, and oxidative damage (diverticulitis?) could also be
causing his cough.
-
Lasix is a loop diuretic. Therefore it will reduce Na, and K, Cl primarily, as well as Mg, Ca.
Reduced bone density would result.
6.
-
Aspirin - Increases risk of bleeding and can decrease Fe. (Pronsky 45)
-
Alcohol is associated with nutrient deficiency and osteoporosis, B vitamins.
-
Lanoxin - Antiarrhythmic drug that treats CHF. It is appetite suppressant. (Pronsky 110)
Describe the effect of surgery on nutrient flux in Mr. R. Estimate the increase in kcal
requirements due to trauma and sepsis. Estimate the maximum number of energy and protein
calories he was receiving on day 4.
-
Surgery increase the need for protein to promote wound healing and to replace the cells that
were destroyed. At 0.85g/kg, he should be given not less than (56.8x0.85) 48.28g.
- Patients often need 1.2-2g.kg/day.(Kraus 891) For Mr. R that is 68.16 - 113.6g.
-
Additional energy may be needed to support wound healing, however, in an ICU patient,
additional calories are not recommended. Excessive energy can lead to hyperglycemia, hepatic steatosis
and excess CO2 production. ( Kraus 891)
7.
Why might Mr. R. have been unable to raise his body temperature in response to infection?
Mr. R is malnourished. Each degree of fever (F) increases resting energy expenditure by 7% (each degree
C increases it by 13%).
Describe the mechanisms through which the inflammatory response to injury is achieved.
Wounds require nutrients and energy (largely glucose): to replace cells that were destroyed; for
secretion of growth factors; for inflammatory cells eg. polymorphonuclear leukocytes PMN and
macrophages; for fibroblasts to synthesize the collagen matrix (including proteoglycans); for endothelial
cells necessary for neovascularization; for osteoblasts, osteoclasts and osteocytes in bone breaks.
In septic shock, microbial products and necrotic debris activate macrophages and other cells to produce
mediators, especially the proinflammatory cytokines, TNFa and IL 1.
Inflammatory Mediators: IL1, TNFa foster hyperglycemia, which is visible in Mr. R on day 10, by
stimulating anti-insulin hormone release (adrenal steroids, epinephrine, growth hormone and glucagon)
thereby promoting insulin resistance;
-
they create a catabolic state with net lipid release, suppress lipoprotein lipase and
increase hepatic TG synthesis, which leads to elevated circulating triglyceride (TG) levels,
also seen in Mr. R has on day 10.
glucagon prevents fatty acid transport into mitochondria, prevents ketone formation
and adaption to starvation;
increased skeletal muscle proteolysis further increasing Mr. R’s protein deficit and poor
musculature (utilize gluconeogenic amino acids in the liver, both for gluconeogenesis
and as substrate for acute phase proteins);
increased bone reabsorption.
IL 1 facilitates sequestration of zinc in liver and other wound tissues, by inducing liver synthesis of
metallothionein.
•IL 1 stimulates the bone marrow synthesis and activity of granulocytes, lymphocytes and monocytes.
•IL 1 and TNF stimulate synthesis of ceruloplasmin an acute-phase copper protein = plasma antioxidant,
sequesters iron bound to ferritin and transferrin.
•Inflammatory mediators (especially IL-1) generate fever by action on the hypothalamus.
– Each degree of fever (F) increases resting energy expenditure by 7%(each degree C increases it by
13%).
8.
Why might he have gained 6 pounds in two days following surgery? Would you suggest daily
weight monitoring to assess nutrient status in this patient? If not, what other methods(s) might be
used. What would you expect to find if plasma albumin was assessed?
-
He appears to have been edematous. Edema and decreased urination is a clinical sign of sepsis.
He should be monitored to ensure that the sepsis resolves.
-
If plasma albumin was assessed it would be low due to his poor intake. Reduced albumin can
lead to edema where osmotic pressure is low and water flows into extravascular places where it
is not being excreted.
-
Urinary output, BUN, creatinine and electrolytes, serum albumin to ensure protein increase and
improvement in LBM as well as normal kidney function. Lactate and pyruvate levels should also
be monitored to ensure that cellular hypoxia as a result of sepsis is improving.
9.
Why did Mr. R’s wound reopen after surgery? What therapy would you recommend?
-
He was nutrient deficient prior to surgery including low vitamin C, A, thiamin and protein.
Vitamin C and protein in particular and needed in greater quantity during wound healing. This
impacted his post-surgical outcome. This was predicted by %PNI.
-
He was then given additional blood thinners to the aspirin he was already taking when may have
prevented platelet aggregation and clotting at the site of the wound.
-
Recommendation: Additional zinc, vitamin C and protein are given to promote wound healing
and should benefit the pre-existing skin breakdown as well.
10. Why do you suppose he developed melena and hematemesis six days after surgery? Would you
continue the iron supplements?
-
The wound was not healing properly, leading to GI bleeding and resulting in melena and
hematemesis. He was given warfarin to reduce the possibility of post-surgical clotting, but he was
already chronic aspirin user prior to hospitalization, which is a blood-thinner. This combination along
with malnutrition may have been excessive to allow the wound to heal.
-
Iron supplement should be continued because blood loss is occurring.
11. In the following table, provide evidence based treatments for this patient related both to diet and
lifestyle. Include both primary complaint and associated conditions.
Recommendation
Rationale for
Desired Effect
Recommendatio
Possible Concerns or
Side Effects
n
Increase overall caloric
intake to at least
recommended amount
per calculated energy
needs.
Pt is frail and
micronutrient
deficient has just
undergone surgery,
which requires
energy for wound
healing.
Improve frailty, PEU
through overall
greater intake and
wound healing.
Increase in soft
palatable foods such as
desserts. He may have
dysgeusia as evidenced
by 6 sugars in coffee.
Fruit and vegetable
intake, not canned or
boiled. At least 2
servings per day.
F&V contain
Vitamin C, Mg, fiber
and other nutrient
content.
Improve dental
looseness, oral pain,
skin breakdown, heal
surgical wound,
confusion.
Improve diverticular
disease.
Poor preparatory
techniques that destroy
content.
Increase protein intake
Pt has poor wound
healing and
muscular weakness
as well as edema.
Close wound, and
skin breakdown,
improve strength,
BMD and joint pain.
Pt has CHF, protein
intake could come with
increased fat intake.
Poor cardiac health
and muscular
Increase HDL and
BMD and muscle.
Poor
compliance./Inability to
to ≥0.85gl/kg.
Physical therapy.
weakness.
comply. Possible injury.
Smoking cessation.
Joint pain and
cough.
Risk factor for
osteoporosis and
cancer. Necessitates
more vite C.
Poor compliance.
Cessation of alcohol
consumption.
Alcohol leads to
deficiency of many
nutrients.
Improvement of
symptoms of
nutrient deficiency
as previously
enumerated.
Poor compliance. Pt
appears to be hiding
alcohol in his room.
Reduce sodium to
1500mg per AHA.
Pt has htn.
Alleviate htn and
reduce CVD risk
factor.
Reduction should not be
done with excessive
fluid loss.
Improve dining
environment.
(Clinical 1 notes)
PEU. Low dietary
intake.
Make eating more
enjoyable.
Poor compliance. May
not be prioritized by
nursing home staff.
Appetite stimulant.
(Clinical 1 notes)
Possible low food
intake.
Improve desire for
food.
Overconsumption.
Watch sugar intake.
Consumes excessive
sugar in coffee and
frequent dessert.
Relieve hypogeusia
and prevent insulin
resistance.
If Zinc related, may be
difficult for the pt to
know when excess is
being consumed.
References
Ciccone, Charles. Davis’s Drug Guide for Rehabilitation Professionals.Philadelphia: F.A. Davis Company,
2013. Print.
Johnson L. Vitamin C Deficiency. Merck Manuals.
http://www.merckmanuals.com/professional/nutritional-disorders/vitamin-deficiency,-dependency,and-toxicity/vitamin-c#v885122. Accessed: December 20, 2015.
Mahan L, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis,
Missouri: Elsevier; 2012. Print.
Morley J. Protein Energy-Undernutrition. Merck Manuals.
http://www.merckmanuals.com/professional/nutritional-disorders/undernutrition/protein-energyundernutrition. Accessed: December 20, 2015.
NIH. Diverticular Disease. US Dept of Health and Human Services. http://www.niddk.nih.gov/healthinformation/health-topics/digestive-diseases/diverticular-disease/Pages/facts.aspx#eating. Accessed:
December 20, 2015.
Pronsky, Zaneta M, Dean Elbe and Keith Ayoob, Food Medication Interactions. Birchrunville; Food
Medication Interactions. 2015. Print.