Download File - Zachary Pfirrman

Zach Pfirrman
KNH 413
2/9/14
PUD Case Study
1. List all the food items that may contribute to GG's condition and explain why.
High fat fast foods, frozen dinners, and fried foods. “Avoid high fat foods. In animal studies, high fat
foods increase inflammation in the stomach lining”(umm.edu).
2. List any additional oral intake that may have contributed to GG's condition and explain
why.
Coffee, alcohol, soda, and aspirin are all oral intakes that may contribute to GG's condition. The main
problems are alcohol and aspirin, which is a non-steroidal anti-inflammatory drug (NSAID). Both of
these reduce the release of protective prostaglandins that protect the gastric mucosa. Coffee is a very
acidic beverage which will add to to the acidity of the stomach and cause more pain and damage.
Nelms p.360-362
3. List the non-oral stimulants (physical or psychological stress) that could contribute to
GG's condition and what she could do to change it.
Smoking, working part-time while going to school, and all of that on top of being a single mom to a
child with ADHD. Smoking and stress are both factors that decrease the blood supply.
Nelms p.361
4. List the symptoms of GG's gastritis.
From what GG has told the doctor, she is experiencing heartburn, indigestion, and abdominal pain in
the RLQ. All of these symptoms have been occurring 30 minutes after eating meals and after drinking
coffee. With gastritis, excessive alcohol consumption can cause abdominal pain and pain in the ride
side of the chest.
5. Was a bland diet necessary? Explain and list the principles of the diet plan that you think
GG should follow.
I do not think that GG needs to go on a bland diet. She does, however need to reduce the fried foods
and high fat foods. Coffee and soda need to be cut out completely. Some foods she can eat include lowfat dairy, non-carbonated beverages, tea, scrambled or hard-cooked eggs, ready to eat cereals, low-fat
non-fried meats, and any fruit or vegetable.
6. What is the mechanism of action of the following medications GG is receiving: Carafate,
AlternaGel, and Pepcid?
Carafate is a medication that is used to heal and prevent ulcers. Sulcralfate (Carafate) makes a sort of
coating that that protects an ulcer and the area surrounding from further injury. AlternaGel is Aluminum
Hydroxide which is an antacid the works rapidly to reduce the acid in the stomach. Antacids in the
liquid form tend to work faster and better than tablets or capsules. Pepcid or, “Famotidine belongs to
the group of medicines known as histamine H2-receptor antagonists or H2-blockers. It works by
decreasing the amount of acid produced by the stomach”(Mayoclinic.org).
7. List the nutrient-drug interactions that are associated with the medications.
a) Carafate needs to be taken on an empty stomach before the meal and calcium or magnesium
supplements separate from the drug. It is important to avoid alcohol, cocoa, and cola
because it can increase stomach acid production. They are also possible interactions if taken
with Aluminum antacids.
b) AlternaGel can deplete or interfere with the absorption of nutrients so taking in more
calcium, folic acid, and phosphorus. It is important to avoid citrate because it can produce
dangerous results.
c) Pepcid can affect level of folic acid and vitamin B12 so supplements may be necessary. It
can also increase the risk for iron and zinc deficiencies.
Drugs.com
8. What is GG's IBW and percent IBW?
IBW: 100 lb for the first 5 ft + 5 lb for each additional inch.
100 + (5 x 2) = 110 lb
98 lb / 110 lb = 89% IBW
9. Estimate her daily energy needs using the Harris-Benedict equation and appropriate
stress factor.
Harris-Benedict equation: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x
age in years )
655 + (4.35 x 98) + (4.7 x 62) – (4.7 x 27) = 1245.8
1245.8 x 1.2 (Out of bed) x 1.2 (Infection) = 1794 kcal/day rounded up to 1800 kcal/day
10. What might be the cause of the LUQ pain along with her usual pain?
The extremely high levels of amylase in the blood is most likely caused by a perforated ulcer. The high
levels of Amylase may contribute to an inflamed pancreas. This would cause the severe pain in the
LUQ of the abdomen. Also heavy alcohol consumption can lead to pancreatic problems.
11. In the second set of lab values, glu, BUN, Cr, ser alb, Na, K, Cl, hgb, and hct all dropped.
This probably means GG was:
a) Bleeding
b) eating poorly in the hospital
c) dehydrated when the first labs were drawn
d) over hydrated when the second set of labs were drawn
12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This probably
means that:
a) Enzymes were elevated due to alcohol
b) Her medications caused them to drop
c) GG was dehydrated when the first labs were drawn
d) GG was over hydrated when the second set of labs was drawn
13. Refer to the two lab tables again, and note that the days after admission, GG’s Alk,
Phos, and CPK remained essentially uncharged. Why?
a) These enzymes are not affected by alcohol or hydration
b) Her medications caused them to drop
c) Dehydrated when the first labs were drawn
d) Over hydrated when the second set of labs was drawn
14. What diagnostic test(s) (not lab values) indicate(S) that GG has an ulcer?
An esophagogastrodoudenoscopy revealed an ulcer on the dorsal wall of the duodenum.
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
16. Define:
a) H2 antagonist: The H2 receptor antagonists are a class of drugs used to block the action of
histamine on parietal cells in the stomach, decreasing the production of acid by these cells
b) Proton pump inhibitor: Proton-pump inhibitors are a group of drugs whose main action is
a pronounced and long-lasting reduction of gastric acid production. They are the most
potent inhibitors of acid secretion available.
17. What is the mechanism of action of the following medications GG is receiving: Nexium,
amoxicillin, and clarithromycin?
a) Nexium is a proton pump inhibitor which decreases gastric acid secretion by inhibiting H+,
K+, and ATPase.
b) Both amoxicillin and clarithromycin are antibiotics that are used to treat the bacterial H.
pylori infection.
18. GG was not receiving counsel at the time the major bleeding started. If you had the
opportunity to counsel GG just before the bleeding, in what areas would you feel
competent to counsel her and in what areas would you refer her to someone else?
Investigate the agencies in your area that are available to provide assistance to someone
like GG.
I would feel comfortable to advise her about her diet and other nutrition needs. I would go into
specifics about what foods have been contributing to her problems and what she would have to avoid in
the future to ensure she stays healthy. Things such as surgeries, medications, and physical therapy, she
would need to consult with a physician and physical therapist.
19. What is the significance of the dark stools?
Dark stools is a sign of active bleeding in the gastrointestinal tract. This is most likely coming from the
ulcer bleeding.
20. Give the pathophysiology for the cause of the following abnormal values: BUN, NH3, and
WBC.
a) An abnormal BUN level indicates impaired renal function, dehydration, hemorrhage into
the gastrointestinal tract, excessive protein intake or protein catabolism.
b) NH3 levels can be abnormal from gastrointestinal bleeding, muscular exertion, certain
medications, and smoking.
c) An abnormal WBC reading indicates high levels of disease fighting cells circulating in the
blood. This can indicate anemia, bone marrow tumors, tissue damage, or leukemia.
21. GG was probably dehydrated on admission since she had been drinking. This means that
some of her lab values were probably higher/lower than indicated.
22. After admission GG received packed cells and IV fluids. How would that affect the next
set of lab values?
With the packed cells and IV fluids being put in her system, her next lab values should return to more
normal range. Much like it did from her first to second labs the first visit to the ER.
23. Define the following terms:
a) Packed cells: A preparation of blood cells separated from plasma to restore adequate levels
of hemoglobin and RBCs without overloading the vascular system with excess fluid
b) Abdominal tap: Belly tap, helps differentiate a surgical abdomen
c) Perforated ulcer: An ulcer extending through the wall of an organ
d) Fistula: An abnormal opening or passage between two internal organs or from an internal
organ to the surface of the body.
e) Exploratory Laparotomy: An operations into the peritoneal cavity where the surgeon
examines all surfaces for lesions
f) Billroth I: Excision of the pylorus with an end-to-end of the s and the duodenum, helps
manage peptic ulcer disease
g) Vagotomy: Severing of the vagus nerve from gastric surgery.
24. Sketch a Billroth I.
25. Compared a Billroth I to a Billroth II as to anatomical changes as well as to dietary
changes, if any.
A Billroth I is when they remove part of the stomach, with a reconstruction, where the top half of the
stomach is reconnected to the duodenum. A Billroth II is when they remove part of the stomach, with a
reconstruction, where the stomach is attached to the jejunum, bypassing the duodenum.
Nelms p.364-365
26. Calculate GG’s energy and protein needs.
Harris-Benedict equation: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x
age in years )
655 + (4.35 x 98) + (4.7 x 62) – (4.7 x 27) = 1245.8
1245.8 x 1.2 (Out of bed) x 1.4 (Surgery) = 2093 kcal/day rounded up to 2100 kcal/day
27. List the principles of a postgastrectomy diet and briefly describe the scientific basis for
each principle.
The guidelines include eating fewer simple sugars because they pass through the stomach quickly and
may cause diarrhea. It is also advised to eat more foods high in soluble fiber because these foods help
slow stomach emptying and prevent sugar from being absorbed quickly. Another recommendation is
that the patient limit fat intake because fats slow the emptying of the stomach and can help to prevent
dumping syndrome or diarrhea from developing. Eat smaller, more frequent meals in order to allow the
body to consume the equivalent of three meals without feeling full too quickly. Drink lactose-free milk
over regular.
Nelms p.366-367
28. Is it possible that GG’s diet will ever change or do you believe she will be on a
postgastrectomy diet for the rest of her life? Explain your answer.
There are definitely parts of the diet she should adhere to for the rest of her life, like small frequent
meals, and liquids between them. Low carbohydrate and high protein, as well as a lactose free oral
intake. She should be able to test and see if there are foods she can reintroduce to her diet, but she
needs to reintroduce them one at a time to see how her body reacts to them.
Nelms p.367-368
References
ALP - blood test: MedlinePlus Medical Encyclopedia. (n.d.). U.S National Library of Medicine.
Retrieved February 11, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/003470.htm
Alternagel (aluminum hydroxide) Drug Interactions. (n.d.). Alternagel Drug Interactions. Retrieved
February 11, 2014, from http://www.drugs.com/drug-interactions/aluminumhydroxide,alternagel.html
Carafate (sucralfate) Drug Interactions. (n.d.). Carafate Drug Interactions. Retrieved February 11,
2014, from http://www.drugs.com/drug-interactions/sucralfate,carafate.html
Gastritis. (n.d.). University of Maryland Medical Center. Retrieved February 9, 2014, from
http://umm.edu/health/medical/altmed/condition/gastritis
Nelms, M. N. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth,
Cengage Learning.
Pepcid Complete (calcium carbonate / famotidine / magnesium hydroxide) Drug Interactions. (n.d.).
Pepcid Complete Drug Interactions. Retrieved February 11, 2014, from
http://www.drugs.com/drug-interactions/calcium-carbonate-famotidine-magnesiumhydroxide,pepcid-complete.html
Peptic ulcer: MedlinePlus Medical Encyclopedia. (n.d.). U.S National Library of Medicine. Retrieved
February 11, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm