Download Nutrition Management of Cerebrovascular Accidents

NUTRITION MANAGEMENT OF
CEREBROVASCULAR ACCIDENTS
Ashley Reese
ARAMARK Dietetic Internship
March 3, 2014
Disease Description
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Result of blood flow to the brain that has been stopped
for a period of time
As brain loses oxygen, cells begin to die
Ischemic strokes: blood flow is blocked by a blood clot
or plaque build up
Hemorrhagic stroke: one of the brain’s blood vessels
become weak and then bursts open
Risk factors: aneurysms, arteriovenous malformation,
high blood pressure, artial fibrillations, diabetes,
family history, high cholesterol, over the age of 55, and
African American race
Disease Description
Signs/Symptoms:
Headache (especially when
there is bleeding in the brain),
changes in
hearing/alertness/taste,
clumsiness, confusion, difficulty
swallowing, difficulty
reading/writing, problems in
eyesight, difficulty
talking/walking, personality
changes
S/S may happen automatically, may show within a few days, or may
not show at all
S/S typically most severe when a stroke first happens
Evidence Based Articles/Studies
Cerebrovascular Accidents
Evidence-Based Nutrition
Recommendations-Article 1
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Study performed to determine if nutrition intervention
altered body composition
Patients that had an acute stroke (>65 years old) were
randomized into different nutrition therapy groups:
Intervention group (58 participants)-energy and protein rich
meals
 Routine nutrition care group (control group-66 participants)
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Patients were monitored during their hospital stay and
followed up after 3 months
Ha L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatrics. 2010;10(75):1-9.
Evidence-Based Nutrition
Recommendations-Article 1 Cont.
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Results:
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During the 1st week of their hospital stay: less weight loss in the
intervention group than the control group
After 3 months
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Weight loss was smaller in women of the intervention group
compared to the control group
Men did not show a significant difference among the groups after 3
months
Concluded: Individualized nutrition support with energy and
protein rich supplementation was considered beneficial for
maintaining body weight and preventing loss during the first
week, and in women in the long run.
Ha L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatrics. 2010;10(75):1-9.
Evidence-Based Nutrition
Recommendations-Article 2
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Study performed to determine appropriate timing and route
of feeding for patients that have experienced traumatic brain
injury
Meta-analysis was performed using PubMed, Embase, and the
Cochrane Library databases
Clinical outcomes and differences in nutrition support efforts
were evaluated in 13 randomized-control trials and 3 nonrandomized prospective studies
Primary conclusions included mortality and poor outcomes
Secondary conclusions included hospital length of stay,
ventilation length, and rate of feeding or infectious
complications
Wang X, Dong Y, Han X, Qi X-Q, Huang C-G, Hou L-J. Nutritional support for patients sustaining traumatic brain injury: A systematic review and meta-analysis of prospective studies. Nutrition Support in Traumatic Brain Injury. 2013;8(3):1-14.
Evidence-Based Nutrition
Recommendations-Article 2 Cont.
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Key findings:
 Early feedings was linked to a reduction in mortality, poor
outcome, and infectious complications
 Parenteral nutrition showed a slight reduction in rates of mortality,
poor outcome, and infectious complications compared to enteral
nutrition
 An immune enhancing formula showed a reduction in the infectious
rate compared to a standard formula
 Small bowel feeding is related to less pneumonia than
nasogastric feeding
 Conclusion: The most effective nutrition support is shown with
feeding quickly by parenteral nutrition. If enteral nutrition is used,
best results come from an immune enhancing formula. (Impact
Peptide 1.5)
Wang X, Dong Y, Han X, Qi X-Q, Huang C-G, Hou L-J. Nutritional support for patients sustaining traumatic brain injury: A systematic review and meta-analysis of prospective studies.
Nutrition Support in Traumatic Brain Injury. 2013;8(3):1-14.
Evidence-Based Nutrition
Recommendations-Article 3
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Dysphagia is a common complication for stroke patients
Enteral nutrition is typically used to treat stroke patients with
swallowing difficulties
If viewed as short term problem: nasogastric tubes are used
If viewed as needed for longer term: PEG tubes are placed
Trial evidence does not support protein and energy
supplementation for stroke patients who are able to eat
orally, unless they are showing signs of malnutrition
(especially if they have pressure ulcers)
Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for problems with swallowing and poor nutrition in patients who have had a recent stroke.Cochrane Database of
Systemic Reviews. 2012;10(CD000323). DOI: 10.1002/14651858. CD000323.pub2.
Case Presentation
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72 year old Caucasian man
Found around 4:00 AM by his wife as he was stumbling around the
house. While trying to return to bed he fell and hit his head-no loss
of consciousness or confusion at the time
Wife stated no aphasia or difficulty swallowing; no difficulty seeing
at the time
Family decided to send patient to the hospital for further evaluation
Dx: right hemispheric stroke
Family wanted to transfer to a larger hospital, but the physician
decided he had passed the window for any additional intervention.
Nutrition Care Process: Assessment
Client History
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PMH: diabetes, hypertension, dislipidemia, chronic
kidney disease, shingles, smoked tobacco for 30
years (quit 20 years ago)
Sx history: cholecystectomy, herniorrhaphy, and
fistula repair
Occasionally drinks alcohol
Mother died at age 45 from a stroke
Father died at age 72 with a history of diabetes
and unspecified cancer
Food/Nutrition-Related History
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Wife reported no aphasia or difficulty swallowing before or
after his CVA
During LOS, he remained NPO
Hx of diabetes, wife stated he monitored and checked
Unknown if he has food allergies due to his unconscious state
and wife’s absence during assessment
Nutritional supplements: 1000 mg fish oil, 600 mg red yeast
rice BID, and 1000 mg vitamin D3 per day
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Patient’s rationale for these supplements is unknown
Patient’s food/supply availability is unknown, as well as his
amount of physical activity
Nutrition-Focused Physical Findings
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Noted in chart, wife stated he had good appetite and
no chewing/swallowing difficulties
Physician ordered to continue statin and blood pressure
control medications
Insulin was provided on a sliding scale
Lipid values were monitored per history of dyslipidemia
Other medications: potassium chloride, lopressor, plavix,
and protonix
Speech evaluation was ordered to determine
swallowing ability-resulted in remaining NPO due to
inability to keep awake and stimulated
Anthropometric Measurements
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Admit weight: 203#
Assessment weight: 207#
UBW unavailable
Height: 5’7” (67 inches)
BMI: 32.41
IBW: 148#
140% of IBW
Biochemical Data, Medical Tests, and
Procedures
Measurement
Value
Normal
Reasoning
Albumin
3.4 L
3.5-4.8 g/dL
Acute/chronic
inflammation,
malnutrition
Calcium
8.0 L
8.9-10.3 mg/dL
Lowered albumin,
decreased intake
Glucose
224 H
74-118 mg/dL
DM, stress, steroid
use
Creatinine
1.36 H
0.61-1.24 mg/dL
Dehydration, CKD
WBC
13.6 H
4.5-11.0 thou/uL
Increased disease
fighting cells
circulating in blood
Biochemical Data, Medical Tests, and
Procedures
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CT scan-determine severity of CVA
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Placed on BiPAP
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Due to shortness of breath and hypoxemia
Chest X-ray
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Large area of ischemic infarction of right cerebral artery
Bilateral alveolar filling=pneumonia or congestive heart
failure
Bedside swallow test
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Unable to evaluate twice, due to unable to be kept awake
Nutrient Needs
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Determined using the Critical Care Guidelines in
consideration of BMI and patient medical history:
REE
Protein
Fluid
1750-1950
kcal/day (19-21
kcal/kg actual BW)
~101 g/day (1.5
g/kg IBW)
~1750-1950
mL/day (1 mL/kcal)
ARAMARK Nutrition Status
Classification
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Moderate Risk (Status 3)
 10
points:
 NPO
anticipated>4 days= 4 points
 BMI>30-34= 2 points
 Albumin 3.4= 2 points
 Diagnosis of CVA= 2 points
 Follow-up
within 5 days
Malnutrition Identification
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According to the ASPEN Consensus Statement:
Characteristics Recommended for the Identification
and Documentation of Adult Malnutrition
 Acute
illness/injury related malnutrition
 Level:
nonsevere/moderate
Nutrition Care Process: Nutrition
Diagnosis
PES Statement
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Inadequate oral intake (NI-2.1) related to
inadequate diet order of NPO as evidenced by PO
of 0%.
Nutrition Care Process: Interventions
Interventions
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Medical Interventions:
Electrocardiogram-no acute findings
 CT scan of brain/head/neck-determined acute stroke with
large area of ischemic infarction in right cerebral artery
 MRI-limited involve of the left frontal lobe superomedially
 CT angiogram-total occlusion of the right internal carotid
artery
 Speech therapy consult
 BiPAP-respiratory distress, then pneumonia
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Interventions
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Nutritional
 Goal:
to provide nutrition (NPO)
 Recommended to provide nutrition within 72 hours of
initiating NPO status (Enteral Nutrition ND-2.1)
 Glucerna
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1.2 @ 65 mL/hr
1872 calories, 94 grams protein, and 1256 mL fluid
 Recommended
to provide an additional 150 mL of free
water flushes every 4 hours to meet fluid needs (Enteral
Nutrition ND-2.1)
Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4th ed. Academy of Nutrition and Dietetics;
2013:162-163, 297.
Goals
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Short Term:
Provide nutrition within 72 hours of NPO status; meet 100%
of nutritional needs.
 Tolerate and reach goal rate once enteral nutrition is
initiated; minimal residuals
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Long Term:
Prevent depletion and maintain weight during LOS
 Maintain skin integrity
 Maintain labs within normal limits
 Per speech, advance diet to oral feedings as capable
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Nutrition Care Process: Monitoring
and Evaluation
Monitoring and Evaluation
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Enteral Nutrition Intake (FH-1.3.1): Provide continuous
enteral nutrition support of Glucerna 1.2 with goal rate
of 65 mL/hr by follow-up. Monitor initiation and rate
advancement of tube feeding.
Enteral Nutrition Intake (FH-1.3.1): Provide additional
150 mL free water flush every four hours to meet fluid
needs by follow-up.
Body Composition/Growth/Weight History (AD-1.1):
Maintain admit weight by follow-up, as usual body
weight was unable to be determined.
Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4th ed. Academy of Nutrition and Dietetics; 2013:28,
297.
Monitoring and Evaluation
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Follow-up:
 Performed
5 days after initial assessment
 Goal rate of 65 mL/hr reached
 Tolerating feedings well; minimal residuals present
 Additional free water had not been provided to the
patient-given large amounts of IV fluids; MD discretion
was recommended for additional free water needs
 Patient maintained stable weight (only 2# gain with
slight edema)
Monitoring and Evaluation
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Follow-up Continued:
 Recommended
to continue Glucerna 1.2 at goal rate of
65 mL/hr to meet needs.
 Recommended to provide additional 150 mL free
water Q4H once IVF d/c.
 Goals:
 Continue
to meet nutritional needs with Glucerna 1.2 at goal
rate by follow-up.
 Continue to monitor weight, laboratory values, skin integrity,
and diet order
Conclusion
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The patient’s mental status continued to decreaseresulting in inability to follow commands
Family decided the patient would not want to live a
life in his condition
Family opted for comfort care and requested to be
transferred to hospice
Patient transferred to a floor room, and soon
passed away