Download File - Medical Nutrition Therapy Portfolio

Rachel Hart
KNH 413
1/29/2013
PUD CS
I. Understanding the Disease and Pathophysiology
1. List all the food items that may contribute to GG’s condition and explain
why.
Looking at GG’s diet history, the following food items may be contributing to her
condition,
 Fast foods
 High fat foods
 Highly processed frozen foods
 Fried foods
 Chocolate bars
 Black coffee
 Rum and coke/ any alcohol
 Milk
These foods may increase acid secretion or cause direct irritation to gastric
mucosa by erosion. In addition, milk increases both gastrin and pepsin secretion
in the stomach (Nelms et al., 2011, p. 360-364).
2. List any additional oral intake that may have contributed to GG’s condition
and explain why.
Looking at GG’s oral intake, the following items may be contributing to her
condition,
 Aspirin
 NSAID’s
 TUMS*
Other than TUMS, these items may increase acid secretion or cause direct
irritation to gastric mucosa. Although TUMS may initially help the pain and
symptoms associated with her condition, they are only masking her underlying
gastric problem and causing her to resist combination medication treatment and
true healing (Nelms et al., 2011, p. 360-364).
3. List the non-oral stimulants (physical or psychological stress) that could
contribute to GG’s condition and what she could do to change them.
 Smoking
 Stress from her husband, child, and financial situation
 Fatigue from lack of sleep, schooling, work, and parenting
GG could try to quit smoking, find ways to alleviate her stress such as trying
yoga, swimming, walking, or reading, and make an effort to get more sleep at
night. GG should also seek counseling for the various emotional aspects of her
life to help her further cope with the transition. To enable time for some of these
activities, GG could decrease her class load for the semester.
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4. List the symptoms of GG’s gastritis.
 Stomach burning
 Severe pain in the RLQ, right side, and chest
 Pain 30 minutes after eating
 Pain after eating certain foods that trigger gastritis
(Nelms et al., 2011, p. 360-364)
5. Was a bland diet necessary? Explain and list the principles of the diet plan
that you think GG should follow.
Given GG’s diagnosis, I do not think that a bland diet is totally necessary. A
bland diet consists of foods that are soft, not very spicy, and low in fiber. In
addition, it mandates that the patient should not drink alcohol or caffeine (United
States National Library of Medicine, 2012). Although some of these principles
are accurate, the diet plan that I would prescribe would include, foods that are
lower in fat and spicy, black and red pepper, caffeine, coffee, and alcohol. I do
not think it is necessary to implement a soft or low in fiber diet. I would advise
GG that smaller, more frequent meals are better tolerated, that she should not lay
down directly after eating and should avoid large meals right before bedtime
(Nelms et al., 2011, p. 363).
6. What is the mechanism of action of the following medications GG is
receiving: Carafate, AlternaGel, and Pepcid?
 Carafate’s mechanism of action is not totally understood but it is thought
to bind and coat the surface of the ulcers and protect it from further injury
by acid or pepsin. It then directly inhibits pepsin in the presence of
stomach acid and binds bile salts coming from the liver via the bile thus
protecting the stomach lining from injury caused by the bile acids. In
addition, Carafate may increase prostaglandin production, which are
known to protect the lining of the stomach.
 AlternaGel is a liquid antacid that works to lower existing acid in the
stomach.
 Pepcid is an oral, H2-blocker that blocks the production of acid by acidproducing cells in the stomach. H2-blockers inhibit the action of
histamine on the cells, reducing the production of acid
(Medicine Net, 2012).
7. List the nutrient-drug interactions that are associated with each medication.
 Carafate
o Many reduce the absorption of calcium and phosphorus
 AlternaGel
o Many reduce the absorption of calcium, folic acid, thiamin, and
phosphorus
 Pepcid
o Many reduce the absorption of B12 and iron
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o May need to supplement Vitamin C and E to protect the stomach
lining
(PeaceHealth Medical Group, 2012)
8. What are GG’s IBW and percent of IBW?
 IBW= Hamwi equation= 100 lbs + 5 lbs(2 in)= 110 lbs
 % 1BW= 98 lbs/ 110 lbs= 89% of IBW
(Nelms et al., 2011, p. 48)
9. Estimate her daily energy needs using the Harris-Benedict equation and the
appropriate stress factor.
 Harris-Benedict equation= REE= 655.1 + (9.6 x wt kg) + (1.9 x ht kg) (4.7 x age yr)
o REE= 655.1 + (9.6 x 44.5 kg) + (1.9 x 157 cm) - (4.7 x 27 yr)
o REE= 1,254 kilocalories/day
o TEE= 1,254 x stress factor 1.2 (infection) x activity factor 1.3 (out
of bed)
o TEE= 1,956 kilocalories/day for a range of 2,000-1,900
kilocalories/day
(Nelms et al., 2011, p. 60)
10. What might be the cause of the LUQ pain along with her usual pain?
The LUQ pain that GG is experiencing is likely from her elevated liver enzymes,
specifically ALP and amylase (Cleveland Clinic, 2012). These can become high
when alcohol is consumed in excess, such as in GG’s case. Her recent binges of
alcoholic drinks have inflamed her liver, causing this specific pain. Her usual
pain in the RLQ is most likely from the irritation of the ulcer from alcohol and
other such substances that cause irritation. GG must abstain from these
substances in order for her tract to heal out. Another cause of her RLQ could be a
perforated peptic ulcer and should be considered and ruled out by her providing
physician.
11. In the second set of lab values, glu, BUN, Cr, ser alb, Na, K, Cl, hgb, and hct
all dropped. This probably means that GG was:
d. Over hydrated when the second set of labs were drawn
(Nelms et al., 2011, p. 364-365).
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
(Nelms et al., 2011, p. 364-365).
13. Refer to the two lab tables again, and note that two days after admission,
GG’s AK Phos and CPK remained essentially unchanged. Why?
a. These values are not effected by alcohol or hydration
(Nelms et al., 2011, p. 364-365).
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14. What diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?
Diagnostic tests that indicate that GG has an ulcer include,
 A test for H. pylori, which can be detected in a blood test, a stool test or a
breath test.
 An endoscopy of the upper digestive system, in which a hollow tube
equipped with a lens, is passed down the throat and into the esophagus,
stomach and small intestine. If ulcers are detected, a small sample may be
removed for laboratory examination. A biopsy can also identify the
presence of H. pylori in the stomach lining.
 An x-ray of the upper digestive system, called a barium swallow or upper
gastrointestinal series, which is a series of x-rays that creates images of the
esophagus, stomach and small intestine.
(MayoClinic, 2012)
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
16. Define the following terms:
 H2 antagonist- competitively inhibits histamine at the H2 receptors and
leads to a reduction in secretion of gastric acid. H2 antagonists are used to
treat gastroesophageal reflux disease (GERD), gastrointestinal ulcers and
other gastrointestinal hypersecretory conditions.
 Protein pump inhibitor- an agent that block the transport of hydrogen
ions into the stomach and hence are useful in the treatment of gastric
hyperacidity.
(MayoClinic, 2012)
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17. What is the mechanism of action of the following medications GG is
receiving: Nexium, amoxicillin, and clarithromycin?
 Nexium is a protein pump inhibitor proton pump inhibitor, which blocks
the production of acid by the stomach (Medicine Net, 2012).
 Amoxicillin belongs to a class of drugs called penicillin’s. These
antibiotics all have a similar mechanism of action and do not kill bacteria,
but stop bacteria from multiplying by preventing bacteria from forming
the walls that surround them (Medicine Net, 2012).
 Clarithromycin is a macrolide antibiotic and prevents bacteria from
growing by interfering with their ability to make proteins (Medicine Net,
2012).
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.
Before her bleeding started again, I would have liked to counsel GG on how to
make easy, quick, and affordable meals that her body can tolerate. This would
have saved her some of the time and stress that her new diet and way of life
brought. In addition, I would have liked to get a more complete diet history and
food preference log so that I could make her new diet as comfortable and
appealing to her as possible. This might have helped her stick to the new diet and
prevented the relapse. I would have referred GG to seek additional counseling
resources for substance abuse, child support, and time management help. Some
of these resources in the area include,
 The Good Samaritan Inn- Drug and Alcohol Treatment Center
 Oxford Early Childhood Center- Afterschool Care
 Franklin Covey- Productivity Workshops
19. What is the significance of the dark stools?
The dark stool is due to the bleeding of GG’s ulcer. The blood eventually dries as
it is passed in the digestive tract with waste and ultimately turns the stool dark.
This is significant because it reveals that the ulcer is openly irritated and has not
healed properly. This shows that GG has not followed her given regimen and
may need further instruction or more invasive measures to heal her upper
gastrointestinal tract (Cleveland Clinic, 2012).
20. Give the pathophysiology for the cause of the following abnormal values:
BUN, NH3, and WBC.
 BUN- concentrations may be elevated when there is excessive protein
breakdown, significantly increased protein in the diet, or gastrointestinal
bleeding (because of the proteins present in the blood).
 NH3- concentrations may be abnormal when there is gastrointestinal
bleeding or liver failure.
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
WBC- concentrations may be elevated with infections, most commonly
caused by bacteria and some viruses, less commonly by fungi or parasites
or inflammation or inflammatory conditions such as rheumatoid arthritis,
vasculitis or inflammatory bowel disease.
(Lab Tests Online, 2012)
21. GG was probably dehydrated upon admission since she had been drinking
this means that some of her lab values were probably higher than indicated.
22. After admission GG receives packed cells and IV fluids. How would that
affect the next set of lab values?
After receiving these treatments, GG’s anticipated lab values would be lower and
dilute the high lab values. If she receives too much of these treatments then her
lab values will become too low and she will be over hydrated. A balance between
these extremes is needed to keep GG healthy (Cleveland Clinic, 2012).
23. Define the following terms:
 Packed cells- a procedure where the blood cells are separated from the
liquid plasma.
 Abdominal tap- a procedure where a needle is inserted to remove fluid
from the abdomen, also called a paracentesis.
 Proliferated ulcer- an ulcer involving the entire thickness of an organ or
the wall of an organ creating an opening on both surfaces.
 Fistula- a permanent abnormal passageway between two organs in the
body or between an organ and the exterior of the body.
 Exploratory laparotomy- a method of abdominal exploration, a
diagnostic tool that allows physicians to examine the abdominal organs.
 Billroth I- an operation in which the greater curvature of the stomach is
connected to the first part of the jejunum in a side-to-side manner.
 Vagotomy-the surgical cutting of the vagus nerve to reduce acid secretion
in the stomach.
(MayoClinic, 2012)
24. Sketch a Billroth I.
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25. Compare a Billroth I to a Billroth II as to anatomical changes as well as to
dietary changes, if any.
 A Billroth I consists of a partial gastrectomy or pyrloroplasty is performed
with a reconstruction that consists of the proximal end of the duodenum to
the distal end of the stomach.
 A Billroth II consists of a partial gastrectomy with a reconstruction that
consists of an anastomosis of the proximal end of the jejunum to the distal
end of the stomach. A blind loop of the duodenum is created.
The patient will be at increased risk for decreased oral intake, maldigestion,
malabsorption, vitamin and mineral deficiency and dumping syndrome (Nelms et
al., 2011, p. 364-365).
26. Calculate GG’s energy and protein needs.
 Harris-Benedict equation= REE= 655.1 + (9.6 x wt kg) + (1.9 x ht kg) (4.7 x age yr)
o REE= 655.1 + (9.6 x 44.5 kg) + (1.9 x 157 cm) - (4.7 x 27 yr)
o REE= 1,254 kilocalories/day
o TEE= 1,254 x stress factor 1.3 (major surgery) x activity factor 1.2
(confined to bed)
o TEE= 1,956 kilocalories/day for a range of 2,000-1,900
kilocalories/day
(Nelms et al., 2011, p. 60)
 Protein needs equation= 1.4 grams of protein/kilogram of body weight/day
o 1.4 g x 44.5= 62.3 grams/day for a range of 60-65 grams/day
(Nelms et al., 2011, p. 61)
27. List the principles of a postgastrectomy diet and briefly describe the
scientific basis for each principle.
 Eat fewer simple sugars- they pass through the stomach quickly and may
cause diarrhea.
 Eat more foods high in soluble fiber- they slow stomach emptying and
prevent sugar from being absorbed quickly.
 Use liberal amounts of fat- slow the emptying of the stomach and can help
to prevent dumping syndrome or diarrhea from developing.
 Eat smaller, more frequent meals- eating 5 or 6 small meals more often
will allow the patient to eat the equivalent of 3 regular meals without
feeling full too fast.
 Drink liquids 30-60 minutes after meals instead of with meals- this will
allow the patient to eat regular meals without feeling full too fast.
 If milk causes distress, try lactose free milk- this will minimize diarrhea.
(ASPEN, 2012)
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.
It is possible for GG to eventually return to a more normal diet if she takes her
regimen seriously and allows her remaining pouch a chance to expand and adapt
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to the new changes. In a few months she will be able to test out other foods and
determine if gastrointestinal tract can tolerate them. There will be a period of trial
and error but GG prognosis is good for returning to a more normal diet (ASPEN,
2012).
29. If GG were to be hospitalized for an extended period of time and a required
tube feeding via duodenum or jejunum, what characteristics would be
appropriate for the tube feeding you would use?
If GG were to become hospitalized for an extended time and required tube
feeding, I would advise the staff to administer small, frequent feedings with a
high protein formula. Also, I would advise that vitamins and minerals be give
through the tube. The food GG is able to eat through normal means should be
calorically dense and not contain those foods that can flare her peptic ulcer
disease state. GG should also watch how much added sugar she is consuming and
try to minimize the amount in her regular diet (Nelms et al., 2011, p. 364-365).
30. Using the table below, compare several of the enteral nutritional supplements
that would be appropriate for GG.
Product
Producer
Form
Cal/
mL
Nonpro
cal/g N
Pro
g/L
CHO
g/L
Fat
g/L
Na mg
K mg
mOsm/
kg
water
Perative
Abbott
Formula
1.3
97:1
66.7
180.3
37.3
1,040
1,735
Osmolite
1.5 Cal
Abbott
Formula
1.5
125:1
62.7
203.6
49.1
1,400
Promote
Abbott
Formula
1.0
75:1
62.5
130.0
26.0
Vital 1.5
Cal
Abbott
Formula
1.5
114.1
101.3
280
Oxepa
Abbott
Formula
1.5
125:1
62.7
105.3
(Abbott Nutrition, 2012)
8
g of
fiber/ L
Free
H2O/L
in mL
460
Vol to
meet
RDA in
mL
1,155
1.6
790
1,800
525
1,000
0
762
1,000
1,980
340
1,000
0
839
85.7
2,250
3,000
610
1,000
9.0
1,150
93.8
1,310
1,960
535
946
0
785
References
Bland diet. (2012). United States National Library of Medicine. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000068.htm
BUN, NH3, WBC. (2012). Lab Tests Online. Retrieved from http://labtestsonline.org/
Carafate, AlternaGel, Pepcid. (2012). Medicine Net. Retrieved from
http://www.medicinenet.com/
Carafate, AlternaGel, Pepcid. (2012). PeaceHealth Medical Group. Retrieved from
http://www.peacehealth.org/
Nelms, M., Sucher, K. P., Lacey, K., Roth, S. L. (2011). Nutrition therapy &
pathophysiology. Belmont, CA: Wadsworth.
Nutrition supplement. (2012). Abbott Nutrition. Retrieved from
http://abbottnutrition.com/
Peptic ulcer. (2012). MayoClinic. Retrieved from
http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-anddiagnosis
Peptic ulcer disease. (2012). Cleveland Clinic. Retrieved from
http://my.clevelandclinic.org/
Post gastrectomy diet. (2012). American Society of Parenteral and Enteral Nutrition.
Retrieved from http://www.nutritioncare.org/
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