Download Libby Sells Professor Matuszak KNH 411 September 17, 2013 Case

Libby Sells
Professor Matuszak
KNH 411
September 17, 2013
Case Study 11-Inflammatory Bowel Disease:Crohn’s Disease
I. Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical literature indicate regarding
its etiology?
a. Inflammatory bowel disease is a group of chronic inflammatory conditions affecting the large and
small intestines. It causes the disruption of the normal functioning of the digestive system, and can be
very painful and debilitating. Two common types of IBD are ulcerative colitis and Crohn's Disease.
b. Current medical literature indicates that IBD is considered to be autoimmune, meaning the body's
immune system is attacking the digestive system. It is thought that IBD occurs due to a combination of
genetic(if parent has it that person is more likely to as well) and environmental(smoking, infectious
agents, intestinal flora, etc) factors.
I. Nelms pg. 415-416
2.Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohn’s. How could
this happen? What are the similarities and differences between Crohn’s disease and ulcerative colitis?
a.Many people suffering from IBD may not have a specific diagnosis at the start of their signs and
symptoms. For example, Mr. Sims was misdiagnosed because ulcerative colitis and Crohn's disease
have very similar signs and symptoms including weight loss, diarrhea, bloody stools, fever, weakness,
fatigue, and abdominal pain and discomfort. Both diseases may also cause an increase risk of intestinal
cancer. Mr. Sim's has experienced weight loss, frequent diarrhea,fever, and abdominal pain, as admitted
by his account of his medical history; these symptoms could easily be mistaken for ulcerative colitis.
The location of the inflammation resulting from the disease are different, however. In Crohn's,
inflammation may occur anywhere along the digestive tract, but in ulcerative colitis, typically only the
large intestine or occasionally the ileum will be inflamed. While signs and symptoms are similar, the
location of the pain may be different. In ulcerative colitis, pain tends to be localized in the lower left
abdomen, while pain tends to be in the lower right abdomen in Crohn's:it may have been difficult for
Mr. Sim's to identify the location of his pain.Other differences include more gallstones, kidney stones,
UTIs, perianal disease, fistulas, fissures, and ulcerations in the bowel wall in Crohn's. Bloody stools are
more commonly indicative of ulcerative colitis, as is constipation, dysplasia, arthritis, and
dermatological changes. Treating Crohn's disease is often more difficult, as many of the medications
used for ulcerative colitis are not a good treatment for Crohn's.
I. Nelms pg. 416
3. A CT scan indicated bowel obstruction and the Crohn's Disease was classified as severe fulminant
disease.What does a CDAI score of 400 indicate? What does a classification of severe-fulminant
disease indicate?
a. A CDAI score of 150-220 in a patient indicates mild to moderate activity of Crohn's disease with
tolerable pain and no dehydration, a score of 220-450 indicates moderate to severe activity and are
unresponsive to treatment, so Mr. Sim's score would likely qualify as severe activity of Crohn’s
disease. A score of less than 150 is often given to those considered to be in remission for the disease.
b.A classification of Crohn's severe-fulminant disease is characterized by severe symptoms that are
persistent often despite of steroid treatment and is indicated by high fevers, on-going vomiting, signs of intestinal
blockage, tenderness of the abdomen, cashexia, or evidence of an abscess. To be classified as this, the CDAI
score must be >450.
I. From Nelms, pg 419
4.What did you find in Mr. Sim’s history and physical that is consistent with his diagnosis of Crohn’s?
Explain.
a.According to his account of his medical and nutrition history, Mr. Sims has several signs and
symptoms of Crohn's disease.While his usual body weight ranges from 166-168 pounds, he has
unintentionally lost 25 pounds over the last six months , likely as a result of frequent bowel movements
and malabsorption of nutrients. In the past six months, he has reported fever (101.5 F), worsening
abdominal pain, and frequent diarrhea, which are all symptoms of Crohn's. The increased frequency
and severity of these signs and symptoms is likely due to increased inflammation, and his disease may
be worsening, as occurrence of ulcerations, fissures, fistulas for example are possibilities with Crohn's
Disease. Distension and extreme tenderness with rebound and guarding (pain from reapplying pressure
and tensing of abdomen wall muscles to protect inflamed muscles) have been reported.
I. Nelm's pg. 416
5.Crohn’s patients often have extraintestinal symptoms of the disease. What are some examples of these
symptoms? Is there evidence of these in his history and physical?
a. Extraintestinal symptoms occur because other organs and organ systems may be affected by
Crohn’s disease. Manifestations of Crohn's Disease may include peripheral arthritis,sacroiliitis,
ankylosing spondylitis, osteopina,and osteoporosis which are muscoskeletal implications of Crohn's,
erythema nodosum,pyoderma gangrenosum, and aphthous stomatitis which are dermatological
implications; uveitis, scleritis,and episcleritis are ocular implications; thromboembolic events may
occur in the vascular system, and nephrolithiasis may occur in the renal area. An increased prevalence
of gallstones may occur due to lack of bile resorption, and painful, swollen, and stiff joints with loss of
joint mobility or function may occur as a result of arthritis due to Seronegative spondyloarthropathy.
Neurological complications like seizures, headaches, depression, stroke, myopathy, and peripheral
neuropathy may also happen. Clubbing, a deformity of the ends of the fingers, may also take place.
None of these are evidenced by Mr. Sim's history and physical.
I. From Evans, 2007 and Nelms pg. 418
6.Mr. Sim's has been treated perviously with corticosteroids and mesalamine. His physician had
planned to start Humira prior to this admission. Explain the mechanism for each of these medication in
the treatment of Crohn's.
a. Often used to put patients into remission, corticosteroids are potent anti-inflammatory drugs
(steroids) used for treating moderate to severe Crohn's disease in adults. They are
recommended only for short term, and long term use can cause many side effects. They work
by targeting the adrenal gland in order to reduce inflammation and stress associated with illness and
injury in the body, which can be the cause of some symptoms (including pain) of the disease.
Mesalamine works by works by stopping the body from producing a certain substance that may cause
pain or inflammation, but also has potential side effects and can be ineffective if the small intestine is
affected. Humira blocks the tumor necrosis factor, a protein produced by the immune system that
caused inflammation. It can reduce flare up and the signs and symptoms of Crohn's disease and may
cause remission, but also has potential side effects. It is often used for moderate to severe Crohn's
Disease.
I. From The Mayo Clinic:Crohn's Disease
7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and
explain.
a. Mr. Sim's albumin value is low which was is likely due to malnutrition, inflammation, and poor
absorption and digestion of protein from food-total protein and pre-albumin (his value at 11 g/dL and
the normal range is 16-35 mg/dL) are also low due to this reason.His total protein level is 5.5 g/dL and
the normal range is 6-8 g/dL. His albumin level is 3.2 g/dL and the normal range is 3.5-5 g/dL. Creactive protein is higher than normal because of inflammation, and his osmolality lab value is low due
to dehydration caused by diarrhea.Mr. Sim's ESR value is high due to inflammation. His alkaline
phosphatase level is also high. This can occur with bile duct obstruction or osteoporosis. Mr.Sim's
HDL-C lab value is low because cholesterol levels tend to fall with illness and also with malnutrition.
Lab values of transferrin ( Mr. Sims is 180 mg/dL normal is 215-365 mg/dL),hemoglobin and ferritin
(proteins that bind and transport iron) are low, and ZPP is high due to iron deficiency because of
malabsorption and malnutrition, and low protein levels. The normal range for ferritin is 20-300 mg/dL;
Mr. Sim's is 16mg/dL. His vitamin D and A levels are both low, as his vitamin D is 22.7 ng/mLwith
normal range of 30-100ng/mL, and his vitamin A is 17.2ug/dL with healthy range of 20-80ug/dLwhich
indication inadequate intake or poor absorption.
8.Mr. Sim's is currently on several vitamin and mineral supplements. Explain why he might be at risk
for vitamin and mineral deficiencies.
a.If Mr. Sim's had a bowel resection involving the removal of 200 cm of his jejunum and proximal
ileum, the small intestine would not able to absorb as many nutrients, vitamins, and minerals (iron,
zinc, magnesium) as normal. With Crohn's, inflammation can occur in the small intestine, affecting
absorption.Malabsorption and malnutrition are also currently apparent due to his dramatic weight loss
and diarrhea. Poor appetite may also occur due to the abdominal pain caused by Crohn's, so he may not
be taking in enough vitamins and minerals with his food, and if he is, he may have problems absorbing
them.
I.From Nelm's pg. 420
9.Is Mr. Sim’s a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide
a rational for your answer.
a. Each part of the small intestine absorbs and digests certain nutrients-short bowel syndrome is a
malabsorption syndrome that could occur due to surgical resection of the small intestine, occurring
when the remaining intestine does not completely adapt to the bowel resection, and malabsorption of
nutrients, vitamins, and minerals can occur as a result. Mr. Sim's will be a likely candidate for short
bowel syndrome if he is not careful and intentional about what he eats, especially because he
eventually undergoes a resection of part of the jejunum and proximal ileum (almost half of small
intestine), which could decrease his absorption for b12 and fat soluble vitamins along with other
nutrients.
I. Nelms pg. 424
10.What type of adaptation can the small intestine make after resection?
a.After resection, the small intestine may undergo a process that can increase absorption. This
involves an increase in the intestinal surface area of the mucosa, creating an increase in absorption and
digestion.Villi may grow and become longer and thicker.The diameter of the small intestine may also
widen, and peristalsis could slow down so that food and nutrients have a longer time to be absorbed. It
is thought that the factors influencing this type of adaption includes hormones, intestinal factors,
gastrointestinal secretions, and nutrients from both in and outside of the intestines.
I. From From National Digestive Diseases Information Clearinghouse
11.For what classic symptoms of short bowel syndrome should Mr. Sim’s health care team monitor?
a.Mr. Sim's health care team should monitor the following:frequency and severity of diarrhea,
abdominal pain and bloating, fever,dehydration, heart burn, electrolyte balance, symptoms of
malnutrition like extreme weight loss, and food tolerance. The health care team should also pay
attention to how well Mr. Sim's is able to follow nutrition and diet recommendations, and they should
monitor any subsequent lab values that would be abnormal because of Crohn's disease and short bowel
syndrome. If part of the ileum is removed, levels of bile acid and b12 should be watched.
12.Mr. Sims is being evaluated for participation in a clinical trial using high dose immunosupression
and autologous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment
help Mr. Sims?
a.In autoPBSCT, a person with compromised stem cells may receive their own stem cells derived
from a peripheral blood source. By replacing these stem cells, it is hoped that a patient's immune
system will basically be reset,which could be beneficial to Mr. Sim's, since Crohn's disease is highly
considered to be autoimmune. He could potentially have decreased inflammation, lessened severity of
symptoms, or go into remission for his disease. Immunosupressive drugs have been used in the
treatment of Crohn's disease to suppress or modify the immune system, and some of these drugs work
to specifically target the chemicals of the immune system that are involved with inflammation. Again,
reduced inflammation would greatly lessen many of Mr. Sim's symptoms.
I. Annaloro, Onida, Deliliers, 2009
II.Understanding the Nutrition Therapy
13.What are the potential nutritional consequences of Crohn's disease?
a. The potential nutritional consequences that Mr. Sim's may experience include inadequacy of
protein, folate,iron, calcium, fat, magnesium, zinc, B12, difficulty with fluid retention , food and
medical interactions,fat soluble vitamins, and other vitamin and mineral deficiencies resulting from
malabsorption, especially due to problems in the small intestine. As a result of malnutrition, Mr. Sim's
could have unintentional weight loss,dehydration, growth failure, and muscle wasting. Often times,
supplementation like multivitamins are recommended for patients. For extremely severe cases, enteral
or parenteral feeding could be required. In some cases, lactose may also not be tolerated. Mr. Sim's may
benefit from both supplementation and smaller, well timed meals.
I. Nelms pg. 420
14.Mr. Sims has had a 200-cm resection of his jejunum and proximal ileum. How long is the small
intestine, and how significant is this resection?
a.Normally, the small intestine in an average adult is around 400 cm long. If the terminal ileum is
preserved, resection of large sections of jejunum is generally feasible as adaptions of the small intestine
may occur. Mr. Sim's resections is very significant, since he had almost half the length of the small
intestine resected. He may very likely experience problems like significant malabsorption problems,
frequent diarrhea, and malnutrition, with specific absorption problems depending on the area removed,
if he does not watch his diet carefully.
15.What nutrients are normally digested and absorbed in the portion of the small intestine that has
been resected?
a.M
Mr. Sims has had a 200-cm resection of his jejunum and proximal ileum Most of the crucial
absorption of fat takes place in the ileum. Due to Mr. Sim's resection, nutrients of digestive and
absorption concern include calcium, folate, vitamins A, D, E, K, free fatty acids, monoglycerides, and
some B12 (absorbed in ileaum), sodium,, and water (absorbed all along digestive tract).
I. From National Digestive Diseases Information Clearinghouse
III.Nutrition Assessment
16. Evaluate Mr. Sims’s anthropometric data by evaluating %UBW and BMI. Interpret your
calculations.
a.Using %UBW = (100 x Actual Weight)/Usual body weight:166-168 pounds. Using the average of
167 lbs, (100 x 140 (current weight))/167 (UBW)=83.8 or 84% of his UBW. If a person has a % UBW
within approximately 70-90% of normal body weight, that means they are at risk of moderate
malnutrition. Using BMI = ( Weight in Pounds / ( Height in inches x Height in inches ) ) x 703, Mr.
Sim's BMI=(140/(69 x 69))x703=20.6.His BMI is approximately 21 kg/m^2, while healthy weight
usually falls in a BMI range of 18.5-25.However, Mr. Sim's weight loss is recent and dramatic, which is
of concern, and his BMI could easily fall below the healthy BMI range.
17.Calculate Mr. Sim’s energy requirements.
a. Using the Mifflin-St. Jeor equation for men, where 10 x weight (kg) + 6.25 x height (cm) - 5 x
age (y) + 5 determines energy needs: 140x.453=63.42 kg for weight and 2.54x 69=175.26 cm, and
(10x63.42)+(6.25x175.26)-(5x35)+5=1559.58 or 1560 kcal for REE for his current, not usual body
weight. For his TEE, since physical activity frequency and duration is not specified, I would give the
patient a PAL of 1.6 or 1.8, since it depends how much he is standing and moving around while he
teaches. 1.6x1560=2496 kcal or 1.8x1560=2808 kcals. When at the hospital, I would give him a PAL of
1.2, which would give 1.2 x 1560=1872 calories.It would, however be an important goal to being
increasing total caloric intake necessary for weight gain once he is released from the hospital.
18.What would you estimate Mr. Sim’s protein requirements to be?
a.Using his current body weight of 140 pounds, and 0.8 g x 63.42 kg=50.7 or 51 grams of protein
per day. Using his usual body weight of 167 pounds, 0.8 x 75.65=60.5 or 61 grams per day.Since
protein is an important part of healing and Mr. Sim's has been malnourished, I would recommend he
get anywhere from 1.0 to 1.5g/kg of protein. Using his usual body weight this would be 1.0 x
75.65=60.5 or 1.5x75.65=113.5 for a protein intake of 61-114 grams. Using his current body weight
this would be 1.0 x 63.42=50.7 or 1.5x63.42=95.15 g for a protein intake of 51-95 grams.
19.Identify any significant laboratory measurements from both his hematology and his
chemistry labs.
a.
Lab value
Normal Range
02/15/52
Total Protein g/dL
6-8 g/dL
5.5 g/dL
Albumin g/dL
3.5-5 g/dL
3.2 g/dL
Pre-albumin g/dL
16-35 g/dL
11 g/dL
C-Reactive Protiein mg/dL
<1.0 mg/dL
2.8 g/dL
HDL-C mg/dL
>55 F, >45 M
38 mg/dL
ASCA
Neg
Pos
PT (sec)
12.4-14.4 sec
15 sec
Hemoglobin g/dL
12-15 F, 14-17 M
12.9
Hematocrit %
37-47 F, 40-54 M
38
Transferrin mg/dL
250-380 F, 215-365 M
180 mg/dL
Ferritin mg/dL
20-120 F, 20-300 M
16
ZPP umol/mol
30-80
16 umol/mol
Vitamin D ng/ml
30-100
22.7
Vitamin A ug/dL
20-80
17.2
Ascorbic Acid mg/dL
.2-2.0
<0.1
20.Select two nutrition problems and complete the PES statement for each.
a. Protein deficiency (NI-5.7.1) related to Crohn’s disease and protein malabsorption as evidenced by
lab values for albumin, total protein, pre-albumin, and C-reactive proteins outside of normal limits.
b. Inappropriate energy intake (FH-1.2) related to Crohn's disease, malabsorption, poor appetite, and
frequent diarrhea as evidenced by recent unintentional weight reduction of 25 pounds
V.Nutrition Intervention
21.The surgeon notes that Mr. Sims probably will not resume eating by mouth for at least 7-10 days.
What information would the nutrition support team evaluate in deciding the route for nutrition
support?
a. Mr. Sims’s route for nutrition support would be determined by the location and amount of his
intestinal resection which may determine the best place for absorption, his nutritional requirements and
what macronutrients, total calories,vitamins, and minerals (magnesium, phosphorus, potassium, and
thiamin) he needs in greater or lesser amounts based on weight, current needs,past malnutrition, and
post-surgery requirements, his hydration status, any indication that there are obstructions or fistulas
present, whether or not vomiting or diarrhea is occurring, and overall GI functionality.The support team
should also consult the patient's lab work, to get a more accurate picture of any abnormal values of
concern. Depending on the location of the resection, Mr. Sim's could be given parenteral nutrition
(through veins) or enteral nutrition (through tube into nose, small intestine or stomach).
I. Nelms pg. 92-93
22.The members of the nutrition support team note that his serum phosphorus and serum magnesium
are at the low end of the normal range. Why might that be of concern?
a.Lower levels of serum phosphorus and serum magnesium may suggest depleting body stores,
malnutrition, steatorrhea, malabsorption, electrolyte imbalance, and dehydration from either vomiting
or diarrhea. Low serum phosphate can cause problems with bone growth, energy storage, and nerve and
muscle production, affecting other body systems like the skeletal system.Low levels of serum
magnesium can affect the muscoskeletal, neurological, metabolic, and cardiovascular systems and can
result in an altered imbalance of calcium and phosphorus, irregular heart beat, nerve conduction, and
muscle spasms. It is vital to monitor these levels because they are important factors in refeeding
syndrome.
I. Annaloro, Onida, Deliliers, 2009 and Nelms pg. 93
23.What is refeeding syndrome? Is Mr. Sim’s at risk for this syndrome? How can it be prevented?
a.Refeeding syndrome can occur when a person is recovering from a period of starvation or
malabsorption and malnutrition, and is commonly seen in those with eating disorders, severe weight
loss,cancer, alcoholism, severe diabetes, chronic malnutrition,and those who have recently had surgery.
It is associated with low levels of phosphate, potassium, and magnesium, and may result in
hyperglycemia and electrolyte/fluid imbalances.This syndrome occurs when a malnourished person is
fed too quickly and aggressively. As a result of nutrient imbalances the following may occur: fluid
retention, heart, bone, and breathing problems, insulin resistance, seizures, and altered mental
status.The condition can be life threatening. Mr. Sims is likely at risk for this because he suffers from
the chronic malnutrition and dramatic weight loss, and has just had surgery. Refeeding syndrome can
be prevented by beginning parenteral feedings and later regular eating in small, gradually increasing
amounts of food and water until the body has an increased tolerance for nutrients, and by giving
supplementations until nutrition needs can be fully met. Hydration status, blood glucose, and other
pertinent lab values should be monitored.
I. Nelms 92-93
24.Mr. Sims was started on parenteral nutrition postoperatively. Initially, he was prescribed to receive
200-g dextrose/L, 42.5-g amino acids/L, 30-g lipid/L. His parenteral nutrition was initiated at 50 cc/hr
with a goal rate of 85 cc/hr. Do you agree with the team’s decision to initiate parenteral nutrition? Will
this meet his estimated nutritional needs? Explain. Calculate pro (g); CHO (g); lipid (g); and total kcal
from his PN.
a.Yes, I agree with decision to begin parenteral nutrition. Mr. Sims just had an intestinal resection,
is malnourished, and GI system needs to time heal before it is able to properly digest solid
foods.Paarenteral nutrition is given through the veins, so nutrients are able to go directly into blood
stream without having to be digested and then absorbed through the GI system.
a. Current weight is 140 lbs or 140/2.2=63.6 kg. Using UBW, 167 lbs or 167/2.2=75.9 kg is used to
determine a kcal goal. Using the Mifflin St Jeor equation and patients usual body
weight:(10x75.9)+(6.25x175.26)-(5x35)+5=1684.4 or 1685 calories. Multiplying 1685 X 1.2=2022 due
to activity and injury factors, 2022 kcals are needed.
b.For Mr. Sim's protein intake: to support post-surgery wound healing, 76 kg x 1.5 g=114 g
protein/day. For concentration of protein in PN, 114 g/2022 mL x 100=5.6% amino acid solution or 114
g/2000 mL x 100=5.7%
c.For Mr. Sim's lipid intake: 1.2 g (maximum lipids that should be administered) x 76=91.2
grams/day. Using a 2000 calorie diet (since 2022 kcals is comparable), 1 mL/kcal=2000 ml. So, 2000 x
.3=600 kcal or 2022 x .3=606.6 or 607 kcals. 607/11 kcal/g=55.1 or 55 g. So 55/2022 x 100=2.72%
lipid or 27 g/L, or 600/11=54.5 g, and 54.5/2000=2.72%.
d.For carbohydrates: 114 g protein x4 kcal/g=456 kcals. 55 g lipid x 11 kcal/g=605 kcals.
605+456=1061 kcals. So, 2022-1061=955 kcal from dextrose. 955/3.4 kcal/g=280.9 or 281 g of
dextrose. 280.9/2022 x 100=13.9% dextrose.
Based on this information, Mr. Sim's is not getting enough carbohydrates from dextrose and not nearly
enough protein. His lipid intake is reasonable.
I. Nelms pg. 99-100
25.For each of the PES statements that you have written, establish an ideal goal (based on the signs
and symptoms) and an appropriate intervention (based on the etiology).
a. For inadequate protein intake, the goal is to get Mr. Sim's abnormal protein levels of albumin, total
protein, pre-albumin, and C-reactive protein back into the normal, healthy range. To do this, once Mr.
Sim's is finished with parenteral nutrition, he should increase his daily protein intake by adding more
lean meats, nuts, dairy, and protein shakes into his diet. Instead of 0.8 g protein/kg of body weight, I
would suggest 1.2 g protein/kg of body weight since he is post-surgery and protein deficient, giving
him a goal intake of protein of 76 g (1.2 x 63.2=75.84g) based on current body weight or 91g (1.2 x
75.65=90.78) based on usual body weight.
b. Since Mr. Sim's has had recent, unintentional weight loss that has significantly lowered his BMI, I
would like to see Mr. Sim's return to his usual weight of 166 pounds by gaining about a pound a week
by adding an extra 500 calories to his diet per day. This may be difficult to accomplish at first, because
he needs to increase food and fluid amount very gradually to avoid refeeding syndrome.
VI.Nutrition Monitoring and Evaluation
26.Indirect calorimetry revealed the following information.
Measure
Mr. Sim's Data
Oxygen Consumption
295
CO2 production
261
RQ
0.88
RMR
2022
What does this information tell you about Mr. Sims?
a.This information reveals that Mr. Sim's oxygen consumption is high, considering the normal
measure is 250 mL/min, which could be caused by an increased metabolic rate due to his disease.
Additionally, Mr. Sim's carbon dioxide production is high (normal production is 200 m/L), likely for
the same reason that oxygen consumption is high. Mr. Sims’s respiratory quotient (volume of
Co2/volume oxygen consumed) value falls within the normal range (0.7-1.0). His RMR (calories
released per kg of body weight at rest) is 2022, which is higher than his REE according to the Mifflin
St. Jeor equation, but less that his TEE when he was healthy, which could explain his weight loss.
I. From the American Heart Association
27.Would you make any changes in his prescribed nutrition support? What should be monitored to
ensure adequacy of his nutrition support? Explain.
a.Mr. Sim's needs more protein due to his previous protein deficiency, increased metabolic rate, and
healing. Protein requirements could at most be doubled. His dextrose could also be increased by 70-80
g, while lipid levels are okay. To ensure adequacy of his nutrition support, Mr. Sim's weight , pertinent
lab values, abnormal signs and symptoms like diarrhea, and hydration status should be closely watched
during nutrition support. If not, consequences such as dehydration, more weight loss, continued
malnutrition, and worsening of his disease could occur.
28.What should the nutrition support team monitor daily? What should be monitored weekly? Explain
your answers.
a.Several times a day, temperature should be monitored. Vital signs like pulse should also be checked
daily, for an easy indication that something is wrong. Fluid status and electrolytes should also be
measured daily to prevent dehydration. Baseline blood tests may also be done daily especially to
monitor blood glucose. The rate of infusion should also be closely watched, so patient gets adequate
nutrition. Sights of the entry of the nutrition support as well as an IV or catheter sights should be
checked for inflammation. Weekly, a full blood count, urea and electrolytes, glucose, and magnesium
and phosphate levels should be checked to ensure that there is no worsening of stagnancy of condition.
Weight should also be monitored weekly, and even daily if it is of high concern.
29. Mr. Sim’s serum glucose increased to 145 mg/dL. Why do think this level is now abnormal? What
should be done about it?
a.Mr. Sim's first glucose lab value was 82, which is at the low end of the normal range of 70110.This was likely due to poor appetite and malabsorption. His recent value of 145 likely indicates
that he is getting too much dextrose in his parenteral feedings, or that his body's energy source has
changed from ketone to glucose. This level is abnormal because of the quick and dramatic increase in
glucose to outside the normal range, which can be harmful if it is persistent. He should be given less
dextrose in his subsequent feedings so that his glucose falls back down to within the normal range.
I.From Nelm's 93
30.Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4 grams. By
using the daily nursing record that records the amount of PN received, calculate Mr. Sim’s nitrogen
balance on postoperative day 4. How would you interpret this information? Should you be concerned?
Are there problems with the accuracy of nitrogen balance studies? Explain.
a.By using the formula to determine nitrogen balance (dietary protein intake/ 6.25)- Urine urea
nitrogen -4. Using the protein he should be getting at usual body weight:(114/6.25)- 18.4 -4= -4.16 and
using the protein he is getting though PN: (42.5/6.25)-18.4-4=-15.6. Both would indicate that Mr. Sim's
nitrogen balance is negative, and he is getting inadequate protein. His protein intake should be raised to
give him a positive nitrogen balance that would be necessary for healing from the worsening of Crohn’s
disease and his recent bowel resection, because healing cannot take place in negative nitrogen balance
because the body breaks down muscle and other body proteins for energy. There is some concern about
the research, as many of the studies are short term and don't reveal long term implications on
nutritional maintenance.
I. Nelms pg 54
31.On post-op day 10, Mr. Sim’s team notes that he has had bowel sounds for the previous 48 hours
and had his first bowel movement. The nutrition support team recommends consideration of an oral
diet. What should Mr. Sims be allowed to try first? What would you monitor for tolerance? If
successful, when can the parenteral nutrition be weaned?
a.The first thing that Mr. Sim's should be introduced to are clear liquids like sodas, clear broths, and
fruit juice. These should be given very gradually to see how patient will respond. Solid foods can be
introduced next, such as low fat foods, beverages, and foods soft and easy on the stomach to digest
(nothing spicy for example)can be given. Lactose should be avoided at first. To monitor for tolerance,
amount and frequency of nausea,cramping, indigestion, vomiting, diarrhea, and bloating should be
watched. If successful, parenteral nutrition could be ceased when the majority (about 2/3) of nutrient
needs can be met orally-this time it could take for this to be possible varies.
32.What would be the primary nutrition concerns as Mr. Sims prepares for rehabilitation after his
discharge? Be sure to address his need for supplementation of any vitamins and minerals. Identify two
nutritional outcomes with specific measures for evaluation.
a.Nutrition concerns include a negative nitrogen balance from too little protein, insulin resistance,
electrolyte imbalance, vitamin and mineral deficiency, overactive metabolism, hydration status, and
hyperglycemia. Mr. Sim's is advised to continue taking his multivitamin, which should contain b12
(since b12 may not be properly being absorbed). Protein supplements or drinks may be added if
insufficient protein in ingested. Mr. Sims needs must closely watch his diet to insure he is getting
adequate nutrition-a food journal is one good way to monitor this. One nutritional outcome is an
increase in caloric intake which can be judged on physical appearance and weight, or BMI. This will be
measured by weighing Mr. Sims, and for specific measures whether or not his weight or BMI has
increased will be used to evaluate his intake and whether or not food is being properly absorbed.
Hydration level (with concern for dehydration) and fluid loss or gain can be measured as nutritional
outcomes. This can be measured by amount of weight loss and urine analysis.
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