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Case Study 20 - Stella Bernhardt
Transcript of Case Study 20 - Stella Bernhardt
Kenneth Tomek, Arthur Valentine Understanding the Disease
and Pathophysiology Question 4 Continued What is a respiratory quotient? How is the figure related to nutritional intake and respiratory status? Question 8 Mrs. Bernhardt has quit smoking. Shouldn't’t her condition now improve? Explain. Question 7 Mrs. Bernhardt’s medical record indicates previous pulmonary function tests as follows: Question 5 Question 4 What risk factors does Mrs. Bernhardt have for this disease? Question 3 COPD includes two distinct diagnoses. Outline the similarities and differences between emphysema and chronic bronchitis. Question 2 Mrs. Bernhardt was diagnosed with Stage 1 emphysema/COPD 5 years ago. What criteria are used to classify this stage? Question 1 Mrs. Bernhardt was placed on oxygen therapy. What lab values tell you that the therapy is working? HO3: SaO2: PaCO2: pH: Define each of the following and interpret Mrs. Bernhardt’s values Why would arterial blood gases (ABGs) be drawn for this patient? Look at Mrs. Bernhardt’s arterial blood gas report from the day she was admitted. Question 6 Understanding the Nutrition Therapy
(MNT) Is there a specific nutrition therapy prescribed for these patients? Question 10 What are the most common nutritional concerns for someone with COPD? Question 9 Nutritional Assessment How would her 1+ bilateral pitting edema affect the evaluation of her weight? Calculate Mrs. Bernhardt’s UBW, percent UBW, and BMI. Do any of these values indicate that she is at nutritional risk? Question 11 Calculate arm muscle area using the anthropometric data for mid-arm muscle circumference (MAC) and triceps skinfold (TSF) How would these data be interpreted? Question 12 Calculate Mrs. Bernhardt's energy and protein requirements. What activity and stress factors would you use? What is your rationale? Question 13 Using Mrs. Bernhardt’s nutrition history and 24-hour recall as a reference, do you feel she has an adequate oral intake? Explain, and provide any evidence. Question 14 From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Question 15 Evaluate Mrs. Bernhardt’s laboratory values. Identify those that are abnormal. Which of these may be used to assess her nutritional status? Question 16 Do her laboratory values indicate that this may be a problem? Why may Mrs. Bernhardt be at risk for anemia? Question 17 From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. Question 18 What factors can you identify from her nutrition interview that probably contribute to her difficulty in eating? Question 19 From the information gathered within the behavioral-environmental domain, list possible nutrition problems using the diagnostic term. Question 20 Nutrition Diagnosis Select two high-priority nutrition problems and complete the PES statement for each. Question 21 Nutrition Intervention A D I What is the current recommendation on the appropriate mix of calories from carbohydrate, protein, and fat for this patient? Question 22 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). Question 23 What goals might you set for Mrs. Bernhardt as she is discharged and beginning pulmonary rehabilitation? Question 24 Monitoring and Evaluation E Mrs. Bernhardt is back for second visit to pulmonary rehab
Current weight 116lbs
Has not been eating much due to difficulty adjusting to medication and oxygen at home
Interview indicates she is hungriest in morning and evening
Too tired to eat
No specific intolerances
No milk products consumed because the would cause more sputum to be produced Background for Question 25 Monday
Coffee – 1C with 2Tbs nondairy creamer, orange juice – ½ C, 1 poached egg, ½ slice toast
½ tuna salad sandwich (3Tbs tuna salad on 1 slice wheat bread), coffee – 1C with 2Tbs nondairy creamer
Cream of tomato soup – 1C, ½ slice toast, ½ banana, Pepsi - ~36oz Food Diary Tuesday
Coffee – 1C with 2Tbs nondairy creamer, orange juice – ½ C, ½ C
oatmeal with 2Tbs brown sugar
1 chicken leg from KFC, ½ C mashed potatoes with 2Tbs gravy,
coffee – 1C with 2Tbs nondairy creamer
Cheese – 2oz, 8 saltine crackers, 1 can V8 juice (6oz), Pepsi - ~ 36oz Using the information from her food diary as a teaching tool, identify three interventions that you would propose for Mrs. Bernhardt to increase her calorie and protein intake. What would you tell her regarding the use of supplements and/or milk and sputum production? Is she meeting her calorie and protein goals? Question 25 M & FEV1 = 0.7
LFVC = 1.5
FEV1/FVC 46% Define FEV, FVC, and FEV/FVC, and indicate how they are used in the diagnosis of COPD. How Can these measurements be used in treating COPD? Why is the patient diagnosed with COPD at higher risk for malnutrition? Stella Bernhardt Background History Initially diagnosed with stage 1 COPD (emphysema) 5 years ago
2 inhalations QID
PMH: No occupational exposures
Smoked for 46 years
Has quit for 1 year UBW = 145-150lbs
% UBW = (119lbs/148lbs)* 100 = 80.4%
BMI = (54.1kg/(1.6m^2) = 21.1 The one indicating most nutritional risk is her current body weight -- 119lbs An arterial blood gas test measures the acidity and the levels of oxygen and carbon dioxide in the blood taken from an artery. For Mrs. Bernhardt, arterial blood gases would be drawn to determine if there is a need for extra oxygen or help with breathing and to make sure there are no other breathing problems or lung diseases present. acidity level in the blood. Normal ranges from 7.35-7.45mmHg. Upon admission her values were 7.29mmHg and by day 3 were 7.4 mmHg. Blood pH stabilized by day 3 due to medical treatment for emphysema, oxygen therapy, and better nutrition. Higher CO2 content caused blood acidification and pH decrease. Oxygen therapy helped return blood pH to normal levels. Bicarbonate is a buffer that keeps the pH of blood from becoming too acidic or too basic. This test measures the level of bicarbonate in a sample of blood from a vein. Normal values are between 24-28. On day one Mrs. Bernhardt had values of 24.7 and on day three her values were up to 28. Although this value is within the normal range, she is borderline alkalotic. Smoking is the number one cause of COPD. After 46 years of smoking, many of the negative effects of such long term use would be irreversible. The fact that she has quit smoking will help alleviate some of her symptoms to an extent. Unfortunately, such long term smoking would cause the lungs to become inflamed and permanently damaged which prevents the air from flowing normally. Oxygen to the blood at this point will also be decreased due to the damaged lungs. However, cessation of smoking at this point does have its benefits. Although the damage that has been done is in large part irreversible, quitting smoking prevents further damage to the lungs and to the body as a whole. She should be encouraged that quitting smoking was not in vain and that her efforts will not only help manage her COPD, but also improve her quality of life. The respiratory quotient is a measure of the ratio of the volume of CO2 expired to the volume of oxygen consumed. Carbohydrate is the macronutrient that increases the respiratory quotient. Nutritionally, the goal is to reduce the amount of carbon dioxide being produced by the body which can be achieved by decreasing carbohydrate in the diet. By decreasing carbohydrate in the diet, the amount of CO2 produced decreases, thereby decreasing the burden of expiration on the patient. This also helps decrease respiratory infections and acidosis associated with emphysema.
Recommended diets to achieve this goal consist of high fats and proteins and low carbohydrates. Breathing requires more energy for people with COPD. The muscles used in breathing may require up to 10 times more calories than those of a person without COPD. It is important that individuals with COPD eat enough calories and follow a healthy diet to prevent wasting of the diaphragm and other pulmonary muscles and reduce the risk of infection. In addition, being overweight increases the strain placed on muscles used for breathing even further. Therefore, it is important that people with COPD maintain a healthy body weight, stay active, and follow a healthy diet. Patients with COPD are at a greater risk for malnutrition because the disease can leave a person feeling weak and tired. COPD can make a person uncomfortable when trying to eat due to shortness of breath and fatigue. In contrast, patients should avoid overeating because it can also make breathing uncomfortable. People with COPD should focus on eating nutritionally dense meals to avoid problems associated with malnutrition. Although there is not a specific diet prescribed to COPD patients, there are several broad dietary recommendations for these patients.
-Include high-fiber foods such as vegetables, legumes, and whole-grain foods
-Control the amount of sodium to prevent fluid retention, which can cause difficulty in breathing
-Avoid overeating and foods that cause gas or bloating such carbonated beverages, greasy foods, apples, avocados, broccoli and Brussels sprouts
-Choose foods that are easy to prepare to save energy for eating
-Rest before eating so you have enough energy to eat your meal
-Drink plenty of non-caffeinated fluids to keep mucus thin and easier to cough up
If problems with shortness of breath are present while eating some recommendations include:
-Eat slowly and choose foods that are easy to chew
-Try eating six small meals a day, with the biggest meals in the morning
-Drink liquids at the end of the meal
- Eat while sitting up Over estimated BMI AMA = [MAC - (3.14 x TSF)] 2 12.56 AMA = [19.05cm - (3.14 x 1.5cm)] 2 12.56 AMA = 16.4cm 2 Mifflin - St Jeor Formula: 10(wt in kg) + 6.25(ht in cm) - 5(age) - 161 10(54.1kg) + 6.25(160cm) - 5(62) - 161 ~ 1070 kcals/day Activity factor 1.2 1070 kcals/day x 1.2 = ~1284 kcals/day Stress factor 1.4 1284 kcals/day x 1.4 = ~ 1800 kcals/day Protein requiments 1.4g/kg 1.4g/kg (54.1kg) = ~76g/day
The criteria utilized to diagnose and classify emphysema/COPD include blood O2 saturation, fatigue, anorexia and/or difficulty chewing or swallowing.
The staging component of emphysema requires the use of pulmonary function tests (PFTs). During a PFT, the patient breathes and blows into a tube while airflow is measured.
The amount of air the patient can forcibly exhale in one second is measured using the forced expiratory volume measurement (FEV1).
Total exhaled breath is also measured as FVC.
Before staging can occur, must first diagnose with emphysema (Patient was diagnosed with stage 1 COPD 5 years ago)
In people with normal lung function, FEV1 is at least 70% of FVC.
An FEV1 less than 70% of FVC can make the diagnosis of COPD in someone with compatible symptoms and history.
FEV1= 0.7 L
FEV1/FVC- 46% (want to be at least 70%) COPD is characterized by the slow, progressive, obstruction of the airways. Emphysema (one of the two types of COPD) is characterized by abnormal, permanent, enlargement and destruction of alveoli. Age 62, female.
Normal FEV1 value = 2.4 FEV1 values Using FEV1, the patient is classified as having stage 1 emphysema if their FEV1 is greater than or equal to 80% of normal (mild)
Stage 2- FEV1 <80% but >50% (moderate)
Stage 3- FEV1 <50% but >30% (severe)
Stage 4 FEV1 < 30% or less than 50% with low blood oxygen levels (very severe)
Patients FEV1 - .7 L
As indicated on previous slide, the patients “normal” FEV1 value is around 2.4 L
Patient therefore is classified as having stage 4 (very severe) emphysema at this point in time Current Staging Bronchitis Emphysema Caused by similar factors
Genetics Characterized by
Slow, progressive obstruction of airways Symptoms
Extreme difficulty breathing
Abnormal, permanent enlargement & destruction of alveoli
Normal hematocrit values
Cannot be cured
Irreversible Energy Expended Energy Consumed
Total Calories: 572 Calories
Protein (g): 8 g Under
Protein (% Calories): Calories 5%
Carbohydrate (g): 130 g
Dietary Fiber: 3 g
Total Fat: 7% of calories 1 C coffee, sips of orange juice, 1/2 C oatmeal, 1tsp sugar, 3/4C chicken noodle soup, 2 saltine crackers, 32oz Pepsi 24 Hour Recall Absolutely Not! Her energy needs are ~ 1800 kcals/day
Only getting ~570 kcals/day
Protein requirements are ~ 75g/day
Only getting 8g/day
Significant weight loss in the past year
20lbs or 20% less than UBW
Decreased palatability of foods
"Everything has a bitter taste."
Inadequate nutrition knowledge
Believes milk increases mucus production
Poor appetite Inadequate energy intake
Inadequate fluid intake
Inadequate bioactive substance intake
Inadequate fat intake
Inadequate protein intake
Inadequate vitamin and mineral intake Extreme cough associated with inflammation of the bronchi
Can lead to:
Inflammation of airways
Mucus production leading to cough
Patients often normal or overweight
May have increased hematocrit values The primary risk factor for Emphysema is smoking While she no longer smokes, Mrs. Bernhardt reported that she had smoked 1 pack a day for 46 years. That’s approximately 16790 packs of cigarettes throughout her life. As alluded to earlier, smoking damages the fibers in the lungs which in turn damages and kills the alveoli. She also reported having both bronchitis and upper respiratory infections during the winter months for the majority of her adult life. Mrs. Bernhardt also lost her mother and two aunts to lung cancer, so she has a history of respiratory problems both in her family history and her personal history. Identify the symptoms described in the MD's history and physical that are consistent with Mrs. Bernhardt's diagnosis, then describe the pathophysiology that may be responsible for each symptom.
Emphysema can be diagnosed with nothing more than an FEV1/FVC ratio of <70%, however, the varying stages are classified as previously listed.
These measurements are useful for:
Determining severity of damage to airflow
Amount of lung function lost
Treatment may include
Stage 1: being proactive - cessation of smoking
Advanced stages: using FEV, FVC, and FEV/FVC values and staging factors can help with recommendations for prescriptions
ex. bronchodilators, corticosteroids FEV1- The amount of air the patient can forcibly exhale in one second
FVC- The amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible
FEV1/FVC: the percentage of the FVC exhaled in the first second
The ratio of FEV1 to FVC should be around 80% for normal airflow
When the ratio is at or below 70%, COPD is diagnosed.
Mrs Bernhardt is clinically diagnosed with COPD
LFEV1/FVC = 46% Self-feeding difficulties related to inability to place food in mouth as evidence of patient’s shortness of breath, need for assistance, and 20lb weight loss in last year.
Inadequate water consumption related to oral intake < recommended as evidence of 24 hour food recall. Ideal goal 1: Increase caloric intake by providing assistance with shopping, preparing meals, and consuming it. Smaller more frequent meals should be implemented to promote oral intake and lessen fatigue.
Ideal goal 2: Increase water intake by incorporating it with each meal. Correcting fluid status is a primary consideration. This will also help thin the mucus Mrs. Bernhardt has been coughing up. Continue to not smoke
Achieve and maintain goals of PES
Consume nutrient dense foods (fiber)
Minimize carbonated beverages to decrease additional CO2 retention. Mrs. Bernhardt is not meeting her calorie and protein needs.
Consuming: ~ 750 kcals and 28g protein
Goals are: 1800 kcals and 75g protein Consider consuming a nutrient dense protein supplement.
Extra sputum production due to milk is a myth
Consume more water to thin out the sputum production. 1) Try supplementing with high calorie and protein formula (ex. Boost)
2) Try consuming a larger breakfast
consisting of more protein
3) Increase fluid intake (especially milk and water) The partial pressure of oxygen that is dissolved in arterial blood. Normal ranges are 35-45. On day one Mrs. Bernhardt’s values were 50.9, which was high, and by day 3 her values were in the normal range at 40.1. This indicates that the oxygen to carbon dioxide in the blood is normalizing and that oxygen therapy Is working. A noninvasive test used to measure the level of oxygen in the blood of the arteries. The measurement is expressed as a ratio of oxygenated hemoglobin for the total amount of hemoglobin. Normal values are greater than or equal to 95. Mrs. Bernhardt’s values were low on day 1 at 92% and also low on day 3 at 90.2%. A possible cause of this is that she may have been more active on day 3 because she was feeling better than she was when oxygen levels were measured on day 1. Being active requires more oxygen and in turn decreases the levels of oxygen in the blood. Mrs. Bernhardt’s lab values for CO2 content started high at 31, and by day three they were normal at 29.8. This indicates that the ratio of oxygen to carbon dioxide is also back to normal. In addition, her pH levels returned to normal by day three, indicating that the levels of CO2 in her blood had decreased as a result of increasing oxygen. Her albumin and total protein, which may be used to assess her nutritional status, are fairly low. In addition, her white blood cell count is very high and red blood cell count, hematocrit, and hemoglobin are all slightly low. -Considering the fact that she has no energy to eat, she is at risk for anemia simply because she isn’t getting the nutrition she needs. Her laboratory values seem relevant, however her symptoms and lack of protein in her diet suggest that she may have anemia. Malnutrition and cachexia are particularly serious problems for COPD patients. Calorie reduction is often reported and this in combination with an increased rate of breathing, systemic inflammation and specific therapeutic interventions add to extra energy expenditure costs. COPD can lead to cachexia, in which muscle and fat mass are lost in spite of inadequate calorie intake. In her case, she is severely underweight, she doesn’t eat much, and her energy level is diminished, so therefore, she is at high risk for nutritional deficiencies. Underweight
Unintended weight loss From her 24-hour diet recall, Mrs. Bernhardt only ate saltine crackers, chicken noodle soup, and oatmeal, and drank Pepsi, orange juice, and coffee, all of which were in extremely small portions. She mentioned that she avoids milk because she heard it causes an increase in mucus production, which makes it difficult to reach needs for protein, calcium, and fat. Other factors contributing to her difficulty eating may include altered taste of food and increased coughing. Her dentures fit loosely, which could make it difficult for her to chew.
She uses all her energy to make food and can’t eat much of it because of her exhaustion.
Increased coughing has made it hard to eat and also has caused her to expend more energy 62 year old Caucasian female
Unable to do anything by herself without experiencing shortness of breath
Coughing up a lot of brownish-green phlegm
Believes she may have caught something at church
Husband tells her she is confused in the morning
She questions if the confusion is related to her COPD
Dx: Acute exacerbation of COPD, increasing
dyspnea, hypercapnia, r/o pneumonia In stable COPD, macronutrient assessment can be initiated based on the DRI, with close monitoring of outcomes. Modifications may be necessary if comorbidities-(Cancer, CV disease, Diabetes Mellitus)
Macronutrient DRIs for 51-70 years old
1.2-1.7 g/kg of body weight – maintain/restore lung and muscle strength
Fat specific DRI not determined
30-45% calories Identify at least 4 features of the physician's examination that are consistent with her admitting diagnosis. Describe the pathophysiology that might be responsible for each physical finding.