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Case Study

MNT Rotation
by

Stephanie Chekos

on 7 January 2013

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Transcript of Case Study

Stephanie Chekos MNT Case Study The Patient Principal Dx at Admission Small bowel obstruction
Pelvic abscess
Weight loss
Malnutrition
Hyponatremia
Volume depletion 10/15/2012 Large fluid collection in pelvis

CT guided percutaneous drainage of fluid

Pt found to have pelvis abscess measuring 9.1 x 9.5 x 9.4 cm, also drained

Distal SBO Past Medical/Surgical Hx CAD w/ stents
HTN
Cecal mass, s/p hemicolectomy (2007)
Bilateral lower extremity ischemia w/ iliac stents (July, 2012)
Smoking Abuse, ~1/2 pack-1 pack per day for about 50 years Initial Nutrition Assessment
10/16/2012 Pt seen per NSG admission hx BY
62 y/o Female
African American
Admitted on October 14, 2012 The patient presented to the ER with complaints of abdominal pain, fever, chills, & N/V. Reports anorexia and weight loss over past 5 days secondary to N/V. Can not tolerate the smell of food. Appears thin and cachectic. Initial Care Path IV antibiotics
CT scan
NGT with low intermittent suction
Hydrate with IVF (D5NS)
NPO status CT of Abdomen and Pelvis Physical Assessment: Ht: 5'1'' Wt: 36.2 kg or 79.64 lbs BMI: 15.05 (severe malnutrition) Patient appears thin and cachectic IBW: 95-116 lbs (using Hamwi equation) % IBW 67-84% * Pt unable to recall Usual Body Weight Meds: Mefoxin, Levaquin, Flagyl, Protonix Labs: Alb 2.1 (mod), Total protein 5.2, Ca 7.5 (corrected Ca 9.0 WNL), WBC 17.9, RBC 3.07, H/H (8.9, 28.3), Mag 2.5 (WNL), Phos 3.4 (WNL)
No Prealbumin Estimated Nutrition Requirements Assessment Weight: CBW, 79.64 lbs Caloric: 1300-1500 kcals/day (estimating 35-40 kclas/kg because severely malnourished) Protein: 43-51 g protein/day
(1.2-1.4 g/kg body weight)
low albumin, need prealbumin to more accurately estimate protein needs Fluid needs: ~1500-1820 cc H2O/day
(high end of kcal range - 1500 mL for first 20 kg
+ 20 mL/kg body weight thereafter)
volume depleted
note: pt is getting 3,000 cc fluid via IVF (NS @ 125 cc/hr) Other Notes Pt for CT tomorrow

Pt with NGT-ILWS

NS @ 125 cc/hr

Diet Order: NPO with ice chips PES Statements Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by pt reports inability to eat over last 5 days secondary to abdominal pain and N/V; Pt with NPO order Involuntary weight loss related to decreased ability to consume sufficient energy secondary as evidenced by pt reports 10 lb unintentional weight loss over a short period of time Increased protein-energy needs related to medical diagnosis/ malnutrition as evidenced by Alb 2.1 (moderate/borderline severe); BMI 15 (underweight); Pt not meeting estimated nutrient needs secodary to NPO order Goals Promote weight gain Optimize protein-energy intake Interventions Follow PO intake, I/O, Alb, lytes
Request PAB & daily weights
Recommend PN support if unable to advance PO diet by 10/17/2012
If diet advance after CT in am, recommend GI soft/low Na+ goal diet
Recommend Ensure Clinical Strength TID, MVI daily Follow up in 2 days 10/17/2012 CT of abdomen and pelvis Increased fluid in abdomen
Thickened wall seen in the small bowel
Bilateral pleural effusions
Pt also has increased WBCs PAB lab results (ordered by RD) PAB = 4.0 (severe)
(18-45 WNL per hospital)
(<7 is severe) RD reconsulted secondary to PPN started 10/17/12 PPN ordered at 125 cc/hr (provides 1896 kcals/day, 102 g protein/day) --> exceeds nutrient needs

Recommended running PPN at 100 cc/hr (provides 1517 kcals/day, 82 g protein/day) 10/22/12 Pelvic abscess improving per physician
Advance diet as tolerated
Pt given liquid tray; c/o abdominal pain after eating
PPN at 125 cc/hr continues for now 10/25/12 Still no bowel movement or flatus, abdomen distended, nausea
CT results show PSBO
Pt NPO, continue PPN
Recommended TPN via central line 10/31/2012 Exploratory Lap and Central Line Placement "A good portion of the ileum was found to be ischemic. The necrotic ileum was removed and resected. The small bowel was re-anastomosed to the colon."

Large abscess within the pelvis

Perforated bowel Findings: Review of Literature Ischemic bowel Defined as damage to part of the intestine due to a decrease in its blood supply Several possible causes include hernia, adhesions, embolus blocking the arteries supplying the intestine, arterial and venous thrombosis, low blood pressure Symptoms Abdominal pain
Diarrhea
N/V
Fever Signs & Tests Lab tests may show a high WBC count & increased acid in the bloodstream
Ultrasound of the abdomen
However, the only sure way to diagnose intestinal ischemia is with a surgical procedure Medical Treatment of Ischemic Bowel Treatment usually requires surgical removal of ischemic portion of bowel If possible, the blockage of the arteries to the intestine is corrected
A colostomy or ileostomy may be needed Source: PubMed Nutritional Implications "Significant resections of the ileum generally produce major nutritional complications. The distal ileum is the only site for absorption of vitamin B12, intrinsic factor, and bile salts. Without bile salts, fats and fat-soluble vitamins are poorly absorbed. In addition, malabsorption of fatty acids can result in malabsorption of electrolytes such as calcium, zinc, and magnesium.
Dehydration and concentrated urine are also associated with ileal resections and can increase risk of kidney stones." Consequences of Ileal Resection Rapid transit of intestinal contents
Decreased fluid aborptive area
Malabsorption of vit B12, intrinsic factor
Malabsorption of bile salts Inadequate bile salts for lipd solubization, digestion, and absorption, leading to loss of fat and fat-soluble nutrients
Malabsorption of Ca, Mg, Zn
Increased risk of kidney stones MNT for Bowel Resections Gut rest (NPO)
TPN to restore and maintain nutritional status
Resume EN: start enteral feeds early and increase concentration and volume gradually
the role of enteral feedings is to provide a trophic stimulus to the GI tract while PN is used to meet fluid and nutrient needs
Transitioning to normal foods may take weeks to months; maximal adaption of the GI tract can take up to a year after surgery Ileal Resections Patients with ileal resections require increased time in the advancement from PN to EN
Limit dietary fat (esp in patients with remaining colon)
Because of losses, fat-soluble vitamins, Ca, Mg, and Zn may need to be supplemented
Small amounts at each feeding are more likely to be tolerated and absorbed * With any colon resection, there is elevated risk of dehydration, electrolyte disorders, and malnutrition Short Bowel Syndrome Resection of ileum significantly increases risk of developing SBS

Factors affecting risk:
Length of remaining small intestine
Loss of ileum, esp distal 1/3
Loss of ileocecal valve
Pt has hx of cecal mass s/p hemicolectomy Coexisting malnutrition
Pt w/ malnutrition upon admission; BMI 15 indicates severe malnutrition Older age at time of surgery
Pt is 62 y/o "malabsorption of fluid & nutrients" Source: Mahan, Escott-Stump 11th ed. Psycho-Social & Family Hx Single w/ no children
Lives w/ mother
Unemployed
Used to do farm work & work at Pizza Hut

Family hx: CAD & MI in both parents Back to the patient.... 10/31/2012 S/P exp lap w/ segmental small bowel resection and reanastomosis, drainage of pelvic abscess, & insertion of central line
Post-op Diagnosis: Pelvic abscess and perforated bowel
Sepsis, beginning septic shock related to abscess and perforated bowel
Azotemia secondary to sepsis
Respiratory failure & pulmonary congestion
Underlying CAD
Malnutrition The pt remains intubated in the ICU

Sedated with Propofol

TPN via central line ordered 11/1/2012 Nutrition F/U Vent. Propofol. TPN Central w/ fats started per protocol with goal rate of 125 cc/hr (provides 3,528 kcals, 102 g protein)
No BS
Recommended changing TPN to Critical Care formula at 75 cc/hr
D/C IVF once TPN at goal IVF at 125 cc/hr for fluid maintenance 11/8/2012 Nutrition F/U Vent. No BS/BM
TPN Central w/ fats continues @ 125 cc/hr
Labs: Alb 1.0 (severe), Na 133, Cl 99, Mag 1.5, PAB 6.5 (mod)
Recommended changing TPN to Critical Care @ 100 cc/hr (provides 2,553 kcals/day, 96 g protein/day)
Increase NaCl and Mag in TPN 11/12/2012 Nutrition F/U S/P exp lap --> Peritonitis Trache placement Pt remains septic TPN changed to Critical Care @ 100 cc/hr Lytes improved 11/13/2012 Trache mask trials started to wean off vent 11/13/2012 Nutrition F/U S/P trache.
+ BS, +BM
TF started via NGT: Vital AF 1.2 @ 10 cc/hr continuous w/ autoflush
TPN decreased to 75 cc/hr
Increase TF 10 cc q 8 hrs until goal rate of 50 cc/hr is reached
D/C TPN

Vital AF 1.2 @ 50 cc/hr w/ autoflush will provide 1440 kcals/day, 90 g protein/day, 1573 cc H2O/day Prognosis Can result in death if not treated promptly
Complications include peritonitis and sepsis
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