1

Corinne Smith
Case Study #11 Inflammatory Bowel Disease: Crohns disease
9/15/15
I. Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical
literature indicate
regarding its etiology?
Inflammatory bowel disease is an autoimmune, chronic inflammatory
condition of the gastrointestinal tract. IBD is a general term from two
diagnoses: Crohns disease and ulcerative colitis. Exact etiology for IBD is
unknown, but current medical literature believes it is a combined interaction
between the environment and clinical factors that cause an inappropriate
immune response in predisposed people (Nelms 418). Environmental factors
include smoking, infectious agents, intestinal flora, diet and physiological
changes in the small intestine. Also, there is a strong genetic association
evidenced by positive family history on approximately 5-15% of patients and
44% positive occurrence in identical twins. Lastly, the genes associated with
IBD share many like factors with other autoimmune diseases (Nelms 418).
Individuals that have the genes and are exposed to certain environmental
triggers will experience an abnormal immune response resulting in the
release of cytokines that trigger an extreme inflammatory response that
destroys the intestinal mucosa. After this response there will be period of
exacerbations and remission (Nelms 419).

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2. Mr. Sims was initially diagnosed with ulcerative colitis and then
diagnosed with Crohns.
How could this happen? What are the similarities and differences
between Crohns disease?
and ulcerative colitis?
Ulcerative colitis and Crohns disease both fall under the IBD umbrella,
making them very closely related. Though both effect the intestinal mucosa
in the GI tract, UC involves only the first two layers of tissue, mucosa and
superficial submucosa within the colon or rectum; whereas Crohns disease
presents a skipping patterns and effects multiple portion s of the GI tract and
damages all of the GI mucosa. Also the inflammatory process in Crohns
disease is characterized by fistulas. When healed these fistulas are replaced
by fibrotic tissue and result in reoccurring bowel obstructions (Nelms 419).
Mr. Sims may have been misdiagnosed due to these and symptom
similarities of abdominal pain and diarrhea. Crohns disease may have
become more apparent when his weightless and malnutrition were
discovered because his oral intake did not match his needs (Nelms 419).
3. A CT scan indicated bowel obstruction and the Crohns disease
was classified as severe fulminant disease. CDAI score of 400. What
does a CDAI score of 400 indicate? What does a classification of
severe-fulminant disease indicate?
A CDAI score of 400 indicates mild Crohns disease. This Crohns Disease
Activity Index is a research tool used to quantify the symptoms of patients

3
with Crohns disease. It quantifies symptoms such as number of liquid stools,
abdominal pain, general well-being, extraintestinal complications,
antidiarrheal drug use, abdominal mass, heamatocrit, and body weight into
one number that describes the level of Crohns disease present (PubMed). A
classification of severer-fulminant disease indicates that very little is able to
move through the GI tract. This is in accordance with his CT scan that
indicated bowel obstruction (PubMed).
4. What did you find in Mr. Sims history and physical that is
consistent with his diagnosis of
Crohns? Explain.
In Mr. Sims history there were no apparent triggers consistent with IBD. He
does not smoke or drink and there is no family history. However, his physical
presents many signs consistent with his diagnosis. He had been previously
hospitalized for related symptoms and was very sick. Then as school started
his symptoms worsened again. This remission and exacerbation is a
characteristic of Crohns disease and was probably brought on by the
changing environment and stress. However, he ignored his symptoms and
they have now worsened and he appears to be in apparent distress and his
running a fever. During his physical, his abdomen appeared to be extremely
and his stool was liquid/soft with present bowel sounds; all of which are
caused by the inflammation present Crohns disease of his small intestine.
Another consistency is his weight loss and gain. Since Crohns disease effects

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the small intestine, nutrient malabsorption is common resulting in weight
loss (Nelms 418-419).
5. Crohns 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?
Extraintestinal symptoms are referring to symptoms outside of the GI tract.
In Crohns disease these can be manifested as osteoporosis, inflammatory
arthropathies, scleritis (inflammation of the sclera), nephrolithiasis
(formation of kidney stones), cholelithiasis (formation of gallstones), and
erythema nodosum (Thad Qilkind, MD). There is no evidence of these in Mr.
Sims history or physical.
6. Mr. Sims has been treated previously with corticosteroids and
mesalamine. His physician
had planned to start Humira prior to this admission. Explain the
mechanism for each of
these medications in the treatment of Crohns.
Mesalamine is an anti-inflammatory agent that works by stopping the body
from producing certain substance that may cause inflammation. It releases
the medication into the the intestines where the effects are needed and
taken daily (MedlinePllus).

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Corticosteroids work to inhibit the over all inflammatory response. They are
most often used in acute exacerbations, but patients are at risk for becoming
steroid dependent (Nelms 420).
Humira (adalimunab) is a biologic therapy for Crohns disease. It works to
interrupt tumor necrosis factor-Alph (TNF- Alpa) and thus the cytokinedirected inflammatory activity (Nelms 420).
7. Which laboratory values are consistent with an exacerbation of
his Crohns disease?
Identify and explain these values.
Ref.
Range
6-8

2/15
1952
5.5

Albumin (g/dL)

3.5-5

3.2

Prealbumin
(mg/dL)
C-reactive
protein (mg/dL)
HDL-C (mg/dL)

16-35

11

<1.0

2.8

>45 M

38

ASCA

Negativ
e
12.414.4

Positive

14-17 M

12.9

Protein, total
(g/dL)

PT (sec)
Hemoglobin
(g/dL)

15

Explanation
Low protein levels are consistent
with protein loss from GI tract
inflammation in Crohns disease
Low levels of albumin are common
in severe exacerbations, due to
inflammation and malabsorption
of protein
^ same as above
Elevated levels= intestinal
inflammation
Decreased fat due to
malabsorption of fat and loss of
fat in steatorrhea
This Antiglycan antibody marks
presence of IBD
This blood coagulation time may
be prolonged due to
malabsorption
Decreased hemoglobin consistent
with iron deficiency anemia
caused by blood loss associated
with gastrointestinal diseases. The
blood loss in the stomach or

Hematocrit (%)

40-54 M

38

Transferrin
(mg/dL)

215-365
M

180

Ferritin (mg/dL)

20-300
M

16

ZPP (umol/mol)

30-80

85

Vitamin D 25
hydroxy (ng/mL)

30-100

22.7

Free retinol
(vitamin A;
ug/dL)
Ascorbic acid
(mg/dL)

20-80

17.2

0.2-2.0

<0.1

intestine cannot be matched by

duodenal iron absorption. IDA is a
common symptom of IBD (PMC).
Consistent with anemia and
malnutrition in Crohns disease
(MedlinePlus)
Consistent with anemia and
malnutrition in Crohns disease
(MedlinePlus)
Consistent with anemia and
malnutrition in Crohns disease
(MedlinePlus)
Consistent with blood loss and
anemia (MedlinePlus)
Vitamin D deficiency common
with long term steroid use and his
lactose-restricted diet
Consistent with Vitamin A
deficiencies in Crohns disease
patients ( PMC)
Consistent with Vitamin A
deficiencies in Crohns disease
patients ( PMC) and not getting
enough in your diet

8. Mr. Sims is currently on several vitamin and mineral supplements.

Explain why he may be
at risk for vitamin and mineral deficiencies.
Mr. Sims may be at risk for vitamin and mineral deficiencies because Crohn;s
disease affects normal digestion and absorption resulting in malnutrition.
Also, medications used to treat IBD, especially corticosteroids, may impact
nutritional status by either increasing nutrient requirements or exacerbating
nutrient loss. Specifically, he is at risk for iron deficiency due to blood loss
and malabsorption, Magnesium and zinc deficiencies due to intestinal losses
like high-volume diarrhea, calcium and vitamin D deficiencies from long time

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steroid use an decreased intake of dairy foods as a result of lactoserestricted diets, and folate deficiencies from medications (Nelms 420).
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define
short bowel syndrome,
and provide a rationale for your answer.
According to OKeefe et al., Short bowel syndrome (SBS) results from
surgical resection, congenital defect or disease associated loss of absorption
and is characterized by the inability to maintain protein, energy, fluid,
electrolyte, or micronutrient balances when on a conventionally accepted,
normal diet (pp. 9-10, 127). Though it is common in patients with Crohns
disease it effects only 2-3 cases per million individuals per year and is more
commonly seen in Crohns disease patients with resulting resections leaving
only 3-5 feet of intact bowel. Since Mr. Sims has not yet undergone any
resection surgeries, I believe that it is a this time highly unlikely he has SBS
(Nelms 426)
10. What type of adaptation can the small intestine make after
resection?
After a resection surgery, SBS generally follows three phases. The first
period, 7-10 days, is characterized by extensive fluid and electrolyte loss
with large volumes of diarrhea. Patients will depend on TPN. The second
phases may last for several months and is characterized by reduction in the
volume of diarrhea with the initial stages of adaptation of the remaining
bowel. Enternal nutrition may be introduced with the gradual transition to an

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oral diet. The third phase is characterized by continuing adaptation of the
remaining bowel, including increased blood flow, secretions, and mucosal
growth. The inner lumen of the remaining small intestine increases in
diameter and this, along with with an increase in villous height, allows for
increased absorptive surface area. The third phase may last for 1-2 years.
Early exposure to enteral feeding will support successful adaptation (Nelms
427).
11. For what classic symptoms of short bowel syndrome should Mr.
Sims health care team
monitor?
Mr. Sims health care team should monitor an inability to maintain protein,
energy, fluid, electrolyte, or micronutrient balances, and increased
abdominal pain and diarrhea. Fluid and electrolyte balance are the primary
concerns in SBS as a result of large volumes of diarrhea. His B12 absorption
and reabsorption of bile salts, which can further contribute to fat
malabsorption, should be monitored. Other vitamin and mineral concerns
that should be monitored include adequate absorption of vitamins A, D, E, K
and deficiencies in sodium, magnesium, iron, zinc, selenium, and calcium (all
lost in large volumes of diarrhea) (Nelms 427).
12. Mr. Sims is being evaluated for participation in a clinical trial
using high-dose
immunosuppression and autologous peripheral blood stem cell
transplantation

9
(autoPBSCT). How might this treatment help Mr. Sims?
This treatment might help Mr. Sims into remission. In clinical trials induce
remission in individuals with Crohns disease. However, it has been debated
whether or not this treatment was safe. According to Hasselblatt et. Al,
Immunoablation by cyclophosphamide and autologous peripheral blood
stem cell transplantation is safe and effective to induce remission of
refractory Crohn's disease, and should be further evaluated in randomised
controlled trials (PupMed.gov).
II. Understanding the Nutrition Therapy
13. What are the potential nutritional consequences of Crohns
disease?
Potential nutritional consequences of Crohns disease include inadequate
energy intake, inadequate energy intake, inadequate oral intake, increased
nutrient needs, inadequate vitamin/mineral intake, impaired nutrient
utilization, food medication interaction and altered nutritional-related
laboratory values. PCM and other nutrient deficiencies can be caused by
decreased nutrient intake, malabsorption, drug-nutrient interactions,
anorexia, and protein-losing enterotherapy. Also severe diarrhea and
abdominal pain can cause patients to restrict what they are eating because it
is painful. A negative nitrogen balance is demonstrated in 50% of patients
due to protein losses in inflammatory exudate. Patients are also at risk for
fluid and electrolyte deficiencies and deficiencies of micronutrients including
calcium, vitamin D, vitamin B12, iron, zinc, and magnesium due to blood loss

10
and high volumes of diarrhea. Food medication interactions such as the
prolonged use of corticosteroids can result in hyperglycemia, nitrogen
wasting, and increased risk of osteoporosis. Lastly surgery would result in an
increased calorie and protein requirements (Nelms 420-421).
14. Mr. Sims underwent resection of 200 cm of jejunum and proximal
ileum with placement
of jejunostomy. The ileocecal valve was preserved. Mr. Sims did not
have an ileostomy, and
his entire colon remains intact. How long is the small intestine, and
how significant is this
resection?
The small intestine is 22 feet or 7 meters long. The small intesting is very
adaptive and can ajust its function rather efficiently. More than 50% of the
small intestine would have to be removed before any significant reduction in
capability is observed (Nelms 381). Mr. Sims surgery resulted in less than
30% of his small intestine being removed, therefore they should be no
significant complications after surgery.
15. What nutrients are normally digested and absorbed in the
portion of the small intestine
that has been resected?
The nutrients normally digested and absorbed in the jejunum include: Lipids,
monosaccharides, amino acids, and small peptitdes, as well as, thiamin,
riboflavin, niacin, pantothenate, biotin, folate, vitamin B12, vitamin C,

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vitamins A, D, E, K, calcium, phosphorus, magnesium, iron, zinc, chromium,
manganese, molybdenum, and selenium (Nelms 387).
III. Nutrition Assessment
16. Evaluate Mr. Sims % UBW and BMI.

% UBW= (current weight/usual weight) X 100

= (63.6 kg/ 75.9 kg)X 100= 84% UBW

BMI= wt. (kg)/ht (meters) squared

= 63.6 kg/ (1.75 )squared = 20.8 (normal BMI)

17. Calculate Mr. Sims energy requirements.

Mifflin- St. Jeor (Nelms 253)
10x wt (kg) + 6.25 x ht (cm) 5 x age +5
10 x 75.9kg + 6.25 x 175 5x 35+5= 1674.6
1674 X (PAL) 1.7= 2847.5
Estimated Energy requirements = 2800-2850 kcal per day to return to
usual body weight

18. What would you estimate Mr. Sims protein requirements to be?
ASPEN guidelines recomened 1-1.5 g protein/kg weight (Nelms 421).

75.9 kg x 1.0 g/kg= 75.9 g

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75.9 kg x 1.5 g/kg= 113.84g

Protein requirement= 76-114 g protein per day to return to usual body

weight and to accommodate muscle wasting and healing after
surgery.

19. Identify any significant and/or abnormal laboratory

measurements from both his
hematology and his chemistry labs.
Refer to table in question number 7.
IV. Nutrition Diagnosis
20. Select two nutrition problems and complete the PES statement
for each.

Inadequate energy intake (NI-1.2) as related to abdominal pain and diarrhea

caused by Crohns disease and lack of appetite as evidenced by involuntary
weight loss of 25 pounds.

Impaired Food Nutrient Utilization of Vitamin D (NC 2.1) related to long term
coricosteriod use to treat Crohns disease as evidenced by decreased Vitamin
D 25 hydroxy of 22.7 ng/mL from a reference range of 30-100 ng/mL.

V. Nutrition Intervention

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21. The surgeon notes Mr. Sims probably will not resume eating by
mouth for at least
710 days. What information would the nutrition support team
evaluate in deciding the
route for nutrition support?
For adults, enternal nutrition is recommended when use of medications is not
feasible and when additional nutrition is needed to improve or maintain
nutritional status. Mr. Sims medical and nutritional status should be
evaluated to determine what type of enternal formula should be used:
chemically defined or polymetric. Progression of eternal feedings is
determined by tolerance with the goal of meeting 25% of needs on day one
and progressing to the goal rate within 24-48 hours. The nutrition support
team should evaluate if Mr. Sims is a good candidate, has he had inadequate
intake for 7-14 days, weightless, or a disorder of the upper GI tract where the
tube could be placed below to bypass dysfunction? Since they answer to all
these questions is yes, Mr. Sims would make a good candidate and other
benefits of eternal feeding would include cost effectiveness, reduced length
of hospital stay, reduced surgical interventions, reduced rate of infectious
complications, improved wound healing, and maintenance of GI function
(Nelms 90).
22. The members of the nutrition support team note his serum
phosphorus and serum

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magnesium are at the low end of the normal range. Why might that
be of concern?
Low levels of serum phosphorus can indicates lack of vitamin D, malnutrition,
and hyperparathyroidism.
Low levels of serum magnesium can indicate chronic diarrhea, ulcerative
colitis, and hyperparathyroidism.
Though both can have indicated different symptoms of Crohns disease, they
overlap in possibly indicating hyperparathyroidism. This is a separate
condition from Crohns, and as a result should be closely monitored and recheck to rule out (MedlinePlus). Also, together these to low levels can show
the presence of refeeding syndrome and can result in cardiac abnormalities
and even death.
23. What is refeeding syndrome? Is Mr. Sims at risk for this
syndrome? How can it be
prevented?
Refeeding syndrome is characterized by metabolic alterations that may
occur during nutritional repletion of starved patients (Nelms 89). Within days
of starvation, liver gluconeogenesis slows, free fatty acids are used to
produce energy in the form of ketones, and basil metabolic rate declines.
Then with the re-introduction of carbohydrates, in Mr. Sims case through
enteral form, results in a shift from ketones to glucose as the primary energy
source. Glucose metabolism required large quantities of phosphorus.
Magnesium, potassium, and thiamin, requirements may increase to meet

15
anabolic needs. The result is a drop in serum levels of phosphorus and
magnesium, associated with cardiac abnormalities. Mr. Sims is at risk for this
syndrome because he has a history of long-term inadequate oral intake as
well as recent minimal intake. Refeeding syndrome can be prevented by
beginning feedings slowly and avoiding overeating (Nelms 103).
24. Mr. Sims was placed on parenteral nutrition support immediately
postoperatively, and
a nutrition support consult was ordered. Initially, he was prescribed
to receive 200 g
dextrose/L, 42.5 g amino acids/L, and 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 teams
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.
cc is equivalent to mL therefore 50 cc/hr = 0.05 L/hr; 1.2 L/ 24 hours
85 cc/hr=0.085 L/h ; 2.04 L/24 hours
Initial PN- 50 cc/hr
Protein= 42.5 g x 1.2=51 grams (51 x 4= 228 kcals)
CHO= 200 g x 1.2 =240 grams (576 kcal, based on 2.4 kcal/g in dextrose)
(Nelms105).
Lipid= 30 x 1.2= 36 grams (36 x 9 =324 kcal)

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Total kcal= 1,128 kcal per 24 hours

Goal PN- 85 cc/hr

Protein=42.5g x 2.04= 86.7 grams (86.7 x 4 = 346.8 kcal)
CHO= 200g x 2.04=408 grams (979.2)
Lipid= 30g x 2.04= 61.2 grams (61.2 x 9=550.8)
Total kcal= 1877 kcal per 24 hours

I agree with the decision to initiate PN and as stated as above this needs to
be done slowly to avoid refeeding syndrome. Once the goal PN is given his
protein needs of 76-114 g per day will begin to be met, which is critical in
correction his malnutrition and muscle wasting. As for the total amount of
calories his PN seems reasonable because you dont want to give to much to
fast and I previously calculate the calories needed to get back to his usual
weight, which will be taken into consideration after his recovery and hospital
stay (Nelms 105-106).
25. For each of the PES statements you have written, establish an
ideal goal (based on the signs and symptoms) and an appropriate
intervention (based on the etiology).
Inadequate energy intake (NI-1.2) as related to abdominal pain and diarrhea
caused by Crohns disease and lack of appetite as evidenced by involuntary
weight loss of 25 pounds.
Goal: Weight gain from current weight of 140 lbs to usual weight of 165 lbs.

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Intervention: Decrease Crohns disease to increase appetite by: maximizing
energy and protein intake, stabilize eating patterns (small but frequent
meals) and encourage a variety of foods (as the patient is able to tolerate
them), consumption of foods high in antioxidants and Omega-3 fatty acids
has been associated with protection against inflammation (ie, fuits, veggies,
vegetable oils, nuts, tuna and salmon), the use of probiotics and prebiotics
enhanced normal flora of the GI tract and has been associated with
decreased IBD symptoms, foods high in oxalate may increase risk for
urolithiasis or kidney stones which can occur in IBD so foods like cocoa, tea,
wheat germ, strawberries, spinach, baked beans, beets and high does of
vitamin C supplements should be avoided (Nelms 422-423).

Impaired Food Nutrient Utilization of Vitamin D (NC 2.1) related to long term
coricosteriod use to treat Crohns disease as evidenced by decreased
Vitamin D 25 hydroxy of 22.7 ng/mL from a reference range of 30-100
ng/mL.
Goal: Increase Vitamin D levels from 22.7 ng/mL to a level within appropriate
range of 30-100 ng/mL
Intervention: Confirm that coricosteriod use is necessary for patient. If so,
vitamin D supplements may be necessary as well as increased Vitamin D in
the diet from fatty fish, citrus fruits, egg yolks, fortified cereals, and sunlight.
VI. Nutrition Monitoring and Evaluation
26. Indirect calorimetry revealed the following information:

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Measure
Oxygen consumption (mL/min)
CO2 production (mL/min)
RQ
RMR

Mr. Sims Data

295
261
0.88
2022

What does this information tell you about Mr. Sims?

This indirect calorimetry reveals that a RMR (resting metabolic rate) of 2022
is actually the amount of calories needed to maintain his current body
weight. This was determined by measurement of oxygen consumed and
carbon dioxide expired in one minute. The indirect calorimetry shows that
energy expenditure is proportional to the bodys oxygen consumption and
carbon dioxide production (Nelms 27, 64, 253-254). The respiratory quotient
(RQ) shows where they energy source is coming from. An RQ of 0.8 is the
average so an RQ of 0.88 means that Mr. Sims is getting most of his energy
from proteins.
27. Would you make any changes to his prescribed nutrition
support? What should be
monitored to ensure adequacy of his nutrition support? Explain.
To ensure adequacy of his nutrition support, calories and protein intake
should be closely monitored to make sure that he is getting the amount he
needs to recover from surgery and to start re-gaining weight. As much as 80
kcal/kg and 1-1.5 g protein/kg. Also, I would add that when oral intake of
food is introduced, it should start with a low residue, lactose free diet with
small frequent meals. As the patient responds to medical therapy adding

19
fiber as the patient can tolerate will advance his diet. Gas producing, spicy,
and friend foods may need to be restricted at first and until the patient can
tolerate them. The addition of an oral diet will need to be high individualized
and what Mr. Sims can tolerate will need to be closely monitored and
adjusted (Nelms 421). When switching to an oral diet, Mr. Sims should be
receiving support from his entire medical team, including his doctor and
dietician. Recovery time is key in his adaptation of the resected small
intestine, and his diet will have to be something he watched for the rest of
his life, so proper monitoring and education is necessary.
28. What should the nutrition support team monitor daily? What
should be monitored
weekly? Explain your answers.
Fluids and electrolytes, calories from protein, CHO, and lipids, and total
calories should be monitored daily to ensure he is getting enough nutrients
for recovery and to start re-gaining weight. With a steadily increasing
nutrient intake, chemistry levels such as albumin, hemoglobin, transferrin,
and ferritin should be increasing daily as well. Urine tests should be tested
daily to look out for glucose or ketones being excreted as this can be a sign
that he is absorption is not improving. Stool samples should be taken as the
pass and screened for loos of fat. Weekly, his HDL levels should be monitored
and increasing and micronutrient deficiencies such as deficiencies of
calcium, vitamins D and B12, iorn, zinc, and magnesium should be tested
weekly. If levels are not improving, supplementation may be necessary.

20
Vitamin D deficiency would be treated with an oral dose of 50,000 IU once
per week for 8 weeks. Calcium supplementation with calcium citrate in
divided doses to provide 1200-1500 mg daily. It is recommended that
additional supplementation include zinc (12-15 mg/liter of stool output),
magnesium (15-30 mEq/day) and copper (0.5-1.5 mg/day). An increase in
antioxidants in the diet is recommended to combat the high levels of
oxidative stress in Crohns disease (Nelms 421-422).
29. Mr. Sims serum glucose increased to 145 mg/dL. Why do you
think this level is now
abnormal? What should be done about it?
This level may have increased due to the eternal feedings and could be a
sign of refeeding syndrome. Eternal feeding levels should be re-evaluated
and possibly slowed to reduce the glucose serum level and avoid refeeding
syndrome (Nelms 102).
30. Evaluate the following 24-hour urine data: 24-hour urinary
nitrogen for 12/20: 18.4 grams. By using the daily input/output
record for 12/20 that records the amount of PN received, calculate
Mr. Sims 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.
N2 balance= (dietary protein intake/6.25)- UUN -4
= (51 g protein (/24 hrs)/6.25)- 18.4-5 = -14.24

21
Mr. Sims is at a negative protein balance and yes this is a concern due to his
muscle wasting and need for increased protein intake for recovery from
surgery. However, there are limitations to measuring nitrogen balance.
Limitations include inherent error of 24-hour urine collection, failure to
account for renal impairment, and inability to measure nitrogen losses from
some wounds, burns, diarrhea, and vomiting. Nitrogen intake may also pose
difficulties. Oral protein intake may be difficult to measure consistently and
accurately, except for when patient is on enteral or parenteral nutrition
support (Nelms 58). .

31. On post-op day 10, Mr. Sims team notes 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?
When oral intake of food is introduced, it should start with a low residue,
lactose free diet with small frequent meals. As the patient responds to
medical therapy adding fiber as the patient can tolerate will advance his
diet. Gas producing, spicy, and friend foods may need to be restricted at first

22
and until the patient can tolerate them. The addition of an oral diet will need
to be high individualized and what Mr. Sims can tolerate will need to be
closely monitored and adjusted (Nelms 421). If foods are introduced that Mr.
Sims cannot tolerate, they should be removed from the diet and can be tried
again in a couple of weeks. Parenteral nutrition can be weaned when there is
no longer and obstructions in the GI tract and his small intestine has fully
healed from resection. From there EN will slowly decrease as oral intake is
tolerated and increased. EN may be kept for assurance of proper fluid and
electrolyte intake. However, the tube should not be removed until the
medical team is sure that Mr. Sims has made adequate progress in is oral
diet and can receive enough nutrients from it.
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.
Maximizing protein and energy intake to facilitate rehabilitation should be
the primary goal. Healthy weight gain combined with some physical activity
will ensure rebuilding of protein stores and muscle mass. His highly
individualized diet plan should contain normalized eating patterns and
encourage a variety of foods. Consumption of foods high in antioxidants and
Omega-3 fatty acids has been associated with protection against

23
inflammation (ie, fuits, veggies, vegetable oils, nuts, tuna and salmon) and
the use of probiotics and prebiotics enhanced normal flora of the GI tract and
has been associated with decreased IBD symptoms. Foods high in oxalate
may increase risk for urolithiasis or kidney stones which can occur in IBD so
foods like cocoa, tea, wheat germ, strawberries, spinach, baked beans, beets
and high does of vitamin C supplements should be avoided (Nelms 422-423).
Supplementation should include treating Vitamin D deficiency with an oral
dose of 50,000 IU once per week for 8 weeks. Calcium supplementation with
calcium citrate in divided doses to provide 1200-1500 mg daily. It is
recommended that additional supplementation include zinc (12-15 mg/liter
of stool output), magnesium (15-30 mEq/day) and copper (0.5-1.5 mg/day)
(Nelms 422).

1. Increase calorie intake to 2800 calories per day.

2. Increase protein consumption to 76-114 grams per day.

REFERENCES

24
"Diagnosis and Management of Crohn's Disease." - American Family
Physician.
AAFP, n.d. Web. 15 Sept. 2015.
<http://www.aafp.org/afp/2011/1215/p1365.html>.
Dretzke, J. "Calculation of Crohn's Disease Activity Index (adapted from Best
Et
Al.39)." PubMed Health. U.S. National Library of Medicine, n.d. Web. 15
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