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Jaclyn Schermer
Keene State College Dietetic Intern
June 2017
About Catholic Medical Center
Was founded in 1858
She is 64 yo, she is married, she lives at home with her husband who is her
primary caregiver when she is at home.
Has been consistently in and out of the hospital since cancer diagnosis in
April of 2016
April Bloody stools Rectal 113 lbs, BMI Chemo and COPD
Unintentional cancer 16.5 radiation symptoms
Weight loss malnutrition
March Liquid ostomy malnutrition 108 lbs , BMI Continued on Admitted into
output 15.4 promote TF, on rehab for
regular diet as stability for
tolerated, ileostomy
unjury reversal
supplement w/
lactaid
Ostomy Output
April 18th Abnormal Anastomotic No new weight Small bowel Placed in rehab
drainage in leak, iron def. or BMI resection with when stabilized
stoma anemia ileostomy due on 24th
anastomotic
leak.
May 2017 Medical diagnosis
Medication Reasoning
Dilaudid Pain management
Medical
Lyrica Nerve and muscle pain
diagnosis: Pt
Prednisone Inflammation and COPD
admitted from
Furosemide Fluid accumulation
rehab with chronic
Protonix Decrease reflux
respiratory failure,
Ferrous sulfate p/o low iron
abdominal pain,
and COPD Diclyclomine IBS symptoms
exacerbation. Methocarbamol Muscle relaxant
Buprenorphine Pain management
Megace Cachexia
Admission Labs May 13th
Pt has Dentures
Previous diet instruction: Calorie counting, low fiber, 2 g sodium diet, 2000 ml
fluid restriction, Eating Your Way to a Healthy Heart
Recent food recall per pt: oatmeal w/ brown sugar (50%), (50%) tapioca
pudding, (25%) grilled cheese, (40%) cordon blue
Nutrition Assessment Review of Labs from 5/13:
Lab Measuring Value
Albumin Protein made by liver to keep fluids from 1.8 g/dL (low)
(Mal.) leaking out of blood . Measures amount of
protein in clear part of blood.
AST Enzymes in the blood 42 (ok)
Total protein Measures the amount of protein found in fluid 5.8 (low)
(Mal) portion of blood
Hemoglobin Tests the total amount of Hgb in the blood 8.4 (low)
(Mal.) which transports O2 and CO2
Medications with Nutritional Importance:
Differences:
Energy needs: 1700-1900 kcal/d( 37-42 kcal/kg), 80-90 g/d( 1.7-2 g/kg), 1900
mls fluid( 1 ml/kcal)
Nutrition Support: TPN cant have lipids due to elevated liver enzymes: Provides
1385 kcals and 114 grams Protein
Recent food recall: oatmeal w/ brown sugar (50%), (50%) tapioca pudding, (25%)
grilled cheese, (40%) cordon blue
Intervention: Day 1
TPN 24hr providing 1385 kcal and 114 grams protein, added unjury
frappes TID
TPN without lipids ( D70 390 ml, AA 15 760 mls) due to elevated
liver enzymes 24 hours a day at 75 mls/hr
Remain on TPN providing 1385kcal and 114 gram protein (lipid free)
LFTs remain elevated (5/13): AST 42, ALT 92, alk phos 121
Abdominal wound care consult and stoma check ordered, wound identified
Day 8-9 (5/23-24)
Requested MD to have new LFT labs drawn (been 10 days since updated)
and wt from the nurse on standing scale
Questioned if liver enzymes were improved enough to add lipids back into
TPN
Ileostomy output around 1600mls which was higher than 800-1000 cc/d
Meeting 89% PO intake and 72% protein low end needs based on
calculated calorie count.
TPN remains the same which provides 1385 kcals and 114 grams
Protein
Plan to monitor liver enzymes and begin pt on cyclic TPN due to PO intake progress
Plan to begin cyclic TPN: D70 260 ml, AA15 510 ml, L20 130 mls (1185 kcal and 76.5
g protein)
AST 42 35 27 25
http://www.ostomy.org/Ostomy_Information.html#ileostomy
https://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq
http://www.gainhealth.org/knowledge-centre/fast-facts-malnutrition/
https://www.nutritioncare.org/Press_Room/2013/One_in_Three_Hospitalized_Patients_is_
Malnourished;_Experts_Call_for_Better_Diagnosis_and_Treatment/
R E Black, L H Allen, Z A Bhutta, et al (2008) Maternal and child undernutrition: global and
regional exposures and health consequences, The Lancet, 2008, Jan 19, 371 (9608), 243-
60.
Snider JT, Linthicum MT, Wu Y, LaVallee C, Lakdawalla DN, Hegazi R, et al. Economic
burden of community-based disease-associated malnutrition in the United States. JPEN J
Parenter Enteral Nutr. 2014;38(S2):77S-85S.