Dietetic

JD Middleton
Ball State University
Intern Case
October 9th, 2018 Study
Presentation
Outline

 Introduction to the Problem

 Introduction to the Subject
 Patient History (broken up into 3 recent admits)
 Nutritional Diagnosis and PES Statement
 Interventions
 Proposed Outcomes to Monitor and Evaluate
 Conclusion
Introduction to the Problem
Protein Calorie Malnutrition (PCM)

 ”Refers to a nutritional status in which reduced availability of nutrients leads to changes in

body composition and function.”2
 Estimated prevalence: 1
 30-50% in hospitals
 As high as 85% in long-term care facilities
 Actual prevalence is unknown1
 Historical inconsistencies in identifying and diagnosing
Protein Calorie Malnutrition (PCM) cont.

 Associated with:
 longer LOS1
 Increased healthcare-related costs1
 Increased rates of further health-related complications1
 Slower wound healing3
 Higher risk of falls3
 Lab levels historically used for diagnosis1
 Albumin
 Pre-albumin
 Patient history and nutrition-focused physical exam (NFPE) used today1
 NFPE assesses nutritional status by focusing on edema, muscle wasting, and subcutaneous fat wasting
Protein Calorie Malnutrition (PCM) cont.
Total
Parenteral
Nutrition (TPN)
Feeding intravenously and bypassing all of
the GI tract
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Percutaneous
Endoscopic
Gastrostomy
(PEG)
Feeding tube placed through the
abdominal wall and into the stomach to https://i1.wp.com/ajnoffthecharts.com/wp-content/uploads/2015/06/figure2-
bypass the mouth and esophagus pegtubedisplacement.png?zoom=2&resize=242%2C196&ssl=1
Gastro-
Jejunal (G-J)
Tube
Extension of the PEG tube into the small
intestine to bypass the stomach
https://ars.els-cdn.com/content/image/1-s2.0-S0025619611630577-gr1.gif
Introduction to the Subject
Patient Intro

 78 years old
 Caucasian
 Female
 Frequently admitted for abdominal pain among other complaints/complications
 Resides at skilled nursing facility
Patient History
Admit 6/29/18-7/20/18

 Admitted for chest pain and acute renal failure

 Anthropometrics at admit:
 Height: 152.4 cm
 Weight: 40.7 kg
 BMI: 17.5 (underweight)
 Needs: 1300 kcal, 47-56 PRO, 1500 mL
 PES Statement
 Inadequate oral/beverage intake (NI-2.1) RT physiological causes AEB pt reports of decreased
appetite and weight loss
 Nutritional Diagnosis
 Severe protein calorie malnutrition related to inability to consume adequate nutrition as evidence
by severe muscle wasting (clavicles, shoulders) and 40 lbs (18.2 kg) weight loss in 1 year
 Admit 6/29/18-7/20/18
Pertinent Dates
 7/2/18
 Diet: Clear liquids
 Diagnosed w/ PCM
 C/o poor appetite for last
month
 Ordered Ensure Clear BID
 7/5/18  7/9/18
 Poor PO continues  Diet: GI soft
 Still receiving Ensure Clear  D/c Ensure and ordered
Magic Cup
 Suggests possible need for TF
and recommends
Osmolite1.5 @ 35 mL/hr
 TF never happens
Admit 6/29/18-7/20/18
Pertinent Dates Cont.

 7/17/18  7/20/18
 Poor PO continues  D/C to SNF
 Diet changed to regular
 Continues to receive Magic
Cup
Admit 8/12/18-9/5/18

 Admitted for UTI and shortness of breath

 Anthropometrics at admit:
 Height: 152.4 cm
 Weight: 40.8 kg
 BMI: 17.6 (underweight)
 Needs: 1211 kcal, 40-48 PRO, 1500 mL
 PES Statement
 Inadequate oral/beverage intake (NI-2.1) RT decreased appetite AEB pt report
 Nutritional Diagnosis
 Severe protein calorie malnutrition related to inability to consume adequate nutrition as evidence
by severe muscle wasting (clavicles, shoulders) and severe fat wasting (triceps)
 Admit 8/12/18-9/5/18
Pertinent Dates
 8/13/18
 Diet: Regular
 Diagnosed w/ PCM
 Still reported poor PO
 Document 75% meal intakes
 Refused any supplements
 8/21/18
 Very poor PO for last 5 days
 RD orders Magic Cup BID
and Ensure Enlive TID
 RD recommended appetite
stimulant or TF if pattern
continues
 C/o abdominal pain begins
 8/24/18
 Poor PO continues
 Abdominal pain continues
 Calorie count completed
and estimated pt is intaking
61.4% of kcal needs and
>100% PRO needs
 Admit 8/12/18-9/5/18
Pertinent Dates

 8/30/18  9/2/18-9/3/18
 9/5/18
 Diet: NPO  Residuals over 100 mL and TF
 TF at goal rate of 45 mL/hr w/
pushed back to 35 mL/hr
 PEG placed better tolerance
 Advanced back up to goal
 D/C to SNF
rate of 45 mL/hr

 8/31/18
 TF starts- Jevity1.2 @ 45 mL/hr
 Will provide 100% of
nutritional needs
Admit 9/21/18-Present

 Admitted for anemia, complicated UTI, metabolic acidosis, and abdominal pain
 Pt came from SNF and was receiving Vital 1.2 @ 35 mL/hr and abdominal pain started
 Anthropometrics at admit:
 Height: 152.4 cm
 Weight: 51 kg
 BMI: 22 (normal)
 Needs: 1275-1530 kcal, 64-77 PRO, 1500 mL
 PES Statement
 Inadequate oral/beverage intake (NI-2.1) RT decreased appetite AEB poor PO intake and need
for TF to meet nutritional needs
 Nutritional Diagnosis
 Severe protein calorie malnutrition related to chronic illness as evidence by severe muscle
wasting (clavicles, shoulders), 3+ generalized edema, and 4+ BUE edema (forearms)
 Admit 9/21/18-Present
Pertinent Dates

 9/28/18
 9/24/18  9/27/18
 Vital 1.2 @ goal rate of 30
 Diet: Regular w/ Vital 1.2  Diet: Regular w/ Vital 1.2 was not tolerated and
@ 40 mL/hr (1152 kcal, 72 @ 20 mL/hr (576 kcal, 36 d/c
PRO) PRO)
 TPN @ 60 mL/hr started
 Abdominal pain  TF running at goal rate (1022 kcal, 72 PRO)
continues and TF d/c
 45% meal PO intake  Family member states PO
 TF advanced to new goal intake causes worse
rate of 30 mL/hr abdominal pain
 9/25/18
 10/2/18
 Vital 1.2 w/ goal rate of 20
mL/hr started  Thoracentesis removed
500 mL of pleural fluid
 Admit 9/21/18-Present
Pertinent Dates
 10/4/18
 10/3/18
 Diet: Regular w/ TPN @ 60
mL/hr (1022 kcal, 72 PRO)
 EGD found no
abnormalities and MD
wants TF to start again
 RD puts in order for
TwoCal HN @ 30 mL/hr
(1440kcal, 60 PRO) w/
slow advancement while
weaning off TPN
 10/5/18
 Diet: Regular w/ TPN @ 60
 TwoCal HN running at 30
mL/hr and TwoCal HN
mL/hr
advancement running at
same time  25% meal PO intake
 Pharmacist calls RD to  Tolerating TF
discuss when to stop TPN advancement and PO
intakes better tolerated
 RD suggests running TPN
after pleural fluid
for rest of the day and d/c
removed
it tomorrow (10/5)
Admit 9/21/18-Present
Pertinent Dates

 10/8/18
 Diet: Regular w/ TwoCal
HN @ 30 mL/hr (1440 kcal,
60 PRO)
 12% PO meal intake
 TF running at goal rate
 Tolerating well w/ no
abdominal pain
 Medical Tests/Procedures

Date Type Reason Findings

9/21/18 Blood transfusion Low hemoglobin

9/28/18 Right internal jugular Severe PCM (central line

triple lumen catheter for TPN), BUE thrombosis,
placement abdominal pain
10/2/18 Left thoracentesis Pleural effusion, dyspnea, Moderate pleural effusion present, removed
hypoxic respiratory failure, 500 mL pleural fluid
CHF, severe PCM, UTI
10/3/18 Upper endoscopy Abdominal pain No esophageal abnormalities, hiatal hernia
present, no duodenal abnormalities, gastritis
 Lab Results
9/22 9/23 9/24 9/25 9/26 9/27 9/28 9/29 9/30 10/1 10/2 10/3 10/4 10/5 10/6 10/7 10/8
RBC 2.81 2.67 2.59 2.76 2.86 2.77 2.74 2.78 3.06 2.28 2.16 2.99 5.07 3.14
(3.8-5.2)

Hgb 8.5 8.3 7.8 8.3 8.6 8.4 8.2 8.3 9.1 7.0 6.7 9.2 15.5 9.6
(11.5-
15.2)

Hct 27.2 26.1 24.7 26.3 27.3 26.5 25.9 26.7 29.6 22.0 20.9 27.8 46.9 29.5
(34.4-
45.6)

Na 138 138 141 145 145 141 143 143 141 136 136 135 136 134 137 137 137
(136-145)

K 5.5 5.7 3.6 3.6 3.4 3.0 3.0 3.6 4.5 5.1 5.3 4.3 3.9 3.6 3.3 3.7 4.1
(3.5-5.5)

Cl 116 115 115 118 119 118 117 117 116 112 110 111 111 111 113 112 112
(98-110)

BUN 52 49 42 36 36 35 31 29 32 32 32 33 33 32 27 24 23
(10-20)

Cr 1.15 1.09 0.97 0.86 0.86 0.90 0.80 0.78 0.71 0.66 0.64 0.61 0.57 0.60 0.62 0.61 0.61
(0.70-1.2)

Glu 96 97 122 90 100 129 95 156 151 128 137 133 125 93 112 117 126
c
(65-99)

Ca 8.5 8.3 8.2 7.9 8.0 8.1 8.1 7.8 7.7 7.6 8.1 7.7 7.7 7.9 8.1 8.2 8.3
(8.4-10.5)
 Medications
Name Type Use
Lomotil Gastrointestinal agent Antidiarrheal
Buspar CNS agent Anxiolytic, sedative, hypnotic
Dextrose 5% + 10 mEq KCl Nutritional product IV nutritional product
Magnesium Sulfate Nutritional product Minerals and electrolytes
Sodium Chloride Nutritional product Minerals and electrolytes
Clinimix 5/15 Nutritional product (TPN) IV nutritional product
Lovenox Coagulation modifiers Anticoagulant
Fentanyl CNS agent Analgesic
Trandate Cardiovascular agent Beta-adrenergic blocking agent
Lactaded Ringers Nutritional product IV nutritional product
Zofran CNS agent Antiemetic/antivergo agent
Sodium Phosphate Nutritional product Minerals and electrolytes
Lasix Cardiovascular agent Diuretic
Potassium Phosphate Nutritional product Minerals and electrolytes
Florastor Cap Alternative medicine Probiotic
Desyrel Psychotherapeutic agent Antidepressent
 Medications Cont.
Name Type Use
Barium Sulfate Radiologic agent Radiocontrast agent
Sodium Bicarb Gastrointestinal agent Antacid
Ceftin Anti-Infective Cephalosporin
Vitamin B12 Nutritional product Vitamin
Benadryl Respiratory agent Antihistamine
Tylenol CNS agent Analgesic
Norvasc Cardiovascular agent Calcium channel blocking agent
Norco CNS agent Analgesic
Coreg Cardiovascular agent Beta-adrenergic blocking agent
Clonidine Patch Cardiovascular agent Antiadrenergic agent
Pepcid Gastrointestinal agent H2 antagonist
Folic Acid Nutritional product Vitamin
Apresoline Cardiovascular agent Vasodilator
Protonix Gastrointestinal agent Proton pump inhibitor
Xifaxan Anti-infective Miscellaneous antibiotic
Proposed Outcomes to
Monitor and Evaluate
Monitoring and Evaluating

 Goals
 Continue to meet nutritional goals
 Prevent further weight loss and wasting
 Progress PO intake
 Monitoring
 No abdominal pain
 Residuals <250 mL
 Weight changes
 Abnormal labs
Proposed Outcomes

 D/C pt back to SNF at current TF formula and rate

 If abdominal pain continues and TF not tolerated:
 G-J tube should be considered to bypass the stomach
Conclusion
Overview

 Pt w/ PCM related to poor PO intake and continuous abdominal pain

 Unable to rely on consistent PO intake to meet nutritional needs
 Unable to tolerate multiple TF formulas at multiple rates
 Jevity 1.2 @ 35 and 45
 Vital 1.2 @ 20, 30, and 40
 Tolerating TwoCal HN @ 30 mL/hr w/ improved PO intake
Sources

 1. Bharadwaj, S. et al. Malnutrition: Laboratory markers vs nutritional assessment.

Gastroenterol Rep. 2016. 4(4), 272-280.
 2. Gabgadharan, A et al. Protein calorie malnutrition, nutritional intervention and
personalized cancer care. Oncotarget. 2017. 8(14), 24009-24030.
 3. Parrish, C. Coding for malnutrition in the adult patient: What the physician needs to
know. Practical Gastroenterology. 2104. 133(1), 58- 64.
Questions?

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