Clinical Rotation at VAMC Orlando: Case Study of a Veteran with Chronic Kidney Disease and CVA

1. The Case of Mr. P By dietetic intern: Julia Whelan

2. Objectives: • Clinical rotation site • Pathophysiology/MNT of diseases • Review Mr. P • Discuss formula types • Discuss kidney decline and end of life care • Review Prostat supplementation • Discuss challenges • Review overall goals

3. Clinical Rotation Site: VAMC Orlando Community Living Center120 bed facility available for veterans eligible to receive nursing home care • The CLC offers the following services: • Skilled Nursing Care • Rehabilitation • Dementia Special Care • Hospice/ End of Life Care • Dementia Respite Care • Spinal Cord Injury Care Mission Statement: Our goal is to provide Veterans the opportunity to achieve optimal function in order to maintain or improve the quality of their lives

4. VAMC Orlando Community Living CenterThe role of the RD: • 3 dietitians total • Work with an interdisciplinary team to care for residents • Collect food preferences • Write diet, supplements, and tube feeding orders • Determine nutritional status • Create special food carts • Provide education to staff on various nutrition-related topics • Participate in wound care rounds, behavior rounds, and enteral nutrition rounds • Provide and advocate for proper dental care of residents • And always advocating for our veterans!

5. What’s to come at the Orlando VA:Lake Nona Hospital Opening Fall 2015: 134 bed inpatient treatment and diagnostic hospital Outpatient Clinics State of the art facilities Campus includes the domiciliary, the community living center, and a nursing simulation center Located in “medical city” alongside Nemours Children’s Hospital and the UCF Medical Hospital The first VA hospital built in the US since 1995

6. Chronic Kidney Disease (CKD) The kidney function: maintain the balance of fluids, electrolytes, and organic solutes in the body through the active process of reabsorption, filtration, and excretion

7. Chronic Kidney Disease (CKD) Definition: theprogressive decline of kidney function over time regardless of the underlying cause or disease Prevalence: 1 in 9 adults in the US Risk Factors: diabetes, hypertension, heart disease, obesity, high cholesterol, age, smoking Labs: Glomerular Filtration Rate (GFR); Blood Urea Nitrogen/ Creatine ratio

9. Chronic Kidney Disease MNTKDOQI Guidelines Limit Phosphorous 0.8-1.7 g/d: balanced and excreted by the kidneys meats, dried beans, dairy, nuts, seeds, chocolate, colas, whole grains Limit Potassium 2.4-4 g/d: balanced and excreted by kidneys fruits, vegetables, dairy, meats, bread, pasta Limit Protein to 0.6-1 g/kg/d: dietary protein has been shows as a factor that increases glomerular pressure and leads to accelerated kidney decline Limit Sodium less than 2.3 g/d: to minimize edema due to reduce fluid excretion

10. Secondary Hyperparathyroidism • Hyperparathyroidism secondary to a disease state such as CKD • An overproduction of PTH caused by several changes that occur in bone and mineral metabolism as a result of decreased kidney function which stimulate an increase in PTH synthesis and secretion • Deficiency of activated Vitamin D • Hyperkalemia • Leads to Renal Osteodystrophy- osteoclast activity, bone breakdown, and resorption leading to weakened bones

11. Cerebrovascular Accident (CVA)

12. Cerebrovascular Accident (CVA) Definition: the blockage of blood to the brain that essentially starves the brain of oxygen leading to dysfunction or death of tissue Prevalence: 3rd most common death in the US, most common cause of disability in the US Risk Factors: old age, hypertension, smoking, obesity, coronary heart disease, diabetes, genetics, and lifestyle Diagnosing: CT scan, MRI, EKG

13. Cerebrovascular Accident (CVA) MNT • Balanced diet- DASH • Limit saturated and trans fats • Promote fiber • Promote flavonoids, vitamins, and minerals • Provide adequate fluids • Assess and manage dysphagia • Enteral nutrition • Altered diet consistencies • Adaptive equipment

14. Mr. P • 73 year old male admitted to the CLC long-term continuous care on 12/29/14 • Transferred from Hunter’s Creek Skilled Nursing Facility • 100% Service Connected • Had 4 hospitalizations between 9/2014-12/2014 • One for CVA • One for GI Bleed • Two for CHF exacerbation • Needed assistance completing majority of ADL’s • Goal at CLC: “receive continuous medical care in a safe environment”

15. Social History • Divorced from 1st wife, widowed from 2nd wife • Quit smoking cigarettes in 2004 • Previously smoked 1 pack/day for 10 years • Social drinker • Completed 1-1 ½ years of college • Career: Military (Air Force 1959-79) and Post Office • Hobby: building model airplanes • Power of Attorney: Daughter

16. Medical History • CVA • CHF • HTN • Diabetes Mellitus with Neuropathy • Chronic Kidney Disease with Secondary Hyperparathyroidism • GI Bleeding (hospitalized in last 3 months) • Anemia of Chronic Disease • Dyslipidemia • Hypothyroidism • Gout • GERD • Sleep Apnea--declines use of CPAP • Depression • Environmental Allergies • Constipation • Hx. of Falls • Hearing Impairment/Tinnitus • FolateDeficiency

17. Nutrition Assessment: Admission • Current Diet: No Concentrated Sweets, No Added Salt with Boost BID • Food Allergy: Shellfish • No diarrhea/constipation, nausea/vomiting, chewing/swallowing issues reported • Previous diet education unknown • Mild Nutritional Risk • Resident reported poor PO intake • BMI= 26 kg/m2 • Wt= 175.4 lbs (110% TBW) • Labs: • BG- low • BUN/Creat- low • K+- high • PO4- high

18. Weights:

19. Mr. P Timeline • January 2015 • 2 Falls- no injury • Shingles • Resident requested decreased medication load • Oxybutynin, Sennosides/Docusate, MVI, Folic Acid, Cholecalciferol, and Citalopram discontinued • F/U with Cardiology Clinic- noted chronic systolic compensated HF • Declined long-term dialysis • Labs: • H&H- low • Creat/BUN- high • Glucose- high

20. Mr. P Timeline • February 2015 • Right eye cataract surgery completed • Labs: • BG- wnl • March 2015 • Decreased insulin dose • Restarted anti-depressant • Started on laxative- constipation • Fall-no injury • Labs: • H&H- low BUN/Creat- high • HDL- low BG and A1C- wnl

21. Mr. P Timeline • April 2015 • Decreased insulin dosage • Decreased antihypertensive medication • 3 teeth extracted • CHF worsened- • F/U with Cardiology Clinic: compensated with evidence of slight volume overload • cardiomegaly, mild prominence of pulmonary vasculature, left pleural effusion • 1 VT episode and 4 non-sustained VT episodes • Declines long term dialysis • Increasing edema and shortness of breath • Labs: • BG- wnl BUN/Creat- high • Na/Cl- high H&H- low

22. Mr. P Timeline • May 2015 • Fall- left ankle pain and swelling • Redness and 2+ edema; soft tissue swelling • Increased incontinence and urgency • Small non-infected blister of left big toe • Declined long-term dialysis • Strange behavior “not acting his normal, staring in space, and speech not clear” • Labs: • BG- wnl • Admitted to Osceola Regional Medical Center 5/26 • Dx CVA and Hyperkalemia

23. Mr. P Timeline • June 2015 • Resident returned to unit 6/5: • Right upper and lower extremity, left lower extremity weakness • Speech minimal • Left facial droop • Incontinent • Multiple skin issues: stage I pressure ulcers on heels and foot; and stage II on buttocks • No swallowing issues with medications • DNR • Puree/Dysphagia diet, No Added Salt, No Concentrated Sweets, Honey Thick liquids • Mild  Moderate Nutritional Risk

24. Mr. P Timeline • June 2015 • Not tolerating anything by mouth 6/6 • Vomiting, retching when meal arrived • Shortness of breath and dyspnea • Admitted to Osceola Regional Medical Center 6/6 • Aspiration Pneumonia • PEG tube placed- Nepro 30ml/hr with a goal of 50ml/hr • 20Fr with mushroom internal fixator • Re-Admitted to CLC 6/12 • PEG tube: Nepro40ml/hr with 20 ml sterile water flushes • Tube insertion site at 4cm • Positive for bowel sounds- last BM 6/11, incontinent • Soft, non-tender abdomen • Skin- left and right hand edema, right heel pressure ulcer, left buttock& right buttock erythema

25. Mr. P Timeline • June 2015 • Nepro rate increased to 50ml/hr x 22hrs on 6/13 • Frequent mouth care • Synthroid therapy • Residuals checks at each med pass- range 1ml-12ml • Normal BM 6/13, 6/16 • Edema continued in right hand • Increased water flushes to 30ml/hr, continued 10 ml water flush with each medication to meet fluid needs on 6/15 • Wounds stable- no prostat • Meds clogging feeding tube: increased water via med pass to 20ml with each medication; decreased automatic water flush to 25ml/hr on 6/16 • Med pass- 10ml to dilute, 10 ml to flush ~15 meds/day

26. Nepro at 50ml/hr x 22hrs with automatic sterile water flushes 25ml/hr and 20ml with each medication Nepro: 1.8kcal/ml; 81g pro/L; 727ml water/L • 50ml/hr x 22hrs = 1100ml/day = 1.1L/day • 1.8kcal/ml x 1100ml/day = 1980 kcals/day • 81g pro/L x 1.1L/day = 89.1 g pro/day • 727 ml water/L x 1.1L/day = 800 ml water/day Automatic Flushes: 25ml/hr • 25ml/hr x 22hrs = 550ml/day sterile water flushes Medications: 20ml/medication • 20ml/medication x 15 medications/day = 300ml water/day Total: 1980kcals; 89.1g pro; 1650ml water Needs: Mr. P = 183.5lbs (83.4kg) 20-25kcal/kg = 1668-2085 kcals/day 0.9-1.1g pro/kg = 75-91.74g pro/day 20-25ml water/kg = 1668-2085 ml water/day

27. Mr. P Timeline • June 2015 • Diarrhea 6/16-6/18 about 5x/day • Residuals averaged 0ml • Lead to opening of wounds to left, right and middle of buttocks • 6/18 began Osmolite 1.5 at 50ml/hr x 22hrs with 25ml/hr automatic sterile water flush • Increase rate to 60ml/hr on 6/22 • 6/23 Hospice care • Constipation 6/20 (small)-6/24 • Sorbitol administered 6/23 • BM 6/24

28. Osmolite1.5 at 60ml/hr x 22hrs with 25ml/hr automatic sterile water flush Osmolite 1.5: 1.5kcal/ml; 55.5g pro/L; 762ml water/L • 60ml/hr x 22hrs = 1320ml/day = 1.32L/day • 1.5kcal/ml x 1320ml/day = 1980 kcals/day • 55.5g pro/L x 1.32L/day = 73.3 g pro/day • 762ml water/L x 1.32L/day = 1006 ml water/day Automatic Flushes: 25ml/hr • 25ml/hr x 22hrs = 550ml/day sterile water flushes Medications: 20ml/medication • 20ml/medication x 15 medications/day = 300ml water/day Total: 1980kcals; 73.3g pro; 1856ml water Needs: Mr. P = 183.5lbs (83.4kg) 20-25kcal/kg = 1668-2085 kcals/day 0.9-1.1g pro/kg = 75-91.74g pro/day 20-25ml water/kg = 1668-2085 ml water/day

29. Mr. P Timeline • June 2015 • 6/25 Jevity 1.5 at 60ml/hr x 22hrs with 25ml automatic sterile water flushes (out of stock) • Labs: • H&H- low • BG-high • BUN/Creat- high • CL- high • Loose stools  switch to Jevity 1.5 due to increased fiber

30. Jevity1.5 at 60ml/hr x 22hrs with 25ml/hr automatic sterile water flush Jevity1.5: 1.5kcal/ml; 63.9g pro/L; 760ml water/L • 60ml/hr x 22hrs = 1320ml/day = 1.32L/day • 1.5kcal/ml x 1320ml/day = 1980 kcals/day • 63.9g pro/L x 1.32L/day = 84.3 g pro/day • 760ml water/L x 1.32L/day = 1003 ml water/day Automatic Flushes: 25ml/hr • 25ml/hr x 22hrs = 550ml/day sterile water flushes Medications: 20ml/medication • 20ml/medication x 15 medications/day = 300ml water/day Total: 1980kcals; 84.3g pro; 1853ml water Needs: Mr. P = 183.5lbs (83.4kg) 20-25kcal/kg = 1668-2085 kcals/day 0.9-1.1g pro/kg = 75-91.74g pro/day 20-25ml water/kg = 1668-2085 ml water/day

31. Mr. P Timeline • July 2015 • Wounds resolving • Continuing oral care • 7/10: Vomiting  tube feeding held • 7/15: Switched to Nepro 50ml x 22hrs • 7/16: Vomiting due to “car sickness” • 7/22 & 7/23: Nausea & vomiting during care  tube feeding held • 7/24: Resistant to care, depressive mood, disconnecting tube feeding • 7/26 & 7/27: Vomiting continued  tube feeding held • 7/28: Resident passed away

32. Nepro at 50ml/hr x 22hrs with automatic sterile water flushes 25ml/hr and 20ml with each medication Nepro: 1.8kcal/ml; 81g pro/L; 727ml water/L • 50ml/hr x 22hrs = 1100ml/day = 1.1L/day • 1.8kcal/ml x 1100ml/day = 1980 kcals/day • 81g pro/L x 1.1L/day = 89.1 g pro/day • 727 ml water/L x 1.1L/day = 800 ml water/day Automatic Flushes: 25ml/hr • 25ml/hr x 22hrs = 550ml/day sterile water flushes Medications: 20ml/medication • 20ml/medication x 15 medications/day = 300ml water/day Total: 1980kcals; 89.1g pro; 1650ml water Needs: Mr. P = 183.5lbs (83.4kg) 20-25kcal/kg = 1668-2085 kcals/day 0.9-1.1g pro/kg = 75-91.74g pro/day 20-25ml water/kg = 1668-2085 ml water/day

33. The Formulas:

34. Kidney Decline & End of Life Care • Symptoms of end of life: • Retained secretions • Shortness of breath • Agitation • Nausea & Vomiting • Pain • Pruritus • Alleviating kidney stress: • Limit sodium and reduce fluid intake  edema • Limit potassium  hyperkalemia • Limit phosphorous  renal osteodystrophy

35. Why no Prostat protein supplement? • Wounds stable • Comfort care only • Formula providing adequate protein for basal needs • Resident refuses dialysis- need to limit burden on kidneys • BUN/Creat elevated- avg. ratio 32:1 • Electrolytes elevated

36. Current PES Statement: Moderate Nutrition Status: Swallowing difficulty related to declined functioning s/p CVA as evidence by history of aspiration pneumonia and PEG tube placement.

37. Challenges: • Rapidly declining cognitive function and ADL ability • Formula tolerance and kidney stress • Diarrhea vs. Constipation • Potassium, phosphorous, and protein amounts • Edema and wound status • Hydration status and protein needs • Drug interactions • Antibiotics cause diarrhea?

38. Goals: • Hospice: comfort care • Provide adequate nutrition to sustain basal needs while limiting stress on the kidneys and heart: met

39. References • Mahan, L. (2012). Krause's food & the nutrition care process (13th ed.). St. Louis, Mo.: Elsevier/Saunders. • Stump, S. (2012). Nutrition and diagnosis-related care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. • The National Kidney Foundation. (n.d.). Retrieved July 3, 2015. www.kidney.org • The National Stroke Assocation. (n.d.). Retrieved July 3, 2015. www.stroke.org • Russon, Lynne, and Andrew Mooney. "Palliative and End-of-life Care in Advanced Renal Failure." Clinical Medicine 10.3 (2010): 279-81. Print. • Noble, H., & Lewis, R. (2008). Assessing palliative care needs in end-stage kidney disease. Nursing Times,104(23), 26-27.

40. Questions? Thank you!!