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Clinical Case Study: Mrs. W

Clinical Case Study: Mrs. W. Presented to you by: Haley Lydstone KSC Dietetic Intern, 2013. Whittier Rehabilitation Hospital (WRH). Part of the Whittier Health Network H as been providing health care services since 1982 Located in Haverhill, MA Long-term acute (LTAC) facility with 60 beds

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Clinical Case Study: Mrs. W

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  1. Clinical Case Study:Mrs. W Presented to you by: Haley Lydstone KSC Dietetic Intern, 2013

  2. Whittier Rehabilitation Hospital (WRH) • Part of the Whittier Health Network • Has been providing health care services since 1982 • Located in Haverhill, MA • Long-term acute (LTAC) facility with 60 beds • Serves patients throughout New England • Provides inpatient, outpatient, pharmacist and home health services • Specialty care designed for medically complex patients who require a longer length of stay

  3. WRH Specialized clinics and programs: • Wound clinic • Memory clinic • Prosthetic/orthotic clinic • Day rehabilitation program • Auditory program Admission Criteria: • Age 16 or older • Significant change in functional status resulting from medical problem(s) • Medically stable & able to take part in rehabilitation activity

  4. Dietician’s Role at WRH • Provide nutrition care to patients in various disease states and conditions • Maximize nutritional support • Avoid delayed healing,speed up recovery, and minimize extended hospital stays • Monitor, assess and optimize nutrition status based upon current condition/nutrition adequacy • Provide education as needed • Making choices to speed up recovery process, prevent disease and maintain a healthy lifestyle • Confer with physicians and other health care professionals • Medical and nutritional needs, recommendations for tube feeds and EN and PN, and dietary supplements

  5. Case Study: Mrs. W

  6. Mrs. W Prior to admission to WRH: • Stroke occurred on 2/24/13 • Pt. was giving speech, experienced facial droop and slurred speech • Lawrence General: Quick treatment with vitamin K • Beth Israel: Pt. experiencing tachycardia and hypernatremia • 2/24: Had L. craniotomy • Complications: 3/1: UTI, 3/6: PEG placement, 3/10: pneumonia

  7. Meet Mrs. W Admit to WRH: 3/11/13 • 72 y.o. African American, female • 5’7”, 171.6# • IBW: 135#, 61 kg. • %IBW: 126% • BMI: 26.9, overweight • Near coma, pt. unresponsive, NKFA • Currently NPO on TF

  8. Initial Admit to WRH Admitting diagnosis: • S/p left craniostomy for evacuation of left intraparenchymal hemorrhage As a result: • PEG tube placement • L. facial droop • Global aphasia • Dysphagia • CAT scan • Hydrocephalus • Afib Hx of anticoagulation w/ coumadin

  9. Craniotomy Image retrieved from: www.hopkinsmedicine.org

  10. Intracranial Hemorrhage

  11. Intracranial Hemorrhage Image retrieved from: Iranian Red Crescent Medical Journal, http://ircmj.com/?page=article&article_id=1686

  12. Pathophysiology S/p left craniostomy for evacuation of left intraparenchymalhemorrhage • Craniostomy: The surgical removal of part of the bone from the skull to expose the brain • Relieving pressure within the brain by removing damaged or swollen areas of the brain that may be caused by traumatic injury, or in Mrs. W’s case, a stroke • Intracranial bleeding (hemorrhage) • Usually caused by head trauma • Intraparenchymal hematoma: occurs when blood pools in the brain • Progressive decline in consciousness www.hopkinsmedicine.org

  13. MNT ICH/Stroke: • Maintain adequate nutrition • Weights, TF tolerance, TF meeting needs • Assess and manage dysphagia • Vitamin and mineral supplementation as needed • EN support as needed Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 934-935. St. Louis, MI.

  14. MNT Dysphagia: • Main concerns: weight loss & anorexia • Minimalize conversations during meal time • Long meal duration & coughing • Adjust consistencies to meet patient’s needs • NPO: 3/12Puree/NTL: 3/26 Puree/thin lix: 4/8 House-MS cut/thin: 4/17 House-MS cut: 4/29 Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 929-931. St. Louis, MI

  15. Initial Admit to WRH Medical History: • HTN • Hyperlipidemia • Breast cancer • BKR • TIA, “mini stroke” Nutrition Diagnosis: “ Difficulty swallowing R/T ICH, dysphagia, AEB need for enteral feeds/SLP evaluation ” • Status: 3, High risk • Pt. at risk for malnutrition • Unknown weight loss, pt. poor historian

  16. Initial Admit to WRH Medications List: • Amiodarone: heart rate • (Anti-arrhythmic) • Diltiazem: anti-HTN • Colace & Senna: constipation • MVI • Prevacid • Humulin: SSI low dose • Levofloxacin: ABX, (txof PNA) • Metoprolol: BP • Pravastatin: Cholesterol • Provigil: increases alertness * Anti-depressants

  17. Initial Admit to WRH Calculated Needs: • IBW: 135#, 61 kg. • Calories: 25-30 kcals/kg • 1535-1840 kcals • Protein: 1.2-1.5 g/kg • 73-92 g. protein • Fluid: 1 mL/kcal • 1535-1840 mL fluid Current TF: • Promote w/ fiber @ 60 mL/hour for 24 hours • 1440 kcals, 90 g. protein, 1196 free water w/ 250 ml water flushes Q6, total water 2196 mL

  18. Initial Admit to WRH: Labs 3/12/13 • No new wt. • Albumin: 2.8 • Prealbumin: 17.2 • Na: 138 • BUN/Cr: 17/0.6 • Glucose: 129 • Hemoglobin A1C: 5.9 3/13/13 • No new wt. • Na: 146 • Glucose: 138 • FSs: 100’s 3/14/13: Tested – for CDiff 3/20/13 • 168.3#, 3# wt.  • Alb: 2.8, FSs 100s (no coverage)

  19. Initial Admit to WRH 3/26/13 • TF change • Trialing foods with SLP • Bolus feeds • 240 mL Jevity 1.5, 4x/day pgt. • Promod 30 mL BID 3/29/13 • Puree/NTL for lunch with SFG, 1:1 spv. • 240 mL Jevity 1.5 4x/day pgt. 30 mL promod BID • Will hold bolus if pt. consumes >50% of meal 3/31/13 • Pt. out acute, chest pain, elevated D-dimer & pneumoperiteum

  20. Initial Admit Summary • Frequent team work: MD, SLP, OT/PT & Dietician • Pt. tolerated TF well; started small amounts of PO • Status remained at a 3 throughout hospital stay (high risk) • Trialing Puree/NTL with SLP, also in SFG • Overall poor PO intake • Poor cognition • Wt’s remained relatively stable • 3 #’s in approx. 3 weeks, 2% (not clinically significant) * Pt. out acute to Beth Israel

  21. Mrs. W: Out Acute at BI • CT of head • Resolution of ICH, no new evidence of hemorrhage or edema • Contract radiograph of PEG • No evidence of leak • LFTs, CBC, CMP, blood cultures all normal Image displays resolved ICH, decreased IVH and decreased hydrocephalus

  22. Second Admit to WRH Readmitted: 4/3/13 Admitting Diagnosis: • Chest/abdominal pain with pneumoperitoneum secondary to PEG (chronic), difficulty communicating. * New dx: GERD, pt. presented w/ loose stools (per therapies) • Readmit main reason: Tx for stroke Nutrition Diagnosis: • “Difficulty swallowing R/T ICH AEB SLP evaluation/NPO status/ trialing dysphagia diet (puree/NTL) upon last admission.” • “Altered GI function R/T potential PEG issue/pneumoperitoneum AEB reported loose stools, hx constipation, abdominal pain, new dx of GERD” • Status: 3, high risk

  23. Admit #2: Pathophysiology Pneumoperitoneum: • Gas within the peritoneal cavity • Presents as bowel injury after endoscopy • Chest/Abdominal pain: Etiology unclear • Possibly related to pneumoperitoneum

  24. MNT GERD • Main factors are caffeine, alcohol, tobacco and stress; avoid dietary irritants. Lifestyle changes include dietary changes, weight loss, smoking cessation and elevating the head of your bed. Multiple loose stools/diarrhea • Identifying the source (? Cdiff) • Adequate fluids and electrolytes • TF adjustments as needed • Regular diet as tolerated Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 616-617. St. Louis, MI

  25. Second Admit to WRH Medications: • Oxycodone, pravastatin, prevacid, senna, colace, SSI low dose Recalculated needs: • Wt: 170.4#, 77 kg. • Fluid: 1 mL/kcal • 1540-1925 mL’s/day • Calories: 20-25 kcals/kg • 1540-1925 kcals/day • Protein (IBW): 1-1.3 g/kg • 61-79 g. protein/day 4/3/13 Labs: • Albumin: 3.2 • Na/K: 141/4.4 • BUN/Cr: 10/0.7 • Glucose: 111 • Ca: 9 4/4/13: Pt. tested – for CDiff

  26. Second Admit to WRH Readmit tube feed order: • Isosource 1.5 @ 240 mL 4x/day (bolus) • 1420 calories, 60 g. protein, 720 mL free water New TF order, 4/3/13: • Osmolite 1.5 @ 70 cc x 10 hours (from 2000-0600) • Osmolite 1.5 120 mL TID pgt. (bolus) • 250 mL water flush QID • Provides: 1583 calories, 66 g. protein, 805 mL free water • Add Promod as needed

  27. Admit #2: Pertinent Dates 4/8/13 • Puree/thin @ BK & lunch w/ SLP • TF order remains the same; Hold bolus if intake >50% • Pt. experiencing abdominal pain, ? R/T reflux or G-tube site. • LBM: 4/7, lg. loose • No new labs; FS’s 100s • Wt.:173.4# 4/12/13 • Same diet order • Intake improving • Considering calorie count with potential to d/cTF orders • No further abdominal pain complaints • LBM: 4/11 • 4/10 labs: K 4.4 • Wt.: 172.2#

  28. Pertinent Dates Cont’d 4/17/13 • House, MS cut/thin • Same TF order (nocturnal + bolus) • Only PO w/ SLP 2x/day • Continue TF until able to increase PO • Wt.: No new 4/22/13 • Discussed pt. in RTC • Neurologist & team D/C’dTF’s House MS cut thin • Cal. count initiated • Wt.: 172

  29. Admit #2: Pertinent Dates 4/27/13 • Pt. not meeting needs po(per calorie counts x 3days) • Pt. refusing all meals, ? secondary to stomach pain • Refused 4/25, 4/26 and BK on 4/27 (per SLP) • Recent hx constipation & loose stools • Prior TF order restarted (bolus only) • Pt. willing to eat BK at 915 am • Plan to bolus 200 mL Osmolite 1.5 if pt. eats <50% meals • Reassess 4/29

  30. Admit #2: Pertinent Dates 4/29/13 • Pt. winces when GT touched (per nursing) • Diet change: House MS cut w/ 1:1 SPV, Mighty shake TID • Refluxed partial bolus • KUB: negative; stools for C-diff: negative • Pt. not eating, refusing bolus • MD wanted to send pt. out acute for abdominal CAT scan • Pt. started on IV fluids • Wt.: 170.6 • 4/26: K 5.4 

  31. Admit #2: Pertinent Dates 4/29-5/2 • Poor tolerance for TFs & bolus, IVs started 4/30-5/1 • Received IV only 5/2/13 • Pt. out acute to BI for PEG evaluation

  32. Admit #2 Summary • Pt. readmitted with loose stools • KUB and Cdiff were negative • Pt. experiencing pain around PEG site • Wincing when touched • Bolus refluxed • Wt.stable, 170-173#s • Status: remained 3 during stay • TF’s D/C’d in attempt to stimulate appetite • MD’s wanted her to eat PO • Thought an increased appetite would prompt her to eat • RD and SLP were skeptical • Pt. “On strike” on a daily basis • Pt. on IV fluids secondary to bowel rest • Pt. discharged for PEG evaluation

  33. Out Acute to BI Mrs. W at BI from 5/2/13-5/6/13 • Abdominal pain secondary to malpositioned G-tube, with decreased flow • CAT scan: PEG placed in 2nd portion of duodenum; soreness around site • Supposed to be in stomach • PEG repositioned • Started on vancomycin secondary to soft tissue infection @ PEG site (observed for 2-3 days) • TF change: 1/2 can (120 mLs) 6x/day Q4hours

  34. Admit #3 5/6/13:Admitting dx: s/p PEG placement, CVA Pathophysiology: • PEG: routine in pt.’s unable to eat PO • Occurs when G-tube placed somewhere other than stomach • Pneumoperitoneum is an early indicator of malpositioned G-tube References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699054/, www.webmm.ahrq.gov

  35. Proper G-Tube Placement

  36. MNT S/p PEG readjustment/placement • Adjust TF to meet patient’s needs & avoid discomfort • Monitor: abdominal distension and comfort • I’s and O’s • Gastric residuals Q4hours • Stool output & consistency • Labs (signs and symptoms of edema & dehydration) • Weights, 3x/week Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 308-312. St. Louis, MI

  37. Admit #3 5/7/13 Nutrition dx: “ Inadequate oral intake R/T cognitive status/recent abdominal pain/ AEB need for EN feeds pgt..” Status: 3, high risk Medications: • Keppra, nystatin, miralax, pravastatin, senna, SSI low dose, colace, MVI, prevacid

  38. Admit #3 Recalculated Needs: • Wt. 173.1#, 79 kg. IBW 135#, 61 kg. • Calories: 20-25 kcals/kg • 1580-1975 calories/day • Protein: 1g/kg (IBW) • 61 g./day • Fluid: 1ml/kcal • 1580-1975 ml/day Admitting TF order: • 120 ml Jevity 1.5 QID Provides: • 710 cals, 30 g. protein, 360 ml free water, 120 ml water flush Q6 hours (480 ml), total water 840 ml New TF order: • 120 ml TwoCal QID (6am, 10 am, 2 pm, 6 pm) Provides: • 950cals, 40 g. protein, 332 ml free water

  39. Pertinent Dates 5/6/13 • Pt. continued to have abdominal pain • Wt. 172.8# 5/7/13 • Started on 1:1 meals w/ SLP 5/9/13 • Pt. discussed in FTC • No new weight TF changed: Osmolite 1.2 @ 40 ml/hr x 20 hrs • Provides: 960 cals, 44 g. protein, 656 ml free water. Goal: Osmolite 1.2@60ml/hrx20 hrs; provides: 1440 cals, 67 g. protein, 984 free water

  40. 5/9: Family Team Conference Attendees: 3rd husband, son, daughter, family friend (Mrs. W’s best girlfriend), psychologist (family friend & priest), MD, RD, SLP, OT, PT FTC Summary: • Husband wants to take her home • Husband and son unsure about depression meds • Pt. attemptedto leave WRH via vehicle w/ husband • Husband not fully understanding Mrs. W’s current issues

  41. Admit #3 5/10 • TF rate increased to 50 ml/hr x 20 hrs • Provides: 1200 cals, 56 g. protein, 1400 ml free water w/ flushes • Tolerating TF well, minimal residuals • PO intake remains poor • Pt. consumed >50% of meal with friend present 5/23 • No TF order changes • M/S cut thin TID 1:1 w/ SLP at BK and lunch • Labs WNLs • Wt. 167.8# 3.2 # • Pt ate >75% BK this am • Will decrease TF volume to 750 ml: 900 calories, 42 g. protein x 10 hours

  42. Discharged to SNF • Pt discharged to SNF • MS cut 1:1 supervision • Nocturnal TFs: Osmolite 1.2 @ 75 ml/hr x 10 hours/day from 8 pm- 6 am

  43. WRH Pt. Plan • To progress pt. to PO status (RD, SLP, MD) • Made several attempts to increase appetite & stimulate intake • Meet patient’s needs with EN pending functioning PEG and tolerating bolus feeds • Work with family and friends to raise awareness of patient’s needs • Discharge to SNF on EN w/ some PO, 1:1 supervision

  44. Mrs. W: Life After WRH • Doing well at SNF • “closed facility” Pt. can ambulate freely around her room • Husband visits daily • Somewhere she can cook • Very supportive group of family and friends

  45. References • http://www.aphasia.net/info/aphasia/global_aphasia.htm • http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/BanhArticle.pdf • http://openi.nlm.nih.gov/detailedresult.php?img=3004506_kjped-53-913-g002&req=4 • http://www.nutrition411.com/professional-learning/professional-refreshers/item/393-albumin-as-an-indicator-of-nutritional-status • http://www.strokecenter.org/professionals/stroke-management/for-pharmacists-counseling/pathophysiology-and-etiology/ • http://www.mayoclinic.com/health/intracranial-hematoma/DS00330/DSECTION=causes • www.meddean.luc.edu  • http://www.whittierhealth.com/rehabilitation_hospitals/bradford.html • http://www.wjem.org/upload/admin/201108/6e21f8f9449aee76f10cda971f3b3bbd.pdf • Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 616-617. St. Louis, MI

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