MNT Case Study. 78 YO woman in a long-term care facility for the past 6 months. PMH includes GERD

Transcription

1 MNT Case Study 78 YO woman in a long-term care facility for the past 6 months. PMH includes GERD and dysphagia. Hip fracture with surgical repair occurred 2 weeks ago. Admitted with fever and infection at surgical site. Speech recommends chopped diet with thin liquids. Daughter comes to visit once a week. Ht: Wt on arrival: 190lbs. Wt today: 166lbs. P.O. intake averaging 75% over the past two days. Labs: Na: 148 meq/l, BUN: 22 mg/dl, Creatinine: 1.5 mg/dl. Alb: 3.0. Meds: Nexium, dilaudid, vitamin D (500mg/d), and sublingual B12. Complaining of constipation. Chart shows no bowel movement for 2 days. 1. Explain the conditions the patient has. The patient has GERD and dysphagia. GERD is when the lower esophageal sphincter weakens and allows acid from the stomach to erode the lining of the esophagus. This is often referred to as heartburn or indigestion. GERD is the result of pathophysiological changes in esophageal function that happen with increasing age 1. Proton pump inhibitors have been said to be more effective for healing reflux esophagitis 1. Dysphagia is characterized by abnormally moving a bolus of food from the mouth to the stomach. It is an interruption in either eating pleasure or the maintenance of adequate hydration and nutrition. Patient may have difficulty chewing, drool, choke, and have food stick in their mouth. Dysphagia is impaired swallowing that causes aspiration, which can lead to pneumonia and increased mortality 2. Hypervolemia, failure to thrive, and upper-airway obstruction also come with dyspahgia 2. Patient had surgery for a hip fracture 2 weeks ago. Was admitted with a fever and infection at the surgical site. 2. Discuss the most common nutritional consequences of these conditions. GERD can result in irritated esophageal lining, low LES pressure, and can increase gastric acid secretions. Patients may have a lower desire to eat, because of the uncomfortable symptoms of this condition. Dysphagia is characterized by abnormally

2 moving a bolus of food from the mouth to the stomach. It is an interruption in either eating pleasure or the maintenance of adequate hydration and nutrition. Patient may have difficulty chewing, drool, choke, and have food stick in their mouth. This can cause the patient to have less than optimal nutrition and hydration. Patients are tried to stay on a diet by mouth so food is appealing and palatable. Food choices are limited depending on severity of dysphagia. For hip fracture surgery, the patient is recommended to consume more protein, an adequate amount of calories for energy, and increase calcium to support maintenance of bone health. A study showed that recruiting dietetic or nutrition assistants to help with patients who had recently had a hip fracture, reduced patients risk of death 3. Having a proper diet specific to ones needs can increase health status enormously. Consuming adequate caloric intake and fluid intake are major risks to these conditions. Being hydrated is important because cell hydration affects cell function 4. Adequate water maintains homeostasis of intra- and extracellular liquid compartments What information is needed from the patient? Patient interview is helpful, so make up answers to these questions to help with your assessment. When were you first diagnosed with GERD? ~When patient was 30 years old What foods upset your GERD? ~Acidic, spicy, coffee, fatty foods Do you consume these types of foods often? ~She tries to avoid, but still enjoys them When were you first told you have dysphagia? ~70 YO Does GERD or dysphagia run in your family? ~Mom and grandma had GERD. Dad had dysphagia.

3 Why did you go into a long-term care facility? ~Needed more assistance, couldn t cook for herself anymore How has your diet intake been since you moved there? ~Eating a little less, bland, blended food. Not as big of an appetite. How did you fracture your hip? ~Fell trying to go to the bathroom How has your activity level changed from before the surgery? ~Used to be able to walk around with a cane, now cannot walk at all. Hopes to walk within the next 2 months Were you on any special diet before the surgery? ~Was on a mechanical soft diet, and thin liquids Has your appetite changed since before the surgery? ~Has little appetite and finds it much more work to eat, more discomfort Are you aware of your 21-pound weight loss in the last 2 weeks? How do you feel about this? ~Knows of weight loss, but wasn t sure of exact number. Was shocked and expressed concern. How many medications were you taking before surgery? ~Was taking three medications Are there any side effects you are feeling from your meds? ~Nausea, abdominal pain, constipation, thirsty, dry mouth, diarrhea How long have you had constipation? ~Since the diet changes after the surgery, 1.5 weeks How much fluid do you take in each day? ~Drinks about 2-8oz glasses of water Do you eat fiber rich foods?

4 ~Not many whole grains, lately pudding, mashed potatoes, yogurt, pureed meat 4. Determine BMI and estimate energy and protein needs based on the current condition. Show your work and explain why you used the formula and activity factor you did. BMI before surgery: Current BMI: 86.36kg/ (1.778)^2 = kg/(1.778)^2 = Women: RMR= (10 x 75.45) + (6.25 x 177.8) (5 x 78) + 5 = 1481kcal 1481 x 1.2 x 1.4 = 2488 kcal/day PRO Needs: x 1.5 = 113 g PRO/day * I used Mifflin St. Jeor because it is more accurate than Harris-Benedict in normal and overweight/obese patients. I used 1.2 for the activity factor because the patient is confined to bed after the hip fracture surgery. I chose 1.4 for the injury factor because she had skeletal trauma. For calculating protein needs I multiplied her weight in kg by 1.5 because she had an infection and major surgery. 5. Discuss the lab values that are outside normal limits why are they outside normal limits? Lab Values: Na 148 meq/l (ideal is meq/l), K: 5.4 meq/l (ideal is meq/l), BUN: 22 mg/dl (ideal is 7-20 mg/dl), Creatininine: 1.5 mg/dl (ideal is mg/dL), Alb: 3.0 g/dl (ideal is g/dl). Na, K, BUN, and Creatinine are above recommended levels and Albumin is below the recommended range. The values are not very far off of the recommended amounts, but still show concern. These labs are outside normal limits because they can be influenced by hydration status, causing some values to be higher and some to be lower based on her being dehydrated. Hyperkalemia could have been caused by her infection. BUN and Creatinine are related to kidney function and high values are related to dehydration. Albumin decreases during stress, injury and illness. It deals with hepatic transport

5 proteins and all negative acute phase reactants. Inflammation from her surgery may cause some values to be increased or decreased from their normal levels. 6. Are there any labs you would order, if you could? Check serum calcium levels. Most likely recommend a calcium supplement to help maintain bone strength after fracture. A study explains that post-surgery antiosteoporotic therapy along with vitamin D and calcium supplementation is needed 5. Check vitamin D levels and vitamin B12 levels to ensure supplementation is working. 7. What is your diet order prescription do you agree with what has been ordered? Describe any modifications to be made these may include increasing or decreasing macronutrients, adding or restricting certain foods or classes of foods, modifying textures, etc. My diet order prescription is to consume small frequent meals while avoiding acidic foods, spicy foods, fatty foods, alcohol, coffee, beer, and wine. Foods high in calcium and B12 should also be eaten to help manage GERD. Adequate calcium intake with also helps with bone health. Level of dysphagia in the patient determines what texture of food to consume. I would recommend continuing with a chopped diet and thin liquids, consuming soft foods easy to chew and swallow. Avoid tough, dry, crunchy foods because they will be difficult for patient to swallow. To help with her fever and infection, I would recommend consuming adequate protein and calories to prevent malnutrition. Higher protein intake for the first few days may be beneficial. 8. Explain the social factors that are positive and negative for your patient. The positive social factors for my patient include: having her daughter come to visit her once a week, still being able to eat a wide variety of normal foods if in the right form, and can eat with friends as long as she follows her diet order. Some negative social factors include her diet restrictions and the difficulty they may cause with consuming meals in a setting other than her long-term care facility or hospital. Food choices in alternate eating

6 settings may pose challenges and limitations. Patient may feel like a burden, or get frustrated with lack of options. 9. List the medications taken, reason for use, impact of lab values, and any FDI or NDI. (Used your medication booklet) Nexium: antiulcer, antisecretory, antigerd, proton-pump inhibitor. May lower absorption of Fe, lower absorption of Vitamin B12, lower absorption of Ca by 61%. Lowers gastric acid secretion, increases gastric ph, avoid alcohol consumption. Dilaudid: painkiller, narcotic. Increases thirst and dehydration. (Insure adequate fluid intake) Lab values are altered with dehydration. Can cause dry mouth, taste changes, dysphagia, constipation, and diarrhea. Increases amylase, increases lipase, anemia, lowers platelets. Vitamin D: Supplementation. Increases calcium absorption. Monitor Ca, P, and renal function. Dry mouth, metallic taste, nausea, vomiting, constipation, diarrhea, lower renal function, and lowered cardiac function. Sublingual Vitamin B12: supplementation given under tongue, treats pernicious anemia, treats severe deficiency or vitamin B12 malabsorption. Lowers potassium, increases platelets, lowers homocysteine. Monitor Vitamin B12, Fe, folate. 10. List the potential nutrition problems using the appropriate diagnostic terms. Inadequate oral intake, inadequate fluid intake, Inadequate fiber intake 11. What is YOUR nutritional diagnosis? (1-3 PES Statements) ~ Inadequate oral intake related to swallowing difficulty as evidenced by dysphagia and 24 pound weight loss in 2 weeks. ~ Inadequate fluid and fiber intake related to food and nutrition-related knowledge deficit as evidenced by skewed lab values, constipation and lack of bowel movement for 2 days.

7 ~ Inadequate oral intake related to decreased appetite as evidenced by weight loss of 24 pounds in 2 weeks and 75% completion of meals. 12. Establish a goal and intervention for each nutritional diagnosis. ~The patient will increase calories to within 10% of her 2,500kcal/day goal within the next 2 weeks. The RD will help patient keep a food record to monitor caloric intake. ~The patient will increase fluid intake along with fiber intake by consuming 2-8oz glasses of water and one serving of a fruit/vegetable/ or whole grain at each meal. RD will ensure dining knows of recommendations. ~ The patient will increase caloric intake following the diet suggestions of small frequent meals, modified textures, low acid, fatty, and spicy foods to help manage GERD and dysphagia. Chef at hospital/ long-term care facility will ensure proper caloric intake and PRO intake with correct foods and textures for patient. Calcium will be increased in the diet. 13. Complete ADIME note. See below. 14. Find or develop one educational tool for your counseling session. See handouts. ADIME: Nutrition Assessment: Client History: -78 yo female -Daughter comes visit -Lives in long- term care facility -Family hx: ~Mom and grandma had GERD ~Dad had dysphagia Food & Nutrition History: - Used to cook more - Less appetite since long-term care

8 -Texture modified foods for past 8 years -Spicy, acidic, fatty foods cause problems, still enjoys them -Pudding, mashed potatoes, yogurt, mechanical soft meats eaten often -Doesn t consume lots of fluid Anthropometrics: Current weight: 166# -BMI: 23.9 Normal -Lost weight in past 2 weeks after hip fracture IBW: 100+(5x10)= 150# +/- 10% # IBW %: 166/150 x 100= 110.6% -Past 2 weeks: lost about # 24/190 x 100= 12% weight loss Biochemical/Tests/Procedures: -Na: 148 meq/l (ABOVE meq/l recom) -K: 5.4 meq/l (ABOVE meq/l recom) -BUN: 22mg/dL (ABOVE 7-20 mg/dl recom) -Creatinine: 1.5 mg/dl (ABOVE mg/dl recom) -Alb: 3.0 g/ml (BELOW g/dl recom) Nutrition Focused Physical Findings: -Appetite has decreased in the past two weeks Comparative Standards: Calories: RMR = (10 x 75.45) + (6.25 x 177.8) (5 x 78) + 5 = 1481 kcal 1481 x 1.2 x 1.4 = 2488 kcal/day PRO: x 1.5 = 113 g PRO /day Fluid: x 30cc = 2264 cc fluid/day Assessment of Patient: Pt is 78 YOWM living in a long-term care facility. Pt has weekly visit from daughter. Pt has family hx of GERD in mother and grandmother and dysphagia in her father. Pt has lost 24# in the hospital the past two weeks due to hip fracture with surgical repair. Pt s height is 5 10 and is currently 166#. Her BMI is 23.9, normal. Pt has been unable to walk since surgery. Pt is consuming 75% of meals and has complained of decreased appetite and constipation. Pt s lab values for Na, K, BUN and Creatinine are above recommended values and Alb is below. Pt is taking Nexium, dilaudid, vitamin D, and sublingual B12.

9 Nutrition Diagnosis/Goals: Diagnosis 1: Inadequate oral intake related to swallowing difficulty as evidenced by dysphagia and 24-pound weight loss in 2 weeks. Diagnosis 2: Inadequate fluid and fiber intake related to food and nutrition-related knowledge deficit as evidenced by skewed lab values, constipation and lack of bowel movement for 2 days. Diagnosis 3: Inadequate oral intake related to altered decreased appetite diet as evidenced by weight loss of 24 pounds in 2 weeks and 75% completion of meals. Nutrition Interventions: Nutrition Rx: general healthful diet of 2488 kcals/day Nutrition Education: 1. Purpose: ~To increase calories, PRO, calcium, fiber and fluid in the diet. 2. Relationship to disease: ~ Inadequate PRO and calories can lead to malnutrition. Low fiber and fluid intake will result in GI problems causing stress on the GI tract and kidneys. 3. Modifications: ~ Consume small frequent meals - Fiber-containing food at each meal -Calcium rich foods will help maintain bone health -Avoid high fat, spicy, acidic foods -texture modified for easy consumption ~Increase fluid intake -Drink 8-8oz glasses of water / day -Drink juices/ fortified beverages -Drink milk daily Nutrition Counseling: ~Health Belief Model ---Perceived susceptibility: Pt needs to improve eating habits to maintain/improve health. Following dietitians suggestions can improve overall quality of life. ---Perceived benefits: lifestyle change is better than current behavior, improve quality of life ---Perceived barriers: changing habits, limited options at care facility ---Perceived seriousness: serious to change and prevent further worsening of health ---Self-efficacy: willingness to change has increased

10 ---Modifiable variables: -drink water, eat more fiber, increase calcium intake, small frequent meals, consume adequate calories/ PRO ~Application Strategies: ---Goal setting: Monitoring Referral of Care: ~ Collaboration with other providers (physician; retest lab values in 3 months) Goals: 1. The pt will increase calories to within 10% of her 2,500 kcal/day goal within the next 2 weeks 2. The pt will increase fluid intake along with their fiber intake by consuming 2-8oz. glasses of water and one serving of a fruit/vegetable/ whole grain at each meal. 3. The pt will increase caloric intake following the diet suggestions of small frequent meals, modified textures, low acid, fatty, and spicy foods to help manage GERD and dysphagia. 4. Patient will consume at least 2 servings of dairy per day to increase calcium within 3 days. Monitoring and Evaluation: -Monitor food record kept by nurse to track caloric intake; goal is to consume about 2,500 kcal/day. -Monitor fluid and fiber intake; goal is to drink 8-8oz glasses of fluid per day and 25g of fiber per day. -Monitor caloric and PRO intake with proper textured diet working with the chef at longterm care facility and hospital; goal is to consume 2,500kcal/day and 113 g PRO per day comfortably. 1. Pilotto A, Franceschi M, Paris F. Recent advances in the treatment of GERD in the elderly: focus on proton pump inhibitors. Int J Clin Pract. 2005; 59 (10): Chen PH, Golub JS, Hapner ER, Johns III MM. Prevalence of Perceived Dyspahgia and Quality-of-Life Impairment in a Geriatric Population. Dysphagia. 2009; 24 (1): Duncan DG, Beck SJ, Hood K, Johansen A. Using dietetic assistants to improve the outcome of hip fracture: a randomized controlled trial od nutritional support in an acute trauma ward. Age aging. 2006; 35 (2):

11 4. Ferry M. Strategies for Ensuring Good Hydration in the Elderly. Nutr Rev. 2005; 65: S22-S Luthje P, Luthje IN, Kaukonen JP, Kuurne S, Naboulsi H, Kataja M. Undertreatment of osteoporosis following hip fracture in the elderly. Arch Gerontol Geriatr. 2009; 49: Handout links: es/factsheetspamphletspocketcardslogos/patienteducationbrochuredehydration.pdf s_l=