clinical case study: mrs. w

Clinical Case Study:Mrs. WPresented to you by:

Haley LydstoneKSC Dietetic Intern, 2013

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

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

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

Case Study:Mrs. W

Mrs. WPrior 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

Meet Mrs. WAdmit 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

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

Craniotomy

Image retrieved from: www.hopkinsmedicine.org

Intracranial Hemorrhage

Intracranial Hemorrhage

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

Pathophysiology

S/p left craniostomy for evacuation of left intraparenchymal hemorrhage

• 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

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.

MNT

Dysphagia:

• Main concerns: weight loss & anorexia

• Minimalize conversations during meal time• Long meal duration & coughing

• Adjust consistencies to meet patient’s needs• NPO: 3/12Puree/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


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


Medications List:• Amiodarone: heart rate

• (Anti-arrhythmic)

• Diltiazem: anti-HTN

• Colace & Senna: constipation

• MVI

• Prevacid

• Humulin: SSI low dose

• Levofloxacin: ABX, (tx of PNA)

• Metoprolol: BP

• Pravastatin: Cholesterol

• Provigil: increases alertness

* Anti-depressants


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

Initial Admit to WRH: Labs3/12/13

• 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)


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

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

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

Second Admit to WRHReadmitted: 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

Admit #2: Pathophysiology

Pneumoperitoneum:

• Gas within the peritoneal cavity

• Presents as bowel injury after endoscopy

• Chest/Abdominal pain: Etiology unclear• Possibly related to

pneumoperitoneum

MNTGERD

• 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


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

Second Admit to WRHReadmit tube feed order:• Isosource 1.5 @ 240 mL 4x/day (bolus)• 1420 calories, 60 g. protein, 720 mL free waterNew 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

Admit #2: Pertinent Dates4/8/13

• 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/c TF orders

• No further abdominal pain complaints

• LBM: 4/11

• 4/10 labs: K 4.4

• Wt.: 172.2#

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’d TF’s House MS cut thin

• Cal. count initiated

• Wt.: 172

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

Admit #2: Pertinent Dates4/29/13

• 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

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

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

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

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

Proper G-Tube Placement

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


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

Admit #3Recalculated 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

Pertinent Dates5/6/13• 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

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. attempted to leave WRH via vehicle w/ husband

• Husband not fully understanding Mrs. W’s current issues

Admit #35/10

• 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

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

WRH Pt. Plan

1. To progress pt. to PO status (RD, SLP, MD)1. Made several attempts to increase appetite & stimulate

intake2. Meet patient’s needs with EN pending functioning PEG

and tolerating bolus feeds

2. Work with family and friends to raise awareness of patient’s needs

3. Discharge to SNF on EN w/ some PO, 1:1 supervision

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

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

clinical case study: mrs. w

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