Bethany Beaver, Mini Case Study - 3/13 Patient: Dx: 70 y.o. WF adm.

03/07/13 Intractable N/V Hypokalemia Abnormal liver enzymes Hepatic mass Crohns disease Liver mass identified 2010 Cataracts Hypertension Appendectomy, Cholecystectomy, Kidney stone with right kidney stent Aspirin (analgesic, antipyretic, anti-inflammatory) Magnesium Oxide Lopressor (antihypertensive beta-blocker) Dilaudid (narcotic pain reliever) Ht: 154cm Wt: 54.8kg BMI: 23 WNL Lovenox (anticoagulant) Potassium Chloride Zofran (antiemetic)

PMH:

PSH: MEDS:

Anthropometrics*:

Nutritional Requirements*: Source Kcal requirements Facility standards 1299-1549 kcal (MSJx1.3+250) EAL N/A Online nutrition care MSJ manual Labs PP Glucose Albumin K Na RBC HGB HCT BUN Creatinine Date 03/07/13 3/7 111 3.1 140 4.2 12.3 37.5 5 0.59 Diet NPO 3/8 122 2 2.8 141 4.2 12.1 37.2 2 0.56 3/9 138 2 3.3 141 4.04 11.8 35.8 2 0.73 3/10 114 2.2 3.6 143 4.18 12 37.3 <1 0.67 3/11 109 3.4 140 4.26 12.3 37.7 2 0.74 Plan

Protein requirements 55-66 g (1.0-1.2 g/kg) N/A N/A 3/12 165 2.5 3.5 137 4.53 13.3 40.2 3 0.75 3/13 98 2.5 3.8 140 4.43 13 39.6 4 0.82 3/14 113 2.2 3.5 138 4.49 12.7 39.5 5 0.76

Fluid requirements 1299-1549 mL (1mL/kcal) N/A N/A Normal Range <160mg (>60yoa) 3.5-5.5g/dl 3.5-5.0mEq/l 137-145mEq/l 3.8-5.2T/l 12-16 g/dl 35-47% 6-21 mg/dL 0.5-1.1 mg/dL

Admitted with intractable N/V, fever, and fatigue. Blood work indicated hypokalemia and abnormal liver enzymes. CT scan indicated worsening hepatic mass and satellite lesions. The mass has been present since 2010. In 2010 the mass was found to be composed of necrotic tissue. Continued N/V and fatigue

03/08/1303/10/13

NPO/Clears

03/11/13

CLD

Patient seen secondary to NPO/Clears x 4 days. Patient received meal tray in the morning and vomited shortly after eating. Patient was placed back on clear liquids. Patient has poor appetite due to N/V. Patient also has had loose stool that was considered normal for the patient because of history of Crohns disease. Patients skin is intact. PES STATEMENT: Inadequate oral intake related to intractable N/V as evidenced by NPO/Clear liquids x 4 days. Goals: 1. Nutrition in 2-4 days 2. Maintain weight 3. Normal GI function and diet tolerance 4. Nutrient needs: 1299-1549 kcal/day (MSJx1.3+250) 55-66 g protein/day (1-1.2g/kg) Interventions: 1. Advance diet per MD, goal GI soft, cardiac diet 2. Send Enlive TID (600kcal, 21g protein) 3. Weigh patient weekly and trend 4. Maintain diet tolerance and monitor PO intake as diet advances 5. Maintain GI function, consider prokinetic agent such as Reglan Continued N/V and fatigue Patient continues to have nausea and poor appetite. Patient has had very poor intake with only sips of clear liquids x7 days. Patient did not vomit today and was able to consume some Jello and Sprite. Patient is s/p CT guided liver biopsy today. Patient has no diarrhea or constipation and patients skin is intact. Nutrient needs: 1299-1549 kcal/day and 55-66g protein/day Interventions: 1. Consider alternate means of nutrition support per patient wishes. Recommend Jevity 1.5 via post-pyloric dobhoff TF. Start at 20mL/hr and advance every 4hrs by 10mL to goal 40mL/hr x 24hrs continuous feed to provide 1440kcal, 61g protein, and 730mL water. - Do not check residuals for post-pyloric TF - Flush with 120mL water every 4 hours - Raise HOB >45 2. If PO intake is tolerated and diet is advanced, recommend GI soft diet 3. Continue to send Enlive TID (600kcal, 21g protein) 4. Record and monitor weight 5. Monitor and record diet or tube feed tolerance 6. Consider prokinetic agent such as Reglan 7. Continue Zofran for N/V

03/12-3/13 03/14/13

CLD CLD

References:
1. 2. 3. Drug Information Online. Drugs.com. Available at http://www.drugs.com/drug_information.html. Accessed 17 March 2013. Nutrition Care Manual. Academy of Nutrition and Dietetics. Available at http://nutritioncaremanual.org/content.cfm?ncm_content_id=83131. Accessed 17 March 2013. Pagana K. Pagana T. Mosbys Diagnostic and Laboratory Test Reference. 10th ed. Missouri: Elsevier; 2011.