CASE STUDY #11

KNH 411
CHELSIE FELLMAN
SEPTEMBER 15, 2015

Inflammatory Bowel Disease: Crohns

Disease
Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical
literature indicate regarding its etiology?
According to Nelms, Sucher, & Lacey, Inflammatory
bowel disease (IBD) is defined as, an autoimmune,
chronic inflammatory condition of the gastrointestinal
tract; IBD is actually the term designating a syndrome
consisting of two diagnoses: Ulcerative Colitis or Crohns
disease (p. 380). The medical literature regarding its
etiology states that the direct cause of the onset of
Crohns Disease remains unknown. Previously, it was
said that factors such as diet and stress were
contributing factors to the onset of the disease, but now
medical personnel are realizing that diet and stress can
upset the Crohns disease, but are not directly related to
the cause (p. 380).
2. Mr. Sims was initially diagnosed with ulcerative colitis and then
diagnosed with Crohns. How could this happen? What are the
similarities and differences between Crohns disease and
ulcerative colitis?

Ulcerative Colitis (UC) is a chronic inflammatory bowl

disease that is primarily located in the colon and
rectum. Patients with blood in their stool are more likely
to suffer from UC than Crohns disease (p. 419). Crohns
disease can affect the entire gastrointestinal tract but
most commonly affects the ileum and the colon whereas
Ulcerative Colitis centralizes around the inflammation of
the colon and rectum alone. The signs and symptoms
for both UC and Crohns disease include diarrhea and
abdominal pain, however patients with Crohns will have
more abdominal pain and cramping than that of
someone with UC (p. 419). Given that the signs and
symptoms are so similar, this leads to why the initial
diagnosis for Mr. Sims was UC and not Crohns disease.
Both UC and Crohns disease are detected using The
Montreal Classification system, which is a clinical tool
that is used to describe the clinical and endoscopic

presentation of both Crohns and UC (p. 419).

3. A CT scan indicated bowel obstruction and the Crohns disease
was classified as severe-fulminant disease. CDAI score of 400.
What does a CDAI score of 400 indicate? What does a
classification of severe-fulminant disease indicate?
For Crohns disease, disease activity is currently
categorized clinically as mild-moderate, moderate-

severe, and severe-fulminant; severe-fulminant being

the most severe form of Crohns Disease (National

Institute of Health, 2014).

Crohns Disease Activity Index (CDAI) is a research
method or tool used to measure clinical response and

remission (NIH, 2014).

The CDAI number is based on a system that measures
the number of liquid or soft stools each day for seven
days, abdominal pain graded on a scale of 0-3 each day
for seven days, general well-being assessed from 0
(well) to 4 (terrible) daily for seven days, presence of
complications, taking diphenoxylate/atropine,
loperamide, or opiates for diarrhea, presence of
abdominal mass, hematocrit of less than 0.47 in men
and less than 0.42 in women, percentage deviation from

standard weight (Dretzke, 2014).

Active disease state for CD is defined as a CDAI score

higher than 220 (Best, Becktel, & Singleton, 1999).

A CDAI score of 400 indicates that Mr. Sims is suffering
from severely active or severe-fulminant CD (Dretzke,

2014).
4. What did you find in Mr. Sims history and physical that is
consistent with the diagnosis of Crohns? Explain.
Prior to now, Mr. Sims was hospitalized due to the
diagnosis of IBD almost 3 years ago. The initial
diagnosis was UC and then later identified as Crohns

Disease. He was very ill at the time and was

hospitalized for 2 weeks. Currently, he states that he
suffers from unbearable abdominal pain and more
frequent diarrhea. The information from his history and
physical that is consistent with the Crohns Disease is
the severe abdominal pain that he is suffering from. CD
affects the entire gastrointestinal tract, which leads to

the extreme abdominal pain (p. 380).

Weight loss in a 6-month period: 140 Height: 59. BMI:
20.7 (Weight(lbs.)/Height(in.)^2 X 705 = 140/69^2 X
705 = 20.7 BMI) UBW: 167-168.
o Mr. Sims is a healthy weight right now but he is on
the brink of being underweight. A common
probable cause of Mr. Sims being under his normal
weight of 167lbs. is due to his lack of caloric
intake. He is fully aware that food will cause him
abdominal pain and diarrhea so he is
subconsciously taking in less food overall; causing

his decrease in weight to 140lbs.

Mr. Sims also has a temperature of 101.5 degrees F. This
elevated temperature is indicative of the swelling taking

place in his intestines (p. 380).

5. Crohns patients often have extraintestinal symptoms of the
disease. What are some examples of these symptoms? Is there
evidence of these in his history and physical?

Some examples of these extraintestinal symptoms for

CD are:
o Osteoporosis
o Inflammatory arthropathies
o Scleritis
o Nephrolithiasis
o Cholelithiasis
o Erythema nodosum
(NIH, 2014).
There is not sufficient evidence in his history/physical of
any of any extraintestinal symptoms but Mr. Sims does
suffer from severe abdominal pain and frequent

diarrhea.
6. Mr. Sims has been treated previously with corticosteroids and
Mesalamine. His physician has planned to start Humira prior to
this admission. Explain the mechanism for each of these
medications in the treatment for Crohns Disease.
According to Crohns and Colitis Foundation of America
(CCFA), the number one goal for Crohns disease is to
achieve remission (absence of symptoms) and maintain
remission. Corticosteroids are fast-acting antiinflammatory drugs that have been the mainstay of
treatment for acute flare-ups of disease. Corticosteroids
are also immunosuppressive which means they
decrease the activity of the immune system (CCFA,

2009).
Humira reduces the effects of a substance in the body
that can cause inflammation (NIH, 2014).

7. Which laboratory values are consistent with an exacerbation of

his Crohns disease? Identify and explain these values.
Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
C-reactive Protein
(mg/dL)
HDL-C (mg/dL)
Vitamin D 25 Hydroxy
Free Retinol (Vitamin A;
mg/dL)
Ascorbic Acid

Ref. Range
6-8
3.5-5
16-35
<1.0

2/15 1952
5.5 (low)
3.2 (low)
11 (low)
2.8 (low)

<45 M
30-100
20-80

38 (low)
22.7 (low)
17.2 (low)

0.2-2.0

0.1 (low)

The values listed above are all low due Mr. Sims Crohns
Disease not allowing him to absorb all the nutrients he
needs in his diet in order to sustain his health.
Malabsorbtion is a major contributing factor to these
laboratory values all being lower than they should be. The
intestines are unable to absorb the nutrients as the food
passes through the GI tract due to the chronic
inflammation, which inevitably means the nutrients are
getting lost and arent being absorbed into his blood
stream. The vitamin D, for example, is low because
patients with CD decrease their intake of dairy foods as a
result of the lactose-restricted diet they are on. His calcium
levels were 9.1mg/dL and so there is also a high chance for
his calcium intake to be deficient in the future as well (p.
420).

8. Mr. Sims is currently on several vitamin and mineral

supplements. Explain why he may be at risk for vitamin and
mineral deficiencies.
As stated above, patients with an IBD such as Crohns
disease are at high risk for vitamin and mineral
deficiencies. Due to the chronic inflammation caused by
the CD, the intestines are not able to properly absorb
the nutrients into his blood stream- resulting in
malabsorption (p. 420). Mr. Sims is very cautious about
what he consumes in his diet for the fear that the food
will give him abdominal pain and/or diarrhea. In his diet,
he most likely restricts food items that contain dairy in
them due to the fact that these negatively affect his CD.
Due to the lack of dairy in his diet, he will suffer from
vitamin D and calcium deficiencies as a result of this
dietary restriction (p. 420).
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define
short bowel syndrome, and provide a rationale for your answer.
According to Nelms, short bowel syndrome (SBS) is
defined as, decreased digestion and absorption that
result from a large resection of the small intestine. (p.

426).
Mr. Sims is a potential candidate for SBS because he has
not had any of his intestines removed according to his
medical record, but he does have CD which lead to

malabsorption problems (p. 426). SBS is diagnosed after

the patient undergoes a surgical procedure to have a
part of their intestine removed (p. 426-427). Given that
Mr. Sims has not had any part of his intestines removed,
he cannot yet be diagnosed with SBS but he will be at
high-risk for developing SBS once he undergoes surgery.
10.

What type of adaptation can the small intestine make after

resection?
According to Nelms, it is understood that 50% of the
duodenum and jejunum can be resected without
significant nutrition deficits (p. 426). The body can
adapt to only have 50% of the intestines left, however,
if less than 100 cm of the small intestine is left,
11.

malabsorption is inevitable (p. 426).

For what classic symptoms of short bowel syndrome

should Mr. Sims health care team monitor?

The medical team should closely monitor the fluid and
electrolyte balance of Mr. Sims by using Total Parenteral
Nutrition (TPN) and intravenous support (p. 427); for it is
very easy to become severely dehydrated when the

intestines are suffering from malabsorption.

Motility is another thing that should be closely
monitored. The motility of his intestines is controlled by
medications used to treat the symptoms of diarrhea.

These medications work to either decrease motility

and/or to thicken the consistency of the stool (p. 427).
The medications used may also improve digestion by
increasing the amount of time nutrients and enzymes
12.

are exposed within the bowel (p. 427).

Mr. Sims is being evaluated for participation in a clinical

trial using high-dose immunosuppression and autologous

peripheral blood stem cell transplantation (auto PBSCT). How
might this treatment help Mr. Sims?
PBSCT paired with high-dose immunosuppression
therapy would benefit Mr. Sims. The PBSCT would help
to form new stem cells and blood cells for Mr. Sims that
would be lost in the high-dose immunosuppression
therapy (NIH, 2014). Essentially, the participation in this
clinical trial would help to re-train his body into how it is
supposed to be digesting food in the intestines.

Understanding the Nutrition Therapy

13.

What are the potential nutritional consequences of Crohns

disease?
Insufficient intake of calories
Anorexia
Fear of abdominal pain and diarrhea after eating
Protein deficiencies
Fluid and electrolyte deficiency
Iron, magnesium, zinc, calcium, vitamin D, B12, folate

deficiencies
Water soluble vitamin deficiencies
10


14.

Fat soluble vitamin deficiencies

(p. 420)
Mr. Sims underwent resection of 200 cm of jejunum and

proximal ileum with placement of jejunostomy. The ileocecal

valve was preserved. Mr. Sims did not have an ileostomy, and his
entire colon remains intact. How long is the small intestine, and
how significant is this resection?
It is good that the distal ileum still remains intact for this
is primarily responsible for assisting in regulation of
transit time. Without the distal ileum, symptoms of
malabsorption and dumping would most likely be

present (p. 427).

The small intestine ranges by individuals but on average
for a man of Mr. Sims height; 700 cm would be the total
length of his small intestine alone. Resecting only 200
cm will not have too many nutritional related deficits. If
less than 100 cm is left of the small intestines,

15.

malabsorption is inevitable (p. 426).

What nutrients are normally digested and absorbed in the

portion of the small intestine that has been resected?

According to the NIH, carbohydrate and

protein

absorption takes place in the duodenum and jejunum,

and the ileum is responsible for absorbing fats bound to
bile salts. The ileum is also responsible for absorbing
fat-soluble vitamins and vitamin B12 (p. 387).

11

It

is

crucial

that

directly

following

the

medical

procedure, we start Mr. Sims on Total Parenteral

Nutrition (TPN) for the sake of making sure he is
adequately nourished.

16.

Nutrition Assessment

Evaluate Mr. Sims % UBW and BMI.

% UBW = current weight/usual weight X 100 =
140lbs./167lbs. X 100 = 84% UBW. The evaluation of the
%UBW means that Mr. Sims is suffering from moderate

malnutrition (NIH, 2014).

BMI = Weight(lbs.)/Height(in.)^2 X 705 = 140/69^2 X
705 = 20.7 BMI. The evaluation of Mr. Sims BMI is that
he is still in the range of a healthy weight, however he is
on the lower end. The nutritional concern regarding his
weight is that he was not trying to lose weight but still
ended up losing 27 pounds in a 6-month period

17.

unintentionally.
Calculate Mr. Sims energy requirements:
Using the Mifflin method:
o EER= 10(63.6)+6.25(175.3)-5(35)+5 = 1,562
kcal/day
o 1,562 kcal X 1.6 PAL = 2,498 kcal
12

o The EER for Mr. Sims daily is 2,400 - 2,500

18.

kcal/day
What would you calculate Mr. Sims protein requirements

to be?

1.0-1.5 g/kg
63.6 kg X 1.0 = 64 g Pro
63.6 kg X 1.5 = 95 g Pro
Range: 64g-95g Pro daily
(p. 421)

19.

Identify any significant and/or abnormal laboratory

measurements from both his hematology and his chemistry labs:

Hemoglobin (Hgb, g/dL)

Hematocrit (Hct, %)
Transferrin (mg/dL)

12.9 (low)
38 (low)
180 (low)

Ferritin (mg/mL)

16 (low)

ZPP (micromole/mol)

85 (high)

Vitamin D 25 hydroxy (ng/mL)

22.7 (low)

Free retinol (Vitamin A;

micrograms/dL)
Ascorbic Acid (mg/dL)

17.2 (low)
<.1 (low)

The values listed above are directly related to his

malnutrition. Mr. Sims also has difficulty with absorbing
nutrients such as vitamin D and Ascorbic acid for
example into his intestines which is the direct cause of
the low values listed on his hematology and lab values.

Nutrition Diagnosis

13

20.

Select two nutrition problems and complete the PES

statement for each.

Inadequate vitamin intake (NI-5.9.1) related to patients
diagnosis of Crohns Disease as evidenced by laboratory
values of 22.7 (ng/mL) vitamin D; 17.2 (micrograms/dL)

Vitamin A; <0.1 (mg/dL) Ascorbic acid.

Inadequate oral intake (NI- 2.1) related to patients
inability to maintain weight as evidenced by a 27 lb.
weight loss in a 6-month period.

Nutrition Intervention
21.

The surgeon notes Mr. Sims probably will not resume

eating by mouth for at least 7-10 days. What information would

the nutrition support team evaluate in deciding the route for
nutrition support?
Information the nutrition support team would need to
evaluate would be how many macronutrients total that
Mr. Sims needs daily and then take that number and
correctly correlate it to the amount of parenteral
nutrition he will need to have while unable to consume
food by mouth. The nutrition support team will also
need to closely monitor and evaluate the hydration
status of Mr. Sims as well as he will not be able to have
water either. The MD, to maintain his hydration, will
most likely place him on a saline solution.

14

Parental nutrition refers to the delivery of calories and

nutrients into a vein. Enteral nutrition is generally
referred to as any method of feeding that uses the
gastrointestinal tract to deliver part or all of a persons
caloric requirements. It can include a traditional oral or
liquid diet, or even delivery of part or all of the daily
requirements an individual needs by the use of tube
feeding (CCFA, 2009). The nutrition team needs to
decide which route will be best for Mr. Sims postoperatively especially since he just underwent a surgical
procedure on his GI tract; enteral nutrition will be the
best choice for Mr. Sims for at least 7-10 days.

22.

The members of the nutrition support team note his serum

phosphorus and serum magnesium are at the low end of the

normal range. Why might that be of concern?
Hypophosphatemia is a condition when the serum
concentration in the blood goes below 2.5 mg/dL. One of
the ways that phosphate can be lost in the body would
be the nonrenal loss, which would occur through the
gut, primarily malabsorptive states or diarrheal
conditions, which leads to why the serum phosphorus
levels of Mr. Sims are low (MedlinePlus, 2015). Having
low amounts of phosphorous in the body- particularly

15

the bloodstream can be harmful to the patient for the

reason that this could lead to Vitamin D deficiency
and/or liver disease. Phosphorus also helps with energy
storage, bone growth, and nerve and muscle production
so it is crucial that the body contains enough of it

(MedlinePlus, 2015).
Adequate amounts of serum magnesium for Mr. Sims
are important because magnesium serves many
functions in the body. Magnesium is needed for nearly
all chemical processes in the body. It helps maintain
normal muscle and nerve function, and keeps the bones
strong and it is also needed in order for the heart to
function normally (MedlinePlus, 2015).

23.

What is refeeding syndrome? Is Mr. Sims at risk for this

syndrome? How can it be prevented?

The National Institutes of Health defines refeeding
syndrome as, the potentially fatal shifts in fluids and
electrolytes that may occur in malnourished patients
receiving artificial refeeding (whether enterally or
parenterally) (Mehanna & Moledina, 2008).
Phosphorous, potassium, magnesium, Glucose, vitamin
deficiency, sodium, nitrogen, and overall fluid balance
are all extenuating factors that directly relate to

16

problems associated with refeeding syndrome. The body

has a shift due to a change in the metabolism and may
result in many issues including death (Mehanna &

Moledina, 2008).
Mr. Sims is most definitely at risk for this syndrome
seeing as he has just undergone a surgery that will
result in him being unable to consume food for 7-10
days. He will be forced to go onto a TPN for the time

being until he is capable of eating again.

Refeeding syndrome can be prevented if the high-risk
patients are identified early on. Any patient with
negligible food intake for more than 5 days is
considered to be at risk for this syndrome. It is
important to identify and promptly correct any issue
that might potentially occur with absorption and/or
adequate intake of nutrients (Mehanna & Moledina,
2008).

24.

Mr. Sims was placed on parenteral nutrition support

immediately postoperatively, and a nutrition support consult was

ordered. Initially, he was prescribed to receive 200g dextrose/L,
42.5 g amino acids/L, and 30 g lipid/L. His parenteral nutrition
was initiated at 50 cc/hr with a goal rate of 85 cc/hr. Do you
agree with the teams decision to initiate parenteral nutrition?

17

Will this meet his estimated nutritional needs? Explain. Calculate:

pro (g); CHO (g); lipid (g); and total kcal from his PN.
Post-operative EER using the Mifflin method: (math
calculations on question 17) 1,562 kcal/day X 1.2 PAL =

1,800-1,900 kcal/day.
I do agree with the teams decision to initiate parenteral
nutrition for the reason that Mr. Sims body will not be
capable of consuming food orally for at least 7 days
post-operatively. He will need the PN in order to reach
his daily caloric goal of 1,800-1,900. The PN initiated by
the team will indeed meet his nutritional needs. The
total kcal provided from the PN is 1,976 kcal and this
total does in fact fall into the range of his goal of 1,800-

1,900 kcal/day.
To calculate the grams of all three macronutrients, I set
up an equation of ratios:
o Pro (g): 42.5g/50cc/hr = x/85cc/hr =72.25g
72.25g X 4.3 kcal/g = 310 kcal Pro
o CHO (g): 200g/50cc/hr = x/85cc/hr = 340g
340g X 3.4 kcal/g = 1,156 kcal CHO
o Lipids (g): 30g/50cc/hr = x/85cc/hr = 51g
51g X 10kcal/g = 510 kcal Lipid
o TOTAL kcal from PN = 310 kcal pro + 1,156 kcal
CHO + 510 kcal lipid = 1,976 kcal
(p. 109)

18

25.

For each of the PES statements you have written, establish

an ideal goal (based on the signs and symptoms) and an

appropriate intervention (based on the etiology).
Inadequate vitamin intake (NI-5.9.1) related to patients
diagnosis of Crohns Disease as evidenced by laboratory
values of 22.7 (mg/mL) vitamin D; 17.2 (micrograms/dL)
Vitamin A; <0.1 (mg/dL) Ascorbic acid.
o Encourage Mr. Sims to consume foods that contain
vitamin D such as dairy products regularly to help
increase the amount being absorbed into the

body.
Inadequate oral intake (NI- 2.1) related to patients
inability to maintain weight as evidenced by a 27 lb.
weight loss in a 6-month period.
o Encourage Mr. Sims to document his weight at the
beginning of each week when he returns home to
note any further fluctuations in his body weight.
Ensuring that he does not go below 18.5 for a BMI
(NIH, 2014) is important for him to maintain his
health status with a healthy BMI of 20.7.

Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed in the following information:

Measure

Mr. Sims data

Oxygen consumption (mL/min)

CO2 production (mL/min)

295
261

19

RQ
RMR

0.88
2022

From the information provided in the chart, Mr. Sims has

a high resting metabolic range of 2022 as well as a high
level of oxygen consumption, which positively correlates
with resting metabolic rate. The normal RMR for a man
of Mr. Sims size is 1580-1800 RMR and the normal
oxygen consumption should be 250 mL/min. This
information signifies that there was a change
somewhere in Mr. Sims diet and/or activity expenditure
(NIH, 2014).

27. Would you make any changes to his prescribed nutrition

support? What would be monitored to ensure adequacy of his
nutrition support? Explain.

The only changes to his prescribed nutrition support I

would make would be to ensure that he is receiving the
correct amount of vitamins and minerals in solution into
his blood stream. This was not mentioned in the
information provided in the case study and so that is
what I would change. The total calories provided from
the PN are sufficient so I would not change anything

regarding that.
The hydration status of Mr. Sims will need to be
monitored for the reason that it is very easy for

20

someone using PN to become dehydrated the fluid

concentration he will be given in his PN will be
mandated by the MD, so I will ensure that he is

receiving enough fluids overall.

Making sure that Mr. Sims is receiving a multi-vitamin
pill once he is discharged from the hospital will further
ensure adequacy of his nutrition in terms of vitamin and
mineral intake as well.

28. What should the nutrition support team monitor daily? What
should be monitored weekly? Explain your answers.

The nutrition support team will be closely monitoring

that Mr. Sims is meeting adequate energy requirements
daily and that he is overall feeling well. It is not an easy
task to go from consuming food orally to PN, even if it is
temporarily so the medical team need to be alert for at
any point Mr. Sims is uncomfortable. Monitoring the
hydration status of Mr. Sims will also take place daily.
The nutrition support team will also need to monitor if
there is a bowel movement daily and if any further

abdominal pains are present.

Weekly, the nutrition team will monitor the weight of Mr.
Sims to ensure he is not losing any more weight. The

21

goal post-operatively would be for him to maintain his

weight of 140lbs or gain a few more pounds; but no
more than 1-2 pounds per week. Also, monitoring his lab
values weekly will need to take place if there are any
significant changes in his bodys ability to absorb
nutrients. Also, the nutrition team will monitor and
evaluate his vitamin and mineral intake through a blood
test to ensure the levels are adequate.
29. Mr. Sims serum glucose increased to 145 mg/dL. Why do you
think this level is now abnormal? What should be done about it?

The normal blood glucose level for a non-diabetic

individual is 70-110 mg/dL so a BG of 145 is actually
quite high. This is most likely related to stress and
current hospitalization. Monitoring every 4 hours for the
next few days should take place to ensure the blood
glucose is coming down. The change from oral
consumption to PN will have caused the fluctuation in
his BG levels in that PN uses dextrose as the CHO unit
and dextrose raises blood glucose levels much quicker
than other sugars (Mayo Clinic, 2010). With the increase
in dextrose going into the body, the pancreas was
struggling to produce enough insulin. It would all
depend on what the MD ordered for us to treat the 145

22

BG with, but I would assume Mr. Sims would be given a

small dose of insulin to begin and then to prevent future
blood sugar spikes in the future, he might be put on
metformin- a drug used to regulate the absorption of
glucose into the body (Mayo Clinic, 2010).
30. Evaluate the following 24-hour urine data: 24-hour urinary
nitrogen for 12/20: 18.4 grams. By using the daily input/output
record for 12/20 that records the amount of PN received,
calculate Mr. Sims nitrogen balance on postoperative day 4. How
would you interpret this information? Should you be concerned?
Are there problems with the accuracy of nutrition balance
studies? Explain.

Nitrogen balance: 72.25g pro/6.25 18.4g 4 = -10.84

nitrogen balance. A negative nitrogen balance may
indicate inadequate protein consumption, malabsorption
or infection (p. 54).

31. On post-op day 10, Mr. Sims team notes he has had bowel
sounds for the previous 48 hours and had his first bowel
movement. The nutrition support team recommends
consideration of an oral diet. What should Mr. Sims be allowed to
try first? What would you monitor for tolerance? If successful,
when can the parenteral nutrition be weaned?
23

Mr. Sims will be allowed to have clear liquids first, and

then slowly move on to a full liquid diet. The nutrition
team should especially monitor for tolerance dairy
products for these are consistent in causing abdominal
discomfort. Mr. Sims should be given a low-fiber diet
and fed small meals frequently throughout the day so
that the body and slowly adjust back to digesting. If
successful, the PN can be weaned when Mr. Sims is able
to consume soft foods orally that will provide him
enough calories to meet his daily needs of 1,800-1,900
kcal (if he is bed-ridden). Once he is able to move
around and exercise again, the EER for Mr. Sims will go
back to 2,400-2,500 kcal/day and it is imminent that he
is aware that that is how many calories he needs daily
in order to maintain his weight.

32. What would be the primary nutrition concerns as Mr. Sims

prepares for rehabilitation after his discharge? Be sure to address
his need for supplementation of any vitamins and minerals.
Identify two nutritional outcomes with specific measures for
evaluation.

The primary nutrition concerns for Mr. Sims upon

discharge from the hospital would be that he is meeting
his nutritional caloric needs daily and he is also taking in
24

adequate amounts of vitamins and minerals. Monitoring

that he is no longer suffering from malabsorption is
important to make sure that his intestines are
functioning properly. To ensure that his needs are being
met, Mr. Sims will be taking a multi-vitamin supplement
daily along with consuming foods rich in vitamins and
minerals. Mr. Sims will also need to drink no less than
80 ounces of water daily to maintain hydration and aid
in his bodys ability to digest the food easily. Mr. Sims
will begin with a low-fiber diet and progress his way
back to eating a diet with adequate amounts of fiber ~

14g per 1,000 kcals.

A specific measure for evaluation that Mr. Sims could
use would be to document all of his meals and snacks
into a food tracking system such as SuperTracker so that
he is able to see what he is deficient or sufficient in
taking in. He will then send the SuperTracker
information to his R.D.N and they will further analyze
the data to see if any additional measures need to be

taken.
Monitor would be a monthly lab test to evaluate his

absorption of vitamins and minerals.

Mr. Sims should keep track of how often he is having a

bowel movement.
Multi-vitamin consumed daily once a day with a meal.

25

Monitor and note any further abdominal discomfort

before or after consuming foods.

References
Best,WR,Becktel,JM,Singleton,JW.Rederivedvaluesoftheeightcoefficientsofthe
CrohnsDiseaseActivityIndex(CDAI).Gastroenterology77(4Pt2),843846
(1999).

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Crohn's&ColitisFoundationofAmerica(CCFA).(2009,October29).Retrieved
September10,2015.
Crohn'sdisease.MayoClinic(2010,May13).RetrievedSeptember10,2015.

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