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CASE STUDY PRESENTATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASECOPD

DIE 6935 – Special Topics in Dietetics

The Nutrition Care Process

Professor: Evelyn B. Enrione, PhD, RD

Presenter: Vania Lederman

� Airflow limitation usually progressive

� Abnormal inflammatory response of the lungs

to noxious particles or gases

� Cigarette smoke is the most common cause

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD

Decramera, M et al. Systemic effects of COPD. Respiratory Medicine (2005) 99, S3–S10

� It is predicted that by 2020, will have become the 3rd most

common cause of death worldwide

� May be subdivided: emphysema and chronic bronchitis

Chronic Bronchitis

Bronchi are red and swollen, and congested with mucous secretions

Healthy Bronchy

Alveoli are enlarged and destroyed

Emphysema

Healthy Alveoli


COPD

SYMPTOMS

EMPHYSEMA

� Dyspnea (shortness of breath)

� Most noticeable during physical activity

� As emphysema progresses, dyspnea occurs at rest


COPD

CHRONIC BRONCHITIS

� Chronic cough and sputum production

� The sputum is usually clear and thick

� As bronchitis progress infections occur more frequently

� Periodic infections can cause fever, dyspnea, coughing, production of purulent sputum and wheezing

NUTRITIONAL COMPLICATIONS OF COPD

� Nutritional wasting: low-energy intake and high-energy requirements

� Early satiety: decreased appetite

� ↑ expenditure: need 10x more energy for breathing

� Fatigue impairs desire to prepare food

� Changes in metabolism: result of inflammation, hypoxia, hypercapnia,

nutritional deprivation, and pharmacologic therapy

• Decramera, M et al. Systemic effects of COPD. Respiratory Medicine(2005) 99, S3–S10• Escott-Stump, S. Nutrition and Diagnosis-Related Care. 5.ed. 2002.

� BEE x 1.3 – 1.5 – maintenance

� BEE x 1.5 – 1.7 – anabolism

� CHO = 40-55%

� PRO = 15-20%

� LIP = 30-40%


COPD

� Case: Chronic Obstructive Pulmonary Disease

� Pt: Stella Bernhardt

� DOB: 10/23

� Age: 62

� Sex: Female

� Occupation: Retired office manager for independent insurance agency

� Household members: Husband, age 68. PMH of CAD.

� Ethnic background: Caucasian

� Referring physician: Debra Bradshaw, MD (pulmonology)

OVERVIEW OF THE CASE

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� Chief complaint:

Pt refers that she is hardly able to do

anything by herself right now. Even taking a

bath or getting dressed makes her short of breath.


� Patient history:

• Medical Dx: stage 1 COPD (emphysema) 5 years ago

• Meds: Combivent (ipratropium bromide and albuterol sulfate)

• PMH: Bronchitis and upper respiratory infections during winter

• Smoker: 1 ppd for 46 years – has quit 1 year ago

• Family hx: CA – mother, 2 aunts died from lung cancer


� Physical exam:

• General appearance: 62-years-old female in no acute distress

• Vitals: Temp. 98.8ºF HR 92 bpm RR 22bpm BP 130/88

• Heart: Regular rate and rhythm; mild jugular distension noted

• Extremities: 1+ bilateral pitting edema. No cyanosis or clubbing


• Neurologic: Alert, oriented; cranial nerves intact

• Skin: Warm, dry

• Chest/lungs: Decreased breath sounds, percussionhyperresonant; prolonged expiration with

wheezing; ronchi throughout; using accessory muscles at rest

• Abdomen: Liver, spleen palpable; nondistended,

nontender, normal bowel sounds

� Hospital course:

• Admitting dx:

�Acute exacerbation of COPD, increasing dyspnea, hypercapnia, r/o pneumonia

• Tx plan:

� O2 1L/min via nasal cannula, O2 saturation 90-91%

� IVF D5 ½ NS with 20mEq KCL @ 75 cc/hr

� Corticosteroid -Methylprednisone: Solumedrol

� Antibiotic -Chephalosporin: Ancef

� Bronchodilator: Ipratropium bromide, Albuterol sulfate

� ABGs q 6 hours, CXR, sputum cultures and Gram stain


� Hospital course:

� Pt dx: Acute exacerbation of COPD 2º to bacterial

pneumonia

� Pt responded well to tx for the emphysema,

however COPD has progressed

� Discharged: home O2 therapy, referred to an

outpatient pulmonary rehabilitation program

� Discharge meds: Combivent + oral course of

costicosteroids + Keflex (10-d)


� The Physician ordered a nutrition consult

�Nutrition history:

• Appetite is poor, fast satiety

• Meal preparations are difficult

• In the previous 2 days, she has eaten very little

• Coughing has made eating difficult

• Food doesn’t taste good, it has a bitter taste

• 5 years ago she weighted 145-150lb, now she is 119lb, 5’3”

• She didn’t weight herself for a while, but clothes are bigger, dentures fit

loosely her family tells her how thin she has gotten

• Avoids milk: “People say it will increase mucus production”

• No previous MNT

• No vit/min supplementation


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� Nutrition history:

• Usual Dietary intake:

AM: Coffee, juice or fruit, dry cereal with small amounts of milk

Lunch: Meat, vegetables; rice, potato or pasta. Pt eat small amounts

Dinner: Soup, scrambled eggs, or sandwich.

Drinks Pepsi throughout the day (3 12-oz cans)

• 24h recall:

½ c coffee with nondairy creamer, few sips of orange juice, ½ c oatmeal with 1 tsp sugar, ¾ c chicken noodle soup, 2 saltine crackers, ½ c coffee

with nondairy creamer, 32oz of Pepsi per day.

OVERVIEW OF THE CASE OVERVIEW OF THE CASE

mg/dl0.2-1.30.4Bilirrubin

mg/dl8.7-10.29.1Calcium

mg/dl2.6-6.03.4Uric acid

mg/dl0.6-1.30.9Creatinine

mg/dl8-269BUN

mg/dl70-12092Glucose

mmol/L24-3031Total CO2

mmol/Kg H2O275-295280Osmolality

mmol/L1.6-2.62.1Magnesium

mmol/L2.5-4.53.1PO4

mmol/L98-108101Chloride

mmol/L3.5-5.53.7Potassium

mmol/L135-155136Sodium

mg/dl200-400219Transferrin

mg/dl19-4319Prealbumin

g/dl6.0-8.05.9Total protein

g/dl3.5-5.03.4Albumin

UnitsNormal range

Pt values

Chemistry Labs

%0-31EOS

%3-73MONOS

%25-4010LYMPHS

%3-65BANDS

%50-6283SEGS

%37-4735HCT

g/dl12-1611.5HGB

x 106mm34-54RBC

x 103mm34.3-1015WBC

UnitsNormal range

Pt values

Hematology Labs

24.7

3.6

2.4

31

92

77.7

50.9

7.29

1d Pt values

mEq/L24-2829.6HCO3-

mEq/L< 3Base deficit

mEq/L> 36.0Base excess

mmol/L1.2Carbonic acid

mmol/L25-3030.8CO2 content

≥ 95%SO2

mmHg≥ 8090.2pO2

mmHg35-4540.1pCO2

7.35-7.457.4pH

UnitsNormal range

3d Pt values

ABG’s Labs

NUTRITION CARE PROCESS

Food / Nutrition History Data

ASSESSMENT

↑↑↑↑

↓↓↓↓

↓↓↓↓

↓↓↓↓

↑↑↑↑

↓↓↓↓

↑↑↑↑

↓↓↓↓

↓↓↓↓

↑↑↑↑

↓↓↓↓

↓↓↓↓

Pt intake x needs

---

8mg

1200mg

43.18g

---

22.30g

218.98g

2400mg

300mg

15.93g

49.55g

1592 kcal

Pt needs

93.24mg

10%

4%

6g

130g

2g

200g

1070mg

5mg

25g

27g

1100 kcal

24h recall

40%Iron

Usual intake

� Diet Analysis

30%Calcium

93.24mgCaffeine

24gProtein

134gSugars

8gDietary fiber

248gTotal carbohydrate

1220mgSodium

55mgCholesterol

28gSaturated Fat

36gTotal Fat

1440 kcalCalories

Anthropometric Data

� Age: 62y

� Ht: 5’3” = 160cm

� IBW: 115lb = 52.3Kg

� UBW: 145-150lb = 65.9-68.1Kg 5 years ago

� Usual BMI: 25.75 = overweight

� ABW: 119lb = 54.0Kg

� Actual BMI: 21.14 = healthy range

� ∆∆∆∆ wt: 20.66% since COPD dx

ASSESSMENT

Biochemical Data

ASSESSMENT

219mg/dlTransferrin

19mg/dlPrealbumin

↓↓↓↓ 5.9g/dlTotal protein

↓↓↓↓ 3.4g/dlAlbumin

Pt valuesChemistry Labs

1%

3%

↓↓↓↓ 10%

5%

↑↑↑↑ 83%

↓↓↓↓ 35%

↓↓↓↓ 11.5g/dl

4x106mm3

↑↑↑↑ 15x103mm3

Pt values

EOS

MONOS

LYMPHS

BANDS

SEGS

HCT

HGB

RBC

WBC

Hematology Labs

mEq/L24-28↑↑↑↑ 29.624.7HCO3-

↑↑↑↑ 3.6

2.4

↑↑↑↑ 31

↓↓↓↓ 92

↓↓↓↓ 77.7

↑↑↑↑ 50.9

↓↓↓↓ 7.29

1d Pt values

mEq/L< 3Base deficit

mEq/L> 36.0Base excess

mmol/L1.2Carbonic acid

mmol/L25-30↑↑↑↑ 30.8CO2 content

≥ 95%SO2

mmHg≥ 8090.2pO2

mmHg35-4540.1pCO2

7.35-7.457.4pH

UnitsNormal range

3d Pt values

ABG’s Labs

Na 136

K 3.7

Cl 101

↑↑↑↑CO2 31

BUN 9

Cr 0.9GLU 92

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ASSESSMENT

Physical Examination Data

� Head and neck

� Teeth: Poorly fitting dentures

� Skin

� Skin: dry

� Edema, peripheral: 1+ bilateral

� Vital Signs

� ↑ Temperature: 98.8ºF

� ↑ Respiratory Rate: 22 bpm

� Shortness of breath

ASSESSMENT

Client History Data�Social history

� Physical activity, easy fatigue with increased activity; unable to

achieve desired levels

�Medical/ Health history

� Chronic Obstructive Pulmonary Disease

� Upper respiratory infections or pneumonia

�Signs and symptoms

� Shortness of breath or dyspnea on exertion or at rest

�Meds and supplements

� Medications that cause anorexia: Albuterol sulfate

Food/Nutrition Hx DataChange in way clothes fit

Changes in appetite /taste

NDTPARAMETER

NUTRITIONAL ASSESSMENT MATRIX

Anthropometric Data NI 1.4 NI 5.3 NI 51.1Weight loss

Biochemical Data

NI 5.1 NI 5.2↓ Albumin, serum

NI 55.1↓ Hemoglobin

NC 2.2abnormal pCo2; pO2

Physical Exam Data

NI 1.1↑ Respiratory Rate

NI 3.1 NI 5.2 NI 51.1Skin: dry

NI 1.4 NC 1.2Teeth: Poorly fitting dentures

NI 1.1↑ Temperature

NC 2.2Edema, peripheral

Client History DataMeds that cause anorexia

NI 1.1COPD

NC 3.2

NC 3.2

NC 3.2

NC 3.2

NC 3.2

NI 2.1

NI 2.1

NI 2.1

NI 2.1

DIAGNOSIS RATIONAL

Normal or usual intake in face of illness

Poor intake, change in eating habits,skipped meals, change in way clothes fit

Anorexia, change in appetite or taste� Food/Nutrition hx

Decrease in body weight that is not planned

Less than established reference standards or recommendations based on physiological needs

� Definition

↑↑↑↑ nutrient needs due to prolonged

catabolic illness

↑ nutrient needs due to prolonged

catabolic illness� Etiology

Weight loss of 5% within 30 days, 7.5% in 90 days or 10% in 180 days

Weight loss� Anthropometric

Fever, ↑↑↑↑ heart rate, ↑↑↑↑ respiratory rateDry skin� Physical Exam.

� Client hx

Conditions associated with a diagnosis or tx (COPD)

Medications associated with weight loss

Conditions associated with a dx or tx of catabolic illness

Medications that cause anorexia

NC 3.2 – Involuntary Weight LossNI 2.1 – Inadequate Oral/Food Beverage Intake

NUTRITIONAL DIAGNOSIS

PES STATEMENT

(P) Involuntary weight loss (NC - 3.2) related to

(E) increased nutrient needs secondary to COPD as evidenced by

(S) 20% of weight loss since COPD diagnosis.

INTERVENTION

1. FOOD AND/OR NUTRIENT DELIVERY

� MEALS AND SNACKS (ND-1)

� Modify distribution, type, or amount of food and nutrients within meals or at

specified time

� Limit fluid intake with mealsDecrease early satiety

� Use 6 small concentrated meals at frequent intervalsDecrease fatigue while eating

� Decrease caffeine intakeDecrease food-drug interaction

Prevent dehydration, which thickens mucus

Prevent fluid retention

Maintain actual body weight, recover plasma protein levels

GOALS

� Fluids = 30ml/Kg = 1620ml/d

� Limit salt intake, restrict Na and increase K intake

� BEE x 1.3 = 1530 Kcal

� PRO = 17% = 65g/d = 1.2g/Kg/d

� CHO = 48% = 183.6g/d

� LIP = 35% = 59.5g/d

MEANS

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INTERVENTION

2. NUTRITION EDUCATION

� INITIAL/BRIEF NUTRITION EDUCATION (E-1)

� Priority Modifications: Communicate relationship between nutrition and specific disease/health issue

� Provide knowledge: no association between milk & mucus production� Explaining the benefits of milk/Calcium intake� Explain: relation between Ca, BMD, osteoporosis risk for post-menopausal women

Increase milk intake

� Encourage the patient to make small, attractive meals

� Explain how to concentrate protein and calories in small feedings

� Avoid distension from large meals or gaseous foods

� Ensure adequate flavor of foods

Overcome anorexia

� Provide knowledge: association between caffeine & bronchodilators

� Provide knowledge of caffeine high-content foods

Decrease food-drug interaction

� Avoid excessively hot or cold foods

� Encourage slow eatingAvoid coughing spells

� Give suggestions of foods that are easy to prepare

� Main meal early in the day to have more energy throughout the rest of the day

� Encourage rest periods before and after meals

Conserve energy during the day

GOALS MEANS

INTERVENTION

3. COORDINATION OF NUTRITION CARE

� COORDINATION OF OTHER CARE DURING

NUTRITION CARE (RC-1)

� Collaboration / referral to other providers:

Physical therapist

� Schedule treatments to mobilize mucus 1 hour before and after meals to prevent nausea

� Improve physical conditioning with planned exercises, especially strengthening exercises

� Make sure the oxygen cannula is worn during and after meals. Eating and digestion require energy, which causes the body to use more oxygen

Improve ventilation before meals and overall physical conditioning to strengthen respiratory muscles

GOALS MEANS

MONITORING & EVALUATION

1. MEALS AND SNACKS (ND-1)

� Monitor: Tolerance to diet, food diary, body weight, presence

of peripheral edema, Labs (ABG’s Labs, Alb, preAlb, H/H)

� Evaluate: Comparison of intake to estimated needs

2. INITIAL/BRIEF NUTRITION EDUCATION (E-1)

� Monitor: Pt understanding, sx of fatigue and shortness of breath, appetite

� Evaluate: Change of dietary habits

3. COORDINATION OF OTHER CARE DURING NUTRITION CARE (RC-1)

� Monitor: Sx of fatigue and shortness of breath, ABG’s Labs

� Evaluate: Improvements in fatigue while eating

DOCUMENTATION

ADIME FORMAT

fat, sugar and caffeine, although with insufficient caloric and micronutrient

intake. Pt is 5’3”, 119lb, BMI 21.14, although pt has been loosing wt since

COPD dx 5yr ago (145-150lb). Labs reveal low albumin and total protein and

pre-albumin has borderline values. Pt presents shortness of breath and cough

which impair food intake.

�D (Diagnosis): Involuntary weight loss (NC-3.2) RT increased

nutrient needs 2º COPD AEB 20% of weight loss since COPD diagnosis.

�A (Assessment): Review of data reveal a 62

year-old female with a medical dx of COPD with poor

food choices comprised of high content of saturated

DOCUMENTATION

ADIME FORMAT

frequent intervals. Initial/Brief nutrition education (E-1) Provide knowledge and

tips to decrease drug-nutrient interactions, conserve energy during the day, prevent coughing spells, overcome anorexia and increase milk intake. Coordination of Other

Care During Nutrition Care (RC-1) Referral to Physical Therapist to improve ventilation before meals and overall physical conditioning to strengthen respiratory

muscles.

�M (Monitoring): Tolerance to diet, food diary, body weight, presence of

peripheral edema, Labs (ABG’s Labs, Alb, preAlb, H/H), pt understanding, sx of

shortness of breath and fatigue while eating, appetite.

�E (Evaluation):Comparison of intake to estimated needs, change of dietary

habits, and improvements in fatigue while eating

�I (Intervention): Nutrition Prescription Meals and Snacks (ND-1) Recommend 1530 kcal diet providing 65g of protein, 184g of CHO, 60g of fat and 1620ml of

fluid/d. Limit sodium and caffeine intake. Eat small meals at

THANK YOU

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