NUTRITION MANAGEMENT OF CEREBROVASCULAR

ACCIDENTSAshley ReeseARAMARK Dietetic InternshipMarch 3, 2014

Disease Description Result of blood flow to the brain that has been

stopped for a period of time As brain loses oxygen, cells begin to die Ischemic strokes: blood flow is blocked by a blood clot

or plaque build up Hemorrhagic stroke: one of the brain’s blood vessels

become weak and then bursts open Risk factors: aneurysms, arteriovenous

malformation, high blood pressure, artial fibrillations, diabetes, family history, high cholesterol, over the age of 55, and African American race

Disease Description

Signs/Symptoms: Headache (especially when there is bleeding in the brain), changes in hearing/alertness/taste, clumsiness, confusion, difficulty swallowing, difficulty reading/writing, problems in eyesight, difficulty talking/walking, personality changes

S/S may happen automatically, may show within a few days, or may not show at allS/S typically most severe when a stroke first happens

Cerebrovascular Accidents

Evidence Based Articles/Studies

Evidence-Based Nutrition Recommendations-Article 1 Study performed to determine if nutrition

intervention altered body composition Patients that had an acute stroke (>65 years

old) were randomized into different nutrition therapy groups: Intervention group (58 participants)-energy and

protein rich meals Routine nutrition care group (control group-66

participants) Patients were monitored during their hospital

stay and followed up after 3 monthsHa L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC

Geriatrics. 2010;10(75):1-9.

Evidence-Based Nutrition Recommendations-Article 1 Cont. Results:

During the 1st week of their hospital stay: less weight loss in the intervention group than the control group

After 3 months Weight loss was smaller in women of the intervention group

compared to the control group Men did not show a significant difference among the groups

after 3 months Concluded: Individualized nutrition support with

energy and protein rich supplementation was considered beneficial for maintaining body weight and preventing loss during the first week, and in women in the long run.

Ha L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatrics. 2010;10(75):1-9.

Evidence-Based Nutrition Recommendations-Article 2 Study performed to determine appropriate timing and

route of feeding for patients that have experienced traumatic brain injury

Meta-analysis was performed using PubMed, Embase, and the Cochrane Library databases

Clinical outcomes and differences in nutrition support efforts were evaluated in 13 randomized-control trials and 3 non-randomized prospective studies

Primary conclusions included mortality and poor outcomes

Secondary conclusions included hospital length of stay, ventilation length, and rate of feeding or infectious complications

Wang X, Dong Y, Han X, Qi X-Q, Huang C-G, Hou L-J. Nutritional support for patients sustaining traumatic brain injury: A systematic review and meta-analysis of prospective studies. Nutrition Support in Traumatic Brain Injury. 2013;8(3):1-14.

Evidence-Based Nutrition Recommendations-Article 2 Cont. Key findings:

Early feedings was linked to a reduction in mortality, poor outcome, and infectious complications

Parenteral nutrition showed a slight reduction in rates of mortality, poor outcome, and infectious complications compared to enteral nutrition

An immune enhancing formula showed a reduction in the infectious rate compared to a standard formula

Small bowel feeding is related to less pneumonia than nasogastric feeding

Conclusion: The most effective nutrition support is shown with feeding quickly by parenteral nutrition. If enteral nutrition is used, best results come from an immune enhancing formula. (Impact Peptide 1.5)

Wang X, Dong Y, Han X, Qi X-Q, Huang C-G, Hou L-J. Nutritional support for patients sustaining traumatic brain injury: A systematic review and meta-analysis of prospective studies. Nutrition Support in Traumatic Brain Injury. 2013;8(3):1-14.

Evidence-Based Nutrition Recommendations-Article 3 Dysphagia is a common complication for stroke patients Enteral nutrition is typically used to treat stroke patients

with swallowing difficulties If viewed as short term problem: nasogastric tubes are

used If viewed as needed for longer term: PEG tubes are

placed Trial evidence does not support protein and energy

supplementation for stroke patients who are able to eat orally, unless they are showing signs of malnutrition (especially if they have pressure ulcers)

Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for problems with swallowing and poor nutrition in patients who have had a recent stroke.Cochrane Database of Systemic Reviews. 2012;10(CD000323). DOI: 10.1002/14651858. CD000323.pub2.

Case Presentation 72 year old Caucasian man Found around 4:00 AM by his wife as he was stumbling

around the house. While trying to return to bed he fell and hit his head-no loss of consciousness or confusion at the time

Wife stated no aphasia or difficulty swallowing; no difficulty seeing at the time

Family decided to send patient to the hospital for further evaluation

Dx: right hemispheric stroke Family wanted to transfer to a larger hospital, but the

physician decided he had passed the window for any additional intervention.

Nutrition Care Process: Assessment

Client History PMH: diabetes, hypertension,

dislipidemia, chronic kidney disease, shingles, smoked tobacco for 30 years (quit 20 years ago)

Sx history: cholecystectomy, herniorrhaphy, and fistula repair

Occasionally drinks alcohol Mother died at age 45 from a stroke Father died at age 72 with a history of

diabetes and unspecified cancer

Food/Nutrition-Related History Wife reported no aphasia or difficulty swallowing

before or after his CVA During LOS, he remained NPO Hx of diabetes, wife stated he monitored and checked Unknown if he has food allergies due to his

unconscious state and wife’s absence during assessment

Nutritional supplements: 1000 mg fish oil, 600 mg red yeast rice BID, and 1000 mg vitamin D3 per day Patient’s rationale for these supplements is unknown

Patient’s food/supply availability is unknown, as well as his amount of physical activity

Nutrition-Focused Physical Findings

Noted in chart, wife stated he had good appetite and no chewing/swallowing difficulties

Physician ordered to continue statin and blood pressure control medications

Insulin was provided on a sliding scale Lipid values were monitored per history of

dyslipidemia Other medications: potassium chloride, lopressor,

plavix, and protonix Speech evaluation was ordered to determine

swallowing ability-resulted in remaining NPO due to inability to keep awake and stimulated

Anthropometric Measurements

Admit weight: 203# Assessment weight: 207# UBW unavailable Height: 5’7” (67 inches) BMI: 32.41 IBW: 148# 140% of IBW

Biochemical Data, Medical Tests, and Procedures

Measurement Value Normal ReasoningAlbumin 3.4 L 3.5-4.8 g/dL Acute/chronic

inflammation, malnutrition

Calcium 8.0 L 8.9-10.3 mg/dL Lowered albumin, decreased intake

Glucose 224 H 74-118 mg/dL DM, stress, steroid use

Creatinine 1.36 H 0.61-1.24 mg/dL

Dehydration, CKD

WBC 13.6 H 4.5-11.0 thou/uL

Increased disease fighting cells circulating in blood

Biochemical Data, Medical Tests, and Procedures CT scan-determine severity of CVA

Large area of ischemic infarction of right cerebral artery

Placed on BiPAP Due to shortness of breath and hypoxemia

Chest X-ray Bilateral alveolar filling=pneumonia or congestive

heart failure Bedside swallow test

Unable to evaluate twice, due to unable to be kept awake

Nutrient Needs Determined using the Critical Care

Guidelines in consideration of BMI and patient medical history:

REE Protein Fluid1750-1950 kcal/day (19-21 kcal/kg actual BW)

~101 g/day (1.5 g/kg IBW)

~1750-1950 mL/day (1 mL/kcal)

ARAMARK Nutrition Status Classification

Moderate Risk (Status 3) 10 points:

NPO anticipated>4 days= 4 points BMI>30-34= 2 points Albumin 3.4= 2 points Diagnosis of CVA= 2 points

Follow-up within 5 days

Malnutrition Identification According to the ASPEN Consensus

Statement: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition Acute illness/injury related malnutrition

Level: nonsevere/moderate

Nutrition Care Process: Nutrition Diagnosis

PES Statement Inadequate oral intake (NI-2.1) related to

inadequate diet order of NPO as evidenced by PO of 0%.

Nutrition Care Process: Interventions

Interventions Medical Interventions:

Electrocardiogram-no acute findings CT scan of brain/head/neck-determined acute

stroke with large area of ischemic infarction in right cerebral artery

MRI-limited involve of the left frontal lobe superomedially

CT angiogram-total occlusion of the right internal carotid artery

Speech therapy consult BiPAP-respiratory distress, then pneumonia

Interventions Nutritional

Goal: to provide nutrition (NPO) Recommended to provide nutrition within 72

hours of initiating NPO status (Enteral Nutrition ND-2.1) Glucerna 1.2 @ 65 mL/hr

1872 calories, 94 grams protein, and 1256 mL fluid Recommended to provide an additional 150

mL of free water flushes every 4 hours to meet fluid needs (Enteral Nutrition ND-2.1)

Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4th ed. Academy of Nutrition and Dietetics; 2013:162-163, 297.

Goals Short Term:

Provide nutrition within 72 hours of NPO status; meet 100% of nutritional needs.

Tolerate and reach goal rate once enteral nutrition is initiated; minimal residuals

Long Term: Prevent depletion and maintain weight during LOS Maintain skin integrity Maintain labs within normal limits Per speech, advance diet to oral feedings as

capable

Nutrition Care Process: Monitoring and Evaluation

Monitoring and Evaluation Enteral Nutrition Intake (FH-1.3.1): Provide

continuous enteral nutrition support of Glucerna 1.2 with goal rate of 65 mL/hr by follow-up. Monitor initiation and rate advancement of tube feeding.

Enteral Nutrition Intake (FH-1.3.1): Provide additional 150 mL free water flush every four hours to meet fluid needs by follow-up.

Body Composition/Growth/Weight History (AD-1.1): Maintain admit weight by follow-up, as usual body weight was unable to be determined.

Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4th ed. Academy of Nutrition and Dietetics; 2013:28, 297.

Monitoring and Evaluation Follow-up:

Performed 5 days after initial assessment Goal rate of 65 mL/hr reached Tolerating feedings well; minimal residuals

present Additional free water had not been provided to

the patient-given large amounts of IV fluids; MD discretion was recommended for additional free water needs

Patient maintained stable weight (only 2# gain with slight edema)

Monitoring and Evaluation Follow-up Continued:

Recommended to continue Glucerna 1.2 at goal rate of 65 mL/hr to meet needs.

Recommended to provide additional 150 mL free water Q4H once IVF d/c.

Goals: Continue to meet nutritional needs with

Glucerna 1.2 at goal rate by follow-up. Continue to monitor weight, laboratory values,

skin integrity, and diet order

Conclusion The patient’s mental status continued to

decrease-resulting in inability to follow commands

Family decided the patient would not want to live a life in his condition

Family opted for comfort care and requested to be transferred to hospice

Patient transferred to a floor room, and soon passed away