presented(by(kayla(jensen( byu(dietetic(intern(...
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Presented By Kayla Jensen BYU Dietetic Intern October 12, 2012
Age: 28 Y Gravida 5 para 1-‐1-‐2-‐2
Approximately 23 weeks and 6 days gestation Married Resides in Orem Occupation: Officer at State Penitentiary in
Draper LDS
Recurrent Bronchitis 1-‐2 episodes/year
Thrombocytopenia Pyelonephritis Pregnancy
Preterm labor Preeclampsia
Cholecystectomy (2000)
A life threatening condition characterized by severe hypoxia, bilateral pulmonary fluid infiltration, and decreased lung compliance.
Occurs without prior lung disease Secondary to catastrophic illness Acute Lung Injury (ALI) I
Less severe form
Aspiration Inhaling smoke/toxic chemicals Lung transplant Pneumonia Septic shock Trauma
The main function of the pulmonary system is gas exchange. Lungs work to filter, humidify, and warm inspired air (1). Inspired air contains many particles and
microorganisms. Mucus that is located in the airways keeps the airways moist and traps the particles and microorganisms
from the inspired air. The microorganisms are discarded in one of three ways.
▪ Cilia sweep the particles up to the pharynx and each time a person swallows the mucus containing particles are pushed down the digestive tract.
▪ Macrophages digest the microorganisms through phagocytosis. ▪ Antioxidant protection of certain nutrients
If not discarded properly microorganisms begin to build up in the lungs. Body sends out inflammatory markers into the body to try to get rid of the microorganisms.
Reduction in the surfactant production of the lungs. ▪ Decreased levels of surfactant in the lung cause the alveoli to collapse—making it harder to breath.
Mucus builds up in lungs and it makes it difficult for proper oxygen exchange Fluid also enters the lungs and inflammatory infiltrates cause diffusion abnormalities.
Excess fluid in combination with the poor alveolar function reduces the thoracic compliance of the patient and increases the dead space in the lungs.
These conditions all lead to increased difficulties with breathing. Eventually oxygen demands exceed the individuals breathing capabilities and a hypoxemic state
will develop If left untreated turns into ARDS.
Low blood oxygen levels Rapid Breathing Low blood pressure Increased opacity in the lungs Crackles in the Lungs Cyanosis
Difficulty breathing Confusion Extreme tiredness Fever Cough
partial arterial pressure of oxygen [PaO2]/fractional concentration of oxygen in inspired air [FIO2] <200. [PaO2] / [FIO2] <200
Chest x-‐rays and CT scans Bilateral alveolar infiltrates Pulmonary capillary wedge pressure
Blood Tests Try to identify cause of ARDS
Development of infections Pneumothorax/ Collapsed Lung Lung Scarring
Lungs become stiff which makes it harder to fill them with air.
Vary depending upon age and other non-‐pulmonary organ dysfunctions.
Mortality rates are decreasing Advancements in supportive care
Outcome is generally determined within 7-‐10 days
Takes approximately 6-‐12 months form normal function to return
Neuropsychiatric problems and muscular weakness.
ARDS is part of a systemic inflammatory response. Increased risk of malnutrition
Increased energy requirements Omega-‐3 Fatty Acids are recommended
Anti-‐inflammatory ▪ Eicosapentaenoic Acid (EPA) & Docosahexaenoic Acid (DHA) ▪ Gamma-‐linolenic acid (GLA)
Fluid requirements are normal—unless underlying cause requires a restriction
Oxygen Therapy positive-‐pressure ventilation with supplemental oxygen and positive-‐end expiratory pressure (PEEP)
Continues until the patient has enough lung function to adequately breath on their own and maintain adequate oxygen levels
Supportive Care Treat underlying cause
Supportive Care-‐treatments that are used to help improve the condition of the patient by relieving their symptoms and preventing further complications. Medications Physical Therapy Occupational Therapy
On September 21st JH went to her doctor. She was experiencing severe pain in her right flank. The Doctor treated her for acute pyelonephritis with Macrobid. JH still developed a fever, and experienced nausea and vomiting from pain in her right Flank.
On September 23rd, JH was admitted to the labor and delivery floor at Utah Valley Regional Medical Center for acute pyelonephritis accompanied by a fever and right flank pain. Complaints of a non-‐productive cough that she said she had had for over a week. ▪ “Hurts my whole body, head, chest, ribs, and back.”
A chest x-‐ray was taken and showed that she had mild bilateral interstitial opacities. ▪ The lungs were also clear to auscultation (CTA) bilaterally with normal respiratory effort with respirations at 93% on room air.
Urine culture on September 22: ▪ greater than 100,000 Escherichia coli gram-‐ negative bacteria and 3 white cells.
September 24th JH began to develop increased shortness of breath, and she said it felt difficult to get air.
Placed on oxygen through a simple mask—without the O2 her oxygen levels plummeted.
Experiencing hypoxemia. Breath sounds could also be heard bilaterally in her lungs Question of a few crackles heard in the right base.
Chest x-‐ray showed a dramatic change with diffuse right lung opacity most compatible with pneumonia.
JH’s condition worsened overnight Experienced increased shortness of breath tachypneic, anxious hypoxemic.
Placed on a BIPAP mask which she tolerated poorly. O2 saturations were in the 90s Respiratory rates in the 40s-‐50s.
Definitive crackles heard in the right lung. Her chest x-‐ray showed persistent bilateral infiltrates,
with right greater than left
September 25th intubated with 100% FIO2. Sedated using Diprovan
Rales and rhonchi continued to be heard throughout the lungs.
Doctors assessment was pyelonephritis with urine culture positive for E. Coli complicated by sepsis and Acute Respiratory Distress Syndrome.
JH continued to intubated for several day. Chest x-‐rays were taken daily and remained opaque until Sept 28th Fetus was also monitored. ▪ Showed reassuring fetal movement and fetal breathing ▪ Normal heart tones and fluid
Lungs were clear Oct.1 Extubated Oct. 1st Patient status continued to improve JH was discharged October 6th.
Prior to admit: Reported having a poor appetite and problems with chewing. Taking a prenatal vitamin. No food allergies.
September 24: placed on a clear liquid diet September 25: JH was experiencing worsening pain, nausea, and
vomiting and she was placed on NPO diet. September 26: Small bowel feeding tube was ordered
Doctor originally asked for replete at 70 ml/ Dietitian recommendation of OXEPA at a rate of 45 ml/hr.
▪ 1620 kcal, 113.7 grams CHO, and 67.7 grams ▪ Started September 28 and continued on this formula until October 2.
October 2, JH was placed on a full liquid diet and Replete with Fiber The Replete was given at a rate of 70ml/hr.
October 3: NG tube was removed and a regular diet with a boost supplement at every meal was ordered. Tolerated the food well and did not mention any problems with chewing.
Urine tests September 22: greater than 100,000 Escherichia Coli (E. Coli) gram negative bacteria and 3 white cells. Blood tests also were positvie for E. Coli. October 1st: Blood cultures showed to be clear. October 2nd : Blood test showed gram positive cocci in clusters.
Upon admit appeared relatively healthy. T After 1st day appeared to be acutely ill
▪ continued to look worse as her condition worsened. September 24th increased shortness of breath
oxygen through a simple mask. Definitive crackles also began to be heard through auscultation and they
continued to be heard until October 1st. September 25th shortness of breath worsened again
placed in a BIPAP mask which she tolerated poorly. Intubated
The first chest x-‐ray taken of JH’s lungs that showed changes was taken on September 23rd there was mild bilateral interstitial opacities. Sept 24th there were dramatic changes in the opacity of the lungs.
▪ The lungs became very opaque and remained so until October 28th when chest x-‐rays began to show improvement
October 1st lungs were clear and extubated.
Typical obese individual with a BMI >30 that is critically ill and vented 22-‐25 kcals/ kg of IBW or 11-‐14kcal/kg of actual weight. For JH we used the 11-‐ 14 kcal of her actual body weight.
▪ range of 1360-‐1730 kcals/day. Adjust for pregnancy
second trimester requires an additional 340-‐360kcals per day. Total intake of 1700-‐2090 kcal/day. Protein needs of pregnant woman in the second half of pregnancy is the
71 gm of protein. Pt that is critically ill and has a BMI > 40 require >2.5 gm/kg of protein
daily. JH’s needs were calculated with a range of 2.5-‐3.0 gm/kg. 113-‐130 grams of protein daily.
Total protein needs ranged from 71-‐130 grams/day. Goal targeted at this time: 113 gm
Fluid needs calculated at 35ml/kg. fluid requirements were 4326 ml.
Age: 28 year old Gravida para 1-‐1-‐2-‐2
23 weeks and 6 days gestation. Positive family history for Diabetes Mellitus. Does not smoke or drink.
1. Inadequate oral intake related to lack of access as evidence by mechanical ventilation.
2. Increased kcal/protein needs related to pregnancy and fetal growth as evidence by 23 weeks and 6 days gestation.
Problem: Inadequate oral intake related to lack of access as evidence by mechanical ventilation. Type of Intervention: Food and/or nutrient delivery. Long Term Goal: Adequate oral intake to provide adequate
growth for pregnancy. Short Term Goal: Increased food intake to improve albumin
levels Intervention: Food and/or nutrient delivery
▪ Administer tube feedings to meet >65% of patients estimated needs. ▪ Objective: Patient will receive >65% of estimated needs from tube feeding.
▪ Recommend Oxepa at a rate of 45 ml/hr to provide 1620kcal, 67.7 gm protein, and 114 gm CHO. ▪ Objective: Client will receive adequate nutrition and prealbumin and albumin
trends will improve.
Problem: Increased kcal/protein needs related to pregnancy and fetal growth as evidence by 23 weeks and 6 days gestation Type of Intervention: Food and/or Nutrient Delivery, Nutrition
Education Long term goal: Patient will experience appropriate weight gain for
pregnancy Short Term Goal: Patient oral intake will meet increased kcal and
protein needs for pregnancy. Intervention: Food and/or Nutrient Delivery
Recommend Carnation Instant Breakfast to be given TID with meals. ▪ Objective: Client will be able to meet additional kcal and protein needs for
pregnancy. Intervention: Nutrition Education
Discuss General Healthful diet during pregnancy. ▪ Objective: Client will be able to identify components of a general healthful diet
for pregnancy to facilitate appropriate weight gain.
Nutrition support began September 26 with the placement of the feeding tube Due to some complications and clotting of the tube, feedings
were not started until September 28. JH tolerated the tube feedings well. Albumin levels and prealbumin levels improved indicating
adequate nutrition. Tube was removed and placed on a clear diet and quickly
advanced to a regular diet. Tolerated the diet well Instant breakfast supplemented to meet needs.
Nutrition education about a general healthful diet for pregnancy was not provided to the patient. JH was discharged before the education was given.
Overall appropriate. Labs indicated that she was receiving proper nutrition
support. Trends for Albumin and prealbumin improved
Ability to be weaned quickly from the ventilator also was a good sign of adequate and excessive nutrition
JH did experience some minor weight loss throughout her stay; however, it was not significant.
By the end of her stay at the hospital, JH had a much better appetite and was eating enough to meet her nutritional needs.
Mahan KL, Escott-‐Stump S. Krause's Food & Nutrition Therapy. 12th ed. St. Louis: Saunders Elsevier; 2008.
Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory distress syndrome: A clinical review. Available at the http://www.thelancet.com. Accessed May 5, 2007.
National Heart Lung and Blood Institute. What is ARDS?. Available at http://www.nhlbi.nih.gov/health/health-‐topics/topics/ards/. Accessed October 4, 2012.
Nutrition Care Manual. Available at: nutritioncaremanual.org. Accessed October 3, 2012.
Gelder L. Lecture slides. Clinical Nutrition, Brigham Young University, September 2012.
Intermountain urban southern region adult patient care nutrition guidelines. Revised March 2010.
Physician’s desk reference. Montvale, NJ: Medical Economics Company; 2001.
