Bryn WilkinSeptember 17, 2013KNH 411: Case Study #11

I. Understanding the Disease and Pathophysiology

1. What is inflammatory bowel disease? What does current medical literature indicate regarding its etiology?

Inflammatory bowel disease (IBD) is defined as an autoimmune, chronic inflammatory

condition of the gastrointestinal tract. It can be used as a general term to describe one of

two diseases: ulcerative colitis, and/or Crohn’s disease. The complete etiologies for both

inflammatory bowel diseases are not known. However, it is clear that environmental

factors play a part in causing an abnormal inflammatory response. These factors include

smoking, infectious agents, intestinal flora, and physiological changes in the small intestine.

There is also a strong connection between IBD and family history. These genetic

associations have been connected within both the innate and acquired immune response.

(Nelms, pg. 415-417)

2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohn’s. How could this happen? What are the similarities and differences between Crohn’s disease and ulcerative colitis?

Mr. Sims may have been mistakenly diagnosed with ulcerative colitis (UC) because of the

similarities of symptoms associated with UC and Crohn’s disease. Both UC and Crohn’s

disease can provide symptoms of diarrhea, weight loss, abdominal pain, fever, and a

presentation of blood in one’s fecal matter. Additionally, Crohn’s disease and UC are

diagnosed using many of the same tests: CT, MRI, abdominal ultrasound, etc. Both diseases

affect both sexes equally. Although there are many similarities between the two diseases,

each disease has a distinct pathology. UC involves an inability of the GI tract to distinguish

between foreign form antigens and self-antigens. This can lead to chronic inflammation of

the colonic mucosa and submucosa and atrophy of the colon. Crohn’s disease involves

inflammation of the bowel mucosa that progresses through the bowel wall. It is generally

localized in the terminal ileum and colon, but can involve other parts of the GI tract. When

comparing the etiologies of both diseases, another difference is discovered. UC is generally

associated with ex-smokers, while Crohn’s disease is associated with current cigarette

smoking. The diseases also differ in their typical peak age of onset. UC has a peak onset

age of 20-30 for patients with a first-degree relative with UC, and a peak onset in middle

age groups for those with a secondary relative with UC. Crohn’s disease, regardless of

family history has an earlier peak onset age of teenage years to twenties. The

complications associated with each disease can also differ. UC involves complications of

severe bleeding, toxic colitis, strictures, perforation, dysplasia, and carcinoma. Crohn’s

disease involves complications such as malabsoprtion, malnutrition, intestinal obstruction,

abdominal fistulas, gallstones, kidney stones, UTIs, and neoplasia. These differences could

easily be detected with further medical testing—and most likely helped to correct Mr. Sims

diagnosis. Depending on the diagnosis, these diseases may receive different treatments.

UC involves drugs that will help to reduce chronic inflammation—immunosuppressants,

adrenocorticosteroid, antidiarrheals, antibotics, etc. UC can also be treated by a colectomy

—whether it is a total, subtotal, or colectomy with ileostomy. Crohn’s disease can also be

treated with immunosuppresants, steroids, and antibiotics, or can involve surgery to

remove any affected areas—ileum, colon, etc. Surgeries can include ileocolic resections,

segmental resections, ileostomy or total proctocolectomy. (Nelms, pg. 416-417)

3. A CT scan indicated bowel obstruction and the Crohn’s 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?

A CDAI of 400 indicates a moderate-severe Crohn’s disease. This includes patients who

have not responded to treatment for mild-moderate Crohn’s disease, or those who have

major symptoms of fever, significant weight loss, abdominal pain, nausea, vomiting, or

significant anemia. A classification of severe-fulminant Crohn’s disease indicates a CDAI

score of 450 or greater. Those patients have persistent symptoms despite the introduction

of steroids or biologic agents. Patients may also have persistent fever, vomiting, evidence

of intestinal obstruction, cachexia, or evidence of an abscess. (Nelms, pg. 419)

4. What did you find in Mr. Sims’ history and physical that is consistent with his diagnosis of Crohn’s? Explain.

Mr. Sims’ history shows that he was hospitalized about three months prior to this episode

because of an abscess and acute exacerbation of his diagnosed, Crohn’s disease. His

Crohn’s disease has also presented with a typical “skipping” pattern—beginning the last 5-

7 cm of the jejunum, and then moving to the first 5 cm of the ileum. In addition, Mr. Sims

reported increased/chronic episodes of diarrhea and abdominal pain—both consistent

with Crohn’s disease symptoms. Mr. Sims described his diarrhea as “constant”—indicating

that is a chronic symptom, distinguishing it as related to Crohn’s disease, not UC. Mr. Sims

also complained of running a fever, which can indicate an increase in the severity of his

disease state. Upon physical evaluation, Mr. Sims appeared to have a distended, tender

abdomen. This tenderness, paired with abdominal pain supports Mr. Sims’ CDAI score of

450. (Nelms, pg. 416-417) (case study book: pg. 116-117)

5. Crohn’s 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 extraintestinal manifestations include osteopenia, osteoporosis,

dermatitis, rheumatological conditions, (ex: ankylosing spondylitis) ocular symptoms, and

hepatobiliary complications. When looking over Mr. Sims’ current blood panel, it shows

that his citamin D levels are very low. Because of his medications and GI distress, Mr. Sims

is experiencing many absorption difficulties. Because of this, patients with IBD are at

increased risk of osteopenia and osteoporosis. Plans to begin Humira may also cause

extraintestinal manifestations because of an extreme immune system suppression. (Krause,

pg. 632)

6. Mr. Sims has been treated previously with corticosteroids and mesalamine. His physician had planned to start Humira prior to this admission. Explain the mechanism for each of these medications in the treatment of Crohn’s.

Corticosteroids work to inhibit the overall inflammatory response within the GI tract. To

do this, these drugs mimic the action of cortical and redistribute the white blood cells.

With a reduction of lymphocytes and an increased number of neutrophils, there is a

decreased production of prostglandins—decreasing inflammation. Mesalamine is an

aminosalicylate that also works as an anti-inflammatory agent. It works to prevent

inflammation in the colon and may also act as an immunosuppressant drug. Humira is

used to treat moderate to sever Crohn’s disease. It is often used on cases where other

medications have not worked to put the disease in remission. Humira works to block the

protein called TNF (tumor necrosis factor). That protein is often found in excess in patients

with Crohn’s disease. Humira blocks the TNF to help reduce the inflammation that causes

Crohn’s symptoms. (Nelms, pg. 389-390)

http://www.humira.com/crohns/how-humira-works.aspx

7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and explain these values.

Mr. Sims’ ASCA, C-reactive protein, hemoglobin, and hematocrit lab values were consistent

with an exacerbation of his Crohn’s disease. ASCA (anti-saccharomyces cerevisiae

antibodies) can help to distinguish Crohn’s disease from UC. High levels of C-reactive

protein can indicate the presence of inflammation in the body—although it may not

necessarily be specific to the GI tract. Low hemoglobin and hematocrit values indicate

malabsorption of iron in the small intestine. (Nelms, pg. 418-419)

8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies.

Mr. Sims may be at risk for vitamin and mineral deficiencies because of a combination of

Crohn’s disease and his current medication. Crohn’s disease affects normal digestion and

absorption, leading an increased caloric, protein, and micronutrient requirement.

Specifically, Crohn’s disease patients may have a fear of abdominal pain and diarrhea as a

result of eating—causing them to reduce their intakes. In addition, inflammation in the GI

tract causes losses of protein and other nutrients. Mr. Sims is also allergic to milk, which

could also contribute to a deficiency of calcium and vitamin D. Mr. Sims’ corticosteroid

prescription could also contribute to his risk of deficiency. Corticosteroids may increase

nutrient requirements or exacerbate nutrient losses in the GI tract. (Nelms, pg. 419-420)

9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide a rationale for your answer.

At this point, Mr. Sims is not a likely candidate for short bowel syndrome. Short bowel

syndrome is defined as the result of a large resection of the small intestine. So far, Mr. Sims

has not had any surgeries—or specifically, no resections of the bowel. However, because

Mr. Sims has Crohn’s disease, he is more likely to develop short bowel syndrome as a result

of chronic inflammation and distress to the GI tract. Because Mr. Sims has been

experiencing chronic diarrhea and shows signs of protein energy malnutrition and

micronutrient deficiencies, his medical team should consider him to be at risk for future

surgical resections, and potentially, short bowel syndrome.

However, after his jejunum and proximal ileum resection, Mr. Sims’ health team should

monitor his future progress in inflammation and absorption, as he will then be at risk for

short bowel syndrome. (Nelms, pg. 424-425)

10. What type of adaptation can the small intestine make after resection?

After a resection surgery, the postoperative period typically follows three distinct phases of

adaption. The first phase begins with large volumes of diarrhea. Patients will be

dependent upon parenteral nutrition during that time. The second phase is characterized

by a decrease in diarrhea. Enteral nutrition can be introduced and the patient can begin to

transition to an oral diet. In the final stage, the most adaptation is noticed. During this

stage, blood flow increases, there are increased secretions, and increased mucosal cell

growth. The inner lumen of the remaining small intestine increases in length and diameter.

Villous height also increases. Enteral nutrition supports the most successful adaptations.

Adaptation is also measured by the health of the remaining bowel and whether or not the

colon is present. (Nelms, pg. 425)

11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care team monitor?

Mr. Sims’ health care team should actively monitor for any symptoms of extreme

abdominal cramping, pain, large volumes of diarrhea, and weight loss/cachexia. In

addition, Mr. Sims’ blood levels of macro and micronutrients should monitor short bowel

syndrome. If Mr. Sims becomes highly deficient in any of the nutrients absorbed in the

short bowel, the health team would be alerted to the likely presence of short bowel

syndrome. Nutrients absorbed within the short bowel include vitamins C and B, iron,

sodium, and potassium. Macronutrients such as carbohydrates, protein, and fats are also

absorbed along the small intestine. If short bowel syndrome exists, a patient will

experience general malnutrition. (Nelms, pg. 425)

http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/#symptoms

12. Mr. Sims is being evaluated for participation in a clinical trial using high-dose immunosuppression and autologous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment help Mr. Sims?

This treatment would help replace damaged stem cells within the small intestine with

healthy ones from other parts of Mr. Sims’ body. Autologous stem cell transplantation

means that Mr. Sims’ is the cell “donor.” This is to his benefit because it ensures that the

cells will not be rejected—they are already part of his body system. When stem cell

transplantation is combined with immunosuppressant drugs, autoPBSCT has been shown

to induce remission of Crohn’s disease. However, relapses have been experienced in some

patients with refractory Crohn’s disease. (Nelms, pg. 173)

II. Understanding the Nutrition Therapy

13. What are the potential nutrition consequences of Crohn’s disease?

Crohn’s disease may cause weight loss and severe nutritional deficits or patients. Crohn’s

disease negatively affects digestion and absorption, increasing a patient’s caloric, protein,

and micronutrient requirements. Without proper nutritional care, a Crohn’s patient may

experience protein energy malnutrition—causing a negative nitrogen balance in the body.

Crohn’s patients are also at risk for iron, zinc, magnesium, and electrolyte deficiencies as a

result of diarrhea and malabsorption. Resections increase calcium and protein

requirements in order for proper healing to occur. Medications such as corticosteroids too

can affect a patient’s nutritional status—causing nitrogen wasting, increased risk of

osteoporosis, and hyperglycemia. (Nelms, pg. 419-420)

14. 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?

Resection of the jejunum and proximal ileum is a “best case scenario” for Mr. Sims when

considering absorption and nutritional status. The jejunum is typically responsible for a

large portion of nutrient absorption. The duodenum is a key player in absorbing key

nutrients such as iron and folate, and also works heavily in the digestion and absorption of

nutrients. The jejunum therefore is left to absorb small amounts of sugars, fluids, and

lipids. However, when a resection of the jejunum occurs, the ileum is able to adapt to

perform the majority of the functions of the jejunum. In the case of Mr. Sims, part of the

proximal ileum was also a part of the resection surgery. This is a “best case” because the

distal ileum is more important in absorption than the proximal ileum. The distal ileum is

the only site for absorption of bile salts, vitamin B12 and also absorbs a large volume of

fluid. The ileocecal valve, which was preserved for Mr. Sims is crucial in maximizing

nutrient absorption. It controls the rate of passage of ileal contents into the colon. The

colon, also preserved during the surgery is essential for reabsorbing electrolyte-rich fluid

each day and helps to maintain a person’s hydration status. Therefore, while every surgical

resection is important, Mr. Sims resection was not the most significant case, as much of the

intestine was preserved.

The duodenum is approximately 0.5 m long, the jejunum 2-3 m, and the ileum, 3-4 m long –

making the approximate length of the small intestine 5.5-7.5 meters in length. Therefore,

after the 200 cm resection, Mr. Sims’ small intestine is most likely about 3.5-5.5 meters

long. When considering short bowel syndrome, Mr. Sims does not need to worry. Short

bowel syndrome is considered 100-120cm of short bowel without a colon, or 50cm of small

bowel with a colon. (a loss of 70-75% of the short bowel) (Krause, pg. 9, 637)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/

15. What nutrients are normally digested and absorbed in the portion of the small intestine that has been resected?

The jejunum is responsible for absorption of sugars, resistant starch, fiber, lipids, dietary

fiber, and fluids. It also absorbs vitamins D and A, sodium, and a small amount of bile salts.

The proximal ileum is responsible for absorbing fat that was not absorbed by the jejunum,

the majority of bile salts, and vitamin B12. Luckily for Mr. Sims, the distal ileum is more

important to nutrient absorption than the proximal ileum. (Nelms, pg. 380) (Krause, pg.

637)

III. Nutrition Assessment16. Evaluate Mr. Sims’ % UBW and BMI.

UBW = 166-168# (166-168#/2.2#) = 75.3-76.2kg 75-77kgCurrent Weight = 140# (140/2.2) = 63.5kg%UBW = (63.5kg / 76.2kg) x 100 = 83.3% 83-84% UBW

At 83.3% of his UBW, Mr. Sims can be considered to be experiencing moderate malnutrition. By subtracting 100%-83%, it is clear that Mr. Sims has also had a severe weight loss of more than 10% within the last six months. (Nelms, pg. 48)

www.uic.edu/depts/mcam/nutrition/ppt/nutrition_assessment.ppt

Current BMI: kg/(m2)Height = 69in. x 2.54cm = 175.3cm/100cm = 1.75mBMI = 63.5kg/(1.752) = 20.8

UBW BMI:BMI = 76.2kg/(1.752) = 24.9

Currently, Mr. Sims’ BMI is within the “normal” BMI range of 18.5-24.9. However, it is on the lower end of the normal range. At Mr. Sims’ highest usual weight, he would still be within the normal BMI range—a more healthy weight for a man of his age and build.

17. Calculate Mr. Sims’ energy requirements.

Mifflin-St. Jeor: men = 10 x wt (kg) + 6.25 x ht (cm) – 5 x age (yrs) + 5Stress factor = 1.4 (Nelms, pg. 421) Mr. Sims: [10 x 63.5kg + 6.25 x 175.3cm – 5 x 35 + 5] x 1.4EER = 2182 kcal/day

Mr. Sims should receive between 2100 and 2200 kcal/day.

18. What would you estimate Mr. Sims’ protein requirements to be?

1.5-1.75 g protein/kg Mr. Sims: 95.3g – 111.1g

Mr. Sims should receive between 95-110 grams of protein/day.

(Nelms, pg. 421)

19. Identify any significant and/or abnormal laboratory measurements from both his hematology and his chemistry labs.

Mr. Sims’ blood panel revealed low levels of protein, including prealbumin and albumin levels. This indicates malabsorption of protein, and should be a risk for protein energy malnutrition. His blood had high levels of C-reactive protein, low HDL, positive ASCA, low hemoglobin, hematocrit, transferrin, ferritin, vitamin D, vitamin A, and ascorbic acid. All of these are indicators of malabsorption of iron, and other micronutrients. ASCA, high C-reactive protein, and low iron are all indicators of classic Crohn’s disease symptoms. His blood also showed high levels of ZPP and prothrombin time. High ZPP levels indicate some sort of iron deficiency or anemia is present. High prothrombin time could be the indication of a food-medication interaction. (Nelms, pg. 418-419)

http://www.nlm.nih.gov/medlineplus/ency/article/003652.htm

IV. Nutrition Diagnosis

20. Select two nutrition problems and complete the PES statement for each.

PES: Malnutrition related to nutrient deficiencies as evidenced by serum blood levels of protein (Total Protein: 5.5g/dL, Normal: 6-8g/dL), iron (Hemoglobin: 12.9g/dL, Normal: 14-17g/dL), and other micronutrients (Vitamin D: 22.7ng/mL, Normal: 30-100ng/mL). (NI – 5.2)

PES: Altered GI function related to diagnosis of Crohn’s disease as evidenced by chronic diarrhea, abdominal pain, micronutrient deficiencies, and protein energy malnutrition. (NC – 1.4)

V. 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?

In order to determine proper nutrition support, the nutrition team would want to first

assess how much of the bowel (length) was left. They should also assess the patient’s stool

and urine output over the last 24 hours and any medications that could affect GI motility or

secretions. Because Mr. Sims’ resection was of mostly the jejunum, he will most likely

recover/adapt more quickly to a normal diet. In this case, it will be important for the

nutrition to provide multiple small feedings throughout a day, with a normal balance of

protein, fat and carbohydrate. The nutrition team would also take into account Mr. Sims’

age in order to predict how quickly and likely it is that he will be able to transition away

from any enteral feeding that is recommended. The team would also need to find out

information about Mr. Sims’ jejunostomy. This is useful in evaluating what Mr. Sims can

tolerate. A jejunostomy indicates that there is normal GI function and an increased

tolerance of early initiation of enteral feeding. However, they would need to also recognize

the risk of irritation and infection at the insertion site. Seven to ten days after surgery will

encompass the first “stage” of adaptation. During this time Mr. Sims may experience

extensive fluid and electrolyte losses within large volumes of diarrhea. For this reason, the

health team will want to closely monitor his hydration and electrolyte balance. (Nelms, pg.

85, 425) (Krause, pg. 638)

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?

Deficiencies of magnesium and phosphorus are generally signs of malabsorption and/or

the result of surgical stress. Low phosphorus levels can sometimes be the product of an

imbalanced/improperly initiated TPN plan. If this were the case, it would be of great

concern to Mr. Sims’ health. In other scenarios, phosphorus deficiencies can be the result

of decreased activation of vitamin D. Mr. Sims already has low levels of vitamin D, and is at

risk for osteopenia. Low phosphorus levels could be a warning sign for any of those

conditions. Magnesium deficiencies can also result from improper TPN. If Mr. Sims is

receiving too little of either of these electrolytes, he may be at increased risk for refeeding

syndrome. (Nelms, pg. 132)

23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be prevented?

Refeeding syndrome is defined as metabolic alterations that may occur during nutritional

repletion of starved patients. Mr. Sims is at risk for this syndrome because of his NPO

status for 7-10 days after his surgery. In addition, his blood panel showed that he was

already presenting with malnutrition—putting him at further risk for refeeding syndrome.

In order to prevent this syndrome, it will be critical for the health team to monitor Mr.

Sims’ serum levels of phosphorus, magnesium, and potassium, and to provide the proper

supplementation as needed until Mr. Sims can receive his goal feedings. Without proper

monitoring, Mr. Sims’ body could go into starvation mode—using free fatty acids as an

energy source in the form of ketones. Glucose metabolism will require large quantities of

phosphorus. Other anabolic needs will require increased magnesium and potassium.

(Nelms, pg. 92-93)

24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively, and a nutrition support consult was ordered. Initially, he was prescribed to receive 200 g 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 team’s decision to initiate parenteral nutrition? Will this meet his estimated nutritional needs? Explain. Calculate: pro (g); CHO (g); lipid (g); and total kcal from his PN.

Yes, I agree with the team’s decision to initiate parenteral nutrition. Mr. Sims’ short bowel

will need time to adapt to the resection surgery. Specifically, the ileum will need to take

over absorption of nutrients once covered by the jejunum. Parenteral nutrition will give

time for the adaptation and allow Mr. Sims to eventually have the jejunostomy removed.

50cc/hr x 24hr = 1200cc/day1000cc = 1 L 1.2 L/day

1.2L x 200g dextrose/L = 240g dextrose/day240g dextrose/day x 3.4kcal/g = 816 kcal dextrose

1.2L x 42.5g amino acids/L = 51g amino acids/day51g amino acids/day x 4kcal/g = 204 kcal amino acids

1.2L x 30g lipids/L = 36g lipids/day36g lipids/day x 9kcal/g = 324 kcal lipids

TOTAL kcal = 1344 kcal

85cc/hr x 24hr = 2040cc/day2.04 L/day

2.04L x 200g dextrose/L = 408g dextrose/day408g dextrose/day x 3.4kcal/g = 1632 kcal dextrose

20.4L x 42.5g amino acids/L = 86.7 g amino acid/day86.7g amino acids/day x 4kcal/g = 346 kcal amino acids

2.04 x 30g lipids/L = 61.2g lipids/day61.2g lipids/day x 9kcal/g = 550 kcal lipids/day

TOTAL kcal = 2528 kcal

At the beginning of Mr. Sims’ treatment, parenteral nutrition received at 50cc/hr will not

meet his nutritional needs. However, at a rate of 85cc/hr, Mr. Sims will be receiving excess

energy. When calculated with a stress factor of 1.4, Mr. Sims requires 2100-2200 kcal/day.

At 85cc/hr, Mr. Sims will be receiving between 2500-2600 kcal/day. In addition, Mr. Sims

should be receiving between 95-110g/protein each day. At 85cc/hr, Mr. Sims will only be

receiving 85-86g of protein. For this reason, I disagree with the team’s parenteral nutrition

plan, but agree that he should be receiving this type of feeding.

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 etiology).

Malnutrition PES- Ideal Goal: Use supplementation of micronutrients and parenteral nutrition to

increase Mr. Sims’ iron and protein intakes, as well as stabilize micronutrient levels. Specifically, Mr. Sims’ protein intake should be increased within an ideal range of 95-110g/day. Iron levels should be monitored until they reach a hemoglobin level between 14-17g/dL. Hematocrit levels should be increased a percentage of 40-54%. Transferrin levels and ferritin levels should be increased between 215-365mg/dL and 20-300mg/mL respectively. Vitamins A (20-80ug/dL), C (0.2-2.0mg/dL), and D (30-100ng/mL) should be increased, while ZPP should experience a decrease. All of these levels can be changed by decreasing or increasing supplementation received through Mr. Sims’ TPN.

- Intervention: Request daily blood panels to be taken from Mr. Sims until serum blood levels indicate an ideal nutrition status with values in normal ranges (as indicated in the ideal goal).

Altered GI function PES:- Ideal Goal: Decrease volume of diarrhea and abdominal pain through proper

nutrition according to the absorption capacity and adaptation of Mr. Sims’ short bowel.

- Intervention: Continue to administer TPN feedings to Mr. Sims until short bowel has adapted to resection surgery. Educate client on gas-related foods and on diet plan for Crohn’s disease, including small, frequent feedings.

VI. Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed the following information:Measure Mr. Sims’ data

Oxygen consumption (mL/min) 295CO2 production (mL/min) 261RQ 0.88RMR 2022

What does this information tell you about Mr. Sims?

RMR: resting energy expenditure in 24 hours- This value gives the total kilocalories needed per day for adequate energy intake.

RQ = volume of CO2 expired/volume of O2 consumed - The RQ value represents the fuel mixture being metabolized. - An RQ value of 0.88 represents that Mr. Sims is receiving a mixed diet, without one

fuel being used significantly more than any of the others.

27. Would you make any changes to his prescribed nutrition support? What should be monitored to ensure adequacy of his nutrition support? Explain.

I would redistribute the macronutrients Mr. Sims is receiving by parenteral nutrition. Mr.

Sims should receive more grams of protein per day, and fewer grams of dextrose that could

be converted into fat if given in excess. The total grams of each macronutrient should be

decreased in order to reach a goal intake of 2100-2200kcal/day. In order to ensure

adequacy of his diet, Mr. Sims’ electrolyte and micronutrient serum blood levels should be

monitored. In addition, indirect calorimetry should be used to ensure that Mr. Sims is

being fueled by a mixed diet (per his RQ values). Finally, taking daily weights can ensure

adequate nutrition. Mr. Sims should not be losing any weight. Instead, it would be healthy

for Mr. Sims to gain some weight to reach his UBW.

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

Daily: The nutrition support team should order daily electrolyte counts as well as blood

panels of serum glucose, BUN, and creatinine. The nutrition team should be monitoring Mr.

Sims’ bowel movements as he transitions through a time of short bowel adaptation. They

should be monitoring his hydration status, and ensure that Mr. Sims is not experiencing

any weight loss. In addition, daily inputs and outputs should be monitored, as well as the

catheter site, clinical status, and patient’s temperature.

Weekly: The nutrition support team should monitor for increased liver enzyme levels,

which could alter the lipid-to-dextrose ratio of TPN. Because the GI tract is largely at rest

during TPN, the nutrition support team should be aware of the risk of cholestasis (bile

accumulation in the gallbladder). The team should also continue to measure weights over

the weeks to calculate any significant weight losses over a month’s time. Finally, the team

should assess for any infection at the insertion site for TPN or within the GI tract. A

patient’s blood count should also be monitored on a weekly basis.

(Nelms, pg. 101) (Krause, pg. 310, 316, 320)

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?

This level could now be abnormal because of the increased rate of parenteral nutrition.

The rate was increased from 50cc/hr to 85cc/hr. The increased rate, and slightly high

dextrose concentration when combined with the low grams of protein administered could

result in the elevated serum glucose level. In addition, the nutrition team should consider

the total kilocalories received per day – overfeeding. Another cause of the high serum

glucose could be a negative stress response by Mr. Sims’ body to surgery.

http://anhi.org/learning/pdfs/bcdecker/Enteral_Nutrition.pdf

30. Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4 gram. 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 nitrogen balance studies? Explain.

N2 balance = dietary protein intake / 6.25 – urine urea nitrogen – 4 N2 balance = (86.7g protein / 6.25) – 18.4g nitrogen – 4N2 balance = -8.5 g

Because this resulted in a negative nitrogen balance, it can be concluded that nitrogen

excretion is greater than nitrogen intake. This can help to assess the effectiveness of the

nutritional intervention Mr. Sims is receiving. Based on this number, I would be concerned

about Mr. Sims’ nutritional status. Excess nitrogen excretion could lead to protein energy

malnutrition for Mr. Sims. There are a few limitations with nitrogen balance studies. There

may be inherent error of 24-hour urine collection, failure to account for renal impairment,

and an inability to measure nitrogen losses from diarrhea, vomiting,, or wounds.

(Nelms, pg. 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?

When an oral diet is first initiated after parenteral nutrition, a patient should be give a low-

residue, lactose-free diet with small, frequent meals—as tolerated. The nutrition team

should then monitor for any steatorrhea. If steatorrhea is present, then fat should be

reduced, and medium-chain triglycerides added through a supplement. As the patient

begins to tolerate the mild diet, small amounts of fiber could be introduced. Foods that are

considered to be “gas-producing,” such as spicy/fried foods or caffeinated beverages

should be avoided. A multivitamin should be given throughout this time. Knowing when to

wean a patient from parenteral nutrition is a highly individualized process. The registered

dietitian will need to slowly wean a patient off of the parenteral diet, assessing how well it

is tolerated, and how complete the patient’s nutrient intake is without any parenteral

nutrition. (Nelms, pg. 421) (Krause, pg. 321)

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.

Primary nutrition concerns would include those of Mr. Sims’ nutrient absorption within the

small intestine, weight maintenance/gain to UBW, and the redevelopment of Mr. Sims’

bacterial flora in the GI tract. Looking at blood panels and evaluating the levels of macro

and micronutrients that should be absorbed by the short bowel could easily monitor

nutrient absorption. (Ex: looking at albumin levels to evaluate protein absorption) Asking

him to keep a weight log at home—both on a daily and weekly basis, could monitor Mr.

Sims’ weight gain. A food log could monitor adequate nutritional intake. Finally, Mr. Sims’

would want to incorporate probiotics and prebiotics into his diet in order to rebuild the

normal flora in his GI tract. This level would need to be assessed by a doctor. The success

of incorporating biotics into Mr. Sims’ diet would require the skill of a dietitian, given Mr.

Sims’ allergy to lactose. (Nelms, pg. 422)

References:

Academy of Nutrition and Dietetics. (2013). International Dietetics & Nutrition Terminology(IDNT) Reference Manual. Chicago, IL.

Fine, B. (2012). Nutrition Assessment. Retrieved from:www.uic.edu/depts/mcam/nutrition/ppt/nutrition_assessment.ppt

Forchielli, M. & Bines, J. (2008). Enteral Nutrition. Nutrition in Pediatrics. Retrieved from:http://anhi.org/learning/pdfs/bcdecker/Enteral_Nutrition.pdf

Humira. (2013). Moderate to Severe Crohn’s Disease: How Humira Works. Retrieved from:http://www.humira.com/crohns/how-humira-works.aspx

Jeejeebhoy, K.N. (2002). Short bowel syndrome: a nutritional and medical approach. Retrieved

from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/

Mahan, L.K., Escott-Stump, S. & Raymond, J.L. (2012) Krause’s Food and the Nutrition CareProcess, 13th Edition. St. Louis, MO.

MedilinePlus. (2013). Prothrombin time (PT). Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/003652.htm

National Institute of Diabetes and Digestive and Kidney Diseases. (2013). Short Bowel

Syndrome. Retrieved from:

http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/#symptoms

Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L. (2011). Nutrition Therapy & Pathophysiology.Edition 2. Belmont, CA.