B E C C A C U R R Y , K E E N E S T A T E D I E T E T I C I N T E R NS E P T E M B E R 2 N D , 2 0 1 5

CLINICAL CASE STUDY:STROKE

OUTLINE

• Holy Cross Hospital• General Information• Role of Clinical RD

• Diagnosis/Background• Stroke• Pertinent elements of the case

• Case Study• P.E.

HOLY CROSS HOSPITAL

• Bed size: 443 beds• Not-for-profit• Location: Silver Spring, Maryland • Staff Numbers• 1 CNM- Aramark

Employee• RD’s on staff employed

by the hospital• 4 FT In-patient• 1 FT NICU, 1 PRN NICU• 1 FT Out-patient • PRN Pool

Image from: http://connectedcommunities.us/showthread.php?t=20542

HCH- ROLE OF CLINICAL RD

• Patient Care• Screen floors to assess daily census• Based on referrals, consults, LOS, NPO/CLD, BMI, or follow-

ups• Determine plan of care• Assess level of risk for patients and provide follow-up care as

appropriate • Determine appropriate nutrition support• Monitor patients on TPN/PPN on a daily basis• Monitor patients on EN

• Calculate estimated energy needs and protein needs for patients

HCH- ROLE OF CLINICAL RD

• Nutrition advocate and expert!• Role as Nutrition Liaison• Meetings• Multidisciplinary and intraprofessional• Hospital committees

• Policy development• QIC tracking

• Preceptor for dietetic interns• Nina Current, MS, RD, LD acted as the primary

preceptor for this case study

DIAGNOSIS

• Stroke• Two main forms- Ischemic or Hemorrhagic • TIA is third form, considered ‘mini stroke’

• Nutrition concerns• Impaired coordination• Paralysis• Dysphagia• Level 1, level 2, level 3, modified diet

Image taken from: http://stroke.ufhealth.org/for-patients/patient-resources/american-heart-associationamerican-stroke-association-2/

ETIOLOGY

• Risk Factors:• Age• Hypertension• CAD• Diabetes• Dyslipidemia• Smoking • Obesity

Image taken from: http://www.neuroskills.com/brain-injury/who-is-at-risk-for-a-stroke-.php

PATHOPHYSIOLOGY

• Ischemic strokes: characterized by arteries in the brain becoming restricted or blocked, generally by a blood clot.

• Hemorrhagic strokes: characterized by leaking or ruptured blood vessels in the brain causing a disturbance in blood supply.

F.A.S.T

F: asymmetrical face drooping, one sided weakness/paralysis

A: inability to control arms equally; weakness/paralysis on one side of the body

S: slurred speech

T: Time! Act fast and call 9-1-1

TREATMENT

• Medical attention is required as soon as possible• Admission to hospital for monitoring and diagnosis

• Mechanical Thrombectomy• Tissue plasminogen activator (tPA)• Break up blood clots; resolves blockages or clots• Appropriate only for ischemic strokes or TIAs caused by

blockages• Anticoagulant medications and cholesterol

lowering meds• Surgical treatment for rupture• Rehabilitation

INTERDISCIPLINARY TEAM

• IDT- A diverse group of health care professionals who collaborate together in order to provide comprehensive care for a patient. • Example: • Hospitalist• Neurology • Speech Therapist• Registered Dietitian • Registered Nurse• Palliative Care

ENTERAL NUTRITION

• Nutrition support • Administration routes• Nasogastric (NGT)• Nasoduodenal (ND)• Nasojejunal (NJ)• Orogastric (OGT)• Percutaneous Endoscopic Gastric (PEG)• Percutaneous Endoscopic Jejunostomy (PEJ)

• Formulas• Indications for Need• Impaired eating/swallowing• Functioning gut• Short-term and long-term nutrition support

PEG PLACEMENT

Image taken from: http://pinnt.com/therapies/enteral-nutrition.aspx

FOCUS AREA

• Level of involvement in patient care• Enteral feeding exposure• IDT collaboration• Family interaction

• Parallels can be made to oncology cases• Career goal- Certified Specialist in Oncology (CSO)

CASE STUDY- P.E.

• P.E. 93 year old male admitted for ischemic stroke• Lives at home alone with daytime care taker• Not a smoker, occasional drinker• Home meds: Metoprolol, Trandolapril, Zocor• PMH: • hypertension• Hyperlipidemia • triple bypass surgery 15 years ago

BASELINE NUTRITION

• Patient of stable weight, with normal intake prior to admittance • Patient did not follow any special diet• No dietary adjustments made after by-pass procedure

• Moderate protein-energy malnutrition• mild fat loss in orbitals and triceps• mild muscle loss in shoulders

NUTRITIONAL CONCERNS

• Speech Therapist Assessment• Severe Dysarthia• Dysphagia concerns• Aspiration risk

• NPO diet • Intolerance to NGT• Required PEG for long-term nutrition administration

ENERGY NEEDS ASSESSMENT

• Assessed based on patient’s: Age, BMI, nutritional standing, and diagnosis

Ht 183 cm Wt 91 kg BMI 27

Energy needs: 1820-2275 kcal (20-25 kcal/ kg)

Protein needs: 109-137 g pro (1.2-1.5 g pro/kg)

LABS

  Labs 7/18 7/19 7/20 7/21 7/22 7/23 7/24

Na (136 – 145 mEqL)

139 138 141 141 137 137

K (3.5 -5.2 mEq/L)

3.7 3.7 4.4 3.9 4.0 3.7

Glu (70 -110 mg/dL)

109 131 112 114 119 121

Ca (8.7- 10.4 mg/dL)

8.6 8.6 8.7 8.4 8.3 8.3

Alb (3.5- 5 g/dL)

3.3 3.4

Phos (2.4 – 4.1 mg/dL)

2.8 2.4 2.8

Mg (1.5 – 2 mEq/L)

1.9 2 1.7 1.8

MEDICATIONS

Medication Classification Nutrition Implication

Aspirin Analgesic/Antipyretic/Antiarthritic/NSAID/Platelet aggregation inhibitor

Can cause GI irritation if not taken with food

Ceftriaxone Antibiotic May cause N/V or diarrhea. Possible side effect of sore mouth

Rosuvastatin/ simvastatin

Antihyperlipidemic May cause nausea, constipation, diarrhea or abdominal pain

D5 + ½ NaCl @ 60/100 mL/hr

IV fluid Provides calories via glucose administered intravenously

Medication Classification Nutrition Implication

Famotidine Antiulcer/antiGERD May cause N/V/C/D; may decrease Ferrous and vit B12 absorption*

KCl electrolyte Necessary for repletion of potassium, May cause N/V or diarrhea

Lisinopril/ metoprolol

Antihypertensive May cause N/V/C/D or lead to anorexia or weight loss

Probiotic Biotherapeutic agent/ antidiarrheal

May cause vomiting or diarrhea; intended to prevent diarrhea especially related to C.diff

Vit B12 B complex Vitamin Replete B12 levels, may cause mild diarrhea or nausea *absorption may be impaired by famotidine

PES

• Moderate protein-energy malnutrition related to acute illness as evidenced by mild fat loss in orbitals and triceps and mild muscle loss in shoulders.

• Inadequate oral intake related to stroke as evidenced by NPO x 3 days.

INTERVENTIONS

• Collaborate with other health care providers---• pending SLP and palliative care consult, will assess

appropriate nutrition and administration• Goal: Determine nutrition POC

• Collaborate with other health care providers---• pending PEG placement

• Goal: PEG placement

INTERVENTIONS

• TEN--- • Jevity 1.2 @ 75 mL/hr

• Goal: Tolerate @ goal

• Collaborate with other health care providers--- • MD and RN assess pt tolerance

• Goal: EN @ goal

NUTRITION PRESCRIPTION

Jevity 1.2 @ 75 mL/hr (2160 kcal, 100 gm pro,1450 mL FW) + 175 mL FW flushes

q6h

Nutrient content calculations:75 (mL) x 24 (hrs) x 1.2 (Kcal/L)= 2160 kcal

(2160 x .185)/4 = 100 gm pro1800 x .80 = 1450 mL FW

2160 – 1450 = 710 mL710/4 = 175 mL FW flushes (1mL/1kcal)

MONITOR AND EVALUATE

• Status post PEG placement• GRV• HCH protocol- TF held for GRV’s > 250 mL/hr• Current studies are suggesting GRV’s may not be an

appropriate assessment of tolerance • Concerns with EN being prematurely stopped especially for ICU

patients• Aspiration• Abdominal distention• Lab values• Phos and Mg- concerns with refeeding syndrome

OUTCOMES

• P.E. responded well to all nutrition interventions.• Successful PEG placement• Tolerance to TF @ goal

• P.E. was discharged to a rehab facility.

LEARNING!

• Role in IDT• Enteral Feedings• PEG placement• Formula calculations• Tolerance/assessment

• Patient care/family care

REFERENCES1. Stroke. (2015). Mayo Clinic. Retrieved August 16 2015. http://www.mayoclinic.org

/diseases-conditions/stroke/home/ovc-201172642. Interdisciplinary Team. The Free Dictionary. Farlex. Retrieved August 28 2015.

http://medical-dictionary.thefreedictionary.com/interdisciplinary+team3. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology. 2nd

editon. Wadsworth CENGAGE Learning; 2007.4. Pronsky ZM. Crowe JP. (2012). Food and Medication Interactions: The Foremost Drug-

Nutrient Interactions Resource. Burchville, PA. Food Medication Interactions5. Act Fast. (2015). National Stroke Association. Retrieved August 27 2015.

http://www.stroke.org/understand-stroke/recognizing-stroke/act-fast6. Holy Cross Hospital (2015). http://www.holycrosshealth.org/hch. Retrieved September

1st 2015.7. Stroke Treatments. (2015). American Stroke Association. Retrieved September 1st

2015. http://www.strokeassociation.org/STROKEORG/AboutStroke/Treatment/Stroke-Treatments_UCM_310892_Article.jsp

8. Fluid and Electrolyte Disturbances Associated with Tube Feedings. Jones and Barlett Learning. Retrieved September 1st 2015. http://samples.jbpub.com/9780763781644/81644_CH12_179_190.pdf

9. Elke G. Felbinger TW. Heyland DK. Gastric Residual Volume in Critically Ill Patients A Dead Marker or Still Alive? NCP. Retrieved September 1st 2015. http://ncp.sagepub.com/content/30/1/59.full