Nutrition Care Conference

Joanna MurawskiDecember 4, 2014Evergreen Health Care Center Stafford Springs CT

Patient Background

•HR•92 years old•Female•Caucasian•Admission date: 8/2/14 initial admission after discharge

from MMH with BLE edema and blistering•Dates seen: 10/16/14, 11/6/14

Physical Signs Psychosocial data

• Swollen, bruised, blistered legs• Other skin areas: intact,

healthy▫No dryness

• Appeared overweight▫edematous

• Previously lived alone at home• In the process of applying for

long term care Medicaid• Currently in the subacute unit

and will be transitioning to long term care

• Non-ambulatory• Roommate

Anthropometric data• Ht: 61” (1.55m)• Wt: 261 lb (118.6 kg)• BMI: 49 (class 3 obese

- Morbid)

• UBW - admission: 182 lb (82.7 kg)• BMI 34 (class 1 obese)

• IBW: 105 lb (47.7 kg)• % IBW: 248.6%

• Adjusted: 144 lb (65.5 kg)• % IBW (using UBW): 173%

• Adjusted: 124.5 lb (56.4 kg)Clinical data:• BP:110/62• Temperature: 98.3°F

Primary Diagnosis

•Anasarca: massive edema. ▫Edema occurs when fluid accumulates in

body cavities or extracellular tissue spaces. fluid buildup in the tissue around the body.

▫May be d/t kidney disease, acute glomerulonephritis (related to acute renal failure), thyroid disease, some medications, and other diagnoses.

▫MNT: sodium and fluid restriction, diuretics. ▫ Input and output should be monitored to

note any decrease in fluid retention.

Secondary Diagnoses• Lower extremity cellulitis and lymphedema:• Lower extremity cellulitis:▫ Inflammatory response, often d/t S. aureus or S. pyogenes infection▫ Typically occurs on lower limbs. Painful swelling, blisters / ulcers▫ Risk factors: obesity, skin trauma / wounds, leg ulcers, foot fungal infections▫ Tx: elevate the leg, keep the area clean, pain relievers, antibiotics

• Lymphedema: ▫ Poor lymph drainage (from leg)▫ Secondary d/t an existing infection▫ Symmetrical lymphedema: typically d/t low albumin, kidney disease▫ Tx: compression, leg elevation, manual drainage

Additional History

•Hypothyroidism

•COPD•GERD•Osteoporosis•Pressure ulcer•Hypokalemia•UTI

• Hx blunt head trauma• ARF• Asthma: acute

exacerbation

• Anxiety

• Spinal stenosis

• Eczema

• Legally blind• Intractable L. ankle

Significant Medications• Protein powder: 1 scoop BID• Lasix: Antihypertensive loop diuretic. ▫ Depletes potassium, can increase blood glucose

• Synthroid: Thyroid hormone▫ May increase glucose levels, grapefruit interaction, do not take with calcium

supplements• Actonel: Osteoporosis treatment▫ Calcium intake should be 1500 mg, Vitamin D intake 800 IU

• Vitamin D3: Calcium regulator▫ Can cause increased thirst, dry mouth▫ Use caution with decreased renal or cardiac function

• Serevent: Asthma, COPD treatment▫ Can cause hypokalemia, stomach ache, N/V, throat irritation, decreased salivation

• Lactulos, Miralax, Colace : Stool softeners/ laxatives

Biochemical Data

Lab Normal RangePt

result: 10/14

Pt result: 10/28

Pt result:

11/9

Pt result: 11/10

Result Significance

BUN 7-18 mg/dL 34 25 23 High Renal failure, infectionsCreatinine .6-1 mg/dL 0.6 0.6 0.7 Normal

Sodium136-145 mmol/L

135 136 136 Normal

CO2 21-32 mmol/L 29.3 34.4 34.4 High May be d/t COPD

Calcium 8.5-10.5 mg/dL 7.9 7.4 7.4 LowLow intake, vitamin D,

osteomalaciaAlbumin 3.4-5 gm/dL 1.7 1.9 1.8 N/A Low Edema, stress on the body

Protein 6.4-8.2 gm/dL 4.2 N/A N/A LowEdema, renal failure, protein

deficiencyPotassium 3.5-5.1 mmol/L 4 3.7 3.4 Low, borderline Hypokalemia, diureticPrealbumin 18-35.7 WNL WNL 16.2 N/A Low Stress, infection, low protein

I & O, Weights

Date I O Difference

29-Oct 1360 1500 -1401-Nov 1400 2400 -10004-Nov 1580 2400 -8207-Nov 1200 1400 -20010-Nov 1380 1450 -7011-Nov 1500 950 55012-Nov 1500 1400 100

Amounts are in cc

Dietary Data

•Appetite: eats 75-100% of meals•No snacks•No allergies•Current diet order: NAS, 1500 cc fluid▫1 scoop protein powder BID

Nutrition Diagnosis

PES: Increased protein needs related to leg cellulitis and lymphedema as evidenced by albumin (1.9 gm/dL).

Dietary intervention adjustments:• Increased protein needs (1.5 g/kg adjusted body wt)•Monitor sodium 2000 mg/day or less•Monitor calcium to meet 1200 mg/day

Intervention

•Follow up:▫Patient knowledgeable about need for protein

Asks for double portions of meat for some meals Eats an egg daily Protein powder with applesauce BID

▫Fluid restriction – Avoiding Xerostomia: Eats oranges slowly morning and night Mints, gum Sips water slowly

•Re-educate staff on supplement preparation

Nutritional Needs

• Harris Benedict:• Adjusted BW, USUAL, AF = 1.2, IF =

1.1 = 1369 kcal• Carbohydrate: 45% 154 g• Protein: 25%: 86 g• 1.5 g/kg ABW (usual) = 84.6 g• 1.1 g/kg UBW = 91 g

• Fat: 30% 46 g

• 1500 cc fluids• 2g Na+

Vitamins & Minerals

•Sodium: 2g Na+ / day•Calcium: strive to meet 1200 - 1500 mg/day•Vitamin D: continue supplementation of 1000 IU QD

Sample Meal PlanBreakfast:

▫ 1 hardboiled egg▫ ½ cup cream of

wheat▫ 1 small orange▫ 4 oz lowfat milk▫ 8 oz water

Lunch:• 5 oz baked salmon• 1/3 cup brown rice• ½ cup cooked

spinach• ½ cup light ice

cream• 4 oz lowfat milk• 8 oz water

Dinner:• Grilled cheese

sandwich:• 2 slices low

sodium cheese with 2 slices low salt wheat bread and 2 tsp butter

• ½ cup cooked zucchini

• 2 oz grapes• 4 oz lowfat milk• 8 oz water

Snacks:• 4 oz applesauce with 1 scoop protein

powder BID, 7 oz water• 4 oz applesauce with 1 scoop protein

powder BID, 7 oz water

Evaluation

•Monitor weight and Intake / Output•Monitor leg wound healing•Lab results:▫Steady decrease in BUN to 18 gm/dL▫Albumin increase to 3.4 gm/dL▫Monitor calcium

Questions?

References• Al-Niaimi F, Cox N. Cellulitis and lymphoedema: a vicious cycle. Journal of Lymphoedema 2009;4(2):38-42. Retrieved from:

http://www.woundsinternational.com/pdf/content_11173.pdf• American Dietetic Association. (2008). Choose Your Foods: Exchange Lists for • Diabetes. Alexandrea, VA: American Diabetes Association.• Anasarca.org. (2007-2014). Anasarca. Retrieved from: http://www.anasarca.org• Lab Tests Online. (2012) Bicarbonate. Retrieved from: http://labtestsonline.org/understanding/analytes/co2/tab/test/• Conde Nast. (2014) SelfNutritionData: Know what you eat. Retrieved from: • http://nutritiondata.self.com/• Mahan, K.L., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition • Care Process (13th ed.). St. Louis, MO: Elsevier Saunders.• MedLine Plus: Trusted Health Information for You. (2014, October 09). Swelling. • Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm• Medline Plus: Trusted Health Information for You. (3 January 2014). Drugs, • Supplements, and Herbal Information. Retrieved from: • http://www.nlm.nih.gov/medlineplus/druginformation.html• The Merck Manual: Professional Edition. (2010-2014). Hypokalemia. Retrieved from: • http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/electrolyte_disorders/hypokalemia.html• NCM: Nutrition Care Manual Pressure Ulcers and Other Skin Conditions (2014): Academy of Nutrition and Dietetics. Retrieved from• Pronsky, Z.M., Crowe, J.P. (2012). Food-Medication Interactions (17th ed.). • Birchrunville, PA: Food-Medication Interactions.• Images:

▫ http://www.algen.com/images/Detecto495_small.jpg▫ http://openi.nlm.nih.gov/imgs/512/278/1852096/1852096_1471-2369-8-6-2.png▫ http://g-ecx.images-amazon.com/images/G/01/aplus/detail-page/B001W6RHRK_043900284101_L11_3D.jpg▫ Eggs: Free Images. (2009) HAAP Media. Retrieved from: http://www.freeimages.com/ http://www.freeimages.com/assets/35/349234/4-eggs-731131-m.jpg