Final Exam

Brooke Bryant
12-08-2015
Gretchen Mautuszak
KNH 411

1. Research Crohns disease and discuss the incidence of the disease, the cause, the
symptoms and the treatment. (10points)
More than half a million American men and women suffer from Crohns disease. The cause of
the disease is not known but researchers believe that there are three factors that can contribute to
the cause of Crohns disease. These factors are inherited genes, immune system, and
environmental factors. Thy symptoms of the disease include frequent diarrhea, rectal bleeding,
weight loss, fever, abdominal cramping/sharp pain, fatigue, and reduced appetite. Crohns can
flare up at any point in time from stress or other environmental factors. It can cause complication
within the body including obstruction of the intestines and formation of scar tissue. The
treatment of Crohns disease consists of monitoring the disease and reducing flare ups.
Combination treatment is usually the best way to treat Crohns this includes doing two of the
following treatment options together: Medication, Diet and nutrition, therapy, or surgery options.
Medication is used to control symptoms of Crohns disease, nutrition and diet adjustments help
by not eating foods that will cause flare ups within the GI tract (Crohns and Colitis,2015).
2. What is the function of Solu-Medrol and what nutritional implications does it have?
(5 points)
Solu-Medrol is a steroid and its primary function is to treat inflammation of chronic diseases.
The medication is used to treat conditions such as arthritis, blood disorders, severe allergic
reactions, certain cancers, eye conditions, skin/kidney/intestinal/lung disease, and immune
disorders. Some nutritional implications Solu- Medrol causes is excess sodium retention, and
potassium and calcium excretion (Solu-Medrol, 2015).
3. What dietary considerations are necessary with an ileostomy? (5 points)

One of the first steps after surgery will be to start on a clear liquid diet and once this is tolerated
an all liquid diet. Once the patient has tolerated this a puree diet will be introduced then to
mechanical soft and then regular diet .Some other dietary considerations that are necessary with
an ileostomy is to eat on a regular schedule and to eat slowly. Try to eliminate swallowing air
with your food because it can cause problems with expanding the pouch to big. Chewing gum
and drinking through a straw should be avoided to not swallow air. To cut down on gas
cucumbers, radishes, melons and sweets should not be consumed and beer/ carbonated beverages
should be avoided. Another dietary consideration that is necessary is to consume 5 to 6 small
meals a day instead of 3 big meals a day this will keep people from getting hungry and eating
solid foods before drinking any fluids will help keep down GI gurgling. People with ileostomy
dehydrate easier than people with normal GI tracts and should consume at least 6 to 8 cups of
fluids a day. When introducing new foods only one per day should be introduced to see how it
affects the body so it can either be eliminated from the diet or known that it can be ate again if
desired. Keeping weight down is another consideration or staying at the same weight because it
will make the ostomy work incorrectly or not fit properly. Some food that does not have to be
avoided but may cause stool to be red are cherries, tomato juice, red peppers, pimentos, beets,
and other red foods that may contain red dye. A lower fiber diet may be considered in the
beginning to reduce gas (Medline, 2014).
4. Are there any food/nutrients that tend to cause diarrhea after the colon is removed?
(5points)
Some food/nutrients that tend to cause diarrhea is too much fiber in the diet at the start because it
can cause the stool to be loose. Milk or dairy products because of the lactose can cause diarrhea
and alternative lactose free milks should be used. Spicy foods can cause a burning on leaving the

body and should be avoided in the beginning and introduced slowly. Nuts should be avoided and
high fiber foods such as beans and peas can cause diarrhea. Meats should be prepared without
added fat. Juices such as prune, grape, cranberry, and fruit peeling should be avoided because
they cause diarrhea. Whole grains should be avoided at the beginning because of the high fiber
content that may cause diarrhea (Nelms, 425-426).
5. If a person with an ileostomy has excessive loss of fluids, are there any foods that may
help electrolyte balance? (5points)
If a person is having excessive fluid loss Gatorade or other sports drinks that contain electrolytes
should be given to keep them hydrated and help put electrolytes back into their bodies. Some
foods that can help aid in balancing the electrolyte deficiency are bananas, apple sauce or apple
without the peel, sweet potatoes without peel, oranges, canned fruit, spinach and avocados Foods
high in calcium and phosphate should be incorporated to help with the electrolyte balance
(Nelms, 426).
6. What would be the purpose of bowel rest an elemental diet for Crohns patients?
(5points)
The purpose of bowel rest and an elemental diet for Crohns patients is so it helps decrease
inflammation in the GI tract. This induces remission and helps Crohns patients from losing
nutrients that would not be absorbed during a flare up or when the GI tract is inflamed. The
elemental diet gives the digestive system time to heal and rest from not having to process
nutrients and solid food through it and this helps leads to less inflammation in the body. The
purpose of bowel rest and an elemental diet is also necessary for a
Crohns patients that are going through therapy and changing medications (Health, 2009).

7. Should there be concern about any vitamins or minerals that are believed to be absorbed
in the ileum? (5points)
There is concern about absorption in the ileum because when the GI is inflamed it cannot
properly absorb vitamins and minerals. The vitamins and minerals that are of concern that will
not be properly absorbed in the ileum are vitamin B12, Iron, Sodium, folic acid, vitamin C and
other water soluble vitamins. This becomes a concern because without the proper amount of iron
being absorbed in the body will cause the patient to have anemia. The lack of sodium will cause
electrolyte imbalance and cause hyponatremia. If not enough B12, folic acid and vitamin C is not
absorbed proteins cannot be broken down properly in the body. This affects metabolism and
immune functions in the body (CCFA, 2015).
8. Determine Mrs. Ms BMI, IBW, and percent IBW. Show work. (5 points)
43.9985 kilograms rounded to 44 and a height of 1.5748 meters.
BMI: 44/ 1.5748^2 = 17.6 BMI= 17.6 A BMI this low puts her in the underweight category on
the BMI scale for women.
IBW: 45.5kg+ 2.3 x3= 52.4
IBW%: (44x100)/52.4= 83.96% or 84%
IBW: 100lb. (for feet) + 2lb( for 2 inches) = 102lbs.
9. Calculate Mrs. Ms energy needs (using Mifflin-St Jeor formula) and protein (grams and
calories). Show work (5 points)
Mifflin- St Jeor formula for women:

Resting energy expenditure= 10x weight kg. (IBW will be used)+ 6.25 x height cm.-5x age-161
Used higher kg to get Mrs. M to the amount of kilocalories she needs to reach her Ideal
body weight instead of calculating kilocalories by her own body weight. A round number of
50.0kg was used when calculating her REE.
REE= 10 (50.0 kg) + 6.25 (157.5 cm) 5 (54 years) 161
REE= 500 + 984 270 161
REE= 1,053 kilocalories
Total energy expenditure 1,053 x1.2 (activity factor for patient that is bed ridden) x 1.4 (For
healing from surgery).
TEE=1,770 kilocalories per day or a range of 1,700-1,800 kilocalories per day.
Mrs. Ms protein needs are increased to 1.5g to 1.7g because of her surgery and the extra protein
needed to heal after the surgery.
1.5x 50kg= 75grams of protein or 1.7x50kg= 85grams of protein so range of 75-85grams protein.
75gx4= 300 calories from protein 85gx4= 340 A range of 300-340 calories will come from
protein. If Mrs. M does not heal at an average rate protein needs may need to be increased to
help her body readily heal from surgery.
10. Calculate the grams/kg and calories that would come from dextrose and lipids in the
parenteral formula. Show your work. (5 points)
Lipid energy requirement: Calculated using higher caloric intake

.30x 1,800kcals= 540kilcalories divided by 9= 60 grams from lipids

540kcal. /2kcal per cc unit= 270cc lipid at 20%
For 24 hours there needs to be 11cc given per hour because the 270cc is divided among the 24
hours.
Carbohydrate energy requirement:
920kcal/ 1,800= 51% carbohydrates
920kcal/ 4grams per carbohydrate= 230grams of carbs.
3.4kcal/gram of dextrose
920kcal/3.4kcal/gram=270grams of dextrose
270grams of dextrose=.50=540cc
11. Calculate Mrs. Ms sodium, potassium, calcium, phosphorus, and magnesium needs.
Show your work. (5points)
Sodium: 1-2 meq/kg 44.1x 1= 44.1meq of sodium
Potassium: 1-2 meq/kg 44.1x1=44.1meq of potassium
Calcium: 10-15 mEq= 10mEq of calcium
Phosphorus: 20-40 mmol= 35 mmol of phosphorus
Magnesium: 8-20 mEq= 15meq/day of magnesium

Mrs. M may need higher amounts of these electrolytes due to her excessive loss of fluids. Since
she is deficient from having diarrhea and is experiencing flare ups with her Crohns disease Mrs.
M may need to take in more so that her body can get the efficient amount to help bring her
electrolytes back into balance. The sodium level will have to be monitored due to the sodium
retention her corticosteroid causes from one of its side effects. Mrs. Ms lab results show that she
is deficient in all of these areas of nutrition.
This chart was found in Nelms on page 103.
12. Calculate Mrs. Ms vitamin, mineral, and fluid needs. Show your work. (5 points)
Vitamins have a standard 10 mL vial of multiple vitamin infusion that includes vitamin K.
Minerals have a standard 5 mL vial of multiple trace element infusion. An increase in iron may
be needed since Mrs. M is anemic because her iron levels are so low (Nelms,98-109).
For Mrs. Ms fluid needs I increased them because she is experiencing so much fluid loss
from diarrhea. I do not want Mrs. M staying dehydrated from losing fluids because it will hurt
the absorption of the vitamins and minerals and hinder her healing process.
30-35 mL per kilogram per day
30-35 mL x 50 kg= 1500-1750 mL fluid per day
1 mL x 1,800 kcal= 1,800 mL fluid per day
13. Write a parenteral nutrition prescription using the attached parenteral form. (15
points).
Attached form on back.

12 hours was used for the Rate and volume because the TPN is only received at night which is
half the time so 12 hours instead of 24 hours.
14. Write an ADIME note regarding the nutrition care given Mrs. M Be specific when
addressing her medical nutrition therapy.

A: 54 year old active female, referred to Registered Dietician after recurrent Crohns disease for
TPN mixture, flow rate, and eventual diet for SBS.
A. Height 52, Weight 97 lbs., BMI: 17.6, IBW: 110 lbs., %IBW: 84%
B. Glu 140mg/dL, Ca 8.8 mg/dL, Na 132 mEq/L, K 3.3 mEq/L, Mg 1.6 mEq/L, Phos 2.3 mg/dL,
Alb 3.0 g/dL, Hgb 11g/dL, Hct 33%, WBC 14.2x10/uL, %Lymph 20%
C. Past medical history reveals that patient has had total colectomy and partial ileectomy with
three different surgeries. Patient has been dealing with diarrhea and balancing electrolytes,
Anemic and dehydration. She has been experiencing fatigue, weakness, and fluid loss.

D. Patient has been on limited solid foods for past yr. MD ordered NPO and on SBR. Placed on
TPN consisting of: 500cc of D50W, 500cc of 8.5% AA, standard electrolytes with 1 amp of MVI
12, and 3 cc MTE every day via Hickman/Broviac catheter, start at 25 cc/hr. TEE found to be
1,770 kcals/day. Appropriate TPN consisting of: 540 cc of D50W, 170 cc 5.6% AA, increased
electrolytes with 1 amp MVI 13, trace elements with Fe, and 11 cc MTE every day via
Hickman/Broviac catheter, start at 64 cc/hr.

D:

Inadequate oral intake related to recurrent Crohns disease as evidence by BMI of 17.6

(NI-2.1).
Inadequate fluid intake related to recent partial ileotomy as evidence by lab values (NI-

3.1).
Complications with GI function related to partial ileotomy as evidence by diarrhea and
dehydration (NC-1.4).

I: Start patient on appropriate TPN consisting of: 540 cc of D50W, 170 cc 5.6% AA, increased
electrolytes with 1 amp MVI 12. Educate patient on eventual 1,800-calorie diet for SBS and on
implementing foods that will reduce negative symptoms associated with the syndrome.
M: Monitor weight of Mrs. M and make sure all her caloric needs are being met and that she is
gaining or at least maintaining weight since she is in the underweight category. Check on her
vitamin and mineral intake and make sure she is increasing in her absorption and that she is not
deficient in any of her vitamin/ mineral needs. If values start to decrease a new TPN order will be
put into place. Education on how important it is that Mrs.s receives proper nutrient proportions
and how the TPN is a vital importance on getting her to a healthy weight and healthy vitamin and
mineral level. Education on how TPN works and how she needs to be on TPN until she is able to
maintain adequate nutrient and electrolyte balance.
E: Evaluate if Mrs. M is doing well on her TPN and has brought electrolyte balance back up to
her needs. Making sure there is nothing that is bothering Mrs. M about her TPN nutrition and
adjust any problems that she might be having. Talk to Mrs. Ms husband about any problems he
might be having with his wifes TPN and if there is any education we can give him about what is
going on with his wife. Evaluate if Mrs. M is gaining weight and if she is not add a higher caloric
intake and check on the different side effects she might be dealing with and how to make it easier

on her and her family to deal with or even adjust medications to a different type or a lower
dosage.

Work Cited

(2009, June 9). Retrieved December 5, 2015, from http://health.usnews.com/healthconditions/digestive-disorders/crohns-disease/managing

Crohn's & Colitis. (2015, August 15). Retrieved December 5, 2015, from
http://www.ccfa.org/resources/nutrition-and-ibd.html?referrer=https://www.google.com/
Ileostomy and your diet: MedlinePlus Medical Encyclopedia. (2014, April 10). Retrieved
December 5, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000070.htm
Ileostomy and your diet: MedlinePlus Medical Encyclopedia. (2014, November 20). Retrieved
December 5, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000070.htm
Learn The Facts About Crohn's Disease and Ulcerative Colitis. (n.d.). Retrieved December 5,
2015, from
https://www.crohnsandcolitis.com/crohns/causes?
cid=ppc_ppd_ggl_cd_da_cause_of_cro
hn's_disease_Exact_64Z1709071
Nelms, M., Sucher, K., & Lacey, K. (2016). Nutrition Therapy and Pathophysiology (3rd ed.).
Cengage Learning.
Solu-Medrol - FDA prescribing information, side effects and uses. (2015, February 17).
Retrieved December 5, 2015, from http://www.drugs.com/pro/solu-medrol.html