Introduction of Patient Case....................................................................................................pg 3
Etiology and Pathophysiology of Conditions..........................................................................pg 4
Medical List of Concerns..........................................................................................................pg 6 Hip Fracture...............................................................................................................................pg 6 Body Inclusion Myositis..............................................................................................................pg 6 Deep Vein Thrombosis................................................................................................................pg 7 Dyphagia/Zenker's Diverticulum................................................................................................pg 7 Pressure Ulcer............................................................................................................................pg 9 Malnutrition..............................................................................................................................pg 10
Nutrition Practice Guidelines................................................................................................pg 10 Dysphagia.................................................................................................................................pg 10 Pressure Ulcers.........................................................................................................................pg 12 Malnutrition and Long-Term Tube Feeding.............................................................................pg 13
Nutrition Care Process...........................................................................................................pg 19
I ntroduction of Patient Case 3
An 81 year old female was admitted to the hospital after visiting the emergency room on January 28th. The patient presented with right leg and knee pain from a mechanical fall at home, due to a history of inclusion-body myositis (IBM). The x-rays that were completed confirmed a displaced supracondylar fracture of the right distal femur. Orthopedics was consulted and the patient underwent a successful open reduction internal fixation (ORIF) surgery on January 29th. Upon nutrition assessment, the patient was flagged for being underweight for age, with a BMI of 22.59 and also reported having a history of difficulty swallowing and weight loss. Due to this condition, the patient was ordered a National Dysphagia Diet mechanical soft (NND2) and honey thick liquids diet. To prevent further weight loss and promote hip fracture healing, the patient was also started on an oral liquid supplement two times per day, a honey thickened carnation instant breakfast. The supplement, however, was not tolerated well and the patient agreed to try nectar thick milkshakes with the addition of a scoop of Beneprotein. Additionally, speech pathology held a barium swallow test on January 30th to determine the safest oral intake consistency. The patient was assessed on the ability to ingest pureed foods, thin liquids, nectar thick liquids, and honey thick liquids. Results of the evaluation were moderate oropharyngeal dysphagia and the discovery of a small to medium sized Zenker's Diverticulum (ZD). Based on results, the diet was downgraded to NDD1 (pureed) and liquids were upgraded to thin. Due to the small size of the ZD and advanced age of the patient, the medical doctor (MD) did not believe the patient was a candidate for surgery. The patient continued to have poor oral intake, continually complaining about not being able to eat favorite or familiar foods. On February 4th, speech pathology upgraded the patient's diet to NDD3 (advanced/soft foods) and thin liquids. At this time, dietary also changed the oral liquid supplementation to Ensure two times a day. Despite these changes, nursing reports continued to state that the patient was not consuming 4
sufficient oral intake so the MD ordered a three day calorie count from February 5th-7th. During the second day of the calorie count, the patient confessed to sneaking snacks outside the parameters of the NDD3 diet. Dietary made all members of the interdisciplinary team aware and requested that the snacks be accounted for in the calorie count. With additional snacks, the patient's calorie count increased, and by day three was able to achieve 90% of caloric needs and 76% of protein needs. However, because the patient was receiving most of their nutrition through oral liquid supplements, the MD ordered a second three day calorie count from February 8th-10th. During the second calorie count, the patient's intake declined, meeting less than 50% of daily caloric and protein needs. Simultaneously, the patient developed swelling in the right lower extremity. A venous Doppler study confirmed deep venous thrombosis (DVT) in the right superficial femoral and poplitheal veins, secondary to prolonged immobilization of legs. A stage two pressure ulcer developed on the patient's right buttocks, which was also caused by being immobile and bedridden since admission. Additionally, a three pound weight loss occurred over a two week period from lack of adequate oral intake. The combination of the above factors, led to a diagnosis of malnutrition from the MD. On February 13th, the MD decided a long-term PEG tube placement was necessary to keep the patient adequately nourished. Dietary was consulted for enteral tube feed calculations. Initial NG-tube placement failed due to the patient's ZD, indicating the need to instead surgically place a G-tube. On February 16th the patient was declared medically stable and was discharged to rehab. Etiology and Pathophysiology of Conditions The patient exhibited a number of conditions that ultimately led to a malnutrition diagnosis. Malnutrition is a broad term, that can be defined as calorie and protein deprivation resulting from inadequate intake, which can result in muscle wasting 1 . The advanced age of this 5
patient is important to the overall case. Advanced age is accompanied by changes that can negatively impact nutritional status, such as decreased appetite, loss in sensory functions, oral problems, gastrointestinal alterations, muscle loss, decreased physical ability, side effects from chronic diseases and medications, reduced social contact, and limited food access 1,2 . Studies have shown that 26-32% of independent elderly and up to 83% of the home-bound elderly are at moderate to high risk for malnutrition 1 . Due to a nutrition assessment in which the patient reported already following a soft foods diet for known difficulty with swallowing, a common symptom of IBM, a progressive inflammatory disease that results in body muscle weakness 3 , and underweight BMI, it is likely that the patient arrived already malnourished. Further evaluation of the patient's swallowing function led to the discovery of a small to medium sized ZD, an abnormal pouch in the throat where ingested food may get stuck, causing aspiration and regurgitation. The combination of the patient's IBM, ZD and ultimately dysphagia made it impossible to meet adequate nutrition needs. Failure to provide the body with essential daily nutrients allowed for a dermal disruption and the development of a pressure ulcer on the buttocks two weeks into the patient's stay, as well as a three pound weight loss. Despite treating the patient's dysphagia by altering the diet order and providing the patient with oral liquid supplementation, the patient was still unable to meet their estimated daily needs. The placement of a long-term tube feed became necessary for this patient to prevent further malnutrition and wasting.
Medical List of Concerns 6
The patient was originally admitted for a hip fracture. However, as indicated above, this patient's case presented several medical concerns such as IBM, right leg DVT, dysphagia/ZD, a pressure ulcer, and malnutrition. Hip Fracture A hip fracture is a break in the upper quarter of the femur and usually occurs from a fall or direct blow to the side of the body 4 . Elderly persons, who often have inadequate nutrition and thus weaker bones are at a high risk for hip fractures 5 . The diagnosis of a hip fracture can be confirmed by an x-ray. Treatment may be surgical or non-surgical, depending on the severity of the break. If surgery is performed, a patient will work with a physical therapist to strengthen the bone and restore their ability to walk 4 . Another common medical intervention may be to take blood thinner medications to reduce the chance of developing blood clots while the fracture heals 4 . Additionally, it is also suggested that increasing protein intake may aid in the recovery process. In the hospital setting, this is often accomplished with the use of an oral liquid supplementation that is higher in calories and protein, as well as enriched with vitamins and minerals. A recent study examined the impact of using oral liquid supplements in elderly hip fracture hospitalized patients with positive results 5 . The patients who were supplemented when compared to the control group had a reduced length of hospital stay and fewer complications such as weight loss and pressure ulcers 5 . Inclusion Body Myositis IBM is the gradual loss of muscle strength, usually occurring in those over the age of 50 6 . Weakness is first noticeable in the wrists and fingers, followed by the forearms and leg muscles 6 . The cause of IBM is unknown, but the suggestion of viruses or certain medications triggering an autoimmune response, as well as genetics has been made 6 . About one-third of people with IBM 7
have difficulty swallowing due to the weakening of throat muscles 6 . Often this symptom goes unnoticed and can lead to unintended weight loss and malnutrition 3 . For example, one study examined 57 patients with the clinical diagnosis of IBM and found that dysphagia was present in 37 (65%) of these patients, but only 17 of these patients (46%) had complained about swallowing to their physician 3 . IBM has not been found to decrease life expectancy, but managing symptoms is critical 6 . In those with dysphagia from IBM modified consistency diets, esophageal dilation, or crycopharyngeal myotomy surgery may be necessary to keep a patient nourished 7 . In extreme cases, a PEG tube or G-tube may be necessary 7 . Medical management may also include medications and physical therapy 6 . Deep Vein Thrombosis DVT occurs when a blood clot forms in one or more of the deep veins in the body, typically the legs, resulting in swelling, pain, and skin color changes 8 . DVT can be caused by multiple factors, but most commonly in the hospital setting it is caused by prolonged bed rest 8 . Either a Doppler ultrasound of the legs or D-dimer test can be performed to confirm the diagnosis. Most patients will be placed on anticoagulant therapy and symptoms will disappear quickly 9 . After discharge, prevention of DVT consists of maintaining a healthy lifestyle by staying physically active, promoting blood flow, maintaining a normal weight, and improving dietary habits by limiting fat and increasing fiber 10 . Dysphagia/Zenker's Diverticulum Dysphagia, also known as swallowing difficulty, currently affects 300,000-600,000 people annually 11 . Dysphagia is common in the elderly, due to reduction in muscle mass and connective tissue elasticity in the esophagus muscles 11 . Reports have shown that dysphagia occurs in 68% of elderly nursing home residents, 30% of elderly admitted to the hospital, 64% of 8
patients after stroke, and 13-38% of elderly who live independently 11 . As previously mentioned, dysphagia is a common symptom in the presence of a ZD due to undigested food debris getting trapped in the diverticulum 12 . A ZD is a sac-like out-pouching of the muscosa and submucosa layers in the throat 12 . The etiology of a ZD is unknown, but most theories conclude a structural or physiological abnormality of the cricopharyngeus muscle of the throat 13 . Some studies have investigated the possibility of a genetic predisposition without much success. A study done in Finland used a questionnaire of 77 patients with ZDs to find a familial linkage. However, only three in 77 of the patients were discovered to have a relative with a ZD 14 . The annual estimated incidence of ZDs is two per 100,000, with prevalence 0.01 and 0.11% 15 . Studies have shown that ZDs occur mainly in the elderly, around the age of 70 and are more common in males than females 12 . The gold standard for diagnosing ZD is the barium swallow which is a test held by a speech language pathologist that allows the speech pathologist to classify the size of the diverticulum and thus determine the best treatment 15 . A ZD can be categorized as small (up to two centimeters), intermediate/moderate (two to four centimeters) or large (four to six centimeters) 16 . Treatment for a ZD is usually surgery, which can be done in three different forms: complete open, rigid endoscopy, or flexible endoscopy 12 . A retrospective study on 22 patients who underwent surgery in one of the three forms for their ZD were followed over ten years and showed that 95% of the patients showed improvement in their ability to swallow 15 . Professionals may disagree on the best form of surgical treatment, but the current trend is flexible endoscopic surgery because it is considered less invasive and has a lower complication rate 16 . However, a literature review study of multiple published studies that used each surgery method found an approximate 90% success rate in all surgery methods, thus concluding no one technique more superior to another 16 . Surgical treatment for a ZD may not be appropriate for 9
some patients because the risks may outweigh the benefits. If this is the case, treatment for a patient with ZD may be through dysphagia management techniques such as altering food and liquid consistencies, adjusting posture, and/or swallowing maneuvers 11 . If dysphagia management strategies still do not allow a patient to their daily estimated needs, long-term nutrition support may be necessary 11 . Pressure Ulcers The Mayo Clinic defines a pressure ulcer as an injury to skin and underlying tissue resulting from prolonged pressure to the area 17 . The National Ulcer Advisory Panel has created a staging system from one to four to grade the severity of pressure ulcers 17 . Many patients in the hospital are bedridden and are more susceptible to sustained pressure on areas of the body 17 . In U.S. acute care facilities, an estimated 2.5 million pressure ulcers are treated a year 18 . In particular, the elderly are at an increased risk of developing pressure ulcers due to fragile skin and poor nutrition 19 . In the acute clinical setting, prevention is key in stopping the development of pressure ulcers. Nursing staff must reposition patients and clean/wrap pressure ulcers per MD orders 17 . Additionally, adequate nutrition, particularly in the form of protein is necessary to promote healing. In a study of 108 patients with pressure ulcers, individuals with low serum protein or serum albumin were found to have significantly less healing capability than those with normal protein values 18 . A common intervention in the clinical setting is to increase calories, protein, and essential vitamins and minerals to promote healing through the use of oral liquid supplements. In a double-blind, randomized trial of 50 elderly patients referred for pressure ulcer management, the use of oral liquid supplementation showed significant reduction in pressure ulcer size and exudates when compared against the control group, as well as additional benefits of weight loss prevention and an increase in cognitive function 19 . 10
Malnutrition The International Dietetics and Nutrition Terminology defines malnutrition as inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting including starvation-related malnutrition, chronic disease-related malnutrition and acute disease or injury-related malnutrition 21 . The Academy of Nutrition and Dietetics and A.S.P.E.N. have developed a table of six clinical characteristics to diagnose malnutrition 21 . This chart is beneficial to clinicians because so many assume that a patient must be underweight to be considered malnourished. For example, in a survey of U.S. primary care physicians, it was found that only 10% assessed overweight patients who could be classified as malnourished 1 . In particular, the elderly are at an increased risk of malnutrition due to multiple physiological changes such as body composition changes, sedentary lifestyles, sensory losses, oral health, gastrointestinal disorders, chronic diseases, loss of functionality, and depression 20 . Among hospitalized elderly patients, 40-60% are malnourished or at risk for malnutrition, 40- 85% of nursing home residents have malnutrition, and 20-60% of home-care patients are malnourished 20 . In a clinical setting, oral liquid supplements are commonly used to increase a malnourished patient's intake 1 . In severe cases, nutrition support may need to be used, especially if malnutrition has developed as a result of the patient's inability to voluntarily consume enough food and/or beverages to meet their estimated needs 20,21 . Nutrition Practice Guidelines When developing a nutrition care plan for this patient, the Dietitian must identify the conditions of the patient that can be alleviated nutritionally. The specific complications of this patient that can be addressed nutritionally are dysphagia, a pressure ulcer, and malnutrition. 11
Decisions on how to treat the selected conditions must be made after carefully investigating the most current recommendations and published guidelines. Dysphagia The intent of dysphagia intervention is to provide adequate oral and fluid intake to maintain a healthy weight, prevent nutrition deficiencies, and support independent eating behaviors 22 . A nutrition care plan can be developed based on finding the safest food and liquid consistencies, determining the patient's needs, food preferences, and addressing underlying medical, psychological, or social factors 22 . Often the NDD is used when modified consistency food and fluids is needed. The three levels of solid foods on the NDD are pureed, mechanically altered, and advanced. The four levels of fluids are thin, nectar, honey, and spoon-thick 22 . However, it is important to note that some studies contradict the use of a modified consistency diet in dysphagia patients. One study compared intake in dysphagia patients on a regular diet to those on a modified consistency diet and showed that patients eating a regular diet had greater oral intake than those on the modified consistency diet 23 . Additionally, another study conducted over a 12 week period, compared dysphagia patients on a modified consistency diet and found that patients who were offered a modified diet with the addition of some regular foods ate greater amounts and gained weight when compared to those patients who were on the standard modified consistency diet 24 . Other general recommendations for dysphagia patients are to avoid alcohol, hot foods and beverages, spicy foods, and caffeine as well as avoiding easily aspirated foods such as popcorn, bran cereal, nuts, cottage cheese, skins of fruit, hully vegetables, and dry, crumbly, or sticky foods 22 .
Pressure Ulcers 12
According to the Academy of Nutrition and Dietetics, the goals of the nutrition intervention in pressure ulcer management are to maintain adequate nutritional status by providing optimum dietary and fluid intake, identifying and treating causes of poor nutritional intake, and monitoring weight status routinely 25 . When determining calorie needs for a patient with a pressure ulcer, The Agency for Health Care recommends increasing energy needs to 30- 35 calories per kilogram of body weight per day 25 . The European Pressure Ulcer Advisory Panel recommends an even higher energy intake per day for those who are underweight or losing weight, at 35-40 calories per kilogram per day 25 . Providing extra protein is also suggested as being beneficial in treating pressure ulcers. Normal protein recommendations per the Institute of Medicine for an adult are 0.8-1.0 grams per kilogram per day
and 1.0-1.2 grams per kilogram per day for elderly patients 26,27 . However, when a patient has a pressure ulcer, protein needs can be anywhere from 1.0-1.5 grams per kilogram per the European Pressure Ulcer Advisory Panel 25 . If vitamin and mineral deficiencies are present, providing a multivitamin to meet the recommended daily intakes for micronutrients is suggested, but no clear data exists to indicate further supplementation will decrease risk or aid in pressure ulcer healing 28 . However, there is some support for the supplementation of the amino acids arginine and glutamine in pressure ulcer healing. In one study, a group of 30 volunteers were provided either a mixed amino acid supplement containing both arginine and glutamine or a placebo supplement. This study found those receiving the amino acids had significantly higher collagen deposition 29 . In a hospital setting, providing a patient with an oral liquid supplement is an easy method to increase calories and protein, as well as vitamins and minerals. Pressure ulcer patients may also benefit from general education on the relationship between adequate calories, protein, and vitamins and minerals in pressure ulcer healing 25 . 13
Malnutrition and Long-Term Tube Feeding According to the Academy of Nutrition and Dietetics and A.S.P.E.N., malnutrition has three typical etiologies: acute illness or injury (severe acute inflammation), chronic illness (mild to moderate chronic inflammation), or social or environmental circumstances (without inflammation) 21 . Standardized characteristics of malnutrition are weight loss, insufficient energy intake, loss of subcutaneous fat, loss of muscle mass, localized or generalized fluid accumulation, and/or diminished functional status (measured by hand-grip strength) 21 . A minimum of two of the above characteristics must be met for a patient to be coded as malnourished 21 . In a patient who has permanent swallowing problems or damage to the esophagus, which prevents them from meeting their daily estimated needs, a long-term enteral tube feed may be necessary and/or useful 30 . According to A.S.P.E.N., when an enteral tube feed must continue for more than four weeks, a nasogastric tube or gastrostomy tube placement is recommended 30 . The Dietitian caring for the patient is responsible for calculating the patients nutritional needs, choosing the proper formula, determining the initiation and goal rate of the tube feeding, and monitoring and evaluating tolerance. Nutrition requirements can be calculated using several methods such as Mifflin St. Jeor or the Harris-Benedict equations, with adjustments based on the confounding medical conditions of the patient and the Dietician's clinical judgement 30 . As previously stated, normal protein recommendations per the Institute of Medicine for an adult are 0.8-1.0 grams per kilogram per day
and 1.0-1.2 grams per kilogram per day for elderly patients 26,27 . Fluid requirements can be determined using a variety of methods, but the most commonly used is assuming 30 milliliters per kilogram is needed, with a minimum of 1500 milliliters 31 . In long-term tube-fed patients, polymeric standard formulas have proven to be the most beneficial, with the potential for the addition of fiber to enhance benefits 30 . A 14
randomized, double-blinded, crossover trial tested the addition of fiber in standardized formulas in long-term enterally fed patients with overall positive results on gut micobitoa health 33 . Tube feedings can be administered continuously, intermittently, or in bolus feeds. Often patients on long-term tube feeds will be fed using an intermittent drip because feedings mimic a typical meal and snack pattern and allow for more freedom and mobility 30 . A bolus tube feed at night to make up for leftover needs may be appropriate in those patients who can orally consume only 500-700 calories on their own during the day 30 . Current guidelines for enteral feeding initiation are not available, but can begin as high 50 milliliters per hour, if desired 32 . However, clinical judgment should be used based on the patient's conditions, meaning a slower initiation may be warranted 32 . After an initial rate is tolerated and advanced to the goal rate, a long-term stable enterally fed patients still need to be monitored. Intake and output as well as bowel movements should be recorded daily, weekly weights recorded, with laboratory values taken monthly, and tube feeding placement and gastric residual volumes checked only if signs/symptoms indicate that the patient's tube may have migrated 32 . Discussion The nutrition care plan developed for this patient utilized all of the guidelines discussed above. The original reason for the patient's admission was a hip fracture, which does not usually call for nutrition intervention. However, because the patient was underweight for age with a BMI of 22.59, the patient was considered at nutritional risk and was placed on an oral liquid supplement. After a nutrition assessment, the patient admitted to having difficulty swallowing, further increasing nutritional concerns, and a swallow evaluation was ordered. The result of the evaluation was a small to moderate ZD, the primary contributor to the patient's dysphagia . The patient was not considered a candidate for surgery, and was placed on NDD1 (pureed) and thin 15
liquids to prevent aspiration and regurgitation. The change in diet order did not satisfy the patient in terms of quality of life and continuous complaints were made. The patient was re- evaluated by the speech pathologist and advanced to NDD3 (advanced/soft). Two separate calorie counts over three days each were utilized to determine if the patient was able to meet their daily estimated nutritional needs. Even after modified consistency diets and the use of oral liquid supplementation, the patient did not reach the required levels. Additionally, a pressure ulcer developed on the patient's buttocks and a three pound weight loss occurred over a two week period. The combination of the characteristics of weight loss and insufficient energy intake, under the etiology of an acute injury, allowed for the medical diagnosis of malnutrition, thus indicating to the MD that a long-term NG- tube placement was necessary. After this placement failed due to the patient's ZD, a G-tube was surgically placed instead of the NG-tube on the following day. Tube feeding recommendations were made by the Dietician using A.S.P.E.N. guidelines. The patient's needs were determined using Mifflin St. Jeor with an activity factor of 1.3, 1.0-1.2 grams of protein per kilogram, and 25-30 milliliters per kilogram of fluids per day. Jevity 1.2, a high-protein, fiber-fortified formula was ordered in the form of bolus tube feeds five times per day, in hopes that the patient could lead a more normal lifestyle and potentially still consume food orally if desired using pleasure feeds. After the patient was declared medically and nutritionally stable, the patient was discharged to a rehab facility where the patient could begin to work on the mobility of her healing hip fracture.
Conclusion/Recommendations 16
The primary concern for this patient became preventing further progression of malnutrition. The care plan for this patient was multi-faceted and required several team members to achieve a stable outcome. Even though the patient was discharged on a long-term tube feed, it is evident that extraordinary efforts were made to keep the patient's quality of life as high, and as normal as possible throughout the hospital stay. Tube feeding became necessary to sustain the life of the patient because the use of an oral liquid supplement and modifications in the consistency of the patient's foods and fluids were not enough to allow the patient to achieve their daily estimated needs. However, the goal of nutrition support should not only be to provide sufficient means of nutrition, but to also improve quality of life 1 . While not immediately apparent, a bolus tube feed was ordered specifically for this reason. The bolus feeds would be a way for the patient to fulfill their physiological need of nutrition, while the option of pleasure feeds would fulfill the psychological need of smell, taste, fullness, and satisfaction with the overall result of enhancing quality of life 1 .
References
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20. Wellman NS, Kamp BJ. Nutrition in aging. In: Mahan LK, Escott-Stump S, ed. 12. Krause's Food & Nutrition Therapy. St. Louis, Missouri: Saunders Elsevier; 2008: 286- 305. 21. Malnutrition. American Academy of Nutrition and Dietetics Nutrition Care Manual Website. http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=109585&highlight=m alnutrition. 2014. Accessed March 2014. 22. Dysphagia. American Academy of Nutrition and Dietetics Nutrition Care Manual Web Site. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=22679&lv2=25 5550&ncm_toc_id=255550&ncm_heading=Nutrition%20Care. 2014. Accessed March 2014. 23. Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition Dietetics. 2005; 18: 213-219. 24. Germain I, Dufresne T, Gray-Donald K. A novel dysphahia diet improveds the nutrient intake of institutionalized elders. Journal of American Dietetic Association. 2006; 106: 1614-1623. 25. Pressure ulcers. American Academy of Nutrition and Dietetics Nutrition Care Manual Web Site. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5546&lv2=166 68&ncm_toc_id=16668&ncm_heading=Nutrition%20Care. 2014. Accessed March 2014. 26. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC: National Academies Press; 2005. 27. Campbell WW, Crim MC, Young VR, Joseph LG, Evans WJ. Effects of resistance training and dietary protein intake on protein metabolism in older adults. American Journal of Physiology. 1995; 268: E1143-E1153. 28. Reddy M, Sudeep SG, Kalkar SR, et al. Treatement of pressure ulcers: A systematic review. JAMA. 2008; 300(22): 2647-2662. 29. Williams JZ, Barbul A. Nutrition and wound healing. Surg Clin North Am. 2003; 83: 571-596. 30. Dorner B, Posthauer ME, Friedrich EK, Robinson GE. Enteral nutrition for older adults in nursing facilities. Nutrition in Clinical Practice. 2011; 26(3): 261-272. 31. American Dietetic Association Evidence Analysis Library. Available to members at: www.adaevidencelibrary.com. Accessed March 2014. 32. Enteral nutrition. American Academy of Nutrition and Dietetics Nutrition Care Manual Website. http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255292. 2014. Accessed March 2014. 33. Schneider SM, Girard-Pipau F, Anty R, et. al. Effects of total enteral nutrition supplemented with muli-fibre mix on fecal short-chain fatty acids and microbiota. Clinical Nutrition. 2005; 28:2267-2279.
Nutrition Care Process 19
Sage Dietetic Internship - NCP Form Patient: MT Referred for: Enteral Tube Feed NUTRITION ASSESSMENT Food and Nutrition Related History: Admin 1/28: NPO for ORIF surgery Assessment: Patient lives at home w/ husband and has health aide who comes to house Mon-Fri to help w/ care. At home pt usually eats soft foods prepared by aide. Pt states not being a big eater and has small snacks throughout the day. Examples provided by patient include eggs, flaxseed toast, chocolate shakes, mashed sweet potatoes, pudding. shaved ham. Pt reports avoiding hard or rough food due to prolonged difficulty swallowing. Pt agreeable to carnation instant breakfast BID (300kcal, 26g pro). 1/30/14: Mech. Altered (NND2), Honey Thick Liquids, Chocolate Milkshake w/ Beneprotein BID (710kcal, 38g pro) 2/1/14: Puree (NND1), Thin Liquids, Chocolate Ensure BID (700kcal, 26g pro) 2/4/14: Advanced (NND3), Thin Liquids, Chocolate Ensure BID (700kcal, 26g pro) 2/5/14: 3-day calorie count *2/5= 870kcal (54% total kcal needs), 34g pro (49% total pro needs)-majority of kcals from ensure *2/6= 760kcal (48% total kcal needs), 21g pro (30% total pro needs)-majority of kcals from ensure, pt found to be sneaking cheese snack crackers and dry honey nut cheerio cereal in between meals *2/7 =1440 (90% total kcal needs), 53g pro (76% total pro needs)-majority of kcals from ensure 2/8: Second 3-day calorie count *2/8=1200kcal (75% total kcal needs), 40g pro (59% total pro needs)-majority of kcals from ensure *2/9=640kcal (40% total kcal needs), 19g pro (27% total pro needs)-majority of kcals from ensure *2/10=720kcal (45% total kcal needs), 24g pro (34% total pro needs)-majority of kcals from ensure, possible 3lb wt loss 2/13: NPO for PEG placement per MD order; placement failed due to Zenker's 2/14: NPO for G-tube placement Anthropometric Measurements Age: 81 Gender: Female Ht: 66" Wt: 140lb (bed scale) Wt Hx: 165lb 2 years ago % Wt change: 19% BMI: 22.59-underweight for age Biomedical Data, Medical Tests & Procedures Labs/Date Albumin Glucose HbA1C BUN Creat Na+ K+ Hgb Hct MCV Other 2/20 2.0 90 N/A 11 0.5 144 4.4 9.2 28.8 93.5 Ca 8.3 Phos 2.4 AST 14 Mg 1.7 Medical Diagnosis: Malnutrition Relevant Conditions: R femoral fracture (ORIF), R L deep vein thrombosis, Zenkers Diverticulum PMH: inclusion body myositis x20 years, vertigo, hemorrhoid surgery, cholescystectomy Fam Hx: noncontributory Pertinent Medications: Bactrim 200/40 mg 5ml 2x/day until Feb 22, Lovenox 60mg subcutaneous q 12hrs until therapeutic, Coumadin 5mg daily based on INR levels, Tylenol 650mg every 4 hrs, Dulcolax 10mg daily, Miralax 17g via tube feed daily, Senokot 1 tablet daily, Prevacid 30mg daily, Vitamin B 1 tablet daily, Chewable Multivitamin 1 tablet daily, Vitamin D3 1 tablet daily, TUMS, aspirin, tropical betamethasone, royal jelly powder. Skin status: Intact X Pressure Ulcer/Non-healing wound Comments: Stage 2 to R buttock 4cm in length; 3cm in width; dressings per MD orders BID Physical Assessment: neurological WNL, mental: WNL, cardiovascular WNL, respiratory: WNL, gastrointestinal: soft abdomen, non-distented, non tender; active bowel sounds, genitourinary: WNL Estimated Nutritional Needs Based on Comparative Standards: Calories: Mifflin St. Jeor x 1.3 activity factor 1417-1717kcal/day Protein: 1.0-1.2g/kg/day 64-77g/day Fluid: 25-30ml/kg/day 1600-1900ml/day Diet Order: NPO
Feeding Ability Independent Limited Assistance Oral Problems Chewing Problem X Swallowing Problem Intake Good (> 75%) Fair (approx. 50%) 20
Extensive/Total Assistance X N/A
Mouth Pain None of the Above Poor (<50%) Minimal (<25%) X NPO No Nutritional Diagnosis at this time X Proceed to Nutrition Diagnosis Below NUTRITION DIAGNOSIS P (problem) Inadequate oral intake related to:
E (Etiology) decreased ability to consume sufficient energy secondary to Zenker's Diverticulum as evidenced by: S (Signs & Symptoms): 2 sets of 3-day kcal counts of pt not meeting est. needs and possible 3lb wt loss in 2 wks. INTERVENTION Nutrition Prescription: Recommend enteral nutrition: Jevity 1.2 bolus feedings; initiate 140ml/hr for first 2 feedings, if tolerated, advance to goal rate of 280ml/hr 5x/day to provide 1680kcal, 78g pro, 1128ml free fluid. Recommend 50ml flushes before and after each bolus to meet est fluid needs 1700ml/day Food or Nutrient Delivery: Enteral Nutrition: Jevity 1.2 bolus feed @280l/hr 5x/day with 50ml before and after each bolus
Nutrition education: Content: purpose of tube-feed, risks/benefits, formula selection, how tube feed will be provided, water flushes, administration of medications, care of tube placement site, advancement goals/discontinuation Nutrition Counseling: n/a Coordination of Care (refer to): During Nutrition Care: daily interdisciplinary meeting Discharge and Transfer of Care to New Setting or Provider: rehab per case manager report Goal(s): Initiate enteral nutrition within 48 hours MONITORING & EVALUATION Indicators: 1. Tube-feed goal rate met 2. Tube-feed toleration Criteria: 1. Jevity 1.2 bolus tube feed @280ml/hr 5x/day 2. Residuals <500 (ASPEN guidelines), normal abdominal distention, no signs/symptoms of edema, adequate I&Os, all electrolytes, BUN, creatinine, phosphorus, magnesium, calcium and glucose lab values within normal limits, normal stool output/consistency, minimal weight fluctuation