Meningitis, Hypertensive

Heart Disease, and

Inadequate Nutrition
Case Study Review
Lea Palmer
 Acute Bacterial Meningitis
Bacteria-caused
Inflammation of the
Meninges

(the membranes that line

surround the brain matter
and spinal cord)
 Epidemiology
Risk Factors:

Age 1
Infants
Elderly

Community Settings 2

Medical Conditions 2

Travel 2

Occurrences:

Decreased 55% since Hib vaccinations- infants 1

4,100 cases (500 deaths) 1

2003-2007
 Pathophysiology
Microbial entry into CNS 1

Neutrophils drawn into CSF 3

Vascular Endothelium cells damaged vasculitis and/or

thrombophlebitis 3

Ischemia and/or infarction 3

Brain edema 3

Blood brain barrier disrupted from vasculitis

Intracranial pressure increases 3

Systemic complications 3
 Signs and Symptoms
Respiratory illness or sore throat precedent 3

Fever 4

Headache 4

Stiff Neck 3,4

Emesis 4

Seizures (30%) 3

Cranial nerve abnormalities (10-20%) 3

Irritability 3

Confusion 4

Drowsiness 3

Stupor 3

Coma 3

Dehydration 3

Infection 3
 Diagnosis
Immediate treatment with suspected diagnosis 3
Corticosteroids- anti-inflammatory
Antibiotics

Blood draw for:

Culture- positive in 90% 3
Gram Stain- shows organisms in 80% 3

Lumbar puncture for CSF (required)

WBC, total protein 1

CT- may look normal 1

MRI w/ gadolinium-
more sensitive to subarachnoid inflammations 1
 Treatment
Medical

Corticosteroids 3

Parenteral Antibiotics 4

Nutritional

4
 Hypertensive Heart Disease

Chronic hypertension-
causing structural and
functional abnormalities
to the heart5
 Epidemiology
Risk Factors:

Obesity 6
50% obese have hypertension
60-70% w/ HHD are obese

Occurrences:
Pathophysiology8

Left ventricular wall thickens in

response to stress from
hypertension9

Diastolic LV dysfunction9

Systolic LV dysfunction9
 Signs and Symptoms
Coronary Artery Atherosclerosis10

Hypertrophic Cardiomyopathy10

Athletes heart10

Sleep Apnea10

Angina 11

SOB 11

Fatigue 11

11
 Diagnosis
MRI 8
LVM
Myocardial composition

3D Echocardiography 8

Looking for LVH 9

Intervention7
 DASH diet14
Dietary Approaches to Stop Hypertension

Vegetables (4-5 servings)12

Fruits (4-5 servings) 12

Low-fat dairy foods (2-3 servings) 12

Whole Grains (6-8 servings) 12

Lean Meat, Poultry, and Fish (<6 servings) 12

Nuts, Seeds, Legumes (4-5 servings/week) 12

Fats & Oils (2-3 servings) 12

Sweets (5 or less) 12
 Patient Profile
JC is a 80 year old Caucasian male
Lives in Logan with wife
Retired
Family Hx:
Father- Cancer
Sibling- Alzheimer's
 Anthropometrics
Admit Weight: 94.4 kg

UBW: 93.18 kg

Height: 180.3 cm

BMI: 28.67

IBW: 78.13 kg

% IBW: 119.3%
 Patient History
Patient Procedures hx:

Tonsillectomy

Breast Growth Removal

Excision of Right Spermacoele

Hemorrhoidectomy (2006)

Extracorporeal Shockwave lithotripsy (2009)

Transurethral Resection of Prostate (2010)

Cataract Surgery (2011)

Colonoscopy (2011)
 Summary of Events
JC was admitted to ER with high fever on 11/02

E. Coli and Sepsis was noted- Given lumbar puncture-

Only 2 mL obtained d/t pt not cooperating

Abdominal CT scan- to find reason for fever- cholelithiasis noted

Creatinine monitored for improvement in kidney injury

Ultrasound for pyelonephritis

MD ordered a cardiac diet and BP checks for heart disease

CPAP therapy
 Lab Day 1 Day 5 Relative Interpretation
Random Glu 115 118 WNL
mg/dL
Alb g/dL 4.3 3.5 WNL Low-end: acute phase reaction
Hct % 49.4 38.2 Below Fast decrease could indicate
anemia, or overhydration from
IV fluids
Hgb (g/dL) 16.8 13.7 Just below Mostly within range, lower
might be d/t heart disease
MCV 90.8 87.6 WNL
(microns3/RB
C)
Creatinine 2.06 1.53 High Kidney damage
(mg/dL)
Na 134 132 Low Kidney damage
(MeQ/L)
 Medication Use DNIs
Na Chloride .9% For e-coli infection No known DNIs
(125 mg every 6 hours)
Enoxaparin (40 mg daily) Anticoagulant No known DNIs

Meropenum Antibiotic for CNS infection, and Na restriction for pt with

(2,000 mg every 12 hours) meningitis hypertension

Metronidazole/ Flagyl Antibiotic for e-coli infection Avoid alcohol during use + 3
(500 mg every 6 hours) days after
Acyclovir Antiviral Increased dehydration risk
(750 mg. every 12 hours)
Acetaminophen Analgesic, antipyretic for fever/ Caffeine increases effect
(650 g every 4 hours PRN) mild pain reliever Avoid alcohol
Aspirin Analgesic, anti-inflammatory, Increase Vit C intake
(81 mg daily) antipyretic for fever/ pain reliever Avoid alcohol
Ondansetron Antiemetic, antinauseant No known DNIs
( 4 mg every 6 hours)
Self Prescribed Vitamin D, Calcium, Vitamin C,
and melatonin
 Clinical- Patient Symptoms
Sepsis

Fever

Acute Encephalopathy

Acute chronic kidney injury

Pyelonephritis

Hypertensive Heart Disease

 Dietary Intake
% PO in hospital: 25-50%

Prior to hospital: normal healthy appetite

Poor appetite r/t fever

Difficulty chewing lettuce d/t tooth implant

Recently has had more spills and has become sloppier

Has had difficulty swallowing carrots

 Dietary Intake
Normal diet:

Variety of meals prepared mostly by wife

Sweets every day

Prefers lots of flavor (Salty)

Self prescribed supplements: hyaluronic acid, Vitamin D,

Calcium, Vitamin C, melatonin
 Nutritional Risk
Malnutrition Risk:

Malnutrition Acute

Moderate Severe

<75% EER for >7 <50% EER for >5

=
daysNourished days
Nutritional Risk:
Wt loss Wt loss
Hypertension- low
Mild Body Fat Moderate Body Fat
Fever- Low
Mild
Muscle Mass
Bacterial Moderate
Meningitis- low Muscle
Mass
Kidney Damage- low
Mild Fluid Moderate to severe
Accumulation
fluid accumulation
Sepsis- moderate

= Moderate Nutritional Risk

 Nutritional Diagnosis
Inadequate Oral Intake (NI-2.1) r/t decreased ability to eat d/t
prolonged catabolic illness AEB PO of 25-50%

Poor appetite r/t fever

Could lead to a risk for severe malnutrition, slow recovery

time, longer LOS, and increased risk for additional infections.

Other diagnosis:

Nutrient related knowledge deficit (NB1.1) r/t cardiac diet AEB

regular diet recall given by wife.

High salt/ fat diet

Hypertensive heart disease

 Intervention
Dietary Needs:

Calories: 2028.4-2305 kcal

Protein:110.64 -138.3g

Fluid: 2305- 2766 ml/day

Education

Importance of adequate nutritional intake

Boost supplement

Cardiac Diet
Decrease sodium, saturated fats, trans fats, and cholesterol
 Goals
Main Goal:

Increase PO >75% by f/u assessment

Other:

Read through cardiac diet education handout and be able to state

understanding and willingness to adhere to the RD
recommendations. (Focus on in follow-up)
 Follow-up/ conclusion
RD to follow-up in 7 days

Check PO and acceptance of Boost in 2 days

If goals are met

Go through cardiac diet education again, and make specific goals

If goals are not met

Consider nutrition therapy

 ADIME notes
Pt is moderately nourished and at moderate risk d/t sepsis. UBW is 93.18 kg w/
a current wt of 92.2 kg. BMI is 28.36. Wt has been stable x 6 mos. Skin status is
normal and healthy. Creatine levels elevated at 1.49 (indicating Stage 2 CKD).
Pt has difficulty chewing lettuce, carrots, and apples d/t teeth implantation. Wife
reports pt having more spills and sloppiness during meals. PO PTA was fairly
normal w/ higher consumption of sweets and sodium. Meals are prepared by
wife. Currently pt has poor appetite r/t fever. Current PO of 25-50% (inadequate
to meet nutritional needs.)
Inadequate Oral Intake (NI-2.1) r/t decreased ability to eat d/t prolonged
catabolic illness AEB PO of 25-50%
RD to order medical food supplement therapy (ND-3.1): Chocolate Boost BID.
Counseled wife on importance of adequate oral intake and plan for intervention
(C-1)
Goals: Increase PO >75% by f/u
Observe PO and acceptance in 2 days
RD to f/u in 7 days to check status of energy intake
 References
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