Clinical Case Study

By Kayleigh Hill
The Swallow Center
Comprised of the:
Cerebral Cortex
Medulla Oblongata
Cranial Nerve Nuclei

The Three Phases of Swallowing:

The Oral Phase
The Pharyngeal Phase
The Esophageal Phase
Northeast Rehab at The Elliot
A rehabilitation center on the 8th floor of the hospital http://www.northeastrehab.com/includes/img/interface/logo.g
if

The RD has a wide role here to ensure that each patient is receiving
adequate nutrition to excel at rehabilitation activities and to set them up for
dietary success when they return home.

The RD works with a wide range of healthcare professionals who have a

common goal of preparing the patient for a safe return home, back to the
real world. Communication is key between every professional.
 67 y/o female, former middle school
teacher with a supportive family

PMHx:

CVA @ 19

Mrs. V Seizure disorder (never specified)

Lupus on her hands

Previously resided at Parkland -
Hypothyroidism
Admitted to Elliot after having a
fall that resulted in a facial droop GERD

Pernicious edema

Per admissions note and Parkland medical

documentation
Anthropometrics per admissions note and RD evaluation
Wt: 175 lbs (80 kg)

Ht: 56 (167.6 cm)

Overweight related to
BMI: 28.2 - Overweight imbalance of intake vs. output
evidenced by BMI of 25-29.9
IBW: 130 -/+ 10 %

% IBW: 122% - Overweight

Medications and Labs
Taking:
Labs:
Lupus: Plaquenil in pill form because it does not upset
her stomach
Not currently taking anything for her seizure disorder due Labs under control at the
to a lack of seizures over the past 7 years and
medication side effects. moment
Reglan and Pepcid for GERD
At Admission pt had large
Dulocolax and Colace
Synthroid - levothyroxin for her hypothyroidism variation in POC glucose levels
(115, 76, 63, 84)
 Throughout her time at The
Elliot her diagnosis was
unclear.

The medical team debated

Diagnosis Glioma vs. Subacute
Stroke

Occurring in the right side

of her brain stem
The Nutritional Complication
Mrs. V Struggles to swallow and
refuses a PEG tube placement.

Used a PEG tube at Parkland MC to

supplement oral intake. On
Fibersource.
The Oral Phase
This phase includes mastication
and formation of a food bolus
that is carried to the back of the
mouth and then moved to the
oropharynx and then the
pharynx via the tongue

https://i.makeagif.com/media/8-23-2015/g0ihYi.gif

Diet
In order to swallow: Turn head to
the left, shift face down and tuck
Dysphagia Puree, Nectar
Thick Liquids
Specialized per patient list
Both the Academy of Nutrition and
Dietetics and the American Speech
Language-Hearing Association were
consulted for the proper MNT for
stroke patients.
With every tray, must be room temp
Kozy Shack Chocolate Pudding
Chocolate Boost Pudding
Nectar Thick Milk
Apple Juice
Cranberry Juice (real - cannot tolerate the sugar content)
1 Gatorade or PowerAde
Applesauce
Custard
2 Drinkable Yogurts - Banana and Strawberry
Thickener Packets
The Multidisciplinary Team
The MD on Northeast Rehab

Nursing Team

The Registered Dietitian (Me!!)

The Speech Language Pathologist

The Neurologist

Mrs. Vs MD from Parkland MC

 Energy: 1600 - 1880 kcal MSJ x
1.2-1.4 AF/SF

Needs Protein: 76 - 82 gm for 1.2-1.3

gm/kg upper IBW
recommendations
Per Elliot Hospital Assessment
tools Fluid needs: 1800 - 2000 mL per
MD
Calorie Counts
On The Tray/day What Was Being Eaten

~ 1660 kcal per tray including protein 250 kcal - less than 25% of needs
powder
Protein intake varied per meal
~ 90 gm
 1. Inadequate oral intake related
to dysphagia evidenced by
need for a mechanically altered
diet and specific swallowing
procedure.

Level of Risk
1. Inadequate oral intake related
High to dysphagia evidenced by
need for a mechanically altered
diet, specific swallowing
procedure and intake of less
than 25% of needs.
 Provide general healthful diet
Intervention Coordinate nutrition
care/intervention with the
health care team
 Food & beverage intake for
tolerance - calorie counts

Weight change
Monitoring Nutrition Profiles pert labs, fluid
status, and GI function

Further medical diagnosis

 Patient has not met nutritional or
Evaluation fluid needs, has been experiencing
depression and, per pt, is beginning
PEG tube is needed to dread eating.
PEG Tube Placed

Percutaneous Endoscopic Gastrostomy

Patients MD from Parkland was

consulted to determine previous PEG
tube implementation.

Successful placement - x-ray taken for

re-assurance

http://www.drbhandari.com/images/peg2.jpg
The Multidisciplinary Team
The MD on Northeast Rehab

Nursing Team

The Registered Dietitian (Me!!)

The Speech Language Pathologist

The Neurologist

Mrs. Vs MD from Parkland MC

TF Recommendation

Fibersource HN for long term use (1.2 kcal)

Goal rate of 55 mL/hr, providing 1330 mL, 1596 kcal/day, 72

gm Protein and 1077 mL free water.

Start at 20 mL/hr increase Q4hr at 20 mL

Monitor for tolerance

 Cyclic: 14 hrs at 95 mL/hr

6pm - 8 am

Evaluation Pt claims to stay in after dinner

time and does not work so
Pt is tolerating TF - consider typically gets up around 8 am.
moving to Cyclic administration
Can enjoy lunch and snacks
for easier home administration
during the day
Oh no! Over the
weekend Mrs. V was
transferred to the ICU after
an episode of facial droop,
aphasia and non-
responsiveness. http://3.bp.blogspot.com/_R3ey-
8xz3oQ/TVGOCyjWy1I/AAAAAAAAAWM/lOd3Lze
3XPg/s1600/Oh+My+Cartoon.png
 NPO
Pt was recognized to have
developed possible aspiration
pneumonia (from episode of
non-responsiveness) and a UTI
Mrs. V was not ventilated but TF
was stopped due to altered mental
state and risk of aspiration.
December 22nd
My last day

Mrs. V is being transferred to Boston where they have the

tools to better investigate her condition.

It takes a smart doctor to cure a patient, but it takes a wise doctor to

know they arent that smart doctor - The NRH MD
Conclusion
It truly does take a team