Case Study 415

Whitney Miller Jennifer Crumm Chelsi Cardoso

Introduction, Meet Mrs. M 64 year old Cuban-American  Admitted to the ER with a Dx of DVT (deep vein thrombosis) in her right leg and hyperglycemia  This is her fifth admission in the last year. Long standing MH that includes: 

 Type 2 diabetes mellitus  PVD (peripheral vascular disease)  Retinopathy  neuropathy  nephropathy  hypertension  and S/P MI (status post myocardial infarction).

Anthropometrics Height: 5’3” (1.6 m)  Weight: 252 lbs (115 kg)  IBW: 100 lbs. for 1st 5 ft. + 5 lbs. for each additional inch = 115 lbs.  %IBW: 252 lbs/ 115 lbs. = 219%  BMI: kg/m2 = 115 kg / 2.56 m2  44.8 kg/m2 => Class III, morbidly obese 

Medications 

Heparin Anticoagulant Hyperkalemia

 Insulin Used to keep diabetes under control Depletes magnesium, potassium, and phosphate

in blood  Potassium

Supplements

Insulin can deplete levels in blood, so

supplement to keep levels normal Contradiction with Heparin

Medications  Phosphorus

Supplements

Take because insulin can deplete levels in

blood Avoid if have kidney issues  Reglan Used to treat slow gastric emptying in

people with diabetes Causes nutritional side effects

Lab Values and Interpretations Basic Metabolic Package TEST

RESULT

REFERENCE UNITS

TEST

RESULT

REFERENCE UNITS

136145mEqu/L 3.5-5.2 mEq/L 96106mEq/L 1.8-2.6 mEq/L 2.7-4.5 mg/dl

Glu (H)

203 mg/dl

70-110 mg/dl Na

144 mEq/L

BUN (H)

27 mg/dl

6-20 mg/dl

3.1mEq/L

Cr (H)

1.2 mg/dl

0.6-1.1 mg/dl Cl

98 mEq/L

Ca

9.1 mg/dl

1.9 mEq/L

Ser alb

3.7 g/dl

8.8-10.0 Mg mg/dl 3.5-4.8 g/dl P

K (L)

4.4 mg/dl

Elevated glucose indicates diabetes and Elevated BUN and creatinine levels indicate kidney disease The low potassium levels could be caused by K+-losing diuretics used to treat hypertension

Lab Values CBC TEST

RESULT

REFERENC E UNITS

TEST

RESULT

REFERENC E UNITS

Hgb

13 g/dl

12-16 g/dl

WBC

6.8 x 103/ µl

4.5-10.5 x 103/cells/mm3

Hct

39 %

36-48 %

% Lymph

25 %

25-40 % of total WBC

RBC

4.6 x 106 /µ

3.6-5.0 x 106/L

MCH

28 pg/cell

26-34 pg/cell

MCV

85 µm3

82-98 µm3

MCHC

33 g/dl

32-36 g/dl

Energy Estimations 

Overweight and Obese Women 19 yrs + TEE= 448 (7.95*age) +PA (11.4*weight(kg) + 619 * height (m)) PA= 1.00 for sedentary lifestyle 448-(7.95*64)+1.00(11.4*115+619*1.6) ○ =2229.2 ○ So we estimate her caloric needs fall within the range of 2100-2400 kcals/day

Energy Requirements  Protein

needs  For obese individuals, protein needs are based on adjusted body weight ABW=.25(ActBW-IBW) + IBW= 149 lbs

 Protein

needs= weight in kg*.7g/kg/day

.7 because she is restricted because of her

kidney condition 67.7kg*.7g/kg/day= about 47g of protein/day

Hospital Course  Treated

with I.V. heparin therapy, insulin, potassium and phosphorus supplementation repeated as necessary, bed rest, and 1000 kcal, 2 g Na diet, with a protein intake not to exceed .7 g per kg IBW.  Progressed well on treatment and clot resolved.

Continued  As

preparing for d/c, developed new symptoms: N/V to a degree such that an N/G tube

placed Abdomen extended and hard to touch but her BS (bowel sounds) decreased=> either gastric ileus or obstruction Physicians to R/O (rule out) a SBO (small bowel obstruction) so esophagogastroduodenoscopy conducted with negative results.

Continued  Gastric 

emptying time delayed:

Venography studies indicated ischemia of the gastric arteries slowing down blood supply to stomach causing decrease in gastric functioning, termed as gastroparesis 2º to diabetic gastrovasculitis.

 GI

tract function beyond stomach:

PEJ performed and feeding tube placed. MD prescribed Reglan to aid in gastric emptying

when pofeedings resumed.

Nutrition History 





Fried plantains, dried black beans, chick peas, yams, french fries, vegetables cooked with animal fat, or lard, sugar is added to many things like coffee, or vegetables. When she watches her son bowl she eats a large hamburger, fries, and soda. After she eats that she may drink a few beers. She lives with her son who is an obese cook and he makes whatever she wants.

Nutrition Diagnosis 

The Third step of the NCP  Nutrition intervention with Medical Nutrition Therapy

(MNT)





PES #1: Excessive energy intake (P) related to eating fried and high sugar foods (E) as evidence by diet history including fried plantains, french fries, vegetables cooked in lard, regular soft drinks and coffee with sugar (S). PES #2: Inadequate calories and incorrect protein requirements (P) related to a increased requirements (E) as evidenced by enteral formula meeting 45% of estimated energy and 81% of estimated protein needs(S).

Intervention: Nutrition Education  Intervention

plan: nutrition education regarding diets focused on diabetes, kidney disease, and hypertension.  First, the main need is to lose weight, since all of her problems stem from obesity. ADA’s position

 If

she is able to loose weight and her hypertension is still high, then DASH Kidney issues need to be watched

Continued  She

needs to continue to monitor her blood glucose throughout  Also, important to incorporate some physical activity in her life Walking would be appropriate for her

condition

Intervention: Revised Meal Plan  Instead of having so many

fried foods she should just incorporate different cooking methods.  Instead of putting sugar on foods she could substitute sugar with a low caloric artificial sweetener.  When she goes to watch her son bowl, she should probably eat before she goes so she isn’t tempted to eat the foods at the bowling alley.  In helping her with her diet, her son should be more restricting on the foods he cooks for her.

Intervention: Enteral Feeding 

Standard Enteral Formula:  1000 kcals, .7 g

protein/kg body weight  1000 kcals/ 1 kcal/ml = 1000 mL/ 24 hr = 41.7 mL/hr => 40 ml/hr x 24 hr = 960 mL x 960 kcal  40 g protein/L x .96 L = 38.4 g protein 

Appropriate Enteral Formula:  Peptamen, kcal/mL: 1.00,

40g protein/L, 127 g CHO/L, 39 g lipids/L, 270 mOsm/kg water, volume to meet RDI in mL: 1500.

QUESTIONS???