Katie Arlinghaus
KNH 411
Professor Matuszak
September 15, 2013
Case Study #11: Inflammatory Bowel Disease: Crohn’s Disease
I. Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease?
Inflammatory bowel disease is characterized as an autoimmune, chronic
inflammatory condition of the gastrointestinal tract. It is the general term for the
diagnosis of both ulcerative colitis and Crohn’s disease. (Page 415)
2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with
Crohn’s. How could this happen? What are the similarities and differences between
Chrohn’s disease and ulcerative colitis?
Ulcerative colitis and Crohn’s disease are similar conditions. In fact, inflammatory
bowel disease is a general term for the diagnosis of both ulcerative colitis and
Crohn’s disease. Both diagnoses are an abnormal immune response resulting in
inflammatory damage of gastrointestinal mucosa with a genetic susceptibility and an
association with smoking. Epidemiology-wise both affect both sexes equally, have
higher prevalence in North American, northern Europe, Ashkenazi Jews, and UK
populations. However, the peak age of onset of Crohn’s disease is teens to twenties,
whereas the peak age of onset of Ulcerative Colitis is 20-30 years with a secondary
peak in middle age. Furthermore, 10% of those with UC have a first degree relative
with the disease. The pathology of the two diseases is different. With UC, the GI
tract is unable to distinguish foreign from self-antigens and is characterized by
chronic inflammation of colonic mucosa and submucosa, atrophy and possible
dysplasia limited to the colon. The extent of the disease varies and may involve only
the rectum left side of the colon to splenic flexure or the entire colon. With Crohn’s
Disease, there is localized inflammation in bowel mucosa progressing through bowel
wall. It tends to be localized in terminal ileum and colon but can involve any portion
of the GI tract. Similar signs and symptoms include blood and/or mucus in stool,
diarrhea, abdominal pain, fever, and weight loss. Other symptoms of UC include
constipation and rectal spasm, arthritis, dermatological changes, and ocular
manifestations. Symptoms of Crohn’s Disease include anorexia, malnutrition, and
delayed grown in adolescents. Those with Crohn’s disease are less likely to have
blood in their stool but usually have more abdominal pain and cramping. The two
different diagnoses have different complications as well. Complications of UC
include severe bleeding, toxic colitis, toxic megacolon, stricture, perforation,
intolerance to immunosuppression, colonic strictures, dysplasia and carcinoma.
Crohn’s Disease, on the other hand, can cause the complications including
malabsorption, malnutrition, abdominal fistuals and abscesses, intestinal obstruction,
bacterial overgrowth, gallstones, kidney stones, urinary tract infections,
thromboembolic complications, perianal disease, neoplasia. Diagnosis methods for
each are the same: abdominal ultrasounds, MRIs, CTs, Antiglycan antibodies, and
Calprotectin, lactoferrin, and polymorphonuclear neutrophil elastase. Crohn’s
Disease can also be diagnosed through clinical presentation (CDAI score), but UC
cannot. Serological markers are used in antibody testing and have been used to
distinguish Crohn’s Disease from UC. Since the two are very similar it is easy to see
how Mr. Sims was initially diagnosed incorrectly. (Page 416).
3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as
severe-fulminant disease. CDAI score of 400. What does a CDAI score of 400
indicate? What does a classification of severe-fulminant disease indicate?
A CDAI score of 400 actually classifies Mr. Sims as having a moderate-severe stage
of the disease (CDAI 220-450). This classification indicates that he has failed to
respond to treatment for mild-moderate disease or has more major symptoms of
fevers, significant weight loss, abdominal pain/tenderness, intermittent
nausea/vomiting or significant anemia. Had he had a CDAI score >450, Mr. Sims
would have been classified as being in the severe-fulminant disease stage. This
would have indicated that he had persisting symptoms in spite of introduction of
steroids or biologic agents as outpatients, or that he was presenting with high fever,
persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia,
or evidence of an abscess. Since Mr. Sims has a CDAI score above 300, though, he is
considered to be having a severe exacerbation of the disease. (Page 418-419)
4. What did you find in Mr. Sims’ history and physical that is consistent with this
diagnosis of Crohn’s? Explain.
Much of Mr. Sims’ history and physical are consistent with the diagnosis of Crohn’s.
His original dianostic workup indicated disease at the end of his jejunum and
beginning of his ileum. He states that he is having abdominal pain, diarrhea, and
running a fever. His abdomen is distended with extreme tenderness with rebound and
guarding. He has minimal bowel sounds. Finally, Mr. Sims is very thin. These
symptoms are all consistent with Crohn’s Disease. (Page 416)
5. Crohn’s patients often have extraintestinal symptoms of the disease. What are some
examples of these symptoms? Is there evidence of these in his history and physical?
Some extraintestinal symptoms of Crohn’s disease include osteopenia, osteoporosis,
dermatitis, rheumatological conditions such as ankylosing spondylitis, ocular
symptoms, and hepatobilary complications. Mr. Sims’s history and physical does not
include evidence of any of these extraintestinal symptoms. (Page 418)
6. Mr. Sims has been treated previously with cortiocosteroids and mesalamine. His
physician had planned to start Humira prior to this admission. Explain the
mechanism for each of these medications in the treatment of Crohn’s.
Cortiocosteroids work to inhibit the overall inflammatory response and are often used
in acute exacerbations. There is a risk for becoming steroid dependent when using
cortiocosteroids. Mesalamine is an aminosalicylate medication that is typically used
with Crohn’s disease that has ileal and colon involvement (like Mr. Sims’ case).
Mesalamine works as an anti-inflammatory agent in the colon and may also act as an
immune suppressant. Humira binds the protein called tumor necrosis factor, which
those with Crohn’s often produce too much of. The excess TNF can attack different
parts of the GI tract and cause inflammation and pain, diarrhea, etc. By binding TNF,
Humira reduces those symptoms. (Page 389, 418-419,
http://www.dailystrength.org/treatments/Humira)
7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease?
Identify and explain these values.
The Laboratory values consistent with an exacerbation of Crohn’s disease include
testing positive for the antibody ASCA. These antibodies are more specific to
Crohn’s disease than UC. Mr. Sims’ albumin levels are low, which is indicative of a
severe Crohn’s case. Normal albumin levels range from 3.5-5 g/dL and Mr. Sims’
albumin is at 3.2g/dL. He also has low prealbumin at 11g/dL when normal is 1635g/dL. He also has low levels of hemoglobin and hematocrit at 12.9 g/dL and 38%
respectively. Low levels of these indicate that iron is being lost. (Page 418).
8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he
may be at risk for vitamin and mineral deficiencies.
Mr. Sims might be at risk for vitamin and mineral deficiencies because with Crohn’s
Disease malabsorption, blood loss, intestinal loss, steatorrhea, and surgical resections
are all common. Long-term steroid use as well as other medications prescribed to
treat Crohn’s can also interfere nutrients. Specifically, Iron deficiency can be caused
from blood loss or malabsorption. Magnesium and zinc deficiencies can be caused by
intestinal losses. Calcium and vitamin D deficiencies can be a result of long-term
steroid use as well as a decreased intake of dairy as a result of lactose-restricted diets.
Surgical resections can cause water-soluble vitamin deficiencies, especially B12.
Finally, fat-soluble vitamin deficiency can be caused by steatorrhea. (Page 420).
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel
syndrome, and provide a rationale for your answer.
Short bowel syndrome intestinal failure results from surgical resection of the small
intestine, congenital defect or disease-associated loss of absorption and is
characterized by the inability to maintain protein, energy, fluid, electrolyte, or
micronutrient balances when on a conventionally accepted, normal diet. Since Mr
Sims has had part of his small intestine removed he is a candidate for short bowel
syndrome and he should be monitored for signs and symptoms. However, I do not
believe that he is a strong candidate because his resection removed only a small
portion of his small intestine. Most short bowel syndrome cases occur when half or
more of the small intestine is removed. (Page 424,
http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/)
10. What type of adaptation can the small intestine make after resection?
After the removal of part of the intestine, the remaining small intestine goes through a
process of adaptation that can take up to 2 years to occur. During this time, the inner
lining of the intestine grows to increase the absorptive surface area to make up for the
part of the intestine that was removed.
(http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/).
11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care
team monitor?
Classic symptoms of short bowel syndrome that Mr. Sims’ health care team should
monitor include diarrhea, cramping, bloating, heartburn, weakness and fatigue.
Developing a food sensitivity could be a sign of SBS as well. Since his resection
occurred in the lower jejunum and upper ileum, Mr. Sims should be monitored for
carbohydrate, protein, fat, vitamin (especially B12), and bile acid deficiencies.
(http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/)
12. Mr. Sims is being evaluated for participation in a clinical trial using high-dose
immunosuppression and autologous peripheral blood stem cell transplantation
(autoPBSCT). How might this treatment help Mr. Sims?
High-dose immunosuppression and autologous peripheral blood stem cell
transplantation has been shown in clinical trials to induce remission in patients who
have not responded to conventional treatments. This treatment might help Mr. Sims
because immunosuppressive medications work by antagonizing purine metabolism
and inhibiting the synthesis of some DNA, RNA, and proteins. AutoPBSCT might
help Mr. Sims based on the premise that the inflammation he is experiencing from
Crohn’s disease is a result of defective mucosal T cells. AutoPBSCT would replace
these defective T-cells with hempatopoietic cells from a healthy donor. (Page 390,
http://clinicaltrials.gov/show/NCT00692939)
II. Understanding the Nutrition Therapy
13. What are the potential nutritional consequences of Crohn’s disease?
There are multiple nutrient deficiencies that are commonly seen with Crohn’s disease.
Protein deficiency occurs from increased protein needs from losses from GI tract due to
inflammation, catabolism, or healing from surgery. Short bowel syndrome and highvolume diarrhea can cause fluid and electrolyte deficiency. Iron deficiency occurs from
malabsorption and blood loss. Intestinal losses, especially form short bowel syndrome or
diarrhea can cause magnesium and zinc deficiencies. Calcium and vitamin D can be
deficient due to long-term steroid use or a decreased intake of dairy foods as a result of
lactose-restricted diets. Surgical resections of stomach (intrinsic factor) and/or of the
terminal ileum can cause water-soluble vitamin deficiencies especially B12. Steatorrhea
can cause a deficiency in fat-soluble vitamins and medications can result in folate
deficiency. Finally, total energy intake is commonly deficient with Crohn’s disease
because of increased energy requirements, fear of abdominal pain or diarrhea after eating,
anorexia, and just insufficient caloric intake. (Page 420)
14. Mr. Sims underwent resection of 200 cm of jejunum and proximal ileum with
palacement of jejunostomy. The ileocecal valve was preserved. Mr. Sims did not have
an ileostomy, and his entire colon remains intact. How long is the small intestine, and
how significant is this resection?
The small intestine is approximately 3 meters long, with 2.75 meters of that being
composed of the jejunum and ileum. Mr. Sims’ resection is not that significant as his
colon is still intact and he doesn’t need to have an outside surgical apparatus. No stoma
was necessary. (Page 423, Medeiros, 34).
15. What nutrients are normally digested and absorbed in the portion of the small
intestine that has been resected?
The small intestine is responsible for the absorption of the bulk of nutrients. Specifically,
the absorption lipids and fat-soluble vitamins occurs in the jejunum. Carbohydrates,
amino acids, and water-soluble vitamins are absorbed in the jejunum and upper ileum,
and the absorption of vitamin B12 and bile salts occur in the terminal ileum. Water is
absorbed throughout the GI tract including in the area of the small intestine that has been
resected. (http://www.shortbowelfoundation.org/index.php/education/2011-03-10-22-2233, facweb.northseattle.edu/.../DIGESTIONandABSORPTION%5B1%5D.ppt)
III. Nutrition Assessment
16. Evaluate Mr. Sims’ % UBW and BMI.
Height: 5’9”*0.0254m=1.75m
Weight:140lbs/2.2kg=65.45kg
BMI=weight (in kg)/ht (meters)2
BMI=65.45/1.752
BMI=21.37=21kg/m2
UBW=166-168lbs
% UBW=(current weight/usual body weight)*100
%UBW=(140/166)*100= 84%
%UBW=(140/168)*100=83%
%UBW=83-84%
(Page 47-48)
17. Calculate Mr. Sims’ energy requirements.
Height: 5’9”*2.54m=175.26cm
Weight:140lbs/2.2kg=65.45kg
Using Mifflin-St. Jeor with stress factor of 1.4:
REE=(10(weight in kg)+6.25(height in cm)-5(age in years)+5)1.4
REE=(10(65.45)+6.25(175.26)-5(35)+5)1.4
REE=2,211kcal
Using physical activity factor of 1.2 because Mr. Sims is in the hospital and mostly bed
bound:
EER=2,211*1.2=2,653kcal.
(Page 48, 421)
18. What would you estimate Mr. Sims’ protein requirements to be?
Protein requirements are based on presence of any lean body mass wasting and
biochemical parameters measuring protein status such as prealbumin and albumin. For
adults, protein needs vary from 1.5-1.75g of protein per kg of body weight. Therefore
Mr. Sims would need between 98g-114.5g protein. (Page 421)
Weight:140lbs/2.2kg=65.45kg
65.45kg*1.5g=98.175g
65.45kg*1.75g=114.54
19. Identify any significant and/or abnormal laboratory measurements from both his
hematology and his chemistry labs.
Mr. Sims’s protein, albumin, and prealbumin levels were all too low indicating a protein
deficiency. Total protein was at 5.5g/dL (should be 6-8g/dL), albumin was at 3.2g/dL
(should be 3.5-5g/dL), and Prealbumin was 11mg/dL (should be 16-35mg/dL). Mr.
Sims’ HDL-C was too low at 38mg/dL (should be above 45), although this total
cholesterol and LDL values were okay. Mr. Sims tested positive for ASCA, which is
very indicative of having Crohn’s disease. His hematology labs shows that he had too
low of hemoglobin, hematocrit, transferring, ferritin, Vitamin D, Free retinol, and
ascorbic acid levels. He also had too high of a ZPP level. This shows that he is deficient
in iron, vitamin D, vitamin A, and vitamin C. It also indicated that his zinc levels are
abnormal.
IV. Nutrition Diagnosis
20. Select two nutritional problems and complete the PES statement for each.
Increased protein needs related to Crohn’s disease as evidenced by laboratory results of
albumin levels of 5.5g/dL, prealbumin level of 11mg/dL, and total protein level of
5.5g/dL.
Inadequate energy intake related to Crohn’s disease as evidenced by patient’s report of
recent dietary intake.
V. Nutrition Intervention
21. The surgeon notes Mr. Sims probably will not resume eating by mouth for at least 710days. What information would the nutrition support team evaluate in deciding the
route for nutrition service?
In deciding the appropriate route for nutrition service the nutrition support team would
evaluate the extent of intestinal involvement, previous surgeries, diarrheal output, and
bleeding. Enteral nutrition is recommended when use of medications is not feasible or
when additional nutrition is needed to improve nutritional status. Enteral nutrition
studies have shown that supplementation may play a role in modifying the inflammatory
response in the disease process, but has not been shown to play a role in remission states.
(Page 421)
22. The members of the nutrition support team note his serum phosphorus and serum
magnesium are at the low end of the normal range. Why might that be of concern?
A low end of normal range serum magnesium level may indicate that Mr. Sims is moving
towards a magnesium deficiency, which is frequently observed with chronic diarrhea
from Crohn’s disease. A low fat diet can improve magnesium balance when this is the
case because the malabsorption of magnesium is secondary to the formation of insoluble
magnesium soaps. In particular, the low level of magnesium could indicate short bowel
syndrome. The low end of normal range serum phosphorus level may also indicate that
Mr. Sims is moving towards a phosphorus deficiency as well. In particular, the low level
of magnesium and phosphorus could indicate short bowel syndrome or refeeding
syndrome. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1855626/, Page 420)
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
Refeeding syndrome is a term used to describe several common metabolic alterations that
may occur during nutritional repletion of starved patients. Mr. Sims is at risk for this
syndrome because he is slightly malnourished, has a history of inadequate oral intake,
and is currently only having clear liquids. To prevent refeeding syndrome it is imperative
that his serum levels of phosphorus, magnesium, and potassium are monitored (especially
as they are currently at the low end of normal). He should also be provided
supplementation until he can reach his goal feedings, and he should be introduced to
feedings slowly as to avoid overfeeding. (Page 92)
24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively,
and a nutrition support consult was ordered. Initially, he was prescribed to receive 200g
dextrose/L, 42.5g amino acids/L, and 30g lipid/L. His parenteral nutrition was initiated
at 50 cc/hr with a goal rate of 85 cc/hr. Do you agree with the team’s decision to initiate
parenteral nutrition? Will this meet his estimated nutritional needs? Explain. Calculate:
pro (g); CHO (g); lipid (g); and total kcal from his PN.
Most research has shown that PN with bowel rest is not needed and clinical trials have
shown that it does not result in improved outcomes of remission. The only time that PN
seems necessary is immediately following an operation until adequate intestinal
adaptation has occurred. Through PN (assuming 24 hours of time), Mr. Sims is receiving
240-408g CHO, 51-87g Pro, and 36-61g Lipids:
1cc=0.001L
50cc*0.001L*200g Dextrose/L=10g dextrose per hour*24hours=240g CHO
85cc*0.001L*200g Dextrose/L=17g dextrose per hour*24hours=408g CHO
240-408g CHO
50cc*0.001L*42.5g amino acids/L=2.1g amino acids per hour*24hours=51g Protein
85cc*0.001L*42.5g amino acids/L=3.6g amino acids per hour*24hours=86.7g Protein
51-87g Protein
50cc*0.001L*30g lipids/L=1.5g lipids per hour*24 hours=36g lipids
85cc*0.001L*30g lipids/L=2.55g lipids per hour*24 hours=61.2g lipids
36-61g Lipids
240g CHO*4kcal/gCHO=960kcal CHO
408g CHO*4kcal/gCHO=1632kcal CHO
960-1632kcal CHO
51g Pro*4kcal/gPro =204kcal Pro
87g Pro*4kcal/gPro =348kcal Pro
204-348kcal Pro
36gLipids*9kcal/gLipid=324kcal Lipids
61gLipids*9kcal/gLipid=549kcal Lipids
324-549kcal Lipids
Total kcal=960kcal CHO + 204kcal Pro + 324kcal Lipids = 1,488kcal
Total kcal=1632kcal CHO + 348kcal Pro + 549kcal Lipids = 2,529kcal
Total kcal: 1,488-2,529kcal
This does not meet his calorie need of 2,653kcal as calculated using the Mifflin-St. Jeor
method. Nor does it meet his protein need of 98-114g protein. However, it is important
to increase energy intake gradually as to prevent overfeeding.
25. For each of the PES statements you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).
Ideal goal: Gradually increase Mr. Sims’ protein intake to 98g-114.5g protein via enteral
or parenteral nutrition until his Crohn’s is under control and can begin to gradually
increase is oral intake of protein.
Ideal goal: Gradually increase Mr. Sims’ overall energy intake to 2,655kcal through the
use of eteral or parenteral nutrition until Crohn’s is in remission. Provide Mr. Sims and
his wife education and guidance on the importance of implanting an appropriate diet as
means to control his Crohn’s and prevent malnutrition.
VI. Nutrition Monitoring and Evaluation
26. Indirect calorimetry reveal the following information:
Measure
Mr. Sims’ Data
Oxygen consumption (mL/min)
295
CO2 production (mL/min)
261
RQ
0.88
RMR
2022
What does this information tell you about Mr. Sims?
Indirect calorimetry is an approach to determine the energy expenditure by measuring a
subject’s oxygen consumption, carbon dioxide production, and minute ventilation. From
this information Mr. Sims’ energy requirements can be accurately calculated so that the
adequacy and appropriateness of nutritional support can be monitored. RMR or resting
metabolic rate is the amount of energy Mr. Sims needs without any activity (2022kcal).
RMR can be calculated using the RQ, respiratory quotient, which is the ratio of CO2
eliminated over O2 consumed. (Page 244)
27. Would you make any changes to his prescribed nutrition support? What should be
monitored to ensure adequacy of his nutrition support? Explain
I would increase the amount of protein prescribed in his nutrition support. This would
also increase his total kcal. Currently his protein and total energy prescribed does not
meet his calculated energy and protein needs of 2,655kcal and 98g-114.5g protein
respectively. I would monitor his albumin, prealbumin, and total protein to ensure the
adequacy of his nutrition support. I would monitor his hematology report, specifically
hemoglobin, hematocrit, transferrin, and ferritin to ensure that he was receiving adequate
iron. I would monitor his weight to ensure that he was intaking enough energy. Finally, I
would monitor his ZPP, vitamin D, Free retinol, and ascorbic acid to ensure that he was
absorbing adequate amounts of zinc, vitamin d, vitamin A, and vitamin C.
28. What should the nutrition support team monitor daily? What should be monitored
weekly? Explain your answers.
Mr. Sims’ bowel movements should be monitored daily. As diarrhea subsides, he may be
able to move away from PN and begin to intake orally. It would also be important to
weigh Mr. Sims daily to monitory that he is receiving enough energy. I would monitor
his albumin, prealbumin, and total protein weekly to ensure the adequacy of his nutrition
support. I would monitor his hematology report, specifically hemoglobin, hematocrit,
transferrin, and ferritin to ensure that he was receiving adequate iron. Finally, weekly I
would monitor his ZPP, vitamin D, Free retinol, and ascorbic acid to ensure that he was
absorbing adequate amounts of zinc, vitamin d, vitamin A, and vitamin C. (Page 421)
29. Mr. Sims’ serum glucose increase to 145 mg/dL. Why do you think this level is now
abnormal? What should be done about it?
This level is now probably abnormal because the only form of CHO Mr. Sims is
receiving is dextrose. It makes sense that his glucose level would raise. His antiinflammatory medicine may also be increasing his blood glucose levels. As his condition
becomes more stable, Mr. Sims should have complex carbohydrates instead of just
dextrose. Currently, however, the easily digested and absorbed form of sugar is
appropriate for him. (http://www.nlm.nih.gov/medlineplus/ency/article/002469.htm).
30. Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4
grams. By using the daily input/output record for 12/20 that records the amount of PN
received, calculate Mr. Sims’ nitrogen balance on postoperative day 4. How would you
interpret this information? Should you be concerned? Are there problems with the
accuracy of nitrogen balance studies? Explain.
Nitrogen balance=(dietary protein intake/6.25)-urine urea nitrogen
Dietary protein intake ~70g
Nitrogen balance = (70/6.25)-18.4g = -7.2g
Therefore, Mr. Sims is in a negative nitrogen balance. A negative nitrogen balance
indicates that his nitrogen excretion is greater than his intake. This is concerning but is
most likely due to his diarrhea. It is also indicative that he may need more protein.
Limitations of measuring nitrogen balance include the inherent error of 24-hour urine
collection, failure to account for renal impairment, and the inability to measure nitrogen
losses from wounds, burns, diarrhea, and vomiting. The loss from diarrhea is especially
important in Mr. Sims’ case. Oral protein intake may also be difficult to measure. (Page
54)
31. On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous
48 hours and had his first bowel movement. The nutrition support team recommends
consideration of an oral diet. What should Mr. Sums be allowed to try first? What would
you monitor for tolerance? If successful, when can the parenteral nutrition be weaned?
When oral intake can be initiated a low-residue, lactose-free diet with small, frequent
meals is best tolerated. Fiber and lactose should be added in small amounts as tolerated
to advance the diet. Gas-producing foods, spicy foods, fried foods, caffeinated beverages
should be avoided. Parenteral nutrition can be weaned as Mr. Sims responds to medical
therapy. (Page 421)
32. What would be the primary nutrition concerns as Mr. Sims prepared for
rehabilitation after his discharge? Be sure to address his need for supplementation of any
vitamins and minerals. Identify two nutritional outcomes with specific measures for
evaluation.
During his remission, Mr. Sims should maximize energy and protein intake to facilitate
rehabilitation. Physical activity would also help to rebuild muscle mass and protein
stores. Mr. Sims should consume foods high in antioxidants and omega-3 fatty acids, as
these have been shown to reduce inflammation. It would also be important for him to
supplement iron and B12. Furthermore, the use of probiotics has been shown to enhance
the normal flor of the GI tract and as been associated with decreased IBD symptoms. Mr.
Sims should concentrate on the nutritional outcome of gaining weight. He should try to
gain 1-2 pounds a week to reach his previous weight of around 160lbs. He should also
increase his physical activity to ensure the rebuilding of protein stores and muscle mass.
This can be evaluated through a lab test of protein with his goal measurement being in the
normal range of 6-8g/dL of total protein. (Page 422)
References
Short Bowel Syndrome Foundation. (2013). Digestive Anatomy. Retrieved from
http://www.shortbowelfoundation.org/index.php/education/2011-03-10-22-22-33
MedlinePlus. (2013). Carbohydrates. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/002469.htm.
Nelms M, Sucher K, Lacey, K., Habash, D., Roth S. Nutrition Therapy and Pathophysiology.
2nd ed.Belmonte, CA: Thomson Brooks/Cole, 2010.
North Seattle Community College (2012). Digestion and Absorption. Retrieved from
facweb.northseattle.edu/.../DIGESTIONandABSORPTION%5B1%5D.ppt
Swaminathan R. (2003). Magnesium Metabolism and its Disorders. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1855626/.
US Department of Health and Human Services, National Digesetive Disease Information
Clearinghouse. (2013). Short Bowel Syndrome. Retrieved from
http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/.
US National Institute of Health. (2012). Autologous Stem Cell Transplantation for Crohn’s
Disease. Retrieved from http://clinicaltrials.gov/show/NCT00692939.