CASE STUDY - MRS .W
ALLISON CALLAN KSDI 2014
WHAT WE ARE GOING TO DISCUSS TODAY
 Clinical Dietician’s role at Wing Memorial
 Thyroid function and Thyroid Storm
 Hyperosmolar Hyperglycemia Non-ketotic Syndrome (HHNS)
 Nutrition Support and Refeeding Syndrome
WING MEMORIAL HOSPITAL AND MEDICAL CENTERS
 Located in Palmer, Mass
 Fully accredited by the Joint Commission
 Wing Memorial is a 74-bed hospital
 Established in 1913
 Provides emergency, medical, surgical and psychiatric services to residents of Palmer, Monson, Wilbraham, Ludlow,
Belchertown and nearby towns.
 ICU, Medical/Surgical, Parker North, Geriatric Psych
 Four additional medical centers were built to provide out patient services to the community
RD ROLE AT WING MEMORIAL HOSPITAL
 One RD manager, part-time

Manages RD’s

Provides outpatient care

Bariatric program
 Three part-time clinical RD’s

Cover all four floors

See every patient

Daily triage

Write diet order, w/ MD cosign
ICE BREAKER
 Think of a health scenario that you, a family member or family friend had to go through?
 Were there a lot of surprises? Or did you know what to expect?
 Was it overwhelming?
 Did you feel like all of your questions were answered?
 Did you feel like you could support your loved one? Be an advocate for yourself?
 Were there things that you wished had gone differently? Better? The same?
 Share?
 Please keep these things in mind as I tell you the story of Mrs. W.
THE STORY OF MRS. W
Social History
85 year old widowed female
Lives with daughter and son-in-law
Uses a cane for assistance with ambulation
Nonsmoker, no known alcohol or illicit drug use
Has six children
No recent known falls
Past Medical History
Extensive past medical history
PATIENT INFORMATION CONTINUED
Past Surgical History
Laparoscopic cholecystectomy (2003)
Home Medications
Metoprolol tartrate, Keflex, Lisinopril/Hydrochlorothiazide
Medication Allergies: ? Penicillin, Amoxicillin (allergies reported from childhood - unknown exact response)
Diet History
Does not follow a certain diet at home
Food Allergies: chocolate, strawberries and seafood
PATIENT INFORMATION
 Medical information prior to admission
 12/20/13 Was seen by PCP for wound of left lower leg
 12/20/13 Antibiotic therapy and pain medication were initiated
 Patient’s family were unaware of the details of the infection and medical history because the patient would not let
her family in the room during doctor’s visits.
HOSPITAL ADMISSION DAY (12/27/13)
 Admit DX in ED: HYPERGLYCEMIA, SEPSIS
 Patient not able to speak at the present time
 Patient presents with lethargy, altered mental status
 Chronic left leg wound infection
 According to the patient’s daughter:

Reduced PO-drinking frequent Ensure supplementation

Polydipsia

Polyuria
HOSPITAL ADMISSION DAY (12/27/13)
 Hypoxic 85%
 Fever 101
 BP 110/90, low at times with systolic between 80-100
 Atrial Fibrillation with rapid ventricular response up to 166 beats per minute
 Hyponatremia 132 (normal 136-145 mEq/dl)
 Hyperglycemia with an initial blood sugar of 1257 (normal 70-100 mg/dL)
 CPK 286 (normal value 30-135 units/L)
 WBC 13.6 (normal 5-10,000/ mm3)
 Creatinine 2.2 (normal 0.5-1.1 mg/dL)
 BUN 61 (normal 6-20 mg/dL)
HOSPITAL ADMISSION DAY CONTINUED
 Chest x-ray
Does not show any acute disease with large goiter
 Stabilized HR with Diltizem between 100-120 beats per minute
 IV fluids to improve BP, 90 systolic
 Blood sugars decreased to 400s with IV insulin
 Transferred to ICU
CURRENT POSSIBLE DIAGNOSES
 Sepsis
 Hypotension
 Atrial Fibrillation (what was it triggered by?)
 Hyperosmolar Hyperglycemia Non-ketotic Syndrome (HHNS)
 Acute Kidney Injury
 Thyroid Storm
THYROID GLAND REVIEW
 Normal Values TSH 0.4-4.0 mlU/L
 Thyroid function
 Role of T3 and T4
THYROID FUNCTION
THYROID STORM

What is it?

Causes

S/S

Treatment
HYPEROSMOLAR HYPERGLYCEMIA NONKETOTIC SYNDROME
(HHNS)
 What is it?
 Causes
 Warning S/S
 Treatment
RD’S ROLE IN CARE FOR MRS.W?
 Interview patient for information?
 Calculate nutrient needs
 Determine what form of nutrients PO, G-tube, TPN, NPO w/ IV fluids?( Po support vs Enteral support at Wing)
 Are there any skin wounds to consider?
 Chronic or acute illness that needs to be considered?
NUTRITION ASSESSMENT
 Physical Assessment

Breathing

Alert

Skin appearance

Wounds present

Odor present
NUTRITION ASSESSMENT
 Current diet
 Swallow status determined
 IV fluids running?
NUTRITION ASSESSMENT

BP- WNL

RR-not labored 20/minute

TEMP- afebrile

Anthropometrics
HT 67”
WT 147
KG 67
BMI 23
UBW ?
DESIRED BODY WT 135LBS- WT DOES NOT NEED TO BE ADJUSTED
NUTRITION ASSESSMENT

Medications

Humalog SS

Propylthiouracil

Inderal

Solucortef

Zosyn

Lovenox

Dilaudid

Vancomycin

Cardizem

Lanoxin

ASA

INSULIN DRIP
LABS
Lab
value
Normal range
Glucose
158
70-100 mg/dL
BUN
40
6-20 mg/dL
Creatinine
1.35
0.6-1.2 mg/dL
Est GFR
37
90-120 mL/min or > 60
Sodium
149
136-145 mEq/L
Potassium
3.9
3.5-5.2 mEq/L
Magnesium
1.5
1.8-3 mg/dL
Albumin
4.3
3.5-5 g/dL
WBC
19.9
5-10,000 mm3
Chloride
117
95-105 mEq/L
Phosphate
2.3
2.4-4.1 mg/dL
HCT
43
36-44.1 %
Hgb
14
12.1-15 gm/dL
NUTRITION ASSESSMENT
 Level One Nutritional Risk
 Patients Needs include

Protein: Minimum 67 grams of protein (1g/kg)

Calorie: 1675-2010 kcals (25-30kcal/kg)

Fluids: 1675-2010 ml (1ml/kcal)
PES
Inadequate oral food/beverage intake R/T DX , lethargy, DM and AKI as evidenced by patient is unable to take in PO at this
time, elevated glucose, abnormal renal labs, open areas on left lower leg, heel and stage 11 skin ulcer on coccyx.
Increased nutrient needs R/T increased demand for nutrient secondary to refeeding syndrome as evidenced by labs values
indicating hypophosphatemia, hypomagnesaemia, and hypokalemia.
NUTRITION ASSESSMENT
 Interventions:

Inform kitchen of allergies (seafood, strawberries and chocolate)

Monitor for PO feasibility and assess for nutritional supplements as feasible

Diet Order: Diabetic/ Cardiac

Recommend once daily MVI with minerals, (zinc ,vitamin C) due to open areas
NUTRITION PROGRESS NOTE (12/30/13)
 Patient could not breath on own intubated and sedated
 Diet order: NPO
 Med Changes:Versed, Fentanyl, Kphos, Magnesium
 Current labs: BG 147, BUN and Creatinine improving, Phos 2.2 and Mag 1.6 being replaced, albumin 2.2 s/p IV
fluids, H+H decreased ? Infectious process
 WT: increased 15.6 LBS since admission on 12/27/13- large positive fluid balance
 Abdominal CT scan showed an small bowel ileus
 Interventions: Monitor labs, replace electrolytes as indicated, if unable to extubate in next 2-3 days would
consider tube feeds, pending resolution of ileus
NUTRITION PROGRESS NOTE (12/31-1/2)
 Diet Order: NPO
 Intubation continues, weaning attempted
 Med: Lasix
 Labs: BG 314 w/ Humalog SS, NA WNL, Phosphate 2.0, will receive 1000 mg/day with KPHOS, K+ WNL , MG++
decreased 1.5, H+H decreased at 9.6, 29.4
 WT: 161.6 LBS, (using 69 KG for calculations)
INTERVENTION (12/31-1/2)
 Intervention:
 Tube feeding initiated Jevity 1.2 started at 30 ml/hr, tolerated without residuals
 Receives 100ml water flushes four times daily
 Goal Rate Jevity 1.2 60 ml/hr with 100 ml water flushes four times daily
 Provide 1728 kcal (25ml/hr ABW), 80 grams protein (1.1g/kg ABW), 1562 ml free water (22ml/kg ABW)
 Provide 1 tab of KPHOS four times daily (each tab: 250 mg Phos, 45mg K+, 298 mg NA), zinc, vit C
 Patient at high risk for refeeding syndrome, advance tube feed by 15 ml every 8 hours as tolerated to goal rate of
60 ml/hr
 Monitor wts, labs, follow refeeding syndrome, adjust water flushes as indicated
REFEEDING SYNDROME
 What is it?
 Causes
 Treatment
 Prevention
NUTRITION PROGRESS NOTE (1/3/14)
 Extubated, swallow evaluation pending at this time
 Diet Order: NPO, tube feed D/C’d, IV fluids D5 1/2 NS AT 100 ML/HR, ice chips are tolerated
 Labs: Indicate Refeeding Syndrome NA elevated 147, K+ decreased 3.3, Phos decreased 1.9, MG++ decreased 1.6
All with supplementation
Glucose 216, A1C >15, prealbumin decreased 6.9 (wounds, sepsis, doxycycline added), H+H stable
 Intervention:

1. Follow swallow evaluation/PO feasibility, labs, weight change

2. Add nutrition supplements as able (vanilla only)

3. If PO not feasible, recommend start tube feed with Jevity 1.2 at 30 ml/hr and maintain at this rate until electrolytes
normalize
NUTRITION PROGRESS NOTE (1/4/14)
 Patient Diet: NPO, IVF D5W 75 ml/hr
 Breathing status change-currently on high flow nasal cannula
 Unable to swallow today
 Meeting set for consultation on transition to hospice/palliative (per patients wishes)
 RD consulted for TPN recommendations
 TPN 940 ml of 10% Aminosyn, 275 ml 50% Dextrose, 225ml sterile water and 250 mls 20% lipids would provide
1690 mls total volume (25ml/kg), 1344 kcals (20kcals/kg), 94 grams of protein (1.4 g/kg)
 Monitor phosphate, magnesium, potassium closely, when stable increase to 25kcal/kg
 3. Use standard additives, provide extra phosphate, magnesium, potassium, via IV if necessary. If sodium level is still
above normal limits, consider custom additives and omit sodium chloride from TPN.
 4. Follow plan of care, (SLP consult?), labs
REFERENCES

Black, J. M., Hawks, J. H., & Keene, A. M. (2001). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (6th ed.). Philadelphia: W.B. Saunders.

Crook, M., Hally, V., & Panteli, J. (2001). The Importance of the Refeeding Syndrome. Nutrition, 17(7-8), 632-637.

Diabetic hyperglycemic hyperosmolar syndrome: MedlinePlus Medical Encyclopedia. (n.d.). U.S National Library of Medicine. Retrieved February 21, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/000304.htm

International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process (4th ed.). (2013). Chicago, IL:
Academy of Nutrition and Dietetics.

Mahan, L. K., & Stump, S. E. (2008). Krause's Food & Nutrition Therapy (12th ed.). St. Louis, Mo.: Saunders/Elsevier.

Manuel, A., & Maynard, N. D. (2009). Nutritional Support. British Medical Journal, 9(4), 1567-1574.

Mehanna, H. M., Moledina, J., & Travis, J. (2008). Refeeding Syndrome: What it is, and How to Prevent and Treat it. British Medical Journal, 336(7659), 1495-1498.

National Endocrine and Metabolic Diseases
Information Service (NEMDIS). (n.d.). Thyroid
Function Tests Page. Retrieved February 21, 2014, from http://www.endocrine.niddk.nih.gov/pubs/thyroidtests/index.aspx

Nursing 2014 Drug Handbook (34th ed.). (2014). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Pagana, K. D., & Pagana, T. J. (2010). Mosby's Manual of Diagnostic and Laboratory Tests (4th ed.). St. Louis, Mo.: Mosby/Elsevier.

Stump, S. (2012). Nutrition and Diagnosis-Related Care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.