Bryn Wilkin
September 17, 2013
KNH 411: Case Study #11
I.
Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical literature indicate
regarding its etiology?
Inflammatory bowel disease (IBD) is defined as an autoimmune, chronic inflammatory
condition of the gastrointestinal tract. It can be used as a general term to describe one of
two diseases: ulcerative colitis, and/or Crohn’s disease. The complete etiologies for both
inflammatory bowel diseases are not known. However, it is clear that environmental
factors play a part in causing an abnormal inflammatory response. These factors include
smoking, infectious agents, intestinal flora, and physiological changes in the small intestine.
There is also a strong connection between IBD and family history. These genetic
associations have been connected within both the innate and acquired immune response.
(Nelms, pg. 415-417)
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
Crohn’s disease and ulcerative colitis?
Mr. Sims may have been mistakenly diagnosed with ulcerative colitis (UC) because of the
similarities of symptoms associated with UC and Crohn’s disease. Both UC and Crohn’s
disease can provide symptoms of diarrhea, weight loss, abdominal pain, fever, and a
presentation of blood in one’s fecal matter. Additionally, Crohn’s disease and UC are
diagnosed using many of the same tests: CT, MRI, abdominal ultrasound, etc. Both diseases
affect both sexes equally. Although there are many similarities between the two diseases,
each disease has a distinct pathology. UC involves an inability of the GI tract to distinguish
between foreign form antigens and self-antigens. This can lead to chronic inflammation of
the colonic mucosa and submucosa and atrophy of the colon. Crohn’s disease involves
inflammation of the bowel mucosa that progresses through the bowel wall. It is generally
localized in the terminal ileum and colon, but can involve other parts of the GI tract. When
comparing the etiologies of both diseases, another difference is discovered. UC is generally
associated with ex-smokers, while Crohn’s disease is associated with current cigarette
smoking. The diseases also differ in their typical peak age of onset. UC has a peak onset
age of 20-30 for patients with a first-degree relative with UC, and a peak onset in middle
age groups for those with a secondary relative with UC. Crohn’s disease, regardless of
family history has an earlier peak onset age of teenage years to twenties. The
complications associated with each disease can also differ. UC involves complications of
severe bleeding, toxic colitis, strictures, perforation, dysplasia, and carcinoma. Crohn’s
disease involves complications such as malabsoprtion, malnutrition, intestinal obstruction,
abdominal fistulas, gallstones, kidney stones, UTIs, and neoplasia. These differences could
easily be detected with further medical testing—and most likely helped to correct Mr. Sims
diagnosis. Depending on the diagnosis, these diseases may receive different treatments.
UC involves drugs that will help to reduce chronic inflammation—immunosuppressants,
adrenocorticosteroid, antidiarrheals, antibotics, etc. UC can also be treated by a
colectomy—whether it is a total, subtotal, or colectomy with ileostomy. Crohn’s disease
can also be treated with immunosuppresants, steroids, and antibiotics, or can involve
surgery to remove any affected areas—ileum, colon, etc. Surgeries can include ileocolic
resections, segmental resections, ileostomy or total proctocolectomy. (Nelms, pg. 416-417)
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 of 400 indicates a moderate-severe Crohn’s disease. This includes patients who
have not responded to treatment for mild-moderate Crohn’s disease, or those who have
major symptoms of fever, significant weight loss, abdominal pain, nausea, vomiting, or
significant anemia. A classification of severe-fulminant Crohn’s disease indicates a CDAI
score of 450 or greater. Those patients have persistent symptoms despite the introduction
of steroids or biologic agents. Patients may also have persistent fever, vomiting, evidence
of intestinal obstruction, cachexia, or evidence of an abscess. (Nelms, pg. 419)
4. What did you find in Mr. Sims’ history and physical that is consistent with his
diagnosis of Crohn’s? Explain.
Mr. Sims’ history shows that he was hospitalized about three months prior to this episode
because of an abscess and acute exacerbation of his diagnosed, Crohn’s disease. His
Crohn’s disease has also presented with a typical “skipping” pattern—beginning the last 57 cm of the jejunum, and then moving to the first 5 cm of the ileum. In addition, Mr. Sims
reported increased/chronic episodes of diarrhea and abdominal pain—both consistent
with Crohn’s disease symptoms. Mr. Sims described his diarrhea as “constant”—indicating
that is a chronic symptom, distinguishing it as related to Crohn’s disease, not UC. Mr. Sims
also complained of running a fever, which can indicate an increase in the severity of his
disease state. Upon physical evaluation, Mr. Sims appeared to have a distended, tender
abdomen. This tenderness, paired with abdominal pain supports Mr. Sims’ CDAI score of
450. (Nelms, pg. 416-417) (case study book: pg. 116-117)
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 examples of extraintestinal manifestations include osteopenia, osteoporosis,
dermatitis, rheumatological conditions, (ex: ankylosing spondylitis) ocular symptoms, and
hepatobiliary complications. When looking over Mr. Sims’ current blood panel, it shows
that his citamin D levels are very low. Because of his medications and GI distress, Mr. Sims
is experiencing many absorption difficulties. Because of this, patients with IBD are at
increased risk of osteopenia and osteoporosis. Plans to begin Humira may also cause
extraintestinal manifestations because of an extreme immune system suppression. (Krause,
pg. 632)
6. Mr. Sims has been treated previously with corticosteroids 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.
Corticosteroids work to inhibit the overall inflammatory response within the GI tract. To
do this, these drugs mimic the action of cortical and redistribute the white blood cells.
With a reduction of lymphocytes and an increased number of neutrophils, there is a
decreased production of prostglandins—decreasing inflammation. Mesalamine is an
aminosalicylate that also works as an anti-inflammatory agent. It works to prevent
inflammation in the colon and may also act as an immunosuppressant drug. Humira is
used to treat moderate to sever Crohn’s disease. It is often used on cases where other
medications have not worked to put the disease in remission. Humira works to block the
protein called TNF (tumor necrosis factor). That protein is often found in excess in patients
with Crohn’s disease. Humira blocks the TNF to help reduce the inflammation that causes
Crohn’s symptoms. (Nelms, pg. 389-390)
http://www.humira.com/crohns/how-humira-works.aspx
7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease?
Identify and explain these values.
Mr. Sims’ ASCA, C-reactive protein, hemoglobin, and hematocrit lab values were consistent
with an exacerbation of his Crohn’s disease. ASCA (anti-saccharomyces cerevisiae
antibodies) can help to distinguish Crohn’s disease from UC. High levels of C-reactive
protein can indicate the presence of inflammation in the body—although it may not
necessarily be specific to the GI tract. Low hemoglobin and hematocrit values indicate
malabsorption of iron in the small intestine. (Nelms, pg. 418-419)
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 may be at risk for vitamin and mineral deficiencies because of a combination of
Crohn’s disease and his current medication. Crohn’s disease affects normal digestion and
absorption, leading an increased caloric, protein, and micronutrient requirement.
Specifically, Crohn’s disease patients may have a fear of abdominal pain and diarrhea as a
result of eating—causing them to reduce their intakes. In addition, inflammation in the GI
tract causes losses of protein and other nutrients. Mr. Sims is also allergic to milk, which
could also contribute to a deficiency of calcium and vitamin D. Mr. Sims’ corticosteroid
prescription could also contribute to his risk of deficiency. Corticosteroids may increase
nutrient requirements or exacerbate nutrient losses in the GI tract. (Nelms, pg. 419-420)
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel
syndrome, and provide a rationale for your answer.
At this point, Mr. Sims is not a likely candidate for short bowel syndrome. Short bowel
syndrome is defined as the result of a large resection of the small intestine. So far, Mr. Sims
has not had any surgeries—or specifically, no resections of the bowel. However, because
Mr. Sims has Crohn’s disease, he is more likely to develop short bowel syndrome as a result
of chronic inflammation and distress to the GI tract. Because Mr. Sims has been
experiencing chronic diarrhea and shows signs of protein energy malnutrition and
micronutrient deficiencies, his medical team should consider him to be at risk for future
surgical resections, and potentially, short bowel syndrome.
However, after his jejunum and proximal ileum resection, Mr. Sims’ health team should
monitor his future progress in inflammation and absorption, as he will then be at risk for
short bowel syndrome. (Nelms, pg. 424-425)
10. What type of adaptation can the small intestine make after resection?
After a resection surgery, the postoperative period typically follows three distinct phases of
adaption. The first phase begins with large volumes of diarrhea. Patients will be
dependent upon parenteral nutrition during that time. The second phase is characterized
by a decrease in diarrhea. Enteral nutrition can be introduced and the patient can begin to
transition to an oral diet. In the final stage, the most adaptation is noticed. During this
stage, blood flow increases, there are increased secretions, and increased mucosal cell
growth. The inner lumen of the remaining small intestine increases in length and diameter.
Villous height also increases. Enteral nutrition supports the most successful adaptations.
Adaptation is also measured by the health of the remaining bowel and whether or not the
colon is present. (Nelms, pg. 425)
11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care
team monitor?
Mr. Sims’ health care team should actively monitor for any symptoms of extreme
abdominal cramping, pain, large volumes of diarrhea, and weight loss/cachexia. In
addition, Mr. Sims’ blood levels of macro and micronutrients should monitor short bowel
syndrome. If Mr. Sims becomes highly deficient in any of the nutrients absorbed in the
short bowel, the health team would be alerted to the likely presence of short bowel
syndrome. Nutrients absorbed within the short bowel include vitamins C and B, iron,
sodium, and potassium. Macronutrients such as carbohydrates, protein, and fats are also
absorbed along the small intestine. If short bowel syndrome exists, a patient will
experience general malnutrition. (Nelms, pg. 425)
http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/#symptoms
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?
This treatment would help replace damaged stem cells within the small intestine with
healthy ones from other parts of Mr. Sims’ body. Autologous stem cell transplantation
means that Mr. Sims’ is the cell “donor.” This is to his benefit because it ensures that the
cells will not be rejected—they are already part of his body system. When stem cell
transplantation is combined with immunosuppressant drugs, autoPBSCT has been shown
to induce remission of Crohn’s disease. However, relapses have been experienced in some
patients with refractory Crohn’s disease. (Nelms, pg. 173)
II.
Understanding the Nutrition Therapy
13. What are the potential nutrition consequences of Crohn’s disease?
Crohn’s disease may cause weight loss and severe nutritional deficits or patients. Crohn’s
disease negatively affects digestion and absorption, increasing a patient’s caloric, protein,
and micronutrient requirements. Without proper nutritional care, a Crohn’s patient may
experience protein energy malnutrition—causing a negative nitrogen balance in the body.
Crohn’s patients are also at risk for iron, zinc, magnesium, and electrolyte deficiencies as a
result of diarrhea and malabsorption. Resections increase calcium and protein
requirements in order for proper healing to occur. Medications such as corticosteroids too
can affect a patient’s nutritional status—causing nitrogen wasting, increased risk of
osteoporosis, and hyperglycemia. (Nelms, pg. 419-420)
14. Mr. Sims underwent resection of 200 cm of jejunum and proximal ileum with
placement 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?
Resection of the jejunum and proximal ileum is a “best case scenario” for Mr. Sims when
considering absorption and nutritional status. The jejunum is typically responsible for a
large portion of nutrient absorption. The duodenum is a key player in absorbing key
nutrients such as iron and folate, and also works heavily in the digestion and absorption of
nutrients. The jejunum therefore is left to absorb small amounts of sugars, fluids, and
lipids. However, when a resection of the jejunum occurs, the ileum is able to adapt to
perform the majority of the functions of the jejunum. In the case of Mr. Sims, part of the
proximal ileum was also a part of the resection surgery. This is a “best case” because the
distal ileum is more important in absorption than the proximal ileum. The distal ileum is
the only site for absorption of bile salts, vitamin B12 and also absorbs a large volume of
fluid. The ileocecal valve, which was preserved for Mr. Sims is crucial in maximizing
nutrient absorption. It controls the rate of passage of ileal contents into the colon. The
colon, also preserved during the surgery is essential for reabsorbing electrolyte-rich fluid
each day and helps to maintain a person’s hydration status. Therefore, while every surgical
resection is important, Mr. Sims resection was not the most significant case, as much of the
intestine was preserved.
The duodenum is approximately 0.5 m long, the jejunum 2-3 m, and the ileum, 3-4 m long –
making the approximate length of the small intestine 5.5-7.5 meters in length. Therefore,
after the 200 cm resection, Mr. Sims’ small intestine is most likely about 3.5-5.5 meters
long. When considering short bowel syndrome, Mr. Sims does not need to worry. Short
bowel syndrome is considered 100-120cm of short bowel without a colon, or 50cm of small
bowel with a colon. (a loss of 70-75% of the short bowel) (Krause, pg. 9, 637)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/
15. What nutrients are normally digested and absorbed in the portion of the small
intestine that has been resected?
The jejunum is responsible for absorption of sugars, resistant starch, fiber, lipids, dietary
fiber, and fluids. It also absorbs vitamins D and A, sodium, and a small amount of bile salts.
The proximal ileum is responsible for absorbing fat that was not absorbed by the jejunum,
the majority of bile salts, and vitamin B12. Luckily for Mr. Sims, the distal ileum is more
important to nutrient absorption than the proximal ileum. (Nelms, pg. 380) (Krause, pg.
637)
III.
Nutrition Assessment
16. Evaluate Mr. Sims’ % UBW and BMI.
UBW = 166-168# (166-168#/2.2#) = 75.3-76.2kg  75-77kg
Current Weight = 140# (140/2.2) = 63.5kg
%UBW = (63.5kg / 76.2kg) x 100 = 83.3%  83-84% UBW
At 83.3% of his UBW, Mr. Sims can be considered to be experiencing moderate
malnutrition. By subtracting 100%-83%, it is clear that Mr. Sims has also had a severe
weight loss of more than 10% within the last six months. (Nelms, pg. 48)
www.uic.edu/depts/mcam/nutrition/ppt/nutrition_assessment.ppt
Current BMI: kg/(m2)
Height = 69in. x 2.54cm = 175.3cm/100cm = 1.75m
BMI = 63.5kg/(1.752) = 20.8
UBW BMI:
BMI = 76.2kg/(1.752) = 24.9
Currently, Mr. Sims’ BMI is within the “normal” BMI range of 18.5-24.9. However, it is on
the lower end of the normal range. At Mr. Sims’ highest usual weight, he would still be
within the normal BMI range—a more healthy weight for a man of his age and build.
17. Calculate Mr. Sims’ energy requirements.
Mifflin-St. Jeor: men = 10 x wt (kg) + 6.25 x ht (cm) – 5 x age (yrs) + 5
Stress factor = 1.4 (Nelms, pg. 421)
Mr. Sims: [10 x 63.5kg + 6.25 x 175.3cm – 5 x 35 + 5] x 1.4
EER = 2182 kcal/day
Mr. Sims should receive between 2100 and 2200 kcal/day.
18. What would you estimate Mr. Sims’ protein requirements to be?
1.5-1.75 g protein/kg
Mr. Sims: 95.3g – 111.1g
Mr. Sims should receive between 95-110 grams of protein/day.
(Nelms, pg. 421)
19. Identify any significant and/or abnormal laboratory measurements from both his
hematology and his chemistry labs.
Mr. Sims’ blood panel revealed low levels of protein, including prealbumin and albumin
levels. This indicates malabsorption of protein, and should be a risk for protein energy
malnutrition. His blood had high levels of C-reactive protein, low HDL, positive ASCA, low
hemoglobin, hematocrit, transferrin, ferritin, vitamin D, vitamin A, and ascorbic acid. All of
these are indicators of malabsorption of iron, and other micronutrients. ASCA, high Creactive protein, and low iron are all indicators of classic Crohn’s disease symptoms. His
blood also showed high levels of ZPP and prothrombin time. High ZPP levels indicate some
sort of iron deficiency or anemia is present. High prothrombin time could be the indication
of a food-medication interaction. (Nelms, pg. 418-419)
http://www.nlm.nih.gov/medlineplus/ency/article/003652.htm
IV.
Nutrition Diagnosis
20. Select two nutrition problems and complete the PES statement for each.
PES: Malnutrition related to nutrient deficiencies as evidenced by serum blood levels of
protein (Total Protein: 5.5g/dL, Normal: 6-8g/dL), iron (Hemoglobin: 12.9g/dL, Normal:
14-17g/dL), and other micronutrients (Vitamin D: 22.7ng/mL, Normal: 30-100ng/mL). (NI
– 5.2)
PES: Altered GI function related to diagnosis of Crohn’s disease as evidenced by chronic
diarrhea, abdominal pain, micronutrient deficiencies, and protein energy malnutrition. (NC
– 1.4)
V.
Nutrition Intervention
21. The surgeon notes Mr. Sims probably will not resume eating by mouth for at least 710 days. What information would the nutrition support team evaluate in deciding
the route for nutrition support?
In order to determine proper nutrition support, the nutrition team would want to first
assess how much of the bowel (length) was left. They should also assess the patient’s stool
and urine output over the last 24 hours and any medications that could affect GI motility or
secretions. Because Mr. Sims’ resection was of mostly the jejunum, he will most likely
recover/adapt more quickly to a normal diet. In this case, it will be important for the
nutrition to provide multiple small feedings throughout a day, with a normal balance of
protein, fat and carbohydrate. The nutrition team would also take into account Mr. Sims’
age in order to predict how quickly and likely it is that he will be able to transition away
from any enteral feeding that is recommended. The team would also need to find out
information about Mr. Sims’ jejunostomy. This is useful in evaluating what Mr. Sims can
tolerate. A jejunostomy indicates that there is normal GI function and an increased
tolerance of early initiation of enteral feeding. However, they would need to also recognize
the risk of irritation and infection at the insertion site. Seven to ten days after surgery will
encompass the first “stage” of adaptation. During this time Mr. Sims may experience
extensive fluid and electrolyte losses within large volumes of diarrhea. For this reason, the
health team will want to closely monitor his hydration and electrolyte balance. (Nelms, pg.
85, 425) (Krause, pg. 638)
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?
Deficiencies of magnesium and phosphorus are generally signs of malabsorption and/or
the result of surgical stress. Low phosphorus levels can sometimes be the product of an
imbalanced/improperly initiated TPN plan. If this were the case, it would be of great
concern to Mr. Sims’ health. In other scenarios, phosphorus deficiencies can be the result
of decreased activation of vitamin D. Mr. Sims already has low levels of vitamin D, and is at
risk for osteopenia. Low phosphorus levels could be a warning sign for any of those
conditions. Magnesium deficiencies can also result from improper TPN. If Mr. Sims is
receiving too little of either of these electrolytes, he may be at increased risk for refeeding
syndrome. (Nelms, pg. 132)
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
Refeeding syndrome is defined as metabolic alterations that may occur during nutritional
repletion of starved patients. Mr. Sims is at risk for this syndrome because of his NPO
status for 7-10 days after his surgery. In addition, his blood panel showed that he was
already presenting with malnutrition—putting him at further risk for refeeding syndrome.
In order to prevent this syndrome, it will be critical for the health team to monitor Mr.
Sims’ serum levels of phosphorus, magnesium, and potassium, and to provide the proper
supplementation as needed until Mr. Sims can receive his goal feedings. Without proper
monitoring, Mr. Sims’ body could go into starvation mode—using free fatty acids as an
energy source in the form of ketones. Glucose metabolism will require large quantities of
phosphorus. Other anabolic needs will require increased magnesium and potassium.
(Nelms, pg. 92-93)
24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively,
and a nutrition support consult was ordered. Initially, he was prescribed to receive
200 g dextrose/L, 42.5 g amino acids/L, and 30 g 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.
Yes, I agree with the team’s decision to initiate parenteral nutrition. Mr. Sims’ short bowel
will need time to adapt to the resection surgery. Specifically, the ileum will need to take
over absorption of nutrients once covered by the jejunum. Parenteral nutrition will give
time for the adaptation and allow Mr. Sims to eventually have the jejunostomy removed.
50cc/hr x 24hr = 1200cc/day
1000cc = 1 L  1.2 L/day
1.2L x 200g dextrose/L = 240g dextrose/day
240g dextrose/day x 3.4kcal/g = 816 kcal dextrose
1.2L x 42.5g amino acids/L = 51g amino acids/day
51g amino acids/day x 4kcal/g = 204 kcal amino acids
1.2L x 30g lipids/L = 36g lipids/day
36g lipids/day x 9kcal/g = 324 kcal lipids
TOTAL kcal = 1344 kcal
85cc/hr x 24hr = 2040cc/day
2.04 L/day
2.04L x 200g dextrose/L = 408g dextrose/day
408g dextrose/day x 3.4kcal/g = 1632 kcal dextrose
20.4L x 42.5g amino acids/L = 86.7 g amino acid/day
86.7g amino acids/day x 4kcal/g = 346 kcal amino acids
2.04 x 30g lipids/L = 61.2g lipids/day
61.2g lipids/day x 9kcal/g = 550 kcal lipids/day
TOTAL kcal = 2528 kcal
At the beginning of Mr. Sims’ treatment, parenteral nutrition received at 50cc/hr will not
meet his nutritional needs. However, at a rate of 85cc/hr, Mr. Sims will be receiving excess
energy. When calculated with a stress factor of 1.4, Mr. Sims requires 2100-2200 kcal/day.
At 85cc/hr, Mr. Sims will be receiving between 2500-2600 kcal/day. In addition, Mr. Sims
should be receiving between 95-110g/protein each day. At 85cc/hr, Mr. Sims will only be
receiving 85-86g of protein. For this reason, I disagree with the team’s parenteral nutrition
plan, but agree that he should be receiving this type of feeding.
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 etiology).
Malnutrition PES
- Ideal Goal: Use supplementation of micronutrients and parenteral nutrition to
increase Mr. Sims’ iron and protein intakes, as well as stabilize micronutrient levels.
Specifically, Mr. Sims’ protein intake should be increased within an ideal range of
95-110g/day. Iron levels should be monitored until they reach a hemoglobin level
between 14-17g/dL. Hematocrit levels should be increased a percentage of 40-54%.
Transferrin levels and ferritin levels should be increased between 215-365mg/dL
and 20-300mg/mL respectively. Vitamins A (20-80ug/dL), C (0.2-2.0mg/dL), and D
(30-100ng/mL) should be increased, while ZPP should experience a decrease. All of
these levels can be changed by decreasing or increasing supplementation received
through Mr. Sims’ TPN.
- Intervention: Request daily blood panels to be taken from Mr. Sims until serum
blood levels indicate an ideal nutrition status with values in normal ranges (as
indicated in the ideal goal).
Altered GI function PES:
- Ideal Goal: Decrease volume of diarrhea and abdominal pain through proper
nutrition according to the absorption capacity and adaptation of Mr. Sims’ short
bowel.
- Intervention: Continue to administer TPN feedings to Mr. Sims until short bowel
has adapted to resection surgery. Educate client on gas-related foods and on diet
plan for Crohn’s disease, including small, frequent feedings.
VI.
Nutrition Monitoring and Evaluation
26. Indirect calorimetry revealed the following information:
Measure
Mr. Sims’ data
Oxygen consumption (mL/min)
CO2 production (mL/min)
RQ
RMR
295
261
0.88
2022
What does this information tell you about Mr. Sims?
RMR: resting energy expenditure in 24 hours
- This value gives the total kilocalories needed per day for adequate energy intake.
RQ = volume of CO2 expired/volume of O2 consumed
- The RQ value represents the fuel mixture being metabolized.
- An RQ value of 0.88 represents that Mr. Sims is receiving a mixed diet, without one
fuel being used significantly more than any of the others.
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 redistribute the macronutrients Mr. Sims is receiving by parenteral nutrition. Mr.
Sims should receive more grams of protein per day, and fewer grams of dextrose that could
be converted into fat if given in excess. The total grams of each macronutrient should be
decreased in order to reach a goal intake of 2100-2200kcal/day. In order to ensure
adequacy of his diet, Mr. Sims’ electrolyte and micronutrient serum blood levels should be
monitored. In addition, indirect calorimetry should be used to ensure that Mr. Sims is
being fueled by a mixed diet (per his RQ values). Finally, taking daily weights can ensure
adequate nutrition. Mr. Sims should not be losing any weight. Instead, it would be healthy
for Mr. Sims to gain some weight to reach his UBW.
28. What should the nutrition support team monitor daily? What should be monitored
weekly? Explain.
Daily: The nutrition support team should order daily electrolyte counts as well as blood
panels of serum glucose, BUN, and creatinine. The nutrition team should be monitoring Mr.
Sims’ bowel movements as he transitions through a time of short bowel adaptation. They
should be monitoring his hydration status, and ensure that Mr. Sims is not experiencing
any weight loss. In addition, daily inputs and outputs should be monitored, as well as the
catheter site, clinical status, and patient’s temperature.
Weekly: The nutrition support team should monitor for increased liver enzyme levels,
which could alter the lipid-to-dextrose ratio of TPN. Because the GI tract is largely at rest
during TPN, the nutrition support team should be aware of the risk of cholestasis (bile
accumulation in the gallbladder). The team should also continue to measure weights over
the weeks to calculate any significant weight losses over a month’s time. Finally, the team
should assess for any infection at the insertion site for TPN or within the GI tract. A
patient’s blood count should also be monitored on a weekly basis.
(Nelms, pg. 101) (Krause, pg. 310, 316, 320)
29. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is
now abnormal? What should be done about it?
This level could now be abnormal because of the increased rate of parenteral nutrition.
The rate was increased from 50cc/hr to 85cc/hr. The increased rate, and slightly high
dextrose concentration when combined with the low grams of protein administered could
result in the elevated serum glucose level. In addition, the nutrition team should consider
the total kilocalories received per day – overfeeding. Another cause of the high serum
glucose could be a negative stress response by Mr. Sims’ body to surgery.
http://anhi.org/learning/pdfs/bcdecker/Enteral_Nutrition.pdf
30. Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4
gram. 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.
N2 balance = dietary protein intake / 6.25 – urine urea nitrogen – 4
N2 balance = (86.7g protein / 6.25) – 18.4g nitrogen – 4
N2 balance = -8.5 g
Because this resulted in a negative nitrogen balance, it can be concluded that nitrogen
excretion is greater than nitrogen intake. This can help to assess the effectiveness of the
nutritional intervention Mr. Sims is receiving. Based on this number, I would be concerned
about Mr. Sims’ nutritional status. Excess nitrogen excretion could lead to protein energy
malnutrition for Mr. Sims. There are a few limitations with nitrogen balance studies. There
may be inherent error of 24-hour urine collection, failure to account for renal impairment,
and an inability to measure nitrogen losses from diarrhea, vomiting,, or wounds.
(Nelms, pg. 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. Sims be allowed to try
first? What would you monitor for tolerance? If successful, when can the parenteral
nutrition be weaned?
When an oral diet is first initiated after parenteral nutrition, a patient should be give a lowresidue, lactose-free diet with small, frequent meals—as tolerated. The nutrition team
should then monitor for any steatorrhea. If steatorrhea is present, then fat should be
reduced, and medium-chain triglycerides added through a supplement. As the patient
begins to tolerate the mild diet, small amounts of fiber could be introduced. Foods that are
considered to be “gas-producing,” such as spicy/fried foods or caffeinated beverages
should be avoided. A multivitamin should be given throughout this time. Knowing when to
wean a patient from parenteral nutrition is a highly individualized process. The registered
dietitian will need to slowly wean a patient off of the parenteral diet, assessing how well it
is tolerated, and how complete the patient’s nutrient intake is without any parenteral
nutrition. (Nelms, pg. 421) (Krause, pg. 321)
32. What would be the primary nutrition concerns as Mr. Sims prepares 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.
Primary nutrition concerns would include those of Mr. Sims’ nutrient absorption within the
small intestine, weight maintenance/gain to UBW, and the redevelopment of Mr. Sims’
bacterial flora in the GI tract. Looking at blood panels and evaluating the levels of macro
and micronutrients that should be absorbed by the short bowel could easily monitor
nutrient absorption. (Ex: looking at albumin levels to evaluate protein absorption) Asking
him to keep a weight log at home—both on a daily and weekly basis, could monitor Mr.
Sims’ weight gain. A food log could monitor adequate nutritional intake. Finally, Mr. Sims’
would want to incorporate probiotics and prebiotics into his diet in order to rebuild the
normal flora in his GI tract. This level would need to be assessed by a doctor. The success
of incorporating biotics into Mr. Sims’ diet would require the skill of a dietitian, given Mr.
Sims’ allergy to lactose. (Nelms, pg. 422)
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