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Jillian O’Neil
KNH 411
09/17/13
Case Study #11 – Inflammatory Bowel Disease: Crohn’s Disease
1. What is inflammatory bowel disease? What does current medical literature
indicate regarding its etiology?
Inflammatory bowel disease, IBD, is an autoimmune, prolonged inflammatory condition of
the gastrointestinal tract. IDB is often associated with ulcerative colitis and Crohn’s disease.
Regarding it’s etiology, there is not current medical literature. Although, several
environmental factors could influence the disease – such as infectious agents, smoking,
intestinal flora, physiological changes in the small intestine and genetic associations.
(Nelms 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?
Ulcerative colitis is a prolonged inflammatory bowel disease that mainly affects in the colon
and rectum. Crohn’s disease is a prolonged inflammatory bowel disease that mainly affects
the ileum and colon although it can affect the entire gastrointestinal tract. This could
happen if the initial diagnosis shown an infection, irritation, or abnormalities in the colon
and rectum. Once he was later diagnosed with Crohn’s, the disease may have traveled up
the digestive system, affecting the rest of his GI tract as well as causing further discomfort.
The similarities of Ulcerative Colitis and Crohn’s disease include: the etiology (abnormal
immune response which causes inflammatory damage of the GI mucosa; it is genetically
susceptibly and often associated with cigarette smoking); the epidemiology (commonly
found in both sexes equally, a higher prevalence in North America, northern Europe, the UK
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and with Jews). In regards to pathology, both diseases affect the GI tract. Similar signs and
symptoms include: abdominal and/or rectal pain and cramping, bloody stools, fever and
weight loss. Each disease has it’s own list of complications. The diagnosis of both include
an abdominal ultrasound, MRI, CT, ASCA/ANCA, and calprotectin, lactoferrin, and
polymorphonecular neutrophil elastase. The prognosis of both usually includes surgery.
For treatments, both use the drugs immunosuppressants, biologic therapies, antibiotics,
and steroids.
The differences include: Ulcerative Colitis usually has a peak onset of 20 to 30 years with a
secondary peak in the middle ages whereas Crohn’s disease has a peak age onset with teens
and those in their twenties. With pathology, Ulcerative Colitis mainly affects the colon and
rectum whereas Crohn’s disease mainly affects the ileum and colon. Signs and symptoms
specified for Ulcerative Colitis are: possibly constipation and rectal spasm, arthritis,
dermatological changes and ocular manifestations. Signs and symptoms of Crohn’s disease
include: chronic diarrhea, anorexia, malnutrition, and delayed growth in adolescents.
Complications of Ulcerative colitis include severe bleeding, toxic mega colon, toxic colitis,
strictures, perforation, intolerance to immunosuppression, colonic strictures, dysplasia and
carcinoma. Complications of Crohn’s disease includes malabsorption, malnutrition,
abdominal fistulas and abscesses, intestinal obstruction, gallstones, bacterial overgrowth,
kidney stones, urinary tract infections, thromboembolic complications, perianal disease
and neoplasia. Crohn’s disease also uses clinical presentation (CDAI score) to diagnosis the
patient. Drug treatment of Ulcerative colitis include adrenocorticosteroids, antiinflammatory, antidiarrheal. Surgery involves the colectomy. Drug treatment of Crohn’s
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disease includes methotrexate and surgery involves removing the affected area (ileoccolic
resections and segmental resections).
(Nelms 377, 416)
3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as
sever fulminant disease. CDAI score of 400. What does a CDAI score of 400
indicate? What does a classification of severe fulminant disease indicate?
Crohn’s Disease Activity Index, CDAI, is the way in which Crohn’s disease is described in
research and clinical trials. In order to determine the stage, factors are evaluated –
diarrhea, abdominal pain, abdominal mass, decreased sense of well-being, extra intestinal
manifestations, weight loss and laboratory features. A CDAI score of 400 indicates the stage
of “Moderate – Severe Disease.” A classification of severe fulminant disease indicates that
the patient has constant symptoms even though he or she was prescribed steroids or
biological agents. Those with a score about 450 also suffer from high fevers, persistent
vomiting, intestinal obstruction, rebound tenderness, cachexia as well as an abscess.
(Nelms 418, 419)
4. What did you find in Mr. Sims’ history and physical that is consistent with his
diagnosis of Crohn's? Explain.
In Mr. Sims history and physical reports, it states he had an abscess as well as acute disease
in the first 5cm of the ileum – both consistent with Crohn’s disease. In addition, abdominal
pain, chronic diarrhea, and a fever correspond to this disease. The report stated his general
appearance was “thin” and his calculated BMI is 20.8, putting him at the lower side of the
normal, healthy weight. Based on the Hamwi method, a healthy weight for a person of his
height would be 160 pounds yet he weighs twenty pounds less than that – signs of Crohn’s:
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weight loss, malnutrition and possibly anorexia. The stool consistency of “soft to liquid”
confirms the diarrhea. With the diagnosis of Crohn’s, Mr. Sims’ history includes orders for a
CT and Antiglycan antibodies. Previously, his clinical presentation was stated – a CDAI
score of 400.
Calculations:
Height: 5’9” = 69 inches = 1.75 m
Weight = 140 lbs / 2.2 = 63.6 kg
BMI = 63.6/(1.752) = 20.8
Hamwi method: 106 + 6(9) = 160 pounds ideally.
(Nelms 47, 48, 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?
Crohn’s patients often have symptoms that occur outside of the intestines. Some symptoms
include: weight loss, fever, anorexia, malnutrition, and delayed growth in adolescents. In
his history and physical, there are evidence showing extraintestinal symptoms. As stated
above, Mr. Sims has had a significant amount of weight loss. In addition to the weight listed
with his vital signs, his general nutrition states he has lost more weight since his previous
hospitalization. This section confirms the weight loss and issue of malnutrition. In addition,
Mr. Sims has a temperature of 101.5 degrees – a fever to the normal body temperature of
98.6 degrees. Lastly, Extraintestinal manifestations may include arthritis, joint pain, ocular
manifestations, uvelitis, and episcleritis. (Nelms 416, American Academy of Family
Physicians)
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6. Mr. Sims has been treated previously with corticosteroids and mesalamine. His
physician had planned to start Humira prior to his admission. Explain the
mechanism for each of these medications in the treatment of Crohn’s.
Corticosteroids are used for patients with acute exacerbations. This drug aids in the
prevention of inflammatory responses as well as help with a quicker recovery. Mesalamine
treats the areas of the GI track that are affected by the disease. As an anti-inflammatory
agent, it works to eliminate pain or inflammation throughout the body – particular
inflamed bowels. Humira is the common name for the drug “Adalimumab.” It is used to
reduce the signs, symptoms and progression of moderate to severe rheumatoid arthritis for
adults. Arthritis is often a common symptom of ulcerative colitis. (Crohn’s and Colitis
Foundation of America, National institute of Health, American Academy of Family
Physicians)
7. Which laboratory values are consistent with an exacerbation of his Crohn’s
disease?
Although Crohn’s disease can’t be diagnosed through blood work, the laboratory values can
support the finings as well as aid in the monitoring of the disease. His protein value was
low – displaying a value of 5.5g/dL when the normal range is 6-8 g/dL. The Albumin and
prealbumin values were also low – values of 3.2g/dL and 11 mg/dL with normal ranges of
3.5-5 g/dL and 16-35 mg/dL. The antibody value, shown as + when the ASCA should be
negative, is a biomarker which indicates the patient suffers from Crohn’s. The C-reactive
protein value was high, 2.8 mg/dL, in relation to the reference range of less than 1.0mg/dL.
The C-reactive protein assesses for inflammation, infection, and disease. (Zonderman, Beth
Israel Deaconess Medical Center)
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8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why
he may be at risk for vitamin and mineral deficiencies.
Mr. Slims may be at risk for vitamin and mineral deficiencies even though he is taking
vitamin and mineral supplements. First, he may be deficient in iron due to blood loss and
malabsorption. A deficiency in magnesium and zinc may be due to the intestinal losses
from extreme diarrhea. Long-term steroid use and a decrease intake do dairy foods can
cause a deficiency in calcium and vitamin D. (Nelms 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 is the reduced digestion and absorptions due to a large resection of
the small intestine. Although his history chart stated he has not had a surgery in the past,
the orders indicate for Mr. Sims to consult with a surgeon. If he were to have surgery, then
he may be a likely candidate for short bowel syndrome. At this point, prior to any surgery,
he may only be at risk for short bowel syndrome due to the malabsorption of nutrients.
10. What type of adaption can the small intestine make after resection?
After surgery, the small intestine may develop adaptations. In particular, the resection may
help the intestine to absorb nutrients properly – if the procedure was successful. If the
procedure wasn’t successful in the direction it was intended, the extensive loss of surface
area will cause a major malabsorption of electrolytes, fluids and nutrients. (Nelms 420)
11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care
team monitor?
His health care team should monitor for the classic symptoms. Large volumes of diarrhea
cause deficiencies in sodium, iron, zinc, magnesium, calcium and selenium. In addition, they
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should monitor for dehydration, bloating, cramping and fatigue. Lastly, they should
monitor his blood work to review the levels of infection, inflammation and disease. (Nelms
425)
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 Mrs. Sims?
The immunosuppressant drug is used to help the body accept the transplant. Without this
drug, the immune system isn’t altered and the body will not corporate with the stem cell
transplant. The transplantation itself will aid in the inflammatory response the body has
been producing. For Mr. Sims, his body has been producing an inflammatory response due
to the Crohn’s disease. Therefore, the autologous peripheral blood stem cell
transplantation will encourage his body to reduce the inflammation and continue to
remission of the disease. (Nelms 554, Clinical Trials)
13. What are the potential nutritional consequences of Crohn’s disease?
The potential nutritional consequences of Crohn’s disease include the common deficiencies.
A deficiency in calories is due to the insufficient intake, increased energy requirements and
fear of abdominal pain along with diarrhea after eating. Protein deficiency is associated
with the increased protein needs, catabolism, and healing from surgery. The fluid and
electrolyte deficiency is due to short bowel syndrome and high volume diarrhea. There
may be a deficiency in iron due to blood loss and malabsorption. A deficiency in magnesium
and zinc may be due to the intestinal losses from extreme diarrhea. Long-term steroid use
and a decrease intake do dairy foods can cause a deficiency in calcium and vitamin D. A
deficiency in B12 and water-soluble vitamins is due to surgical resections (loss of ileum).
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Medications can cause a deficiency in folate and steatorrhea causes deficiency in fat-soluble
vitamins. (Nelms 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?
The small intestine is about 5.5 m to 6 m (550 – 600 cm) in length. The jejunum is about 2.5
meters in length (250cm). With a resection of 200 cm of the jejunum, the small intestine
was reduced to 350 to 400cm in length. This resection provides a major significant change
for Mr. Sims. The jejunum is responsible for the absorption of many vitamins and minerals
– including Thiamin, Riboflavin, Niacin, Pantothenate, Biotin, Folate, Vitamin B6, Vitamin C,
A, D, E, K, Calcium, Phosphorus, Magnesium, Iron, Zinc, Chromium, Manganese, and
Molybdenum. This resection will cause a decrease in the absorption of the important
nutrients Mr. Sims needs for a healthy, everyday diet. (Nelms 384)
15. What nutrients are normally digested and absorbed in the portion of the small
intestine that has been resected?
The portion of the small intestine that has been resected was the jejunum and proximal
ileum. The nutrients that are normally digested and absorbed in this restricted area
include: Thiamin, Riboflavin, Niacin, Pantothenate, Biotin, Folate, Vitamin B6, Vitamin C, A,
D, E, K, Calcium, Phosphorus, Magnesium, Iron, Zinc, Chromium, Manganese, and
Molybdenum. (Nelms 384)
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16. Evaluate Mr. Sims’ % UBW and BMI.
Mr. Sims’ percent Usual Body weight is 83.8%. Interpreting this result, he has a percent
weight change of 16.2%. He has a BMI of 20.8. (Nelms 47, 48)
Calculations:
%UBW= (current weight/usual body weight) * 100
(140/167)*100
%UBW = 83.8%
% weight change = 100-%UBW
100 – 83.8 = 16.2%
Height: 5’9” = 69 inches = 1.75 m
Weight = 140 lbs / 2.2 = 63.6 kg
BMI = 63.6/(1.752) = 20.8
17. Calculate Mr. Sims’ energy requirements.
Mr. Sims’ energy requirements were determined using the EEE equation with a physical
activity coefficient of 1.11 for low active. His daily caloric requirement is 2,000 calories.
Calculations:
Weight: 140 lbs / 2.2 = 63.6 kg
Height: 5’9” = 69 inches = 1.75 m
Age: 35 years old
TEE=662-9.53(age) + PA (15.91*weight + 539.6*height)
662-9.53(35) + 1.11(15.91*63.6 + 539.6*1.75)
662-333.55 + 1.11(1011.9 + 944)
328.45 + 2171 = 2500 calories
(Nelms 242)
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18. What would you estimate Mr. Sims’ protein requirements to be?
If Mr. Sims consumed 10% of his daily energy intake for proteins, this would be 250
calories of protein per day. This amount is equivalent to 62.5 grams of protein.
Calculations:
2500 calories/day *.10 =250 calories of protein/day (1g/4 cal) = 62.5g protein
(Nelms 243)
19. Identify any significant and/or abnormal laboratory measurements from both his
hematology and his chemistry labs.
In regards to his chemistry laboratory measurements, his protein value of 5.5g/dL is low
in reference to the normal range of 6-8 g/dL. The Albumin and prealbumin values were
also low – values of 3.2g/dL and 11 mg/dL with normal ranges of 3.5-5 g/dL and 16-35
mg/dL. The C-reactive protein value was high, 2.8 mg/dL, in relation to the reference range
of less than 1.0mg/dL. Mr. Sims’ HDL cholesterol count was low with a value of 38mg/dL in
comparison to the reference point of above 45 for males. The biomarker, antibody value
(ASCA) was displayed at a positive (+) when it s preferred to be negative. In regards to his
hematology laboratory measurements, the ideal hemoglobin range for males is 14-17g/dL.
Mr. Sims’ was low with a value of 12.9 g/dL. His Hematocrit value was also low with 38%
and the normal reference range for males of 40-54%. The transferrin and ferritin levels
were low with values of 180 mg/dL and 16 mg/mLL – the reference ranges for males are
215-365 mg/dL and 20-300 mg/ML. His zinc protoporphrin (ZPP) levels were high with a
value of 85 μmol/mol – the reference range is 30 to 80 μmol/mol. The labotory results for
hematology also showed a low value of Vitamin D 25 hydroxy – 22.7 ng/mL with the
reference range of 30-100. A decreased value of 17.2 μg/dL was also shown for Free retinol
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(vitamin A) with the reference range of 20-80 μg/dL. Lastly, the ascorbic acid range of 0.22.0 mg/dL was shown to be low with a value of <0.1mg/dL.
(A Case Study Approach 119-121)
20. Select two nutrition problems and complete the PES statement for each.
A. Inadequate Calorie Intake

Inadequate caloric intake (NI-1.2) of 2,236 calories related to lifestyle-diet
choices as evidence by the recent dietary intake and a weight loss of 40
pounds.
B. Poor Eating Habits

Poor eating habits of processed foods and minimal fruit/vegetable intake
related to lifestyle-diet choices as evidence by the recent dietary intake and
laboratory results.
Mr. Sims energy intake is roughly 2,236 calories. His estimated needs is 2,500 calories.
(www.fitday.com)
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21. The surgeon notes Mr. Sims probably will not resume eating by mouth for at least
7-10 days. What information would the nutrition support team evaluate in
deciding the route for nutrition support.
When a patient is designated as NPO, the nutritional support team needs to assess the
situation and decide on a route to continue the essential nutritional support. The team
would choose the route of Total Parentarel Nutrition because of the circumstances of NPO.
TPN provides the patient with proper fluids and nutritional needs by way of intravenous
feeding. Seven to ten days is considered short term; so, this option would be best. The team
will also need to take into consideration that the patient will need to be supplied with
additional supplementations: zinc (12-15mg/L of stool output), calcium (10-25 mEq/day);
magnesium (15-30 mEq/day) and Copper (0.5 to 1.5 mg/day).
(Nelms 422, 577)
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?
The low serum phosphorus and serum magnesium values are of concern because of the
ways in which it will further affect him. First, low serum phosphorus levels can lead to
fatigue, irregular breathing, loss of appetite, weight fluctuation, painful and fragile bones.
Secondly, low serum magnesium levels can be associated with anxiety, sleeping disorders,
vomiting and nausea, seizures, abnormal heart rhythm, confusion, muscle spasm, low blood
pressure and insomnia. Both levels are of concern to prevent further medical issues to the
patient. (University of Maryland Medical Center, Nelms 132)
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23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
Refeeding syndrome is the metabolic alterations that may occur due to the nutritional
repletion of starved patients. Mr. Sims is at risk for this problem because he has had a
record of low energy intake. In addition, the next seven to ten days of his hospitalization
will include a NPO diet. Lastly, as stated in Nelms, a drop in serum levels of phosphorus
mass result due to the refeeding syndrome. The nutritional support team has already
noticed the drop in these levels. This syndrome can be prevented by avoiding to overfeed
the patient as well as to begin the feedings slowly. (Nelms 81, 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 200g dextrose/L, 42.5 g amino acids/L, and 30g lipid/L. His
parenteral nutrition was initiated at 50cc/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 nutrition needs? Explains. Calculate pro (g); CHO (g); lipid (g); and total
kcal from his PN.
I agree with the team’s decision to initiate parenteral nutrition. Mr. Sims has not only lost
weight recently but is also on an NPO diet for the next week or so. Therefore, it is crucial to
initiate a plan that guarantees for him to receive the nutrients needed. He will not meet his
nutrition needs with this amount of nutrients he was prescribed. With the prescription, he
would receive 240 g carbohydrates per day (816 kcalories), 48 grams of protein per day
(60 calories), and 36 grams of lipid per day (396 calories). In total, he will have a caloric
intake of 1,272 calories per day. This is a problem that he will not meet his nutritional
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needs because he is already in a form of deficit. His recent weight loss and diet habits have
influenced his point of medical treatment at this point. Therefore, the nutritional team will
need to increase intake. Once the goal rate of 85cc/hour, his total calories per day is 2155.
He will receive 408 g of carbohydrates, 87 grams of protein, and 60 grams of lipid per day.
Using the rate of 85cc/hour will be more beneficial to Mr. Sims because the calories are
closer to his initial calorie goal of 2500kcal. (Nelms 95, 96)
Calculations:
50 cc = 0.05 L ; 85 cc = 0.085 L
200 g dextrose/L (0.05L) = 10gCHO per hour * 24 = 240gCHO per day
240gCHO *3.4cal/g = 816 kcal of CHO per day
42.5 g amino acids/L (0.05L) = 2g pro per hour *24 = 48 g pro per day
48g pro (1kg/0.8g) = 60 kcal of Pro per day
30g lipid/L (0.05 L) = 1.5 g lipid per hour * 24 = 36 g lipid per day
36 g lipid (11kcal/gram) = 396 kcal of lipid per day
Total kcal = 816 + 60 + 396 = 1272 calories per day
200 g dextrose/L (0.085L) = 17gCHO per hour * 24 = 408gCHO per day
408gCHO *3.4cal/g = 1387 kcal of CHO per day
42.5 g amino acids/L (0.085L) = 3.6g pro per hour *24 = 87 g pro per day
87g pro (1kg/0.8g) = 108 kcal of Pro per day
30g lipid/L (0.085 L) = 2.5 g lipid per hour * 24 = 60 g lipid per day
60 g lipid (11kcal/gram) = 660 kcal of lipid per day
Total kcal = 816 + 600 + 396 = 2155 calories per day
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25. For each of the PES statements you have written, establish and ideal goal (based
on the signs and symptoms) and an appropriate intervention (based on the
etiology).
A. Ideal goal: increase overall body weight by improving on the lifestyle-diet choices
and increasing the daily caloric intake. For example, Mr. Sims would increase caloric
intake by choosing a calorie and nutrient dense snack instead of cola and crackers.
B. Ideal goal: increase intake of fruit and vegetables while decreasing the amount of
processed foods by improving on lifestyle-diet choices and knowledge on healthy
eating habits. For example, Mr. Sims could chose to have fruit as a snack, add
vegetable options to dinner and lunch, and make homemade potato chips rather
than snacking from the pre-packaged bag.
26. Indirect calorimetric revealed the following information:
Measure
Oxygen consumption (mL/min)
CO2 production (mL/min)
RQ
RMR
Mr. Sims’ data
295
261
0.88
2022
What does this information tell you about Mr. Smith?
This information tells me that Mr. Sims’ Resting Metabolic rate is 2,022kcalories. This is the
amount of energy when he is at rest – not taking into consideration any extra activities. In
addition, his respiratory quotient of 0.88 indicates the level of protein used. This data tell
us that he uses 295 ml of oxygen per minute (oxygen consumption) and produces 261 ml of
carbon dioxide per minute (CO2 production). Mr. Sims’ cardiac input is greater than his
cardiac output. (National Library of Medicine)
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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 not make changes to his prescribed nutrition support if he reaches the goal rate of
85cc/hour. If that goal has been obtained, I would increase it to 90cc/hours to reach the
desired energy intake and ultimately healthy weight for Mr. Sims. In order to ensure the
adequacy of his nutrition support, I suggest to continue with testing of indirect
calorimetric because it’s the main way to accurately estimate his calorie needs. This data
will notify the care team of an increase in caloric needs, which is affected by weight loss or
weight gain.
28. What should the nutrition support team monitor daily? What should be
monitored weekly? Explain your answers.
The nutrition support team should monitor the amount of ccs per day. This is important to
know when is the correct time to increase the amount of energy intake per day. When
beginning at 50cc/hour, it is important to slowly increase to 85cc/hour to prevent further
refeeding syndrome. The nutrition support team should monitor his caloric needs weekly
using indirect calorimetry. This is important to support or deny the weight gain as well as
assist the team in knowing when to continue to increase the ccs. Ultimately, the team wants
Mr. Sims to reach a full recovery by eating foods rather than through parenteral nutrition.
By monitoring daily and weekly, the team can assist in the recovery.
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?
A serum glucose level above 126 mg/dL is abnormal. His level of 145 mg/dL is high and
associated with high blood sugar as well as diabetes. Although he has a high level, I do not
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believe Mr. Sims has diabetes. I believe his high level is due to the 200g/L of dextrose that
is directly put into his bloodstream with parenteral nutrition. To lower his increased
glucose level, a lower dosage of dextrose can be used. Another option would be to use it at
60cc/hour while slightly increasing protein and lipid to 95cc/hour. (National Library of
Medicine)
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.
The Urinary Nitrogen value of 18.4g is the amount of protein in the body during a
designated 24-hours. His total was 85 g. He is in a catabolic state with a negative nitrogen
balance of -8.8. This value puts him in the category of extreme stress. This is something to
be concerned with because he may need in increase intake to balance out the loss with the
intake levels. These numbers may be altered from improper I/O, the fudge factor of 4
grams that takes into account the nitrogen losses. (Nelms, Parenteral Nutrition)
Calculations:
18.4g Urinary Nitrogen/L (0.05L) = 85 g protein on day 4
368g pro (1kg/4) = 93 kcal of Protein on day 4
nitrogen intake = 85/6.25=13.6
nitrogen loss = 18.4 + 4 grams = 22.4 grams
Balance = intake – loss – 13.6-22.4 = -8.8
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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?
First, he should be allowed to try sugar-free, isotonic clear liquids. I would monitor his
bowel function and sounds, his stool color and consistency, his temperature and his
respiration rate. If successful, parenteral nutrition can be weaned. This is a very slow
process and cannot be rushed. Only one food at a time should be added to the diet to
prevent further complications. If the GI symptoms are worsened, the food added will need
to be removed and gradually introduced again. (Nelms 426)
32. What would be the primary nutrition concerns as Mr. Sims prepares for
rehabilitation after discharge? Be sure to address his need for supplementation
of any vitamins and minerals. Identify two nutritional outcomes with specific
measurement for evaluation.
Primary nutrition concerns for Mr. Sims would be: if he can continue on the “slow
additions” of new foods into his diet, if he can choose foods that will not aggravate the
disease, if he can avoid processed foods and chew foods well, and if he can eat smaller
meals more often. In addition, he will need to take supplementation of vitamins and
minerals in liquid or chewable form. Iron supplements are needed to prevent anemia and
restore iron levels. A calcium and vitamin D supplement is important to prevent
osteoporosis because Chronis disease increases the risk of this disease. Lastly, I would
suggest a Vitamin B12 supplement for proper nerve function. The first nutritional outcome
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would be to increase Mr. Sims weight. An increase of 500 calories per day (3500 calories
per week) would increase his weight by 1 pound. If he can slowly increase his caloric
intake, he will be able to successfully gain weight. This can be measured for evaluation by
having a “weigh in” at every counseling session, once a week. The second nutritional
outcome would be to increase his knowledge about healthy lifestyle choices. By educating
Mr. Sims on these choices, he can improve his overall health as well as feel better during his
recovery process. I would first educate him and then provide him with a journal. In this, he
will create a log of all intakes. The measurement for this outcome would be to review the
progress of change at the weekly meeting. Also, by pointing out and suggesting where he
can improve in his diet, Mr. Sims will be able to reach a new goal for the following week’s
evaluation.
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References
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<http://clinicaltrials.gov/show/NCT00692939>.
"CCFA: Corticosteroids." CCFA: Crohn's | Colitis | IBD. N.p., n.d. Web. 15 Sept. 2013.
<http://www.ccfa.org/resources/corticosteroids.html>.
"Glucose test - blood: MedlinePlus Medical Encyclopedia." National Library of Medicine National Institutes of Health. N.p., n.d. Web. 12 Sept. 2013.
<http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm>.
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