Rachel Hart
KNH 411
Final Exam CS
December 11, 2012
1. Research Crohn’s disease and discuss the incidence of the disease, the
cause, the symptoms, and the treatment.
Crohn’s disease is characterized by the general term of inflammatory bowel
disease (IBD), which can be either Crohn’s disease or ulcerative colitis (UC).
These two disease states are similar but have distinct differences that should
be noted. Most importantly, Crohn’s disease affects both the small and large
intestines and occurs in patches, where as ulcerative colitis affects just the
large intestine and is continuous throughout the affected area (Columbia St.
Mary’s, 2012). Crohn’s disease is characterized by localized inflammation in
bowel mucosa progressing through the bowel wall.
Prevalence of IBD is higher in countries within the Northern Hemisphere
specifically, North America and Northern European countries. In the United
States, incidence ranges from 5-15 people per 100,000 and prevalence
ranges from 388-444 people per 100,000. Prevalence is fairly equal in both
men and women and is higher in those populations with Caucasian and
Ashkenazi Jewish ancestry (Nelms, 2011, pg. 415). Although the etiology for
Crohn’s disease is unknown, it is thought to be a multiple factor condition.
Environmental factors include, smoking, infectious agents, intestinal flora,
and physiological changes in the small intestine from which an abnormal
inflammatory response is triggered. There is also a strong genetic
association with family history and the disease (Nelms, 2011, pg. 415-416).
Symptoms of Crohn’s disease includes, chronic diarrhea, abdominal pain and
cramping, blood and/or mucous in the stool, anorexia, weight loss,
malnutrition, fever, and delayed growth in adolescents (Nelms, 2011, pg.
415).
Treatment of Crohn’s disease depends on the severity of the symptoms and
number of exacerbations. Drugs include immunosuppressants, antibiotics,
steroids, methitrexate, and biologic therapies. Surgery is required seventy
percent of the time involves removal of the affected areas including, ileocolic
resections, segmental resections, and total proctocolectomy and ileostomy
(Nelms, 2011, pg. 417).
2. What is the function of Solu-Medrol and what nutritional implications
does it have?
Solu-Medrol, also know as methylprednisolone, is a corticosteroid that is
used to relieve inflammation in different parts of the body and is used in the
treatment of many diseases. This medication can be given either orally or
intravenously, although most physicians agree that the intravenous option is
the most effective route. Corticosteroids, like Solu-Medrol, can stimulate
appetite and increase water retention. It is advisable to follow a low-salt
and/or potassium-rich diet and watch your caloric intake because the
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medicine can cause high blood pressure and loss of potassium (National
Multiple Sclerosis Society, 2012). It also impairs calcium absorption and new
bone formation. Calcium and vitamin D should be supplemented for people
on this medication. In addition, indigestion can also be a nutritional
implication of the medicine.
3. What dietary considerations are necessary with an ileostomy?
After the surgery, the patient will be transitioned to an oral diet starting
postoperatively day 1. This begins with liquids and progresses as tolerated
to a low-residue diet with 4 to 6 small feeds per day (Nelms, 2011, pg. 423424). The purpose of an oral diet after a surgical ileostomy is to avoid
blockage and reduce fecal output. This diet most importantly restricts
dietary fiber, which is resistant to digestion. In addition, ascorbic acid and
folate are limited. The American Society for Parenteral and Enteral Nutrition
(ASPEN) has established guidelines for a diet after an ileostomy. Raw fruits
and canned fruits that have skins or seeds should be avoided. Vegetable
juices, purees, and some tender cooked vegetables, such as asparagus tips,
beets, broccoli tips, carrots, peeled eggplant, peeled potatoes, peeled
tomatoes, pumpkin and squash can be eaten. Refined and white grains as
well as tender cuts or meat, poultry, and seafood, and eggs and soft cheeses
should be consumed. Foods should be eaten slowly, chewed thoroughly, and
plenty of fluids should be taken in to avoid dehydration. Lastly, foods that
can cause blockage and should be avoided at all costs include, celery, dried
fruit, popcorn, raw carrots, coconut, grapefruit, salads, oranges, coleslaw,
corn, and nuts (ASPEN, 2012). Ability to absorb and retain fluids (water),
electrolytes (Na, Mg, and Ca), vitamins (B12, A, D, E, and K), and minerals (Fe,
Zn, and Se) must also be considered and managed depending on what stage
the patient is in (Nelms, 2011, pg. 423).
4. Are there any foods or nutrients that tend to cause diarrhea after the
colon is removed?
Foods that can cause loose stools or diarrhea are baked beans, beer, broccoli,
chocolate, dried beans, excessive coffee, heavily spiced foods, hot beverages
or soups, licorice, prune juice, red wine, and spinach. Eating very large meals
and a diet high in insoluble fiber or fat can also cause symptoms. Small,
frequent meals that incorporate more soluble fibers with foods like
applesauce, bananas, cream of rice, peanut butter, rice, tapioca, and weak
teas can help manage the undesirable symptoms that comes with diarrhea
(The Permanente Medical Group, 2012).
5. If a person with an ileostomy has excessive loss of fluid, are there any
foods that may help electrolyte balance?
Taking corticosteroids and having major surgery can alter a person’s
electrolyte balance specifically, calcium, magnesium, sodium, potassium,
chloride, and phosphate. Therefore, it is important to replace these
important substances with sources from the diet, as they will aid with
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recovery. Dietary sources of calcium include milk, eggs, sardines, meat, figs,
blackberries, turnip greens and broccoli. Foods high in magnesium include
nuts, cereal grains and green leafy vegetables. Milk, bananas, melons,
oranges, prunes, raisins, potatoes and spinach are excellent sources of
potassium. Sauerkraut, green olives, corn bread, pork, beef, sardines and
canned goods are generally high in sodium and chloride. Phosphate can be
found in milk, cheese, eggs, meat, fish, and nuts (University of WisconsinMadison, 2012).
6. What would be the purpose of bowel rest and an elemental diet for
Crohn’s patients?
Bowel rest consists of nothing given to the patient to eat by mouth and
instead nutrients and fluids are received through a tube that is connected
through a vein. After two to three days of bowel rest, the patient is given
something by mouth to eat. If the obstruction has cleared up, no surgery is
needed. If the obstruction remains, bowel rest may be continued. If repeated
periods of bowel rest fail to clear up the obstruction, surgery to remove the
diseased part of the intestine may be considered. This technique is helpful in
diagnosing whether surgery is actually needed and is the appropriate
method of treatment (United States National Institutes of Health, 2012). An
elemental diet consists of a completely liquid diet where the nutrients
themselves have been processed in a way that they’re pre-digested.
Consequently, there is very little digestion that occurs, making it easy on the
patient digestive system. This can be used along with bowel rest to give the
digestive system a break from the digestive process and also to reduce the
stool volume going into the colon (NIH, 2012).
7. Should there be concern about any vitamins and minerals that are
believed to be absorbed in the ileum?
There should be great concern about vitamin and mineral absorption
because the small intestine’s ability to absorb many vitamins and minerals in
the body has been removed with the removal of the ileum. These specific
nutrients of concern include, vitamins C, B12, D, K, and folate and the mineral
magnesium (Nelms et al., 2011, p. 384). All of these vitamins and minerals
are specifically known to be absorbed in the ileum. In addition, other
vitamins and minerals may be absorbed in the ileum depending on the
transit time. Therefore it is easy to see why the ileum is an essential part of
digestion. Specifically, vitamin B12 is of bigger concern because it requires
adequate ileal receptors and transit time. A general multivitamin is
recommended (Nelms et al., 2011, p. 424).
8. Determine Mrs. M’s BMI, IBW, and percent IBW. Show your work.
Mrs. M’s weight is 97 pounds and her height is 62 inches.
 BMI=[weight (kg)]/[height (m2)]
o Weight= 97/2.2= 44.1 kg
o Height= ((62x2.54)/100)2= 2.48 m2
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o BMI= 44.1 kg/ 2.46 m2= 17.8 kg/m2
o This puts her in the underweight category
 IBW= Hamwi formula for women= 100 pounds for the first 5 feet + 5
pounds for every inch over
o 100 pounds + (5 x 2)= 110 pounds
o Plus or minus 10 percent= 110 x .1%= 11 pounds
o 110 + 11= 121 pounds, 110 – 11= 99 pounds; 121-99 pounds
 Percent IBW [actual weight (kg)]/[ideal weight (kg)]
o 110 pounds used because of no description of body frame size
o 97 pounds/ 110 pounds= 88 percent of IBW
o 100-88 percent= 12 percent missing IBW
(Nelms et al., 2011, p. 47-48)
9. Calculate Mrs. M’s energy needs (using Mifflin-St. Jeor formula) and
protein (grams and calories). Show your work.
Mifflin-St. Jeor formula for women:
 Resting energy expenditure= 10 x weight (kg (IBW will be used)) +
6.25 x height (cm) - 5 x age (yr) – 161
o REE= 10 (50.0 kg) + 6.25 (157.5 cm) – 5 (54 years) – 161
o REE= 500 + 984 – 270 – 161
o REE= 1,053 kilocalories
 Total energy expenditure= REE (1,053 kcals) x 1.2 (activity factor for
a patient confined to bed) x 1.4 (stress factor for surgery and healing)
o TEE= 1,770 kilocalories for a range of 1,700-1,800 kilocalories
o Will go with 1,800 kilocalories because of increased energy
needs
Protein energy requirement:
 Increased protein needs at 1.5-1.7 grams per kilogram of ideal body
weight
o 1.5-1.7 g x 50.0 kg= 75-85 grams of protein
o 66.2-75.0 grams x 4 calories per gram= 300-340 calories
coming from protein
o Will go with higher protein amount for about 19% of
kilocalories coming protein
(Nelms et al., 2011, p. 61)
10. Calculate the grams/kilograms and calories that would come from
dextrose and lipids in the parenteral formula. Show your work.
1,800 total calories per day - 340 grams of protein= 1,460 calories left over
for lipids and carbohydrates
Lipid energy requirement:
 30% x 1,800 kcals= 540 kilocalories from lipids / 9= 60 grams
lipid
 Using 20% lipids
o 540 kcal / 2 kcal per cc= 270 cc lipid at 20%
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o 270 cc / 24 hours= 11 cc per hour
o 270 cc should run at 11 cc per hour over 24 hours
1,800 total calories per day – (340 calories of protein + 540 calories of lipid)=
920 calories left over for carbohydrates
Carbohydrate energy requirement:
 920 kcals/1,800 total kcals per day= 51% carbohydrates
 920 kilocalories from carbohydrates / 4 grams per kilocalorie=
230 grams of carbohydrates
 920 kilocalories / 3.4 kcal/gram of dextrose= 270 grams of dextrose
o 270 g dextrose / 50% (D50W solution)= 540 cc D50W
(Nelms et al., 2011, p. 99-100)
11. Calculate Mrs. M’s parenteral sodium, potassium, calcium, phosphorus,
and magnesium needs. Show your work.
Mrs. M is having difficulty maintaining her electrolyte balance, as evidence by
her recurrent diarrhea, dehydration status, and low sodium, potassium,
calcium, phosphorus, and magnesium lab values. Mrs. M’s kidney function
does appear to be abnormal. Therefore, she can be given extra electrolytes to
maintain her levels.
 Sodium: 50 kg x 2 mEq/kg= 100 mEq of sodium
 Potassium: 50 kg x 2 mEq/kg= 100 mEq of potassium
 Calcium: 10-15 mEq= 12 mEq of calcium
 Phosphorus: 20-40 mmol= 30 mmol of phosphorus
 Magnesium: 8-20 mEq= 18 mEq of magnesium
With acetate and bicarbonate to balance out the solution.
(Nelms et al., 2011, p. 92, 99-100)
12. Calculate Mrs. M’s parenteral vitamin, mineral, and fluid needs. Show
your work.
 Vitamins: A standard 10 mL vial of multiple vitamin infusion that
includes vitamin K (MVI-13)
 Minerals: A standard 5 mL vial of multiple trace element infusion,
plus supplementation of iron is needed because patient is anemic
 Fluid needs are increased because the patient is experiencing
diarrhea:
o 30-35 mL per kilogram per day
 30-35 mL x 50 kg= 1500-1750 mL fluid per day (1750
cc fluid per day)
o or 1 mL pre kilocalorie
 1 mL x 1,800 kcal= 1,800 mL fluid per day (1800 cc
fluid per day)
o Will go with higher fluid amount of 1,800 mL/cc because of
increased fluid needs to combat dehydration
(Nelms et al., 2011, p. 97, 99-100)
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13. Write a parenteral nutrition prescription using the attached parenteral
form.
 Parenteral nutrition in the form of a 2 in 1 solution to provide:
o 85 grams of protein
o 270 grams of dextrose
o 100 mEq sodium
o 100 mEq potassium
o 12 mEq of calcium
o 30 mmol of phosphorus
o 18 mEq of magnesium
 With acetate and bicarbonate to balance out the
solution
o 1 standard 10 mL vial of multiple vitamin infusion that
includes vitamin K (MVI-13)
o 1 standard 5 mL vial of multiple trace element infusion, plus
supplementation of iron is needed because patient is anemic
 In a volume of 1.53 L daily to run at 64 cc per hour over 24 hours daily
 In addition, 60 grams of lipid in a volume of 270 cc to run at 11 cc per
hour over 24 hours daily
See attached nutrition prescription
(Nelms et al., 2011, p. 100)
14. Write an ADIME note regarding the nutrition care given Mrs. M. Be
specific when addressing her medical nutrition therapy.
A: 54 year old active female, referred to R.D. after recurrent Crohn’s disease for TPN
mixture, flow rate, and eventual diet for SBS.
Anthropometrics: ht. 5’2”, wt. 97 lbs, BMI: 17.8 kg/m2, IBW: 110 lbs, %IBW: 88%
Biochemical: Glu 140mg/dL, Ca 8.8 mg/dL, Na 132 mEq/L, K 3.3 mEq/L, Mg 1.6
mEq/L, Phos 2.3 mg/dL, Alb 3.0 g/dL, Hgb 11g/dL, Hct 33%, WBC 14.2x10/uL,
%Lymph 20%
Clinical: Past medical history reveals that patient has had total colectomy and
partial ilectomy with three different surgeries. Patient has been battling diarrhea
and balancing her electrolytes (low levels of Na, K, P, Ca, & Mg) and fluid intake.
Anemic and dehydrated. Experiencing fatigue, weakness, fluid loss. Now on SoluMedrol, 30mg I.V. q 4 hrs and I.V. with NS, 50 cc/hr.
Diet history: Patient has been on limited solid foods for past yr. MD ordered NPO
and on SBR. Placed on TPN consisting of: 500cc of D50W, 500cc of 8.5% AA,
standard electrolytes with 1 amp of MVI 12, and 3 cc MTE every day via
Hickman/Broviac catheter, start at 25 cc/hr. TEE found to be 1,770 kcals/day.
Appropriate TPN consisting of: 540 cc of D50W, 170 cc 5.6% AA, increased
electrolytes with 1 amp MVI 13, trace elements with Fe, and 11 cc MTE every day via
Hickman/Broviac catheter, start at 64 cc/hr.
D: PESS statements include:
1. Inadequate oral intake related to recurrent Crohn’s disease as evidence by weight,
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BMI, %IBW, and limited solid food intake (NI-2.1).
2. Inadequate fluid intake related to related to recent partial ilectomy as evidence by
lab and electrolyte values and dehydration status (NI-3.1).
3. Altered GI function related to decreased functional length of GI tract as evidence
by diarrhea and dehydration status (NC-1.4).
I: Start patient on appropriate TPN consisting of: 540 cc of D50W, 170 cc 5.6% AA,
increased electrolytes with 1 amp MVI 13, trace elements with Fe, and 11 cc MTE
every day via Hickman/Broviac catheter, start at 64 cc/hr. Educate patient on
eventual 1,800-calorie diet for SBS and on implementing foods that will reduce
negative symptoms associated with the syndrome.
M/E:
Measure and monitor outcomes:
Direct nutrition related outcomes: increase caloric and fluid intake, eventual
transition to diet for SBS
Clinical and health outcomes: increase wt., BMI, attain IBW, increase and stabilize
electrolytes (Na, K, Ca, P, & Mg), decrease blood glucose
Outcomes will be measured through food diary/journal, activity log, and
anthropometric and biochemical data.
Evaluate outcomes:
Baseline data will be compared to changes in above outcome data and tracked over
time. Progress will be discussed with client and any problems will be addressed and
used to modify intervention.
(IDNT, 2011)
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References
Bowel rest and nutrition therapy in the management of active Crohn's disease.
(2008). United States National Institute of Health [NIH]. Retrieved from
http://www.ncbi.nlm.nih.gov/
Differences between crohn’s disease and ulcerative colitis. (2012). Columbia St.
Mary’s Hospital. Retrieved from http://www.columbiastmarys.org/
Health information. (2012). University of Wisconsin-Madison: School of Medicine
and Public Health. Retrieved from http://www.uwhealth.org/
Ileostomy diet. (2012). American Society For Parenteral and Enteral Nutrition
(ASPEN). Retrieved from http://www.nutritioncare.org/
International dietetics & nutrition terminology (IDNT) reference manual:
Standardized language for the nutrition care process, Edition 3. (2011).
Academy of Nutrition and Dietetics. Retrieved from http://www.eatright.org/
Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition therapy &
pathophysiology. Belmont, CA: Wadsworth.
Patient handbook for colectomy. (2012). The Permanente Medical Group. Retrieved
from http://www.permanente.net/
Solu-Medrol. (2012). National Multiple Sclerosis Society (NMSS). Retrieved from
http://www.nationalmssociety.org/
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