Clinical Case Study:
Mrs. W
Presented to you by:
Haley Lydstone
KSC Dietetic Intern, 2013
Whittier Rehabilitation
Hospital (WRH)
•
Part of the Whittier Health Network
• Has been providing health care
services since 1982
•
Located in Haverhill, MA
•
Long-term acute (LTAC) facility
with 60 beds
•
Serves patients throughout New
England
•
Provides inpatient, outpatient,
pharmacist and home health services
• Specialty care designed for medically
complex patients who require a longer
length of stay
WRH
Specialized clinics and
programs:
• Wound clinic
• Memory clinic
• Prosthetic/orthotic clinic
• Day rehabilitation program
• Auditory program
Admission Criteria:
• Age 16 or older
• Significant change in
functional status resulting
from medical problem(s)
• Medically stable & able to
take part in rehabilitation
activity
Dietician’s Role at WRH
• Provide nutrition care to patients in various disease states and
conditions
• Maximize nutritional support
• Avoid delayed healing, speed up recovery, and minimize
extended hospital stays
• Monitor, assess and optimize nutrition status based upon current
condition/nutrition adequacy
• Provide education as needed
• Making choices to speed up recovery process, prevent disease
and maintain a healthy lifestyle
• Confer with physicians and other health care professionals
• Medical and nutritional needs, recommendations for tube feeds
and EN and PN, and dietary supplements
Case Study:
Mrs. W
Mrs. W
Prior to admission to WRH:
• Stroke occurred on 2/24/13
• Pt. was giving speech, experienced facial droop and slurred
speech
• Lawrence General: Quick treatment with vitamin K
• Beth Israel: Pt. experiencing tachycardia and hypernatremia
• 2/24: Had L. craniotomy
• Complications: 3/1: UTI, 3/6: PEG placement, 3/10: pneumonia
Meet Mrs. W
Admit to WRH: 3/11/13
• 72 y.o. African American, female
• 5’7”, 171.6#
• IBW: 135#, 61 kg.
• %IBW: 126%
• BMI: 26.9, overweight
• Near coma, pt. unresponsive, NKFA
• Currently NPO on TF
Initial Admit to WRH
Admitting diagnosis:
As a result:
• S/p left craniostomy for
evacuation of left
intraparenchymal
hemorrhage
• PEG tube placement
• L. facial droop
• Global aphasia
• Dysphagia
• CAT scan
• Hydrocephalus
• Afib
Hx of anticoagulation w/ coumadin
Craniotomy
Image retrieved from: www.hopkinsmedicine.org
Intracranial Hemorrhage
Intracranial Hemorrhage
Image retrieved from: Iranian Red Crescent Medical Journal, http://ircmj.com/?page=article&article_id=1686
Pathophysiology
S/p left craniostomy for
evacuation of left
intraparenchymal hemorrhage
• Craniostomy: The surgical
removal of part of the bone
from the skull to expose the
brain
• Relieving pressure within the
brain by removing damaged
or swollen areas of the brain
that may be caused by
traumatic injury, or in Mrs.
W’s case, a stroke
www.hopkinsmedicine.org
• Intracranial bleeding
(hemorrhage)
• Usually caused by head
trauma
• Intraparenchymal hematoma:
occurs when blood pools in
the brain
• Progressive decline in
consciousness
MNT
ICH/Stroke:
• Maintain adequate nutrition
• Weights, TF tolerance, TF meeting needs
• Assess and manage dysphagia
• Vitamin and mineral supplementation as needed
• EN support as needed
Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 934-935. St. Louis, MI.
MNT
Dysphagia:
• Main concerns: weight loss & anorexia
• Minimalize conversations during meal time
• Long meal duration & coughing
• Adjust consistencies to meet patient’s needs
• NPO: 3/12Puree/NTL: 3/26 Puree/thin lix: 4/8
House-MS cut/thin: 4/17 House-MS cut: 4/29
Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 929-931. St. Louis, MI
Initial Admit to WRH
Medical History:
Nutrition Diagnosis:
• HTN
• Hyperlipidemia
“ Difficulty swallowing R/T
ICH, dysphagia, AEB need for
enteral feeds/SLP evaluation ”
• Breast cancer
•
• BKR
• Pt. at risk for malnutrition
• TIA, “mini stroke”
• Unknown weight loss, pt.
poor historian
Status: 3, High risk
Initial Admit to WRH
Medications List:
• Amiodarone: heart rate
• (Anti-arrhythmic)
• Diltiazem: anti-HTN
• Colace & Senna: constipation
• MVI
• Prevacid
• Humulin: SSI low dose
• Levofloxacin: ABX, (tx of PNA)
• Metoprolol: BP
• Pravastatin: Cholesterol
• Provigil: increases alertness
* Anti-depressants
Initial Admit to WRH
Calculated Needs:
Current TF:
• IBW: 135#, 61 kg.
• Promote w/ fiber @ 60
mL/hour for 24 hours
• Calories: 25-30 kcals/kg
• 1535-1840 kcals
• Protein: 1.2-1.5 g/kg
• 73-92 g. protein
• Fluid: 1 mL/kcal
• 1535-1840 mL fluid
• 1440 kcals, 90 g. protein,
1196 free water w/ 250 ml
water flushes Q6, total water
2196 mL
Initial Admit to WRH: Labs
3/12/13
3/13/13
• No new wt.
• No new wt.
• Albumin: 2.8
• Na: 146
• Prealbumin: 17.2
• Na: 138
• BUN/Cr: 17/0.6
• Glucose: 129
• Hemoglobin A1C: 5.9
• Glucose: 138
• FSs: 100’s
3/14/13: Tested – for CDiff
3/20/13
• 168.3#, 3# wt. 
• Alb: 2.8, FSs 100s (no coverage)
Initial Admit to WRH
3/26/13
3/29/13
• TF change
• Puree/NTL for lunch with
SFG, 1:1 spv.
• Trialing foods with SLP
• Bolus feeds
• 240 mL Jevity 1.5, 4x/day
pgt.
• Promod 30 mL BID
• 240 mL Jevity 1.5 4x/day
pgt. 30 mL promod BID
• Will hold bolus if pt.
consumes >50% of meal
3/31/13
• Pt. out acute, chest pain,
elevated D-dimer &
pneumoperiteum
Initial Admit Summary
• Frequent team work: MD, SLP, OT/PT & Dietician
• Pt. tolerated TF well; started small amounts of PO
• Status remained at a 3 throughout hospital stay (high risk)
• Trialing Puree/NTL with SLP, also in SFG
• Overall poor PO intake
• Poor cognition
• Wt’s remained relatively stable
•  3 #’s in approx. 3 weeks, 2% (not clinically significant)
* Pt. out acute to Beth Israel
Mrs. W: Out Acute at BI
• CT of head
• Resolution of ICH, no new
evidence of hemorrhage or
edema
• Contract radiograph of PEG
• No evidence of leak
• LFTs, CBC, CMP, blood
cultures all normal
Image displays resolved ICH, decreased
IVH and decreased hydrocephalus
Second Admit to WRH
Readmitted: 4/3/13
Admitting Diagnosis:
•
Chest/abdominal pain with pneumoperitoneum secondary to PEG
(chronic), difficulty communicating. * New dx: GERD, pt. presented
w/ loose stools (per therapies)
•
Readmit main reason: Tx for stroke
Nutrition Diagnosis:
•
“Difficulty swallowing R/T ICH AEB SLP evaluation/NPO status/
trialing dysphagia diet (puree/NTL) upon last admission.”
•
“Altered GI function R/T potential PEG issue/pneumoperitoneum
AEB reported loose stools, hx constipation, abdominal pain, new dx
of GERD”
•
Status: 3, high risk
Admit #2: Pathophysiology
Pneumoperitoneum:
• Gas within the peritoneal
cavity
• Presents as bowel injury after
endoscopy
• Chest/Abdominal pain:
Etiology unclear
• Possibly related to
pneumoperitoneum
MNT
GERD
• Main factors are caffeine, alcohol, tobacco and stress; avoid
dietary irritants. Lifestyle changes include dietary changes,
weight loss, smoking cessation and elevating the head of
your bed.
Multiple loose stools/diarrhea
• Identifying the source (? Cdiff)
• Adequate fluids and electrolytes
• TF adjustments as needed
• Regular diet as tolerated
Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 616-617. St. Louis, MI
Second Admit to WRH
Medications:
•
Oxycodone, pravastatin,
prevacid, senna, colace, SSI
low dose
Recalculated needs:
4/3/13 Labs:
• Albumin: 3.2
• Na/K: 141/4.4
•
Wt: 170.4#, 77 kg.
• BUN/Cr: 10/0.7
•
Fluid: 1 mL/kcal
• 1540-1925 mL’s/day
• Glucose: 111
•
Calories: 20-25 kcals/kg
• 1540-1925 kcals/day
• Ca: 9
•
Protein (IBW): 1-1.3 g/kg
• 61-79 g. protein/day
4/4/13: Pt. tested – for CDiff
Second Admit to WRH
Readmit tube feed order:
• Isosource 1.5 @ 240 mL 4x/day (bolus)
• 1420 calories, 60 g. protein, 720 mL free water
New TF order, 4/3/13:
• Osmolite 1.5 @ 70 cc x 10 hours (from 2000-0600)
• Osmolite 1.5 120 mL TID pgt. (bolus)
• 250 mL water flush QID
• Provides: 1583 calories, 66 g. protein, 805 mL free
water
• Add Promod as needed
Admit #2: Pertinent Dates
4/8/13
4/12/13
• Puree/thin @ BK & lunch w/
SLP
• Same diet order
• TF order remains the same;
Hold bolus if intake >50%
• Pt. experiencing abdominal
pain, ? R/T reflux or G-tube
site.
• Intake improving
• Considering calorie count
with potential to d/c TF
orders
• No further abdominal pain
complaints
• LBM: 4/7, lg. loose
• LBM: 4/11
• No new labs; FS’s 100s
• 4/10 labs: K 4.4
• Wt.:173.4#
• Wt.: 172.2#
Pertinent Dates Cont’d
4/17/13
4/22/13
• House, MS cut/thin
• Discussed pt. in RTC
• Same TF order (nocturnal +
bolus)
• Neurologist & team D/C’d
TF’s House MS cut thin
• Only PO w/ SLP 2x/day
• Cal. count initiated
• Continue TF until able to
increase PO
• Wt.: 172
• Wt.: No new
Admit #2: Pertinent Dates
4/27/13
• Pt. not meeting needs po (per calorie counts x 3days)
• Pt. refusing all meals, ? secondary to stomach pain
• Refused 4/25, 4/26 and BK on 4/27 (per SLP)
• Recent hx constipation & loose stools
• Prior TF order restarted (bolus only)
• Pt. willing to eat BK at 915 am
• Plan to bolus 200 mL Osmolite 1.5 if pt. eats <50% meals
• Reassess 4/29
Admit #2: Pertinent Dates
4/29/13
• Pt. winces when GT touched
(per nursing)
• Diet change: House MS cut
w/ 1:1 SPV, Mighty shake
TID
• Refluxed partial bolus
• KUB: negative; stools for Cdiff: negative
• Pt. not eating, refusing bolus
• MD wanted to send pt. out
acute for abdominal CAT
scan
• Pt. started on IV fluids
• Wt.: 170.6
• 4/26: K 5.4 
Admit #2: Pertinent Dates
4/29-5/2
• Poor tolerance for TFs &
bolus, IVs started
4/30-5/1
• Received IV only
5/2/13
• Pt. out acute to BI for PEG
evaluation
Admit #2 Summary
•
Pt. readmitted with loose stools
•
KUB and Cdiff were negative
•
Pt. experiencing pain around
PEG site
•
• MD’s wanted her to eat PO
• Thought an increased appetite
would prompt her to eat
• RD and SLP were skeptical
• Wincing when touched
• Bolus refluxed
•
•
Wt. stable, 170-173#s
Status: remained 3 during stay
TF’s D/C’d in attempt to
stimulate appetite
• Pt. “On strike” on a daily basis
•
Pt. on IV fluids secondary to
bowel rest
•
Pt. discharged for PEG evaluation
Out Acute to BI
Mrs. W at BI from 5/2/13-5/6/13
• Abdominal pain secondary to malpositioned G-tube, with
decreased flow
• CAT scan: PEG placed in 2nd portion of duodenum; soreness
around site
• Supposed to be in stomach
• PEG repositioned
• Started on vancomycin secondary to soft tissue infection @ PEG
site (observed for 2-3 days)
• TF change: 1/2 can (120 mLs) 6x/day Q4hours
Admit #3
5/6/13:Admitting dx: s/p PEG
placement, CVA
Pathophysiology:
•
PEG: routine in pt.’s unable to
eat PO
•
Occurs when G-tube placed
somewhere other than stomach
•
Pneumoperitoneum is an early
indicator of malpositioned Gtube
References:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699054/,
www.webmm.ahrq.gov
Proper G-Tube Placement
MNT
S/p PEG readjustment/placement
• Adjust TF to meet patient’s needs & avoid discomfort
• Monitor: abdominal distension and comfort
•
•
•
•
•
I’s and O’s
Gastric residuals Q4hours
Stool output & consistency
Labs (signs and symptoms of edema & dehydration)
Weights, 3x/week
Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 308-312. St. Louis, MI
Admit #3
5/7/13 Nutrition dx:
“ Inadequate oral intake R/T cognitive status/recent
abdominal pain/ AEB need for EN feeds pgt..”
Status: 3, high risk
Medications:
• Keppra, nystatin, miralax, pravastatin, senna, SSI low
dose, colace, MVI, prevacid
Admit #3
Recalculated Needs:
• Wt. 173.1#, 79 kg. IBW 135#, 61
kg.
Admitting TF order:
• 120 ml Jevity 1.5 QID
Provides:
• Calories: 20-25 kcals/kg
• 1580-1975 calories/day
• 710 cals, 30 g. protein, 360 ml free
water, 120 ml water flush Q6 hours
(480 ml), total water 840 ml
• Protein: 1g/kg (IBW)
• 61 g./day
New TF order:
• Fluid: 1ml/kcal
• 1580-1975 ml/day
• 120 ml TwoCal QID (6am, 10 am, 2
pm, 6 pm)
Provides:
• 950cals, 40 g. protein, 332 ml free
water
Pertinent Dates
5/6/13
• Pt. continued to have abdominal pain
• Wt. 172.8#
5/7/13
• Started on 1:1 meals w/ SLP
5/9/13
•
Pt. discussed in FTC
•
No new weight
TF changed: Osmolite 1.2 @ 40 ml/hr x 20 hrs
•
Provides: 960 cals, 44 g. protein, 656 ml free water.
Goal: Osmolite 1.2@60ml/hrx20 hrs; provides: 1440 cals, 67 g. protein, 984 free water
5/9: Family Team Conference
Attendees: 3rd husband, son, daughter, family friend (Mrs. W’s
best girlfriend), psychologist (family friend & priest), MD, RD,
SLP, OT, PT
FTC Summary:
• Husband wants to take her home
• Husband and son unsure about depression meds
• Pt. attempted to leave WRH via vehicle w/ husband
• Husband not fully understanding Mrs. W’s current issues
Admit #3
5/10
5/23
• TF rate increased to 50 ml/hr
x 20 hrs
• No TF order changes
• Provides: 1200 cals, 56 g.
protein, 1400 ml free water
w/ flushes
• M/S cut thin TID 1:1 w/ SLP
at BK and lunch
• Tolerating TF well, minimal
residuals
• PO intake remains poor
• Pt. consumed >50% of
meal with friend present
• Labs WNLs
• Wt. 167.8#  3.2 #
• Pt ate >75% BK this am
• Will decrease TF volume to
750 ml: 900 calories, 42 g.
protein x 10 hours
Discharged to SNF
• Pt discharged to SNF
• MS cut 1:1 supervision
• Nocturnal TFs: Osmolite 1.2 @ 75 ml/hr x 10
hours/day from 8 pm- 6 am
WRH Pt. Plan
1. To progress pt. to PO status (RD, SLP, MD)
1. Made several attempts to increase appetite & stimulate
intake
2. Meet patient’s needs with EN pending functioning PEG
and tolerating bolus feeds
2. Work with family and friends to raise awareness of
patient’s needs
3. Discharge to SNF on EN w/ some PO, 1:1 supervision
Mrs. W: Life After WRH
• Doing well at SNF
• “closed facility” Pt. can ambulate freely around her
room
• Husband visits daily
• Somewhere she can cook
• Very supportive group of family and friends
References
•
http://www.aphasia.net/info/aphasia/global_aphasia.htm
•
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-supportteam/nutrition-articles/BanhArticle.pdf
•
http://openi.nlm.nih.gov/detailedresult.php?img=3004506_kjped-53-913-g002&req=4
•
http://www.nutrition411.com/professional-learning/professional-refreshers/item/393-albumin-as-an-indicator-ofnutritional-status
•
http://www.strokecenter.org/professionals/stroke-management/for-pharmacists-counseling/pathophysiology-and-etiology/
•
http://www.mayoclinic.com/health/intracranial-hematoma/DS00330/DSECTION=causes
•
www.meddean.luc.edu
•
http://www.whittierhealth.com/rehabilitation_hospitals/bradford.html
•
http://www.wjem.org/upload/admin/201108/6e21f8f9449aee76f10cda971f3b3bbd.pdf
•
Reference: Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 616617. St. Louis, MI