Nutrition Management of Cerebrovascular Accidents Ashley Reese ARAMARK Dietetic Internship March 3, 2014

Disease Description Result of blood flow to the brain that has been stopped for a period of time As brain loses oxygen, cells begin to die Ischemic strokes: blood flow is blocked by a blood clot or plaque build up Hemorrhagic stroke: one of the brain’s blood vessels become weak and then bursts open Risk factors: aneurysms, arteriovenous malformation, high blood pressure, artial fibrillations, diabetes, family history, high cholesterol, over the age of 55, and African American race

Disease Description Signs/Symptoms: Headache (especially when there is bleeding in the brain), changes in hearing/alertness/taste, clumsiness, confusion, difficulty swallowing, difficulty reading/writing, problems in eyesight, difficulty talking/walking, personality changes S/S may happen automatically, may show within a few days, or may not show at all S/S typically most severe when a stroke first happens

Evidence Based Articles/Studies Cerebrovascular Accidents

Evidence-Based Nutrition Recommendations-Article 1 Study performed to determine if nutrition intervention altered body composition Patients that had an acute stroke (>65 years old) were randomized into different nutrition therapy groups: Intervention group (58 participants)-energy and protein rich meals Routine nutrition care group (control group-66 participants) Patients were monitored during their hospital stay and followed up after 3 months Ha L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatrics. 2010;10(75):1-9.

Evidence-Based Nutrition Recommendations-Article 1 Cont. Results: During the 1st week of their hospital stay: less weight loss in the intervention group than the control group After 3 months Weight loss was smaller in women of the intervention group compared to the control group Men did not show a significant difference among the groups after 3 months Concluded: Individualized nutrition support with energy and protein rich supplementation was considered beneficial for maintaining body weight and preventing loss during the first week, and in women in the long run. Ha L, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatrics. 2010;10(75):1-9.

Evidence-Based Nutrition Recommendations-Article 2 Study performed to determine appropriate timing and route of feeding for patients that have experienced traumatic brain injury Meta-analysis was performed using PubMed, Embase, and the Cochrane Library databases Clinical outcomes and differences in nutrition support efforts were evaluated in 13 randomized-control trials and 3 non- randomized prospective studies Primary conclusions included mortality and poor outcomes Secondary conclusions included hospital length of stay, ventilation length, and rate of feeding or infectious complications Wang X, Dong Y, Han X, Qi X-Q, Huang C-G, Hou L-J. Nutritional support for patients sustaining traumatic brain injury: A systematic review and meta-analysis of prospective studies. Nutrition Support in Traumatic Brain Injury. 2013;8(3):1-14.

Evidence-Based Nutrition Recommendations-Article 2 Cont. Key findings: Early feedings was linked to a reduction in mortality, poor outcome, and infectious complications Parenteral nutrition showed a slight reduction in rates of mortality, poor outcome, and infectious complications compared to enteral nutrition An immune enhancing formula showed a reduction in the infectious rate compared to a standard formula Small bowel feeding is related to less pneumonia than nasogastric feeding Conclusion: The most effective nutrition support is shown with feeding quickly by parenteral nutrition. If enteral nutrition is used, best results come from an immune enhancing formula. (Impact Peptide 1.5) Wang X, Dong Y, Han X, Qi X-Q, Huang C-G, Hou L-J. Nutritional support for patients sustaining traumatic brain injury: A systematic review and meta-analysis of prospective studies. Nutrition Support in Traumatic Brain Injury. 2013;8(3):1-14.

Evidence-Based Nutrition Recommendations-Article 3 Dysphagia is a common complication for stroke patients Enteral nutrition is typically used to treat stroke patients with swallowing difficulties If viewed as short term problem: nasogastric tubes are used If viewed as needed for longer term: PEG tubes are placed Trial evidence does not support protein and energy supplementation for stroke patients who are able to eat orally, unless they are showing signs of malnutrition (especially if they have pressure ulcers) Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for problems with swallowing and poor nutrition in patients who have had a recent stroke.Cochrane Database of Systemic Reviews. 2012;10(CD000323). DOI: 10.1002/14651858. CD000323.pub2.

Case Presentation 72 year old Caucasian man Found around 4:00 AM by his wife as he was stumbling around the house. While trying to return to bed he fell and hit his head-no loss of consciousness or confusion at the time Wife stated no aphasia or difficulty swallowing; no difficulty seeing at the time Family decided to send patient to the hospital for further evaluation Dx: right hemispheric stroke Family wanted to transfer to a larger hospital, but the physician decided he had passed the window for any additional intervention.

Nutrition Care Process: Assessment

Client History PMH: diabetes, hypertension, dislipidemia, chronic kidney disease, shingles, smoked tobacco for 30 years (quit 20 years ago) Sx history: cholecystectomy, herniorrhaphy, and fistula repair Occasionally drinks alcohol Mother died at age 45 from a stroke Father died at age 72 with a history of diabetes and unspecified cancer

Food/Nutrition-Related History Wife reported no aphasia or difficulty swallowing before or after his CVA During LOS, he remained NPO Hx of diabetes, wife stated he monitored and checked Unknown if he has food allergies due to his unconscious state and wife’s absence during assessment Nutritional supplements: 1000 mg fish oil, 600 mg red yeast rice BID, and 1000 mg vitamin D3 per day Patient’s rationale for these supplements is unknown Patient’s food/supply availability is unknown, as well as his amount of physical activity

Nutrition-Focused Physical Findings Noted in chart, wife stated he had good appetite and no chewing/swallowing difficulties Physician ordered to continue statin and blood pressure control medications Insulin was provided on a sliding scale Lipid values were monitored per history of dyslipidemia Other medications: potassium chloride, lopressor, plavix, and protonix Speech evaluation was ordered to determine swallowing ability-resulted in remaining NPO due to inability to keep awake and stimulated

Anthropometric Measurements Admit weight: 203# Assessment weight: 207# UBW unavailable Height: 5’7” (67 inches) BMI: 32.41 IBW: 148# 140% of IBW

Biochemical Data, Medical Tests, and Procedures Measurement Value Normal Reasoning Albumin 3.4 L 3.5-4.8 g/dL Acute/chronic inflammation, malnutrition Calcium 8.0 L 8.9-10.3 mg/dL Lowered albumin, decreased intake Glucose 224 H 74-118 mg/dL DM, stress, steroid use Creatinine 1.36 H 0.61-1.24 mg/dL Dehydration, CKD WBC 13.6 H 4.5-11.0 thou/uL Increased disease fighting cells circulating in blood

Biochemical Data, Medical Tests, and Procedures CT scan-determine severity of CVA Large area of ischemic infarction of right cerebral artery Placed on BiPAP Due to shortness of breath and hypoxemia Chest X-ray Bilateral alveolar filling=pneumonia or congestive heart failure Bedside swallow test Unable to evaluate twice, due to unable to be kept awake

Nutrient Needs Determined using the Critical Care Guidelines in consideration of BMI and patient medical history: REE Protein Fluid 1750-1950 kcal/day (19-21 kcal/kg actual BW) ~101 g/day (1.5 g/kg IBW) ~1750-1950 mL/day (1 mL/kcal)

ARAMARK Nutrition Status Classification Moderate Risk (Status 3) 10 points: NPO anticipated>4 days= 4 points BMI>30-34= 2 points Albumin 3.4= 2 points Diagnosis of CVA= 2 points Follow-up within 5 days

Malnutrition Identification According to the ASPEN Consensus Statement: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition Acute illness/injury related malnutrition Level: nonsevere/moderate

Nutrition Care Process: Nutrition Diagnosis

PES Statement Inadequate oral intake (NI-2.1) related to inadequate diet order of NPO as evidenced by PO of 0%.

Nutrition Care Process: Interventions

Interventions Medical Interventions: Electrocardiogram-no acute findings CT scan of brain/head/neck-determined acute stroke with large area of ischemic infarction in right cerebral artery MRI-limited involve of the left frontal lobe superomedially CT angiogram-total occlusion of the right internal carotid artery Speech therapy consult BiPAP-respiratory distress, then pneumonia

Interventions Nutritional Goal: to provide nutrition (NPO) Recommended to provide nutrition within 72 hours of initiating NPO status (Enteral Nutrition ND-2.1) Glucerna 1.2 @ 65 mL/hr 1872 calories, 94 grams protein, and 1256 mL fluid Recommended to provide an additional 150 mL of free water flushes every 4 hours to meet fluid needs (Enteral Nutrition ND-2.1) Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4th ed. Academy of Nutrition and Dietetics; 2013:162-163, 297.

Goals Short Term: Long Term: Provide nutrition within 72 hours of NPO status; meet 100% of nutritional needs. Tolerate and reach goal rate once enteral nutrition is initiated; minimal residuals Long Term: Prevent depletion and maintain weight during LOS Maintain skin integrity Maintain labs within normal limits Per speech, advance diet to oral feedings as capable

Nutrition Care Process: Monitoring and Evaluation

Monitoring and Evaluation Enteral Nutrition Intake (FH-1.3.1): Provide continuous enteral nutrition support of Glucerna 1.2 with goal rate of 65 mL/hr by follow-up. Monitor initiation and rate advancement of tube feeding. Enteral Nutrition Intake (FH-1.3.1): Provide additional 150 mL free water flush every four hours to meet fluid needs by follow-up. Body Composition/Growth/Weight History (AD-1.1): Maintain admit weight by follow-up, as usual body weight was unable to be determined. Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual. 4th ed. Academy of Nutrition and Dietetics; 2013:28, 297.

Monitoring and Evaluation Follow-up: Performed 5 days after initial assessment Goal rate of 65 mL/hr reached Tolerating feedings well; minimal residuals present Additional free water had not been provided to the patient-given large amounts of IV fluids; MD discretion was recommended for additional free water needs Patient maintained stable weight (only 2# gain with slight edema)

Monitoring and Evaluation Follow-up Continued: Recommended to continue Glucerna 1.2 at goal rate of 65 mL/hr to meet needs. Recommended to provide additional 150 mL free water Q4H once IVF d/c. Goals: Continue to meet nutritional needs with Glucerna 1.2 at goal rate by follow-up. Continue to monitor weight, laboratory values, skin integrity, and diet order

Conclusion The patient’s mental status continued to decrease- resulting in inability to follow commands Family decided the patient would not want to live a life in his condition Family opted for comfort care and requested to be transferred to hospice Patient transferred to a floor room, and soon passed away