Case Study: R.P. DesireÉ Wentzell

Patient profile & background 56yo, female, single Chef w/ Aramark No regular exercise Prior to admission  large appetite, regular diet, regular liquid Former smoker, no current consumption of alcohol

Diagnosis History Diagnosis htx: esophageal reflux, interstitial lung disease, polymyositis, primary cirrhosis, T2DM, and Sjorgen’s disease. History of dysphagia Family history

Anthropometrics Height: 66 inches BP: 95/46 mmHg Weight: 181lbs Kg: 82.27kg BMI: 29.2, overweight status BP: 95/46 mmHg Temperature: 97.8 degrees F Respirations: 18 breaths/min

Current diagnosis Crohn’s disease Bleeding ulcer Colonoscopy for Crohn’s Disease and ulcer, esophagogastroduodenoscopy for esophageal reflux, BP to determine chronic systolic heart failure

Background of Disease Crohn’s disease: inflammation of g.i. tract, can happen anywhere but mostly in small intestine and colon Peptic ulcer: open sore in digestive tract Signs & symptoms: belly pain, cramps, blood in feces, diarrhea, fatigue, fever, loss of appetite, mouth sores, urgent bowel movements, and weight loss

Pathophysiology & Etiology Local abscess, bile salt diarrhea, fissure, fistula, malabsorption, malnutrition, small intestinal bacteria growth, strictures, arthritis, bone loss, vitamin D deficiency, skin and eye problems, liver and kidney problems. Immune system problems genetics, smoke, bacteria infections, and medications that may cause inflammation of g.i.

Factors surrounding admission Generalized weakness, anemia, lactic acidosis, chronic leukocytosis, interstitial lung disease, Sjoren’s disease, T2DM, chronic systolic heart failure, depression, DVT, Crohn’s disease, and Gerd. Tylenol, Lexapro, flulaval quad, Imodium, toProl XL, NSS infusion, protonix, sodium chloride, Carafate, ursodiol (given in the hospital), Prilosec, deltasone, Carafate, ursodiol, Glucophage xr, deltasone, Lexapro, onetouch ultra 2, onetouch ultra blue, onetouch delica lancing dev, Toprol XL, Imodium are given daily.

Altered labs WBC 32.59 (H) RBC 2.74 (L) HGB 7.6 (L) HCT 21.9 (L) Glucose 184 (H) Alkaline phosphate 294 (H) Albumin 2.3 (L)

Diet related factors Kcal: 1625kcal/d Protein: 99g/d (1.2gm/kg, wounds) Consumption: 25-100%, 240-420cc fluids per meal No diet was placed for Crohn’s disease prior to admission to the Meadows Moderate nutritional risk

MNT CCD, NAS, low residue, bland, low fiber, and no nuts/seeds/skins Understands current diet order, but consumes some food products that are not prescribed Weight loss has occurred Consistent loose stools

PES statements Inadequate energy intake r/t GI upset AEB diagnosis of Crohn’s, bleeding ulcer, and nursing notes of consistent loose stools. Altered nutrition related lab values r/t DM AEB Glucose lab value of 184 H. Inadequate protein intake r/t poor PO intake AEB variable meal consumption and unresolved wounds.

Current status Still suffering from increased loose stools Follows diet and all medications as provided Weight loss of 10.6lb has occurred as of 12-6-18 Admin. wt of 181lb, current wt. of 170.4lb Wounds are unresolved Irregular heartbeat, along with fluid in lungs (admin. to GWV) Bronchitis or Pneumonia may be present

Intervention Continue with currently ordered medications and diet Monitor loose stools, diet consumption, fluid consumption Maintain weight and monitor weekly weights taken Continue protein supplement, CCD, NAS, bland, low fiber, no nuts/seeds/skins diet