1.  Hilary Smith

2.  84 year-old male from Courtland Gardens Nursing Home  Admitted 11/23/14  CC: change in mental status  Dx: ischemic stroke  Has unstageable left ankle pressure ulcer per CWOCN

3.  L thalamic stroke  DM  HTN  Hyperlipidemia  CVA  GERD  Peptic Ulcer Disease  BPH  TURP  EF 60%  Pulmonary HTN  Diverticulosis

4.  Height: 165 cm  Weight: 64.6 kg  BMI: 23.8  %IBW: 107%  IBW: 60 kg

5.  Albumin 3.5 normal  Glucose 108 high, improved  HbA1c 8.7 high, poor glucose control

6.  Docusate  SSI  Protonix  Miralax  Lactulose PRN  Zofran PRN

7.  Calorie Needs – Mifflin St. Jeor o Weight used: 64.6kg (RD measured current weight) o Activity factor: 1.2 – 1.3 o 1522-1648 kcal/day  Protein Needs o 1.1-1.3 g/kg o 71-84 g/day  Fluid needs o 25-30 ml/kg o 615-1938 ml/day

8.  Patient was sleeping, obtained his weight using bed scale  Failed 2 SLP swallowing trials, not safe for PO  PEG discussed with wife and daughter, wait if pt improves  NG tube may be needed, NPO x 3 days at time of assessment  PES: Inadequate oral intake as r/t swallowing difficulties AEB NPO

9.  If NG tube placed, Glucerna 1.2 @ 30 ml/hr and increase by 10 ml/hr until 65 ml/hr is tolerated  100 ml water flush Q4H  1560 kcal  78g pro  1053 ml water  1653 ml water from TF and flushes  Meets 100% estimated needs

10.  Nutrition via appropriate route  1-2 days

11.  Family decided for hospice care at the 3 rd failed swallow eval  Final diagnoses:  Cerebellar cerebrovascular accident  Left pleural effusion  Left lower lobe pneumonia  Oropharyngeal dysphagia secondary to cerebrovascular accident  Left heel deep tissue injury

12.  Cerebellar, cerebral, or brain stem strokes can impair swallowing physiology  JS’s neurologist suggests his stroke had brain stem involvement  Brain stem strokes result in the largest swallowing compromise o Can affect sensation of the mouth, tongue and cheek, timing in the trigger of the pharyngeal swallow, laryngeal elevation, glottic closure, and cricopharyngeal relaxation Dyspagia After Stroke: Martino et. Al. stroke.ahajournals.org

13.  In the acute stage of stroke 30 to 50% of patients suffer from dysphagia  Incidence drops to around 10% six months later  Affected patients prone to dehydration and malnutrition and increased risk for aspiration pneumonia  Malnutrition present in about 24% of stroke patients  Gastric tube placement does not present a higher risk for aspiration pneumonia than duodenal or jejunal tube placement Guideline Clinical Practice in Patients With Stroke: Experimental & Translational Stroke Medicine 2013, 5:14