1. Case Study: R.P.
DesireÉ Wentzell

2. 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

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

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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)

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

11. 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

12. 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.

13. Current status Still suffering from increased loose stools
Follows diet and all medications as provided
Weight loss of 10.6lb has occurred as of
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

14. 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