1. Caryn Massimino UConn Health Center
Care Conference
Caryn Massimino
UConn Health Center

2. Introduction Admission Date: 10/08/14 Age: 64 Gender: Male
Assessed from 11/4/14 – 11/11/14
Age: 64
Gender: Male
Diagnosis: Intestinal perforation, hyperglycemia, MRSA, Sepsis
Past Medical History: CHF, COPD, Asthma, Afib, Gout, Seizures, Pneumonia, Sleep Apnea
Pt in ICU for 5 weeks

3. Anthropometrics Height: 5’5” Current Weight: 75.3kg (11/6)
Previous weights: Adm wt = 99kg, 88.9kg (10/23), 87.3kg (10/28), 85.4 (10/31), 77.8kg (11/5)
%Wt Change: -23.9% weight loss in 1 month
BMI: 27.6 (Overweight)
IBW: 62kg
%IBW: 121%
%wt change = 23.9% weight lost in 1 month (SIGNIFICANT)

4. Physical Findings Patient on Bi-pap ventilator
Confused from heavy drugs in ICU
NG tube for Tube Feeding
Edema: LUE, RUE, LLE, RLE – pitting +1
Skin: abdominal wound, open area near ileum; all other skin on body intact not surrounding surgical area
NGT for suctioning from ileostomy

5. Social History History of chronic asthma from the age of 3
On corticosteroids since asthma diagnosis
Uses C-pap ventilator for sleep apnea PTA
Lives at home with wife
Former Smoker
2 packs/day

6. Intestinal Perforation
Treated with temporary Ileostomy or Colostomy
Definition: Contents of intestines leak into abdominal cavity
Can be caused by Crohn’s disease, overuse of corticosteroids, cancer
Complications include wound failure
Partial/total disruption of any layers of operative wound
Higher risks with patients who use Corticosteroids, Sepsis, heavy coughing

7. Diet Orders During Hospitalization
Current Diet Order: Peptamen AF TF 10cc/hr 24hr trickle c TPN D 20/AA cc/hr 24hr = 1699kcal, 126g pro
Previous Diet Orders:
(11/6): Peptamen AF TF 50cc/hr 24hr trickle c TPN D 14/AA cc/hr 24hr c 1 pro-source sup daily = 1702kcal, 158g pro
(10/30): Peptamen AF TF 10cc/hr 24hr trickle c TPN D 17.5/AA 8.75, 66cc/hr 24hr, 20% lipids 5x/wk = 2006kcal, 144g pro
(10/24): TPN D 17.5/AA 8.75, 66cc/hr 24hr, 20% lipids 5x/wk = 1718kcal, 126g pro
Assessment of Diet Order: Contrary to 11/10-diet order, pt receiving TPN at 70cc/hr c Peptamen at 20cc/hr, while still receiving pro-source supplement even when it was dc’ed from the diet orders, which is overfeeding the patient and may be adding to his respiratory distress. The actual 11/10-diet order is appropriate for this patient’s needs to maintain weight and trying to start using the gut for nutrition rather than TPN procedures.

8. Nutritional Requirements
Mifflin St. Jeor = (99.9 x 75.3kg) + (6.25 x cm) + (4.92 – 64) (1.2 IF) (1.2 AF)= 2347kcal
Penn State 2010 = 1699kcal
30Kcal/kg = 2259kcal
Protein = 2g/kg/day = 151g/day
Fluid = 25cc/kg/day = 1833cc/day
Other nutrients deemed necessary: Vitamins A, C, K, D, thiamin, zinc, phosphorous, calcium
Possibly arginine & glutamine for wound healing
Patient was receiving nutrition based on Mifflin, not Penn State for his ventilated status
Used older adult recommendation (>75 years old)
Possibly supplement arginine & glutamine for wound healing (research is conflicting)

9. Lab Value 11/6/14 Result 11/10/14 Result Interpretation Rationale
145
143
WNL
Patient has normal Na levels c IV NS to decrease risk of dehydration, lower edema risk, decrease malabsorption K
4.6
3.3
Low
Decreased in patient d/t GI loss, malnutrition, malabsorption, chronic stress and fever, steroids Cl
107
115
High
Increased in patient d/t possible anemia, hyperventilation, cardiac decompression
CO2 27 20
Decreased in patient d/t hyperventilation, lack of 02, fever
BUN 57 47
Increased in patient d/t renal failure, infection, gout
Creatinine
1.3 .8
WNL c no signs of acute & chronic renal disease, hyperthyroidism
Glucose
219
220
Increased in patient d/t severe infections, prolonged physical inactivity, malnutrition, drugs (corticosteroids, high dose anti-hypertensives)

10. Lab Value 11/6/14 Result 11/10/14 Result Interpretation RationaleCa
1.27
1.24
Low
Decreased in patient d/t hypoalbuminemia, malabsorption Mg
2.4
High
Increased in patient d/t overuse of antacids
Phosphate
4.4 2
Decreased in patient d/t hyperinsulinemia, gout
HgB
9.8
8.9
Decreased in patient d/t possible anemia
Hct
29.6
27.3

11. Medication Name Purpose Possible Side Effects
Citalopram
Antidepressant
Patient has decreased BP, tachycardia, allergic rhinitis
Diltiazem
Anti-angina, antihypertensive, Ca channel blocker
Patient has low Ca levels, although Na levels WNL
Enalaprilat
Antihypertensive
Ensure adequate fluid intake c this patient, decrease kcal diet on this drug – may not be appropriate, caution c K supplementation
Furosemide
Antihypertensive, diuretic
Patient has WNL Na, K, Mg labs that may become problematic, decreased kcal diet on this drug – may not be appropriate; can also cause increased BUN
Heparin
Antihypertensive, anti-angina, CHF treatment
Decreased kcal diet, extreme caution c asthma/bronchospasm, bradycardia, palpitations, CHF, may reduce insulin release
Enalaprilat – caution with K supplement, patient’s K labs are WNL and constantly monitored
Lopressor – many heart complications, raises blood glucose which has been an issue for this patient

12. Medication Name Purpose Possible Side Effects
IV Insulin (regular doses) & Lantus
Anti-diabetic, hypoglycemic
May increase weight, serum glucose may be out of limits, K, Mg, P WNL
Pantoprazole
Antiulcer, Anti-GERD, Anti-secretory
May decrease absorption of Fe, vit B12, Ca (all WNL), may increase gastric pH, may cause pneumonia in rare cases
Vancomycin
Antibiotic
May cause lower GI absorption – weight loss may be d/t Crohn’s diagnosis and malabsorption, can cause pseudomembranous colitis
Zosyn
Caution c K supplementation (WNL), hypernatremia (WNL), may cause epigastric distress, pseudomembranous colitis
Pantoprazole – can induce pneumonia, this patient has history of upper respiratory infections
Pseudomembranous colitis – need to monitor closely c MRSA and Sepsis diagnoses

13. Diagnosis
Patient assessed with increased nutrient needs R/T intestinal perforation, MRSA, and Sepsis AEB unintentional weight loss of 52lbs in course of hospitalization, multiple infections, delayed wound healing, and low albumin levels.

14. Intervention Food/Nutrient Delivery:
Provide Peptamen AF TF at 30cc/hr 24hr c TPN D 20/AA cc/hr 24hr to provide 2275kcal, 160g pro
Decrease TPN c TF tolerance advancement to promote transitional feeding
Coordination of Care:
Assess residuals/tolerance of tube feeding daily
Assess wound healing and infection status daily
Obtain daily weights
Work with MD to change patient’s nutrition support orders properly
for increased needs in this patient from infection and perforated intestine to promote wound healing and maintenance of weight

15. Monitoring & Evaluation
Food/Nutrition Related Outcomes:
Monitor residuals for TF and tolerance to advancement daily
Anthropometric Measurements Outcomes:
Check weight daily to see if patient maintaining/gaining weight to promote healing and diet advancement 
Biochemical Data:
FSG, TG to monitor tolerance to lipids and TF daily
Monitor I/OS daily to test for edema
Monitor intolerance to TF daily through residual levels
Monitor protein labs weekly to assess for malnutrition/over-nutrition
Monitor electrolytes weekly to see if patient is tolerating supplements and TF/TPN 
Nutrition Focused Physical Outcomes:
Monitor physical appearance daily for wound healing, edema, weight loss/gain to assess diet advancement

16. Alterations To Diet Order
Peptamen AF TF: 30cc/hr 24hr
TPN: D 20/AA cc/hr 24hr
Provides: 2275kcal and 160g protein to provide adequate nutrition for wound healing and weight maintenance for patient to start transitional feeding to be solely dependent on tube feed as tolerated.

17. Transitional Feeding Diet Order
Peptamen AF TF: 50cc/hr 24hr
TPN: D 20/AA cc/hr 24hr
Provides 2263kcal and 154g protein to provide adequate nutrition while advancing the tube feeding to promote GI usage if tolerated. This would provide advancement to wean the patient off of TPN nutrition and on to relying solely on tube feedings to provide complete nutrition.

18. References
Mahan, L. Kathleen, Sylvia Stump, Janice L. Raymond, and Marie V. Krause. Krause's food & the nutrition care process. 13th ed. St. Louis, Mo.: Elsevier/Saunders, Print.
Pronsky, Zaneta M., and Jeanne P. Crowe. Food medication interactions. 16th ed. Birchrunville, Penn.: Food-Medication Interactions, Print.
Stump, Sylvia. Nutrition and diagnosis-related care. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Print.
"WebMD - Better information. Better health.." WebMD. WebMD, n.d. Web. 6 Feb
"Mayo Clinic - Mayo Clinic." Mayo Clinic - Mayo Clinic. N.p., n.d. Web. 8 Apr

19. Questions?