1. JOHNSON MEMORIAL HOSPITAL CRISTINA GONZALEZ 4/30

2. PATIENT BACKGROUND Age – 78 Gender – Female Height – 5’1” / 155 cm Weight – 164 lb / 74.54 kg Admitted: 4/6/15 Seen: 4/9/15 Admitted Dx: GI bleed, asymptomatic anemia PMHx: HTN, arthritis, GERD, Barrett’s Esophagus (1yr), bile reflux

3. PATIENT BACKGROUND CONT. Social Hx: smoked 1.5 ppd until 1984, sister with colon cancer Treatments/Therapies: colonoscopy at Windham Hospital Nutrition Focused Physical Findings Not able to see patient No complaints of pain

4. GI BLEED Bleeding in the gastrointestinal tract (upper or lower) Possible causes Upper – peptic ulcer disease, gastritis, esophageal varices, esophageal or stomach cancer, inflammation Lower – diverticulosis, colon cancer, IBD, hemorrhoids, polyps MNT Decrease EtOH, caffeine and coffee, spicy foods Increase fiber (softens stool) and foods with fiber contain other vitamins and minerals that aid in GI healing Increase iron rich foods (supplementation will also be needed)

5. GASTRITIS Occurs when infections, chemical, or neural abnormalities irritate or erode the mucosal lining of the stomach MNT – decrease EtOH consumption, spicy foods, and coffee/caffeine Increase consumption of omega 3 and omega 6 FA Causes: H. pylori, infections, pernicious anemia, bile reflux, excessive alcohol use, chronic vomiting, stress Symptoms: N/V, abd pain

7. ANTHROPOMETRICS IBW 110 / 99-121 % IBW 149% Adjusted BW – 123.5 lb BMI 30.4 (Stage I Obesity) UBW, % UBW – N/A

8. DIET INFORMATION Diet Order before surgery: 2 gm sodium, soft diet Consumed 80% of meals Current Diet Order: NPO (surgery) After surgery: clear liquids, full liquids, low residue, 2 gm, bland soft diet Appropriateness of Diet Order: appropriate for patient

9. NUTRITION REQUIREMENTS Calories = 1548 cal/day CHO = 48%, 743 cal, 186 g Protein = 22%, 340.5 cal, 85 g Fat = 30%, 464 cal, 52 g Fluids = 30 ml/kg  2236 ml

10. BSLSDS 1/2 cup farina (5 mg Na) 1 cup 2% milk (100mg Na) 2 oz baked cod (230 mg Na) 1/4 cup granola (0 mg Na) 2 oz ground chicken, seasoned (no salt), 1 tsp olive oil (120 mg Na) 1.5 oz cornbread (100 mg Na) 1/2 cup orange juice (1 mg Na) 1 piece whole grain bread (159 mg Na) 1/2 cup cooked broccoli (15 mg Na) 3/4 cup blueberries (1 mg Na) 1/2 cup cooked, green beans (7 mg) 1 small banana (1 mg Na) 2 scrambled egg (342 mg Na) 1/2 avocado (7 mg Na) 1/2 cup sweet potato, mashed (37 mg Na) 2/3 cup plain yogurt (nonfat) (100 mg Na) 1/2 cup spaghetti sauce – low sodium (30 mg Na) 1 cup water 1/3 cup pasta (110 mg Na) 1 roll 1 cup water 1365 mg Na total 1 starch, 1 fruit, 2 medium fat protein 1 fruit, 1 milk, 2.5 fat, 1 starch 2 lean fat protein, 2 veg 1 starch, 1 fruit, 1 milk 2 starch, 1 milk, 2 lean protein, 2 veg, 2 fat 2 fruit, 1 starch

11. MEDICATIONS MedicationPurposeInteractions Neomycin Aminoglycoside antibiotic – used to decrease amount of bacteria in intestines May need to take with food to avoid stomach upset, take with water to avoid dehydration Nausea and diarrhea may occur ErythromycinAntibiotic Increase gastric motility, epigastric distress, N/V, abdominal cramps, diarrhea Rare – pseudomembranous colitis PantaprozoleAntiGERD (PPI) May decrease abs of Fe, decrease abs of Vit B12, decrease gastric acid secretion, increase gastric pH, nausea, abd pain, diarrhea Possible decrease in Blood/serum B12 ZofranAntimetic, antinauseantAbd pain, diarrhea, constipation

12. Fasting Blood Glucose (70-99 mg/dL)85 mg/dL Normal – Pt does not have diabetes, Thi def, chronic hepatic dysfunction, severe infections, hyperthyroidism, pancreatitis, malnutrition, bacterial sepsis, glycogen storage disease, or EtOH abuse RBC (3.9-5.5 mill/mm)3.31 mill//mm (L) Decrease with anemia, Fe def Hemoglobin (12.1 – 15.6 g/dL)8.9 g/dL (L) Decrease with anemia Hematocrit (34-45%)27% (L) Decrease with anemia, blood loss Serum Folate (2.8-40 ng/dL)20 ng/dL Decrease with megaloblastic or hemolytic anemia, malnutrition, hepatic disease Pt does not have megaloblastic or hemolytic anemia according to this value Blood StoolPositive Pt has GI bleed Vit B12 (210-911 pg/ml)225 pg/ml – on the low side Decreased with pernicious anemia and malabsorption syndromes Mg (1.3-2.1 mEq/L)2.1 mEq/L Increased with renal failure, diabetic acidosis, hypothyroidism, dehydration Decreased with chronic diarrhea, alcoholism, pancreatitis, renal disease, hepatic cirrhosis, hyperthyroidism, ulcerative colitis, malnutrition Pt presents with none of these problems according to this value TSH (0.4-5.0µU/ml)1.68 µU/ml Increase with primary hypothyroidism Decrease with hyperthyroidism, secondary hypothyroidism, thyroid hormone therapy Pt presents with none of these problems according to this value Fe (50-160 µg/dL)33µg/dl (L) Decrease with Fe def anemia TIBC (240-450 µg/dL)437 µg/dL (on the high side) Increase with Fe def anemia MCVWNL Unable to obtain patient’s specific value due to high demand for the chart – pt has both microcytic and macrocytic anemia MCHWNL Unable to obtain patient’s specific value due to high demand for the chart MCHCWNL Unable to obtain patient’s specific value due to high demand for the chart RDWResults not yet available Increased = increased variation in RBC size

13. DIAGNOSIS PES: Patient presents with altered nutrition related lab values related to gastritis and GI bleed as evidenced by low ferritin, RBC, H/H, and B12 values as well as a somewhat high TIBC and positive blood stool.

14. INTERVENTION Food and/or Nutrient Delivery Avoid spicy foods, caffeine and coffee Increase omega 3 and omega 6 FA Iron supplement B12 injection Nutrition Education Gastritis and affects on diet Hypertension and salt restriction Diet process post op Foods to avoid Coordination of Care RD should talk to MD and discuss the aptions anemia. MD should prescribe the necessary amounts of iron and B12 Team meeting to discuss the patient’s GI bleed, bile reflux, gastritis, and (potential) colon cancer

15. MONITORING/EVALUATION f/u once pt on supplements Go back to consuming 80% meals post op Monitor all labs r/t patient’s anemia (H/H, RBC, serum folate, ferritin, Vit B12, TSH, BCV, MCH, MCHC, RDW) after supp given See if there is blood in stool post op Assess patient’s pain and appetite Pt education Gastritis Anemia and deficiencies Foods to avoid/increase and why

16. REFERENCES LK Mahan, S Escott-Stump. Krause’s Food, Nutrition & Diet Therapy, WB Saunders, 13 th Edition. Mayo Clinic Staff. "Gastritis." MayoClinic. N.p., n.d. Web. 29 Apr. 2015.. "Nutrition Terminology Reference Manual." eNCPT. Academy of Nutrition and Dietetics, n.d. Web. 2 Dec. 2014.. Pronsky, Zaneta, and Jeanne P. Crowe, Sr. Food Medication Interactions. 16th ed. Birchrunville: Food-Med Interactions, 2010. Print.

17. QUESTIONS?