TMH Case Study

Here is most of my case study... there was a lot more to the written document but I wanted to share most of the clinical part.. 

Introduction:

While working at the Tallahassee Memorial Hospital (TMH) I found many patients very interesting, however, most of these interesting patients had already been seen by the dietitians. After a few days of searching for a case study, I found a patient whose case involved complex digestive problems and a need for the use of total parenteral nutrition (TPN).

Nutrition care process was carried out for this patient per TMH and Sodexho protocol following the Sodexho medical nutrition therapy guidelines. Initial assessment for this patient was carried out by Brittany Pond. Patient was screened to be at risk due to NPO status times three days in the intensive care unit (ICU) using the TMH nutrition screening guidelines. The medical record was reviewed and patient was seen. The assessment was written using the PowerChart system. Once the initial assessment was completed with an RD who signed off on the assessment note. Due to Christmas break, the follow-ups were carried out by the TMH dietitians.

Patient’s History

The patient is an elderly 79 year old Caucasian female who was admitted for sudden abdominal pain with copious episodes of nausea and vomiting. The family was concerned the patient had an abdominal obstruction and brought her to the emergency room. A CT scan showed focal ileus in the right upper quadrant with air fluid levels in the small bowel but no focal transition, suggestive of a small bowel obstruction. Free fluid in the right upper quadrant raised a question of gastroenteritis versus peritonitis. Also present in the patient is diverticulosis without inflammation of the colon. Patient’s last bowel movement was the night prior to admission with no diarrhea.

Patient’s Past Medical History Includes:1. Hypertension2. Transient ischemic attack3. Spontaneous pneumothorax in 20094. Hyperlipidemia5. Partial small bowel obstruction in 20106. Microscopic colitis7. Stage I diastolic dysfunction and minimal aortic sclerosis in 20118. Cholecystectomy9. Multiple bladder surgeries10. Bilateral tubal ligation11. Appendectomy12. A-fibrillation
Past Surgical History:Patient had a partial small bowel obstruction requiring resection in 2010 at Emory University Hospital in Atlanta, Georgia.

Allergies: Atropine, Codeine, Sulfa Drugs.

Physical Exam:General: 79 year old, ill appearing, elderly Caucasian femaleVital Signs: Afebrile, temperature 97.4, heart rate 90, respirations 18, blood pressure 138/77,Neurologic: Alert and orientated to person, place, situation, time


Primary Diagnosis:Necrotic tissue was found in the patient’s small intestine leading to a small bowel resection this admission.

Patient’s course of stay prior to first nutrition visit:· 12/19/12: Patient arrived at TMH emergency room (ER), had contrast scan (CT) of abdomen and pelvis with contrast, admitted to the cardiac intensive care unit (CICU).· 12/20/12: Exploratory laparotomy revealed necrotic tissue in patient’s small bowel with removal of this section of the small bowel.· 12/21/12: Patient initially assessed by nutrition.

Nutrition Care Process: Assessment

In order to begin the nutrition care process for this patient, the patient’s medical charts and past history were reviewed. Initial nutrition assessment was on 12/21/12. Patient was on a clear liquid diet with instructions to sip clear liquid with NG in only.

Anthropometric Data:Height: 60 inches, 152.4 cmWeight: 116 pounds, 52.6 kgBMI: 23 kg/m2 (normal)Ideal Body Weight: 45.5 kg

Subjective Data:Patient assessed due to NPO x3 days. Patient is a small framed, pale, white female seen lying in bed with NG tube connected to suction with dark green/brown output. She had a partial small bowel resection in June 2010, after which, the patient had frequent vomiting and diarrhea resulting in weight loss. Uncertain how many pounds patient actually lost since this time, but patient was able to state her weight was 160 pounds prior to 2010. In 2011 she had a small bowel obstruction. Current admission is for abdominal pain, nausea, and vomiting. Patient had an ex lap 12/20/12 with results that showed an area of necrotic small bowel secondary to adhesions. This area of necrotic small bowel was removed this admission.

Objective Data:Laboratory Data: Sodium, Glucose, CalciumIVF: Amiodarone IV @ 17 mL/hrD5 ½ NS + KCl @150 mL/hr (Providing ~681 kcal/day)Braden Score: 14Urinary: Foley, amber colorBowel Status: hypoactive, last bowel movement was 2-3 days prior+ afebrile+nasal cannula+edema Ankle Bilateral+edema Arm Bilateral

Biochemical Data (Labs):Na 133 (L), Ca 7.3 (L), 97-172 BBGs past 48 hours

Estimated Nutritional Needs for Patient’s Ideal Body Weight of 45 kg:· 1242-1426 kcals based on 27-31 kcal/kg increased for wound healing needs.· 46-55 g protein based on 1.0-1.2 g/kg increased for wound healing needs.· 1150-1380 mL fluid based on 25-30 mL/kg.

Nutrition Care Process: Diagnosis

Moderate malnutrition related to current NPO status x 3 days with poor intake prior to admission as evidenced by review of diet order and patient report.

Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record.
Inadequate protein-energy intake related to NPO status and no alternate nutrition yet initiated as evidenced by review of current diet order, visual observation, and medications/IVF providing minimal protein-sparing kcals.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #1, previous small bowel resection in 2010, NG tube output, and hypoactive bowel sounds.

Nutrition Care Process: Interventions

1. If patient has improvement in GI function and patient’s NG tube is discontinued, please add Enlive supplement and advance diet as able.2. If improvement in gut function not anticipated, recommend TPN to allow bowels to rest and heal.· Suggest Clinimix 5/20 with a goal rate of 42 mL/hr, 250 mL 20% lipids daily.i. To provide: 1008 mL total volume, 1385 kcals, 50g protein, 202g CHOii. 2.64 mg/kg/min dextrose infusion rate and 36% kcal from lipidsiii. Please add MVI and MTE, insulin per physician3. Monitor K, Mg, and Phos for signs of refeeding syndrome. If these labs are low, continue TPN at ½ rate of 21 mL/hr until labs normalize.4. Please monitor weights and labs per parenteral nutrition order set.5. Continue to provide anti-nausea medications as needed
6. Bowel Care per MD.

Nutrition Care Process: Monitor and Evaluation

1. Nutrition Goal: Patient to start oral diet or TPB within next 24 hours.2. Weight Goal: Patient to remain within 1-2% of admission weight.3. Bowel Goal: Patient to have evidence of improving function, i/e: decreased NG tube output, + bowel movement.4. Lab Goal: Maintain BBGs >70, <180; electrolytes WNL.

Free Text Nutrition Note: 12/22/12

TPN started per RD recommendations: Clinimix 5/20 @ 42 mL/hr + 200 mL 20% lipids daily + MVI 3x/week + MTE daily. Potassium dropped from 3.9-3.4, may be related to re-feeding syndrome. Check magnesium and phosphorus once-twice daily to appropriately manage possible re-feeding syndrome. If these values are not adequate, may continue TPN at ½ goal rate. Patient continues with clear liquid diet, drinking minimally. Encourage oral intake.

Follow Up Assessment- 12/24/12

Patient is seen in follow up. The patient was lying down in bed at time of visit with family present. Patient is post-operative day number 4 since the small bowel resection. The patient continues to have TPN support. RD spoke with patient who reported no nausea or emesis at this time. Patient indicated they have bouts of diarrhea. No alleviating factors during last bowel resection. RD discussed food preferences and need to advance diet slowly. Patient and family verbalized understanding.

TPN Regimen: Clinimix 5/20 @ 42 mL/hr with 250 mL of 20% lipids daily. Doctor ordered multivitamin on Monday, Wednesday, and Friday schedule and will monitor multi-trace elements.
PO Regimen: Mechanical soft, carbohydrate controlled. Patient was on a full liquid diet prior to interview.

Biochemical Data (Labs): Ca 7.6 (L), Phos 2.2 (L), Mg 1.3 (L), 92-370 BBGs past 48 hrs.
Nutrition Diagnosis:

Moderate malnutrition related to current NPO status x 3 days with poor intake prior to admission as evidenced by review of diet order and patient report. Progress: Continue/unresolved.
Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record. Progress: Continue/unresolved.
Inadequate protein-energy intake related to previous NPO status x3 days and clear liquid diet as evidenced by review of current diet order, visual observation, and medications/IVF providing minimal protein-sparing kcals. Progress: Improving.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #4, previous small bowel resection in 2010, NG tube output, and hypoactive bowel sounds. Progress: Continue/unresolved.

Interventions1. Continue with mechanical soft, carbohydrate controlled regimen as medically appropriate/tolerated· Consider GI soft/bland restriction to promote diet tolerance· Consider Boost Glucose Control BID is PO regimen is well tolerated.2. Continue TPN to allow bowels to rest and heal as medically appropriate, wean per physician.3. If signs of refeeding syndrome present (low K, Mg, Phos) continue TPN as ½ rate (21mL/hr) until labs normalize and decrease PO regimen.4. Please monitor weights and labs per parenteral nutrition order set.5. Continue to provide anti-nausea medications as needed.6. Bowel Care per MD.

Final Follow-Up Assessment- 12/27/12

Patient is seen in follow-up. Patient complains of ongoing chronic diarrhea related to microcytic colitis. The Patient reports an okay appetite, she states she feels full quickly and portion sizes sent on meals are too large. RD discussed consuming small frequent meals. The patient drinks Boost at home and would like some sent to her with meals. The patient’s TPN was discontinued today due to lack of parenteral access. Diet: Healthy heart. PO intake: Fair.
Biochemical Data (Labs): Na 135 (L) Ca 7.6 (L, same), 101-121 BBGs
Nutrition Diagnosis:

Moderate malnutrition related to fair intake on current diet as evidenced by review of diet order and patient report. Progress: Improving
Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record. Progress: Continue/unresolved.
Inadequate protein-energy intake related fair intake on current diet as evidenced by patient report, review of current diet order. Progress: Improving.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #7, previous small bowel resection in 2010, and ongoing diarrhea. Progress: Continue/unresolved.

Interventions1. Encourage intake of small frequent meals· Send Boost supplement per patient request2. Recommend a multivitamin with minerals to ensure micronutrient needs are met.3. Recommend Lactinex 1 packet BID to promote GI health.

Patient’s Course of Hospital Stay at TMH

· 12/19/12: Patient arrived at TMH ER, had CT of abdomen and pelvis with contrast, admitted to CICU.· 12/20/12: Ex lap revealed necrotic tissue in patient’s small bowel with removal of this section of the small bowel.· 12/21/12: Patient initially assessed by nutrition due to NPO x 3 days.· 12/22/12: Patient moved to 5B- Diabetes Floor. Free text nutrition note.· 12/24/12: Patient seen for nutrition follow up, on full liquid diet then moved to mechanical soft diet. 12/27/12: Patient seen for nutrition follow up, heart healthy diet with fair intake. TPN stopped.· 12/31/12: Patient tolerating small meals, waiting for a rehab bed.

Conclusion:

The patient was treated for 12.6 days at TMH. Initially she was moderately malnourished. Before transferring to TMRH, her nutrition had improved based on her lab values and her ability to eat a heart healthy diet. The RD’s had discussed future nutrition care for the patient by explaining the importance of eating small frequent meals and bland foods with the patient. The patient was transferred to TMRH on December 31st, 2012 for continued care and rehabilitation.