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Mini-Case Study Presentation

Mini-Case Study Presentation. Hilary Smith November 17, 2014. Patient SL. 84 y/o female Transported by EMS from home, pt unsure who called 911 Admitted 11/2/14 with weakness, UTI and signs of alcohol withdrawal Number of intern contacts: 3, 1 with RD Number of RD contacts: 1.

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Mini-Case Study Presentation

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  1. Mini-Case Study Presentation Hilary Smith November 17, 2014

  2. Patient SL • 84 y/o female • Transported by EMS from home, pt unsure who called 911 • Admitted 11/2/14 with weakness, UTI and signs of alcohol withdrawal • Number of intern contacts: 3, 1 with RD • Number of RD contacts: 1

  3. Social History • Does not have a Primary Care Physician • Lives at 2-story home with 50-year old son who is wheelchair-bound and takes care of him, and 24 y/o grandson • SL using a wheelchair more often, was unable to get up 3 days prior to admission • Patient arrived unkept

  4. Prior Medical History • H/o alcohol use, unknown how much/often • Alcohol level 150 upon admission • Smokes 1 pack/day • H/o L hip repair surgery, acute renal failure, b/l lower extremity cellulitis, HTN • No home meds

  5. Diet History • Upon first contact, was not able to obtain history • Patient sleeping and no PO intake • Visited 2 days later • Pt says she eats 2 meals/day at home • Usually a bagel, sometimes with lox for breakfast/lunch • Used to cook but now eats pizza or Chinese food for lunch or dinner • Current intake: inconsistent ~50%, likes Ensure

  6. CIWA Protocol • Clinical Institute Withdrawal Assessment • SL was put on protocol upon admit • Measures 10 symptoms to assess pt risk for withdrawal • Assessment score • >8-10, minimal to mild withdrawal • 8-15, moderate withdrawal • 15+, severe withdrawal • Pt assigned detoxification program

  7. Medications • IV NS @ 120 ml/hr alternating with IV NS + MVI + folic acid + thiamine @ 150ml/hr “Banana Bag” • Ceftriaxone – ABT for UTI • Consider Na content with low Na diet; anorexia • Folic acid • Thiamine • Multivitamin w/ Minerals • Diazepam – Alcohol withdrawal symptoms • Limit caffeine to <400-500 mg/day, caution with grapefruit • Ativan PRN – Alcohol withdrawal symptoms

  8. Labs • K - 3.3 mmol/L – low • Ref. range 3.5-5.1 • Ca - 7.6 mg/dL – low • Ref. Range 8.5-10.1 • Albumin - 2.7 g/dL – low • Ref. Range 3.4-5.0 • Ethanol – 150 mg/dL - high

  9. Nutrition History • Diet at time of assessment: Room Service, Heart Healthy (3-4g Na, low fat, low cholesterol) • Liberalized to House Menu, Regular on 11/9

  10. Physical • Appearance: frail • 2 Pressure ulcers: R ischium, unstageable; L ischium Stage II, staged per wound care RN • Demeanor: lethargic; first visit pt was sound asleep (Ativan PRN)

  11. Anthropometric Data • Height: 152 cm • Weight: 44.6 kg • BMI: 19.3 • IBW: 51 kg • %IBW: 87% • UBW: unknown per pt, thinks she may have lost some weight prior to admission

  12. Nutrition Needs • Calorie needs – Mifflin St. Jeor • Weight used: 44.6 kg (admit wt) • Activity factor: 1.3-1.4 (pressure ulcers, frail appearance) • 1067-1149 kcal/day • Protein 1.5 g/kg (pressure ulcers) • 67g/day • Fluid Needs: 1,338 ml/day • 30 ml/kg (Age 55+)

  13. PES Statement Inadequate oral intake related to ETOH withdrawal as evidenced by patient not eating solid food

  14. Plan/Recommendations • Level: Severe Level 4 (1-4 scale) • Reassess every 2-4 days • Poor PO intake averaging <25% of needs • Continue with current diet • Add Ensure Complete BID to breakfast and dinner (350 kcal, 13g protein) • To increase potential for calorie intake and promote wound healing • Monitor diet tolerance, supplement tolerance, labs, weight, intake and output

  15. Goal • Increase oral intake to 50-75% of meals/supplements • Timeframe to achieve: 3 days

  16. Hospital Course • 11/2/14 Admission • 11/3/14 1st visit and assessment with RD • 11/5/14 Intern visit to obtain diet history, UBW, encourage intake, assess appropriateness for education • 11/6/14 Discharge to Sub-Acute Rehab unit at Northwest Hospital • 11/8/14 2nd assessment by RD • Added Magic Cup 1x/daily (290 kcal, 9g protein) • Liberalized diet to regular to increase food choices • 11/9/14 Changed to House, Regular

  17. Wound and Weight Status • Currently has unstageable pressure ulcer on R ischium and healing stage II pressure ulcer on L ischium • Current weight 46.5 kg • gained 4.18 lbs since admission

  18. Nutrition Literature Support • NPUAP-EPUAP (National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel) Guidelines • All individuals should have nutrition assessment upon admission and with each condition change • Provide sufficient calories • 30-35 kcal/kg for pts under stress and pressure ulcer • Provide adequate protein for positive N balance • 1.25-1.5 g/kg protein • No evidence-based recommendation for Arginine or Glutamine • Provide and encourage daily fluid intake • Provide adequate vitamins and minerals • Through diet; offer supplement if deficiency confirmed/suspected

  19. Medical Literature Support • Alcohol impairs wound healing and increases incidence of infection • EtOH intoxication at time of injury is a risk factor for increased susceptibility to infection in a wound • Acute EtOH exposure can lead to impaired wound healing by weakening the early inflammatory response, preventing wound closure, angiogenesis, and collagen production, and changing the protease balance at the site of the wound.

  20. Questions?

  21. References • The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper • Factors Affecting Wound Healing, Journal of Dental Research

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