Benedictine University

Dietetic Internship ProgramCASE STUDY ASSIGNMENT 2

For Clinical and LTC/Sub Acute Rotation and NTR 622

Objective: This project allows the Dietetic Intern to exhibit his/her ability to seek, comprehend, analyze, apply, and integrate essential data into a comprehensive medical nutrition therapy plan of care, which views the patient/client as a whole. The assignment also provided the intern with experience in application of principles of all steps in the Nutrition Care Process.

Instructions: Use this template to complete your assignment. The template is designed to incorporate

the steps included in the Nutrition Care Process (NCP). You may add rows and additional data to the template as appropriate.

Make sure to type your assignment. Make yourself a copy of your completed case, as the original will not be returned to you It is highly recommended to share drafts of your case study with site preceptor(s) and the

DI Director prior to giving a case study presentation. Include a table of all references cited. A minimum of 5 references must be used to

complete the case study. One reference must be a current research article related to one or more aspects related to your case study presentation. Use the format of: Guidelines for journal authors, J Am Diet Assoc. The guidelines are found in the January issue yearly.

The Case study is to be presented to the dietitians in both written and verbal format. A written copy of the case study report must be submitted to the Dietetic Internship

Director, and your site preceptor(s), as they request. All Dietitians attending the presentation are to complete the Presentation Evaluation

Form – prior to your presentation, be certain to copy one form per dietitian expected to be attend the education session.

Prior to Beginning your report, complete the following: Review the patient/client medical record (computer and/or paper versions) Conduct an in depth interview and/or diet history (as appropriate) Never complete an assessment without visiting your patient and completing a physical

assessment and/or interview. Complete a Care Plan Form (You may use BU’s form or the site’s form)

o ATTACH a copy of your care plan to your report

NCP Step 1: Nutrition Assessment

Patient ProfilePractice Setting in which you are assessing this patient/client

Clinical – Intensive Care Unit to Telemetry Floor

Age 85 years oldGender MaleRace African AmericanRelevant personal data (e.g. does not speak English, marital status, lives in a nursing home, SES etc.)

Father to 11 children who are all actively involved in his treatment and recoverySlightly deaf (do not need to talk louder, just closer)

Symptoms/complaints Abdominal painCURRENT Medical Conditions/Diagnoses Gastric CancerPAST Medical Conditions/Diagnoses Gastric Cancer, HTN, arthritisMedical Test(s) conducted or planned Daily lab data, human albumin IV, EKG, rhythm

stripMedical procedure(s) conducted or planned Total gastrectomy, esophagealjejunostomy,

enteroenterostomyEpidural

Anthropometric Data:Indicator Value for the patient/client Assessment of patient/client valueHeight 167 cm 66 in ---Weight 79 kg 174lb ---Weight change 4 # in 1 month ---UBW 77kg 170lb ---IBW 71kg 156.2# Upper 10% BMI% IBW 111% Within Normal LimitsBMI 28.3 Overweight BMIAdjusted Body Weight --- ---Patient Weight Goal Maintain current body wt ---

Food/Nutrition Related HistoryFood Allergies NKFAChewing and/or Dental Problems N/ASwallowing Problems N/ABowel Habits/Problems Occasional stomach pain d/t gastric cancerRecent Changes in Eating Habits Decreased appetite 1 week PTA d/t gastric painCurrent Appetite Decreased appetite PTA, normally good appetiteFood Preferences Regular diet w/ specific preferences for greens,

bananas, fatty/fried foods (fried meats, starches, bacon, etc.)

Nutrient Malabsorption Problems? None PTAN/V/D Occasional of all three d/t gastric cancerPast Diet Prescriptions Low sodium dietPast Diet Instructions Low sodium diet

24 – Hour Recall

Meal Type of Food Cooking Method PortionFirst Meal of Day --- --- ---Snack 1 banana Home prepared Medium sizedSecond Meal of Day Turkey Sandwich,

white bread, cheese, lettuce, tomato, mayonnaise

Home prepared 2 slices commercial sized bread, 3-4 oz. pre-sliced deli turkey, 1 lettuce leaf, 2 slices tomato, 2 Tbsp. mayonnaise.

Snack --- --- ---Third Meal of Day Spaghetti w/ meat

sauce, milk, 1 slice Texas toast garlic bread

Home prepared (Texas toast was store bought frozen)

1 cup cooked spaghetti (w/ salt), 8-10 oz. milk (2%)

Snack --- --- ---If a diet recall is not appropriate for this patient, please explain why in the space provided:A rough dietary recall was obtained from patient’s daughter d/t patient being sedated s/p total gastrectomy.

Food Recall AssessmentPart A

1. Analyze the recall using MyPlate Guidelines

According, to the patient’s daughter, this was not exactly a normal day of eating for this patient. The types of foods are the same, but the amount eaten throughout the day is great. The patient had been experiencing decreased appetite for a week or so, hence the reduced intake. In terms of MyPlate guidelines, this patient was on target for the servings of grains and protein that he needed to be eating (though the grains were all refined). The patient was <50% on target for his fruits, vegetables, and milk/dairy foods. This patient has a history of hypertension, and according to his daughter he does not follow a terribly low-sodium/cardiac diet. He does though, enjoy various ‘greens’, such as collard/mustard greens, as well as green beans, and broccoli, which would have increased the nutritional content of his diet had he eaten some of these foods during these 24 hours. This recall is high in refined grains, and contains several sources of saturated fat, sodium, and processed foods. This recall was low in fresh fruits and vegetables, whole grains, legumes, fiber, and adequate sources of nutrient dense foods.Part B

1. Analyze the recall using a computer nutrient analysis program of your choice.2. Attach the computer analysis output to this assignment.3. Explain the adequacy of the intake below in terms of macro and micro nutrients.

The following is rough dietary recall of this patient’s daily intake. Portion sizes and quantities were estimated based on daughter’s interview and perceived portion sizes consumed. MyPlate SuperTracker gave this patient a 2,000 calorie daily intake, based on his weight, height and lack of physical activity.

This patient’s rough daily intake was high in the non-desirable nutrients and low in the desirable ones. He fell short of his calorie intake by 589 calories (due to his recent decreased appetite), exceeded his carb intake by 31 grams and exceeded his saturated fat intake by just 1%. He was also

a high in sodium (2953 mg as compared to <2000 mg – due to hypertension). This patient was low in his dietary fiber (14g as compared to 25g), his alpha-linolenic acids, calcium, potassium, vitamins A, C, D, E, K, and folate, though his B6 and B12 levels were good. Overall, this diet was high in macronutrients and sodium, and low in most vitamins and minerals.

Nutrition Focused Physical AssessmentPhysical Appearance Appeared well nourished, though overweightMuscle and fat wasting N/ASwallowing function GoodAppetite Poor – patient s/p total gastrectomy (NPO) and

sedated*Appetite poor x 1week prior to admission due to increased stomach/abdominal pain

Affect (e.g. lethargic, sleeping, coma, energetic, in pain, etc.)

Sedated, agitated first few days. Patient calmed and became more alert and oriented a few days after surgery.

LABORATORY DATA:

Date: 11/4 Date: 11/5 Date: 11/7-8 Date: 11/10 Date: 11/11Laboratory Test: Normal Values: Values: Values: Values: Values: Values:Diet Order --- NPO NPO Clear Liquid Postgast Pureed Postgast PureedHeight --- 66in 66in 66in 66in 66inWeight --- 174# 174# 174# 174# 174#Blood Pressure 120/80 --- --- --- --- ---Albumin > 3.5 mg/dL 2.4 --- 2.4 --- ---Sodium 135 –145 mEq/L 126 139 120 147 142Potassium 3.7 – 5.2 mEq/L 3.0 3.8 4.0 3.2 3.5Chloride 96 – 106 mEq/L 101 109 116 114 110Carbon Dioxide 23 – 29 mEq/L 25 24 26 26 22Glucose <140 mg/dL 192 124 130 149 131BUN 7 – 20 mg/dL 14 21 33 44 36Creatinine 0.7 – 1.3 mg/dL 1.75 2.27 3.38 2.71 2.42GFR > 60 48 35 22 29 33Magnesium 1.2 – 2.2 mg/dL --- 1.6 2.5 2.2 2.1Phosphorous 2.4 – 4.1 mg/dL --- --- --- 3.7 ---Hemoglobin/Hematocrit 12 – 16 g/dl / 36-

48%10.6/33.8 9.9/31.2 10.2/33.2 10.0/33.2 10.3/33.2

DISCUSSION of Laboratory DataInstructions:Discuss the relation of laboratory values to disease state and nutritional status.

Consider the following: What significance do the abnormal laboratory results have for this patient

(example: type anemia? type hyperlipidemia)? If the case is being completed during a rotation where minimal laboratory data is available

(such as WIC), provide a discussion regarding what labs would be helpful in completing a more complete assessment of the patient/client.

Electrolytes:- During the first few days after this patient’s surgery, his electrolyte levels tending to be

towards the lower range, and they fluctuated until he became more stable by the final day. Anesthesia can cause dehydration, and because of this, this patient was placed on different IV fluids, which could have caused the fluctuating electrolyte levels until we were able to stabilize him. This patient’s GFR was trending down during most of his stay, which could have accounted for the varying electrolyte levels.

Blood Work:- This patient continued to display a low hemoglobin/hematocrit, which could have arisen

from several factors. If the patients diet prior to admission was not nutritionally adequate, he could have been missing out on sources of blood nutrients, such as iron. Low H/H can also arise from cancer in the body, which is the likely case for this patients low H/H levels. We also removed his entire stomach during his stay, which accounts from some blood and tissue loss.

Other:- This patient’s glucose levels were continually high during his recorded lab tests. High

glucose levels are not always a sign of poorly controlled blood sugars, but can be a sign of stress within the body. Hormones, such as corticosteroids (including medications), are released during times of illness, infection, or stress on the body, which can explain this patient’s high levels during his stay.

- His GFR was also tended to be low, which is a measure of kidney failure and can represent onset kidney failure in this patient, either occurring prior to her stay, or advanced in the hospital - often, kidney function tends to decline the longer a patient stays in the hospital. According to a study published in the Oxford Journals titled “Treatment-related acute renal failure in the elderly: a hospital-based prospective study”, acute kidney injury is a common occurrence in the elderly hospitalized population. The researchers found that, among the various different causes of acute kidney injury, surgery (specifically abdominal surgery) was a large contributor. This study mirrors the situation of this patient who underwent a total gastrectomy and then began to show declining kidney function. One the last stay of his stay, his kidney function finally began trending upwards.

http://ndt.oxfordjournals.org/content/15/2/212.full

MEDICATIONS:

Date: Medication &Amount: Purpose or Function: Significant Nutritional Implications:11/4 – Ciprofloxacin IV @ 200 An antibiotic in a group of drugs called Do not take ciprofloxacin alone with dairy

11/5 ml Q12H fluoroquinolones. Ciprofloxacin fights bacteria in the body.

products such as milk or yogurt, or with calcium-fortified juice. It could make the medication less effective.

11/4 – 11/10

Heparin IV 0.5 ml Q12H An anticoagulant that prevents the formation of blood clots. Used to treat or prevent these clots in the veins, arteries, or lung. Heparin is also used before surgery to reduce the risk of blood clots.

Avoid alcohol, as heparin causes blood thinning and alcohol only exacerbates this effect.

11/6 – 11/10

Metoprolol @ 5 mg slow IV push Q4H

A beta-blocker that affects the heart and circulation Metoprolol is used to treat angina and hypertension is also used to treat or prevent heart attack.

Metoprolol should be taken with a meal or just after a meal.

11/4 – 11/8

Protonix @ 40 mg IV push daily

Proton pump inhibitor that decreases the amount of acid produced in the stomach – important if patient receiving little to no oral nutrition to prevent ulcers.

Medication can cause diarrhea, but antidiarrheal pulls should be avoided, unless physician indicated.

11/4 – 11/10

NaCl 0.9% @ 125 ml/hr. Used to provide sodium and water to the body to aid in rehydration/hydration maintenance

Medical histories of kidney problems, heart problems (such as heart failure), body water/salt imbalance should be considered when administering NaCl.

11/4 Fentanyl @5 ml/hr. (w/ anesthesia - surgery)

Narcotic pain reliever, can be used as part of anesthesia to help prevent pain after surgery or other medical procedures

Side effects of fentanyl can include nausea or vomiting, slowed heart rate and hypertension, among others. Other drugs such as vitamins and herbal supplements

11/7 – 11/8

Albumin human @ 100 ml BID

Used to treat a variety of conditions, including shock due to blood loss in the body, burns, low protein levels due to surgery or liver failure, and as an additional medicine in bypass surgery.

Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); change in heart rate or breathing; chills; confusion; excess saliva; fainting; fever; headache; nausea; vomiting; weakness.

11/4 – 11/10

Amlodipine @ 10 mg daily

A calcium channel blocker. Amlodipine relaxes blood vessels and improves blood flow. Amlodipine is used to treat hypertension or angina

Amlodipine is only part of a complete program of treatment that may also include diet, exercise, weight control, and other medications. Follow diet, medication, and exercise routines very closely. Drinking alcohol can further lower your blood pressure and may increase certain side effects of amlodipine.

11/10 – 11/12

Warfarin @ 5 mg (evenings)

An anticoagulant (blood thinner). It reduces the formation of blood clots.Warfarin is used to prevent heart attacks, strokes, and blood clots in veins and arteries.

Foods that are high in vitamin K (liver, leafy green vegetables, or vegetable oils) can make warfarin less effective. If these foods are part of the diet, eat a consistent amount on a weekly basis.

DISCUSSION of MedicationsInstructions:Discuss drug-nutrient interactions and side effects the medicines may cause that have nutritional

significance.

Consider the following: Include whether the patient exhibits any of these side effects. Discuss relevant relations of medications to disease symptom complaints.

- Several of these medications cause side effects such as nausea, vomiting, diarrhea, rash, facial/mouth swelling, etc. Fortunately, this patient did not experience any of these side effects during his inpatient stay. We met with this patient almost every day after his surgery to assess how his bowels were recovering and handling the onset of different degrees of diets. He never had complaints of nausea or vomiting and experienced very little, mild diarrhea while we were bringing him into more solid foods.

- In terms of nutritional/dietary implications, once specific medication that we educated this patient on was the interaction between Coumadin (warfarin) and vitamin K. This patient starting taking - Coumadin during his inpatient stay, and had thus no prior education. He had a preference for dark, leafy greens (high in vitamin K) such as collard and mustard greens, so he needed education on keeping a consistent intake of these foods while in Coumadin to avoid issues with INR fluctuation and blood thinning/clotting inconsistencies.

- Ciprofloxacin has specific nutrient interactions with milk, yogurt and calcium fortified juice, but these were non-issues since he was totally NPO while on his Cipro IV.

http://www.drugs.comNutrition Care Manual: Client Education – Warfarin and Vit K

NCP Step 2: Nutrition DiagnosisPATHOPHYSIOLOGYCURRENT Medical Conditions/DiagnosesList ALL current medical conditions and describe the pathophysiology of each. Add

additional rows as needed. Be sure to reference your findings. Diagrams may also be helpful in explaining the pathophysiology of some diseases/conditions.Gastric Cancer- Gastric cancer is described as cancer that occurs in the tissues of the stomach. According to the National Cancer Institute, each year in the United States, about 13,000 men and 8,000 women are diagnosed with stomach cancer. Most are over 70 years old. This patient presented with two of the above risk factors for gastric cancer: being a male over 70 years old. This patient developed his gastric cancer several years ago, and it had reached a recent degree of severity that called for a total gastrectomy. Like other forms of cancer, gastric cancer develops in the cells of the stomach tissue. Normally, cells grow and divide to form new, healthy cells. In cases of cancer, the cells develop incorrectly and the mechanism for spotting these issues with the cell is missed. This allows the damaged to cell to multiply and grow and take over the healthy cells of the tissue. The buildup of these damaged cells eventually forms a mass of tissue called a growth, polyp, or tumor. Again, as with other cancers, gastric tumors can be considered benign or malignant. In the case of this patient, he was experiencing malignant cancer, which means that the tumor was continuing to invade the surrounding tissues and damaging the healthy tissue of his stomach. As his cancer spread, he continued to lose normal stomach function. Several weeks before his surgery, his family noticed that his appetite was decreasing and he was experiencing more stomach pain then usual. This patient and his family has considered that a total gastrectomy may occur, and these symptoms prompted his family to make the outpatient surgical appointment.http://www.cancer.gov/cancertopics/wyntk/stomach/WYNTK_stomach.pdf

S/P Total Gastrectomy | Esophageal Jejunostomy | Enterenterostomy

- A total gastrectomy is exactly what it sounds: a complete removal of the stomach. This also calls for an esophageal jejunostomy, which is a connection of the lower end of the esophagus with the jejunum of the small of intestine. The procedure for this process calls for a connection of the jejunum with the end of the esophagus, thus maintaining a continued path from the start to end of the digestive system. Eventually, the connection between the jejunum and esophagus will grow a bit in size and begin to take over the function of the stomach, to some degree. The pancreatic juices will continue to flow into the small intestine to help

digest the food that is consumed. This will make it easier for the patient to eat a fairly normal diet and hopefully avoid issues of Dumping Syndrome.

- Apart from the total gastrectomy and the esophagealjejunostomy, this patient also underwent an enteroenterostomy. It is used to restore bowel continuity after resection of a segment of the bowel or after creation of a Roux-en-Y loop of jejunum. When performed as a bypass procedure, enteroenterostomy relieves bowel obstruction, though this was not the specific case for this patient.

http://emedicine.medscape.com/article/1891769-techniquehttp://www.nostomachforcancer.org/gastric-cancer/life-without-a-stomach/youre-having-what-about-total-gastrectomy

PAST Medical Conditions/DiagnosesGastric Cancer- See above definitionHypertension

- Hypertension is defined as persistently high arterial blood pressure. The systolic blood pressure has to be 120 mmHg or higher or he diastolic blood pressure has to be 80 mmHg or higher (higher then 120/80) to be clinically defined as hypertension. Hypertension is divided into two groups: primary – which often has no identified etiology and tends to develop gradually over many years and, secondary – which is caused by an underlying disease, such as kidney, adrenal, or thyroid problems, certain medications, alcohol abuse, etc. The pathophysiology of hypertension includes several key points: increased systemic vascular resistance, increased vascular stiffness, and increased vascular responsiveness to stimuli. Basically, there is increased pressure on the arteries, causing increased smooth muscle formation to make up for this pressure, ultimately leading to increased arterial resistance. From a nutritional standpoint, the onset of hypertension can be preceded by a high sodium diet. Sodium pulls water with it, thus increasing fluid volume in the blood and increased the pressure on the vascular walls of the arteries. The heart also tends to work harder to pump blood through the body. Following this type of diet for a long time continues to put pressure on these walls and raises blood pressure to a point that one is finally diagnosed with hypertension. This extra pressure and pumping of the heart can damage the heart muscle and lead to other cardiovascular complications.

- In the case of this patient, it was obtained from his daughter that the foods he ate tended to be high in salt and he did not have any previously followed “low-sodium” diets. He did enjoy a variety of healthy foods, but his age paired with his preference for friend and some sodium heavy foods contributed to his history of hypertension.

http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/symptoms/con-20019580

Arthritis- Arthritis is defined as inflammation/swelling of one or more of one’s joints. There are several different types of arthritis, the most common of which being osteoarthritis and rheumatoid arthritis. Osteoarthritis is a chronic condition in which cartilage between the joints breaks down. This causes the bones to rub against each other, causing stiffness, pain and loss of joint movement. The cause is not fully understood. Rheumatoid arthritis on the other hand, is an autoimmune disorder in which the body causes the immune system to function abnormally and mistakenly attack healthy cells, specifically the synovium - a thin membrane that lines the joints. This attack results in fluid build up in the joints, causing pain and inflammation. Over time, this can wear away the cartilage and bone, causing limited function and mobility. In most people, the inflammation usually becomes systemic, affecting organs such as the skin, heart and lungs.http://www.arthritis.org/

Medical Conditions/Diagnoses INTER-RELATIONSHIPSDescribe the inter relationship of the patient/clients disease states.The use of a diagram is encouraged, but the diagram must be accompanied by a narrative explanation. Be sure to reference your findings.

- The biggest inter-relationship that this patient displays is between his history of gastric cancer and his surgery that was performed. As explained above, gastric cancer – if malignant and spreading – can damage enough healthy tissue that it becomes necessary for part of all of the stomach to be removed. Apart from pain and discomfort relief, this procedure is also done to protect the rest of body from the spread of the cancer, as well as protect the integrity of the gastrointestinal tract. According to No Stomach for Cancer, Inc. the recommended procedure to prevent the development or spread of gastric cancer is prophylactic (preventive) total gastrectomy. People with other forms of stomach cancer may also undergo total gastrectomy as part of their treatment plan. Total gastrectomy is also performed to treat some non-cancer medical conditions. The reconstruction is referred to as Roux-en-y.

- The above diagrams show the before and after picture of a total gastrectomy. The part of the

small bowel that is initially cut at the end of the duodenum is what is extended straight up to meet the esophagus (esophagealjejunostomy). That cut end of the duodenum is then reconnected to the small bowel. The procedure takes 4-5 hours followed by a hospital stay of 7-12 days. In the case of this patient, he was admitted for roughly 8 days. According to No Stomach for Cancer, Inc. no food or drink is permitted for the first 5 days, not even ice chips. This patient healed quite well from his surgery and we were able to administer a clear liquid diet by day 4, which we tolerated quite well and had no instances of leakage, diarrhea, abdominal discomfort or other GI issues.

http://www.nostomachforcancer.org/gastric-cancer/life-without-a-stomach/youre-having-what-about-total-gastrectomy

Assessment of Nutrition Needs based of off 79kg (pt’s actual weight)

Calories: 2,370 kcalsShow your work:30 kcal/kg30 kcal/kg x 79 kg = 2,370 kcals

Rationale for calorie level:It was enough calories to ensure that the patient did not experience any weight loss and had enough kcals to promote healing after his surgery.Protein: 103 gShow your work:1.3 g/kg1.3 g/kg x 79 kg = 103 g pro

Rationale for calorie level:Increased protein needs are necessary for hospitalized individuals. Advocate Trinity’s standard is 1.0 g/kg protein for hospitalized adults. In addition, this patient underwent surgery and as such, needs increased protein needs to promote healing and avoid a catabolic state. 1.3 g/kg is an appropriate protein amount to meet his increased needs, avoid a catabolic state, and also avoid an excess amount of protein.Other pertinent micronutrient levels:Show your work:B12 shots – likely monthly (prescribed by physician)* Amounts vary between 500mg and 1,250mg depending on the amount needed and the presence of any long-term B12 deficiency

Rationale for pertinent level:Since his entire stomach was removed, this patient no longer has intrinsic factor to transport any dietary B12 into his small bowel for absorption. In order to prevent a B12 deficiency that can lead to unfavorable neurological deficits, we advised this patient and his family that B12 shots will be necessary. They were to speak with their physician regarding the exact amount and occurrence of these shots.http://www.mayoclinic.org/drugs-supplements/vitamin-b12/dosing/hrb-20060243Fluid: 2,370mlShow your work:30 mL/kg30 mL/kg x 79 kg = 2,370 ml

Rationale for fluid level:To match his increased kcal needs necessary to promote healing, increased fluid needs are also required. When a person undergoes anesthesia, there body will undergo dehydration and needs increased fluid.

Which of the following domains is the patient/client presenting with:

DOMAIN Check () if patient presents with this

characteristic

If checked, explain evidence to support this decision

INTAKENutrient Intake

1) Due to the total gastrectomy, this patient’s nutrient intake was restricted for 2 days, and then his diet was carefully advanced as tolerated.2) As stated above, this patient has no intrinsic factor to absorb B12, so B12 shots will be necessary to fix this nutrient intake issue.

CLINICALFunctional

This patient displays altered GI function due to a total gastrectomy, thus affecting his nutrient intake and needs to be corrected with monthly B12 shots. This patient also needed to gradually advance his diet as tolerated to compensate for his altered GI function.

BEHAVIORAL-ENVIRONMENTALKnowledge and Beliefs

This patient had a knowledge deficit regarding his diet post-total gastrectomy, as well as the food/drug interaction between Coumadin and vitamin K, and thus required education on these topics.

What is the Nutrition Diagnosis for this client/patient?Diagnosis or

ProblemEtiology Signs and/or Symptoms

Altered GI function

Food and Nutrition Related Knowledge

Deficit

Related to

Related to

GI Surgery

Lack of Exposure to

Prior Information

Related to

Related to

Need for NPO status

GI Surgery and New Medication

NCP Step 3: Nutrition Intervention:

Nutrition Prescription (Diet Order)Indicate the diet changes and progression since patient’s admission to present

Date Diet Prescription/Order11/4 NPO11/7 NPO11/8 Clear Liquid11/10 Postgastrectomy Pureed11/11 Postgastrectomy Mechanical Soft

Discussion of Diet Order(s)Consider:

Rationale & indications for current diet order Do you agree with the order? Discuss why or why not. Would any other dietary modifications be realistic and appropriate? Discuss why or why

not.This is a proper diet order and advancement for a patient with this type of gastric surgery. Initially the patient was to remain NPO for the first few days after surgery to give the bowels time to rest and heal. He was then advanced to a clear liquid diet for one day, which he tolerated well. This patient was then advanced to a postgastrectomy pureed and then mechanical soft diet, which again he tolerated well. One reason for this type of diet advancement and prescription order is to avoid dumping syndrome as well as delayed gastric emptying. Dumping syndrome occurs when the undigested contents of the stomach (or small intestine if the stomach is removed) move too rapidly into the small bowel. Common symptoms include abdominal cramps, nausea and diarrhea. By following a postgastrectomy diet (which consists of small portions, beverages between meals, and no concentrated sweets), dumping syndrome can be avoided. In the case of delayed gastric emptying, the reported incidence of delayed gastric emptying (DGE) after gastric surgery is 5% to 25% (according to the American Journal of Surgery). A research article published by the American Journal of Surgery studied the occurrence of delayed gastric emptying (DGE). They discovered that DGE continues to affect a considerable number of our patients (24%) after gastric surgery and is particularly common in patients with diabetes, malnutrition, and gastric or pancreatic cancer. However, gastric motility does return in 3 to 6 weeks in most patients and the need for re-operation for gastric stasis is rare. In the case of this patient, his recovery went smoothly and he is expected to resume an almost 100% normal diet within 6 weeks of his surgery.

http://www.sciencedirect.com/science/article/pii/S0002961096000487http://www.mayoclinic.org/diseases-conditions/dumping-syndrome/basics/definition/con-20028034

Nutrition Intervention PlanProblem Etiology of

the Problem

Sign/Symptoms Intervention Goals for this Intervention

Altered GI function

GI Surgery Need for NPO status

Food and/or Nutrient Delivery:- For this patient, we spoke with his daughter about diet advancement as appropriate once okay with the surgery department. We expected a transition to oral diet in the first few days following his surgery pending the return of his bowel function. Plan was to monitor indications for diet advancement vs. prolonged NPO status and need for TPN support.

The first and most important goal for this intervention is appropriate diet progression for this patient. The patient was agitated and confused during the first 2 days after his surgery, so we worked with his daughter to ensure that his diet was progressing as expected. He was NPO for about 3 days after the surgery, and then was able to be advanced to a clear liquid diet, then a postgastrectomy pureed and finally a postgastrectomy mechanical soft. Overall, this patient tolerated his diet progressions well and had wonderful family support to ensure that he was following the proper postgastrectomy diet, as is explained below.

Food and Nutrition Related Knowledge Deficit

Lack of Exposure to Prior Information

GI Surgery and New Medication

Nutrition Education:- Along with ensuring proper dietary advancement, we needed to make certain that this patient was following a proper postgastrectomy diet: no concentrated sweets, eating small meals, chewing thoroughly, and having beverages in between meals, all to avoid dumping syndrome.- This patient was also receiving Coumadin, which required Coumadin/Vit K drug-nutrient interaction education.- Need for B12 shots post D/C

We worked with his daughter, and the patient himself (once he became more alert by day 3) to explain the proper way to resume his ‘normal’ diet. Both the patient and daughter were extremely compliant with the new dietary orders and the patient tolerated all dietary advancements extremely well. The kitchen was responsible for avoiding the concentrated sweets and providing smaller portion sizes, but the patient and family were responsible for ensuring that all food was chewed thoroughly and that beverages were consumed in between meals. This patient also was receptive to the Coumadin/Vit K interaction education and demonstrated an acceptable level of knowledge and understanding regarding this new medication.

Nutrition Intervention PlanNutrition PrescriptionCurrent order: Postgastrectomy Mechanical Soft (diet prescription at time of discharge)

Your Nutrition Prescription Recommendation:

Continue same type of diet at home and advancement of diet as tolerated

Which goal is the priority at this time?

Proper diet advancement.

If instruction was given, who did you instruct?

Patient and daughter

What instructional materials did you use? Where they effective? Why or why not?

Nutrition Care Manual – Coumadin/Vitamin K drug-nutrient interaction. The materials and explanation were effective, and copies were made for the patient and daughter.

If patient has been education, what is their motivation/compliance level at this time?

Both patient and daughter were quite motivated and entirely compliant with the all the nutritional education given. His daughter had come prepared with research regarding his surgery and the nutritional implications for post-surgery. Overall, his family (including other sons and daughters) were incredibly involved in his recovery and receptive to all education and information given.

Does the patient have any barriers to compliance to the interventions?

None – see description of involved family above.

NCP Step 4: Monitoring and EvaluationHealth Care OutcomesBased on your Nutrition Intervention indicate below what outcome measurements you will use to monitor progress and success of the interventions.Complete for all interventions listed in Part 3.Intervention

Health & Disease Outcomes

Cost Outcomes Patient Outcomes

Proper diet advancement post GI surgery

- Proper healing and bowel rest- Avoidance of surgical complications (ie. sepsis, infection, internal bleeding)- Normal WBC levels, which indicate no infection occuring

- Cost of patient stay: the quicker the patient can heal and be discharged, the less expenses that are endured on his recovery (including lab test, meals, IV fluids, nursing staff/hours, etc.)

- Toleration of diet advancement, including avoidance of nausea, vomiting, diarrhea, cramps, pain, etc.- Proper healing of bowels post surgery- Improvement in patient alertness and orientation during days following surgery

Diet and Drug/Nutrient interaction education

- Ensure proper dietary behaviors appropriate for a postgastrectomy diet to ensure avoidance of dumping syndrome and delayed gastric emptying

- Cost of meals to be delivered to patients, as well and any costs endured through complications of GI distress (dumping syndrome, DGE)

- Demonstrating an acceptable level of understanding regarding a proper post-gastrectomy diet advancement as well as the drug/nutrient interaction regarding his Coumadin medication and vitamin K foods.

Monitoring and EvaluationQuestion to Consider Answer/Reflection

What indices are you using to determine success of your intervention?

Proper healing post-surgery, toleration of diet advancement as well as understanding nutrition education

Did the intervention work? Explain Yes – the patient recovered well and showed proper understanding of nutrition education given to both patient and family.

If the intervention is not working, indicate what follow up action you took.

N/A

What are the causes of initial interventions that did not work?

All interventions worked well for patient.

How will you monitor success of your follow up interventions?

Continue to monitor diet advancement and toleration, provide addition educations as necessary, and ensure that patient was not readmitted for issues relating to GI distress.

DOCUMENTATIONAttach all initial and follow up notes for this patient/client to this report. Be sure to delete any data that may identify the patient such as name or room number.

References

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8. High Blood Pressure (Hypertension). Mayo Clinic Website. http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/symptoms/con-20019580 Accessed October 17th

9. Stomach (Gastric) Cancer. National Cancer Institute at the National Institutes of Health Website. http://www.cancer.gov/cancertopics/wyntk/stomach/WYNTK_stomach.pdf Accessed November 14.

10. Types of Arthritis. Arthritis Foundation Website http://www.arthritis.org/ Accessed November 14, 2014