Patient Presentation

By Kara LeClair

Patient Basics and Social Hx

• Age: 96

• Sex: F

• Antrhotpometrics: • Ht: 61”/155 cm Wt: 144 lbs/65kg• IBW: 105 +/-10%(115.5-94.5lbs) %IBW: 137%

UBW: current %UBW: 100% • BMI: 27.2 - overweight

• Social Hx: • Pt. lives on her own in a senior housing apartment. • Her son lives close by and her family is very involved

in her.

Medical Hx

• Diagnosis: Colon Cancer • Pt was admitted with UTI with sepsis,

led to discovery of colon obstruction and distention

• PMHx:• aortic stenosis, iron deficiency anemia,

diverticulosis, elevated cholesterol, HTN, kidney stones, CHF

Treatments • Past medical: Partial nephrectomy

• Left hemicolectomy – colon resectioning (3/31)• CT scan: mass lesion at

descending and sigmoidal colon junction

• Blood transfusion post op. (4/1)

• Nasogastric tube inserted twice post op – pulled out by pt. both times

MNT for Hemicolectomy & Colostomy

• Colon Cancer and Diverticulitis• High-fiber diet

• 25 g/day

• Adequate hydration

• Colostomy• Odorous stool formation may concerning for

patients• These foods include: legumes, onions, garlic,

cabbage, eggs and fish.

• HTN, CHF• DASH Diet – low sodium

Diet Order

• Current Diet Order: NPO

• Path of recovery: Pt. will progress to clear liquids, soft foods, low fiber diet and then gradually increase fiber intake to 25 g/day

• Before Surgery: 2 gram Na restriction

Pertinent Medications

• Current Medications: • Lasix: diuretic – post op. • Levaquin: antibiotic – UTI/sepsis

treatment• Lovenox: anticoagulant – post op. • Flagyl: antibiotic IV – UTI/sepsis

treatment

• Prior to admission pt. was taking only aspirin each day

Pertinent Labs

• Lasix use:• Serum Potassium (N) • Mg (N)

• Iron deficiency Anemia:• MCH (L)• RDW (H)• RBC (L)• HGB (L)• HCT (L)

PES

• Pt. has inadequate energy intake related to colectomy on 4/1/15 as evidenced by no bowel movement since surgery.

Nutritional Education

• Pt. is currently NPO, which requires no education.

• Upon return to normal diet, focus emphasis on:• Reduced sodium diet, such as added salts to food• Increase fiber; may use supplement such as

Metamucil• Adequate energy intake

• Supplementation with Ensure Plus – normal intake only 50-75%

• Diet order once recovered: • Increased fiber intake (at least 25 g/day), no

added salt and supplement Ensure Plus TID

Caloric and Macro Nutrient

Requirements • Total Calories:

• 25 kcal/kg for patients >65= 1,625kcal• Mifflin St. Jeor: (9.99*65)+(6.25*155)-

(4.92*96)-161= 1,929*1.2 (AF)*1.2 (IF) = 1,418kcal

• Protein Requirements: • 1.5g protein g/kg/day = 98 grams/day

• Fluid Requirements: • 30 mL x 65 kg = 1,950 mL/day (~65 oz)

Sample Menu

• Breakfast: • 1 small banana• 5.3 oz greek yogurt

• Snack:• Ensure Plus, 8 oz

• Lunch • ½ egg salad sandwhich

on WW• 1 apple, sliced • Ensure Plus, 8 oz.

• 20 oz water throughout afternoon

• Dinner:• 4 oz. grilled chicken, 1/3 cup

WW pasta with lite tomato sauce, 1 cup steamed kale

• 12 oz water w/ Metamucil

• Evening: • Ensure Plus, 8 oz.

• Total Calories: 2,140kcal

• Carbs: 1,211g Protein: 82g Fat: 44g Na: 1,000mg K: 1,560 mg Fluid: 62 oz

Intervention• Food and/or Nutrient Delivery

• Whoever prepares the meals for the pt should be educated on a no added salt and increased fiber diet

• High in potassium and magnesium (if still on Lasix)• Due to the patients past medical history of iron deficiency, blood loss

(indicated by the blood transfusion) and lab values for RDW, HCT, HGB and RBC it may be beneficial to add an iron supplement. • More blood work should be done after the blood transfusions are completed

to see if this supplementation is warranted.

•  Coordination of Nutrition Care • This decision will be based on how well the patient recovers. • Full recovery: she should be able to return to her senior housing. • Limitations in recovery, or requires a more specialized diet: (remains on

Lasix) her diet may require more attention, at which point her dietary needs must be addressed with whoever prepares her meals.

• If she is responsible for cooking for herself, there should be a plan set in place for someone to check on her regularly to make sure she is adhering to the diet and consuming enough potassium and magnesium.

Additional Treatment

• The family should seek advice from an oncologist and decide whether or not she will receive additional treatment for the colon cancer.

Monitor & Evaluate • Food/Nutrition Related Outcomes:

• Pt. will progress to a normal diet with the return of bowel sounds, and consume 75% of each meal, along with three Ensure Plus supplements and one serving Metamucil or other fiber supplement as tolerated daily.

• Biochemical Data Outcomes: • Increase MCH, RBC, HGB, HCT & decrease RDW by taking an iron

supplement as directed.• Other altered lab values are likely influenced by infection or stress

of surgery and should return to normal limits as she recovers. • Keep an eye on serum K & Mg with the use of Lasix.

• Anthropometric Outcomes: • Pt. should aim to maintain her weight.

References

• Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's Food & the Nutrition Care Process. St. Louis, MO: Elsevier/Saunders, 2012. Print. 

• http:www.myfitnesspal.com

• Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville,

Penn.: Food-Medication Interactions, 2010. Print.

• *All images obtained from Google search engine

Questions