Clinical Case Report: Nutrition Management for Left Aspect ......8. Mahan L, Escott-Stump S, Raymond...
Transcript of Clinical Case Report: Nutrition Management for Left Aspect ......8. Mahan L, Escott-Stump S, Raymond...
Clinical Case Report:Nutrition Management for
Left Aspect Medulla Oblongata Infarction
Alisha MukadamARAMARK Dietetic Internship
Lafayette General Medical Center December 19, 2016
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Disease Description
❏ Also known as Wallenberg Syndrome❏ A rare condition in which an infarction (stroke) occurs in
the lateral medulla. ❏ The lateral medulla is a part of the brain stem. ❏ Oxygenated blood does not reach to the medulla when
the arteries that lead to it are blocked. ❏ A stroke can occur due to this blockage. This condition is
also sometimes called lateral medullary infarction.
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Disease Description: Etiology
❏ It's not known what initially causes Wallenberg's syndrome.
❏ However, some researchers have found a connection between people who have the syndrome and who have peripheral artery disease, heart disease, blood clots, or minor neck trauma.
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Disease Description: Epidemiology
❏ Rare Disease❏ Affects less than 200,000 people in the US❏ Overall occurrence of Wallenberg’s Syndrome is not very
well documented.
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Disease Description: Pathology
Since there is no cure for Wallenberg's syndrome, treatment usually involves relieving the symptoms a person is experiencing, which may include the following:
❏ A feeding tube to help with swallowing complications❏ Speech therapy to help with talking and swallowing❏ Medication to help alleviate pain, such as the anti-epileptic
drug gabapentin (Neurontin)❏ Blood thinner medication, such as heparin or warfarin, to
help reduce or dissolve the blockage in the artery
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Disease Description:Clinical Signs and Symptoms
❏ Difficulty swallowing (dysphagia)
❏ Hoarseness❏ Nausea❏ Vomiting❏ Hiccups❏ Difficulty Walking &
Maintaining Balance (ataxia)
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Case Presentation64 year old African American male was admitted to the hospital from the Emergency Room for shortness of breath, respiratory failure with an O2 saturation of 84%, and dizziness.
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Diagnoses: 1. Left aspect medulla
oblongata infraction2. Thyroid Mass3. GI Bleed4. Severe Dysphagia with
tracheal aspiration5. Sepsis 2/2 Pneumonia6. Ataxia
Client History
Medical History: ❏ Pt has not seen a PCP
in over 30 years❏ HTN
Social History:❏ Drinks alcohol socially
once in a month ❏ Smokes 1 ½ - 2 packs
of cigarettes a day 10
Food and Nutrition Related History: ❏ N/A
Anthropometric Physical Findings
❏ Height: 167 cm, 5 ft 6 in
❏ Weight: 94.04 kg, 207 lbs
❏ Body Mass Index: 33.72 kg/m2
Obese Class 1- BMI: 30.0 - 34.9
❏ Usual Body Weight: 95.45 kg, 210 lbs11
Biochemical Data
Abnormal Laboratory Values Upon Admission
Patients Value Normal Value
BUN 22.0 mg/dL 7-18 mg/dL
Creatinine 1.38 mg/dL 0.6-1.3 mg/dL
Calcium 8.0 mg/dL 8.5-10.2 mg/dL
RBC 4.60 x10/mcL 4.7-6.1 x10/ mcL
Hgb 11.8 gm/dL 13.5-17.5 gm/dL
Hct 35.0% 38.8-50%
Chloride 110 mmol/L 96-106 mmol/L
Sodium 146 mmol/L 136-145 mmol/L
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Medical Tests and Procedures
❏ PICC Line ❏ PEG Tube Placement❏ Urine analysis❏ Upper GI Endoscopy❏ Esophagram❏ Barium Swallow Study❏ MRI of the Brain❏ CAT scan of the thorax❏ CT of the soft tissue neck❏ MRA of the head and neck❏ 2-D Echo ❏ MRA of the head and neck
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Nutrient Needs
Nutrient Estimated Needs
Formula Used
Calories 2181 kcal/day Mifflin St Jeor 1677 x (stress factor 1.3)
Protein 109 grams/day 20% of total calorie requirement
Fluid 2363 mL/day 25 mL/kg
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Initial Assessment
❖ Continuous nausea and vomiting❖ Spots of blood in vomit❖ Hoarse from vomiting and has a burning throat❖ Labs, BUN (45 mg/dl) and Creatinine (3.37 mg/dL) were
elevated.
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Initial Assessment
Test Results:
❖ CT of the Thorax showed moderate wall thickening of the entire esophagus
❖ Electrocardiogram identified severe inflammation of the esophagus.
❖ MRI confirmed nonhemorrhagic medulla oblongata infraction.
❖ Per Speech Therapy, patient continues to present with dysphagia and remains unsafe for PO intake.
❖ Esophagram supported tracheal aspiration per SLP.
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Aramark Nutrition Care LevelInitial Assessment (11/3/16)
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Nutrition Care Indicator Category Priority Points
Nutrition/Diet Order or anticipated NPO > 4 days (4 points)
Weight Status BMI. 33.72 (0 points)
Primary Diagnosis/Contributing Condition
Sepsis (4 points)
Energy Intake <=50% of estimated energy requirements for >/ 5 days (points 4)
Interpretation of weight loss 1-2% in 1 week (3 points)
Total points: 15 points High Risk
Follow up #1
❖ Patient unable to swallow 2/2 to stroke. ❖ Modified Barium Swallow: Result: NPO, severe dysphagia
with tracheal aspiration. PEG recommended.❖ Patient refusing PEG
➢ Personally witnessed living life with a PEG tube.➢ Father-in-law did not enjoy his life because of the
adversities he faced ■ Pain and daily flushing and cleaning of tube.
Patient did not want PEG tube to hinder his ability to take part in everyday life.
❖ Clinimix Started
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Aramark Nutrition Care LevelFollow up # 1 (11/7/16)
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Nutrition Care Indicator Category Priority Points
Nutrition/Diet Order or anticipated New Parenteral Nutrition (Clinimix 4.25%/10% + IV IntraLipids) (4 points)
Weight Status BMI. 33.72 (0 points)
Primary Diagnosis/Contributing Condition
Sepsis (4 points)
Energy Intake <=50% of estimated energy requirements for >/ 5 days (points 4)
Interpretation of weight loss 1-2% in 1 week (3 points)
Total points: 14 points High Risk
Follow up #2
❖ Hiccups for 2 days❖ Agreed to PEG- Big thank you to his wife!
❖ TPN Consult Received❖ PICC Line inserted
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Aramark Nutrition Care LevelFollow up # 2 (11/10/16)
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Nutrition Care Indicator Category Priority Points
Nutrition/Diet Order or anticipated New Parenteral Nutrition (TPN) (4 points)
Weight Status BMI. 33.72 (0 points)
Primary Diagnosis/Contributing Condition
Sepsis (4 points)
Energy Intake (0 points )
Interpretation of weight loss 1-2% in 1 week (3 points)
Total points: 11 points High Risk
Follow up #3
❖ PEG tube endoscopically: unsuccessful
➢ thick endometrial lining
❖ TPN was started
❖ 2nd Attempt: PEG placement surgically placed:
Successful.
❖ Enteral Feeding Started; TPN Discontinued
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Aramark Nutrition Care LevelFollow up # 3 (11/14/16)
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Nutrition Care Indicator Category Priority Points
Nutrition/Diet Order or anticipated New Enteral Nutrition (Jevity 1.2 cal @ 75 mL/hr.) (4 points)
Weight Status BMI. 33.72 (0 points)
Primary Diagnosis/Contributing Condition
Sepsis (4 points)
Energy Intake Meeting greater than 75% of needs (0 points )
Interpretation of weight loss 1-2% in 1 week (3 points)
Total points: 11 points High Risk
Malnutrition IdentificationDegree of Malnutrition:
Non-Severe (moderate) Malnutrition
1. Pt has been NPO for 5 days
2. 1-2% weight loss in 5 days
3. Fat wasting in tricep region and orbital region
4. Muscle wasting in temporal region
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1) Acute disease or injury related malnutrition related to stroke resulting in dysphagia as evidence by mild muscle and fat wasting, 1% weight loss in the past 5 days, and meeting </=50% of estimated energy for >/= 5 days.
2) Altered nutrition-related laboratory values related to GI bleed as evidence by medical dx and decreased hgb/hct.
Initial Nutrition Diagnoses:PES Statements
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1. Advance to GI Soft- low residue diet when medically appropriate per MD and SLP rec’s
2. Recommend Clinimix 4.25%/10% + IV IntraLipids 20% @ 83 mL/hr. This will provide the pt with 1515 calories (69% of needs), 85 grams of protein (78% of needs), and 1992 mL of fluids (84% of needs).
3. If patient agrees to NG/PEG tube feeding use the following recommendations:
Osmolite 1.2 cal @ 20 mL/hr increasing slowly to goal rate of 75 mL/hr. This will provide the patient with 2160 calories (99% of needs), 99 grams of protein (90% of needs), and 1476 mL of fluid (62% of needs). 28
Medical Intervention
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❏ Consultations:❏ GI ❏ Neurology ❏ Speech Therapy❏ Physical Therapy❏ Surgery
❏ Rehydration
Goals
Short Term Goals:
❏ Meet at least 75% of nutritional needs through Parenteral Nutrition (Clinimix)
❏ Maintain Weight throughout Hospitalization❏ If patient continues to refuse Enteral Nutrition, advance to
TPN and meet a 100% of nutritional needs.
Long Term Goals:
❏ Meeting a 100% of needs through PEG placement and Enteral Nutrition
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❏ Tolerance and rate of PPN/EN support were monitored during every follow up.
❏ Laboratory values and electrolyte were closely monitored and addressed if abnormal.
Monitoring & Evaluation
Conclusion
Pt was discharged to home health with a PEG tube on enteral nutrition of Osmolite @ 75 mL/hr. This provided the patient with 2160 calories (99% of needs), 99 grams of protein (90% of needs), and 1476 mL of fluid (62% of needs).
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Question 2
Wallenberg affects ….
a. more than 200,000 people in the worldb. less than 200,00 people in the worldc. None of the above
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Question 3
___________ and ________ needs to be monitored to check TPN tolerance
a. Triglyceridesb. Sodiumc. Phosphorus d. Glucose
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2005;65(5):714–718. doi:10.1212/01.wnl.0000174441.39903.d8.
3. Cassata C. Cathy Cassata. http://www.everydayhealth.com/wallenbergs-syndrome/guide. Accessed January 19,
2017.
4. Kinman Medically T. Wallenberg syndrome. http://www.healthline.com/health/wallenberg-syndrome. Accessed January 19, 2017.
5. Wallenberg syndrome . National Institutes of Health. https://rarediseases.info.nih.gov/diseases/9263/wallenberg-syndrome. Published March 12, 2012. Accessed January 14, 2017.
6. PEARCE J. Wallenberg’s syndrome. Journal of Neurology, Neurosurgery, and Psychiatry. 2000;68(5):570. doi:10.1136/jnnp.68.5.570.
7. http://www.csun.edu/~lisagor/Fall%202012/NutritionCareProcess.pdf8. Mahan L, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition Care Process. St. Louis, MO: Elsevier
Saunders; 2012.9. Madsen H, Frankel EH. The hitchhiker’s guide to parenteral nutrition management for adult patients. Practical
Gastroenterology. 2006;30(7): 46-68.10. Definition of Terms List. Academy of Nutrition and Dietetics’ Web site.
http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/definitionoftermsashx. Updated August 2012. Accessed January 13, 2016.
11. Hui K, McCauley S. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. Journal of the Academy of Nutrition and Dietetics. 2013;11 3(6):S17-S28.
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