Emily Sinn

ND 568
Marywood University
Grand View Hospital

Clinical Case Study Report

Introduction/Patient Profile:
I chose my patient during my second week of my acute care rotation at Grand
View Hospital (GVH). She is someone who was unfortunately admitted to the
hospital for more than three weeks but I felt this gave me a good opportunity to get
to know her, learn about her medical conditions and provide care both
independently and alongside a Dietitian.
My patient is a 66 year old Caucasian female who is married and of the
Mennonite religion. Currently, my patient is retired but formerly she worked at
Grand View Hospital as a Diet Technician. Upon her admission she was 5’5” (65
inches) tall and 94.5 kg (208 pounds). My patient’s appetite was variable during her
admission. Her intake was very poor initially but improved with time; the
variability occurred when she was NPO for testing or surgery. In addition, her sleep
schedule was very unpredictable; on several occasions during the day she would be
extremely lethargic or sleeping to make up for no sleep the night before. These
irregular sleep patterns also affected her food consumption. In regards to GI/dental
or swallowing issues, my patient had no issues and maintained all of her natural
teeth. My patient passed her initial dysphagia screening and there was never a need
for an additional consultation from a Speech Language Therapist or altered textured
diet. Moreover, her bowel movements remained consistent and there was no
history of substance abuse for my patient. There was also no significant past family
medical history to report on. On several accounts, emotional episodes related to
anxiety and depressions were documented however, no action was taken or psych
consultation put in place. My patient lives at home with her spouse and receives
help from her son as well; she is retired but previously met credentials set by the
Academy of Nutrition and Dietetics to become a Diet Technician.

Current Admission:
In regards to my patients most recent admission her diagnosis includes: non-
healing ulcers and cellulitis of lower extremities, asthma dependent on inhaled
steroids, obstructive sleep apnea, heart failure with reduced ejection fraction,
sepsis, a fib, C. diff colitis, hypoxia, hypotension, diet-controlled DM. Past medical
history includes: pneumonia, hypervolemia, hypertension, congestive heart failure,
type 2 diabetes, hyperlipidemia, depression, chronic obstructive pulmonary disease,
hereditary lymphedema and chronic lower extremity wounds.
My patient was sent to the ER from wound care with worsening R leg
wounds that became foul smelling and were determined as gangrene. In attempt to
avoid amputation, multiple debridements of her R calf, L calf, L thigh and L forefoot
occurred in addition to regular leg cultures to monitor the likely development of
infection. Inevitably, she developed Pseudomonas and Bacteroides, both gram-
negative strands of bacteria that were treated with antibiotics. In addition, she
developed C. diff, which was also treated with antibiotics. Lastly, Novolog Sliding
Scale Insulin was initiated along with our Female CHO Controlled Diet to manage
her diabetes. In January 2017, my patient was admitted to the hospital for a similar
amount of time and had one debridement of her right leg; during her most recent
admission January 2018 – February 2018 she underwent six additional
debridements to remove dead and infected skin tissues.
Regarding therapy, she was admitted to the Rehab unit of GVH with
anticipation of helping my patient regain strength and mobility in her lower
extremities. Home aids visit her at home three times each week for dressing
changes and to manage my patients lymphedema wraps; my patient also visits
wound care through GVH once each week to monitor and reassess her chronic non-
healing ulcers.
During the course of her most recent admission my patients was on several
notable medications. Anticoagulants (Eliquis, Heparin, Lovenox) to reduce blood
clots from forming; diuretics (Lasix and Aldactone) to eliminate more urine from
her body and manage edema and CHF; Lactated Ringer’s to replenish electrolytes
and fluid; vitamin D3 to promote bone health; antibiotics (Flagyl, Cefepime,
Levaquin) to fight infections and promote wound healing; Bronchodilator (Brovana)
to control asthma; Sedatives (Zoloft, Ativan, Diprivan) to help my patient relax and
act as a sleep aid. During my initial meeting with my patient, the Dietitian
recommended Juven nutrition supplementation to promote wound healing and
increase her protein intake (at this time her meal consumption was minimal, she
was often times refusing meals). After multiple refusals of the Juven supplements in
both flavors we carry at GVH, we tried sending her Ensure Enlive everyday with
lunch, which she was also not fond of. There were some discrepancies in her
charting as to weather it was a matter of her not accepting the supplements or if the
supplements were not delivered on her tray. Regardless, she was not complying
with our supplement recommendations.

Nutrition Care Process:

Nutrition Assessment-
Based on 25 kcal/kg x IBW kg my patients energy needs are 1,425 kcal/day;
based on 1.5 g/kg x IBW kg her protein needs are 90 grams/day (I rounded up as I
feel she could benefit from the addition protein) and her fluid needs are 1,500 mL
based on ~1 mL/kcal. My patient is 65 inches tall (5’5”), 94.5 kg (208 pounds), BMI
35.2 (Obese Class II) and her IBW is 56.8 kg (125 pounds). I was unable to obtain a
24-hour recall however, per EMR I was able to see that during the last 7-10 days at
GVH my patient was consuming 83% of her estimated energy needs. As previously
mentioned, she lives at home with her spouse and does receive help from her son;
she relies on them to do food shopping and cooking due to her immobility.
As seen by the snapshot of my patients lab values, her sodium, potassium,
BUN, blood glucose and magnesium all remained stable during her admission. Her
Creatinine improved over the course of three weeks indicating kidney function
improvement; her albumin level remained low which tells me she has low amounts
of protein in her blood; my patients BNP almost doubled indicating heart failure and
I was unable to get a third reading prior to her discharge; lastly, her calcium
remained stable but low throughout her admission that tells me she’s not producing
enough of the parathyroid hormone.

Nutrition Diagnosis-
Problem, Etiology, Signs and Symptoms statements are as follows:
1. Increased nutrient needs as related to delayed wound healing as evidenced
by pressure ulcer/wound.
2. Not ready for diet/lifestyle as related to unwillingness to learn / apply
information as evidenced by noncompliance to diet.
3. Overweight / obesity as related to excess energy intake as evidenced by high
BMI.

Nutrition Intervention-
In attempts to improve the condition of my patient several measures were
taken. First and foremost she was placed on a Female CHO Controlled Standard diet
in addition to initiating multiple nutrition supplements to help my patient achieve
additional calories and protein. In addition, I personally provided this patient with
nutrition education on several accounts regarding both a low sodium diet (related
to her CHF) and a CHO controlled diet (related to her DM). Both the Dietitian and I
followed up with her several times both together and independently during her
admission and ultimately she was uninterested in any nutrition counseling. We did
also encourage her to consider Outpatient Nutrition Counseling.
I wanted to include that from the date my patient was admitted (January 26th,
2018) to the day she was discharged (February 20th, 2018) she lost 6.9 kg, which is
considered to be a severe weight loss in 3 weeks. Such a severe weight loss in an
individual who appears to have given up and is unwilling to comply with any dietary
recommendations is concerning. Unfortunately, no psych consult was every ordered
and although mental health is a sensitive topic no measures were taken to address
this underlying issue my patient was dealing with.

Nutrition Monitoring/Follow-up-
My patient was discharged to Quakertown Center for Short Stay
Rehabilitation on February 20th, 2018. A Cardionet monitor was put in place three
times each week to monitor her a fib; IV diuretics will continue to control her edema
and CHF; wound care follow-ups with GVH weekly along with home aid visits three
times a week for continued assistance with cleaning her wounds and changing her
leg wraps; DM agents have been discontinued due to her significant weight loss and
moving forward her DM should be managed with diet alone (sliding scale insulin as
needed).

Summary/Conclusion:
In conclusion, my patient’s general disinterest and inability to comply with
wound care and diet recommendations from the nutrition department have left her
with chronic non-healing wounds that have compromised her mobility. As a former
Diet Tech she has the knowledge and skills to make diet and lifestyle changes but is
not willing to do so. Her underlying mental health issues are a concern and should
have been acknowledged during her admission; perhaps with a more stable mind
and positive outlook on her current situation and the rest of her life she may gain
the motivation she is currently lacking to make permanent changes. I am not
confident she will comply with her follow-up recommendations or reach out to our
Outpatient Nutrition services but I hope she is able to make some changes at her
own pace to improve her situation.