CLINICAL

CASE STUDY
Emily Sinn
ND 568
Marywood University Dietetic Intern
Grand View Hospital
PATIENT PROFILE
 Gender: Female
 Age: 66 years old
 Marital status: Married
 Ethnic/Religious considerations: Caucasian, Mennonite
 Occupation: Retired; formerly a Diet Technician
 Height/ Weight: 65 in at 94.5 kg or 208 lbs.
 Appetite: Variable during admission
 GI/ dental or swallowing issues: No issues
 Passed her Dysphagia screening and no need for additional consultation from SLP
during admission
 No need for altered texture diet
 Elimination: Consistent 1-2 each day
 No history of substance abuse
CURRENT ADMISSION
 Diagnosis
 Non-healing ulcers and cellulitis of lower extremities, asthma dependent on
inhaled steroids, OSA, heart failure with reduced ejection fraction, sepsis, a
fib, C. diff colitis, hypoxia, hypotension, diet-controlled DM
 Circumstances/medical history
 PNA, hypervolemia, HTN, CHF, T2DM, hyperlipidemia, depression,
COPD, hereditary lymphedema, chronic lower extremity wounds
 Family history
 No significant past family medical history
CURRENT ADMISSION CONTINUED
 Diagnostic Procedures & Interpretation
 Pt sent to the ER from Wound Care with worsening R leg wound that became
foul-smelling; determined as gangrene
 In attempt to avoid amputation, multiple debridement's occurred
 R calf, L lower calf, L thigh, L forefoot
 Regular leg cultures ordered to monitor development of infection

 Development of C. diff; treated with ABX

 ABX therapy initiated upon admission to fight infections and continue to aid
in wound healing
 Several emotional episodes noted throughout Pt’s stay related to anxiety and
depression
 Sliding Scale Insulin and Female CHO Controlled Diet in place for DM
management
CURRENT ADMISSION CONTINUED
 Treatment
 Surgical
 January 2017- Sharp excisional debridement to right lower extremity

 January 2018- R calf debridement, L thigh wound; Bilateral debridement

 January 2018- L thigh sharp scalpel debridement
 February 2018- Necrotic ulcer on L forefoot; sharp excisional debridement

 February 2018- Excision of dead skin and subcutaneous tissue on L foot

 February 2018- Complicated open wound on R lower leg
 February 2018- Additional debridement on L forefoot prior to d/c

 Therapy
 Admitted to Rehab at GVH
 Home aids visit Pt 3 times/week for dressing changes and to manage lymphedema wraps

 Pt visits wound care 1 time/week

CURRENT ADMISSION CONTINUED
 Lactated Ringer’s (Fluid and
 Treatment
electrolyte replenishment)
 Medications  Lisinopril (ACE inhibitor,
 Eliquis, Heparin, Lovenox (Anticoagulant) treats high blood pressure and
heart failure)
 Lasix, Aldactone (Diuretics)
 Ativan (Sedative)
 Vitamin D3 (Bone health, DM management, Kidney function)
 Mag-Ox (Treats low Mg in the
 Metoprolol (Beta-blocker, treats high BP) blood, important for cells,
 Zoloft (Selective Serotonin Reuptake Inhibitor, treats nerves, muscles, bone and
depression) heart function)
 Zocor (Statin, treats high cholesterol and triglyceride levels)  Solu-Medrol (Steroid, treats
inflammation, chronic
 Dilaudad (Narcotic, pain medication) illnesses)
 Cefeprime, Flagyl, Levaquin (Antibiotics)  Diprivan (Anesthetic, causes
 Brovana (Bronchodilator) relaxation and sleepiness)
 Pulmicort (Steroid, treats ulcerative colitis and when inhaled  Supplements
treats asthma)  1/30- 1 pack Juven with 8 oz.
 Cardizem (Calcium channel blocker and antihypertensive Diet Ginger Ale BID (lunch
drug, treats high BP and chest pain) and dinner) fruit punch flavor
preferred
 Tikosyn (Antiarrhythmic agent, treats irregular heartbeat)
 2/7- Ensure Enlive QD (lunch)
 Novolog Sliding Scale Insulin
CURRENT ADMISSION CONTINUED
 Weight History:  Weight History prior to most
 2/20 (d/c date): 86.8 kg recent admission:
 2/18: 94.2 kg  2/14/17 (d/c date): 100.2 kg

 2/16: 99.8 kg  2/13/17: 100.2 kg

 2/14: 104.2 kg  2/11/17: 112 kg

 2/11: 102.6 kg  2/9/17: 117.2 kg

 2/10: 94.7 kg  2/8/17: 111 kg

 1/26 (admit date): 93.7  1/24/17: 111 kg

 Weight loss of 6.9 kg during most  Weight loss of 10.8 kg during previous
recent admission admission
 7.4% weight loss in 3 weeks is  9.7% weight loss in 3 weeks
considered to be a severe weight loss
NUTRITION CARE PROCESS
NUTRITION ASSESSMENT
 Diet Order: Female CHO Standard Diet
 Macronutrient Needs:
 Energy needs: 1425 kcal/day; based on 25 kcal/kg x IBW kg
 Protein needs: 90 grams/day; based on 1.5 g/kg x IBW kg
 Fluid needs: 1500 mL/day; based on ~1mL/kcal
 Anthropometric Measurements:
 Ht.: 65 in. BMI: 35.2 (Obese Class II)
 Wt.: 94.5 kg IBW: 56.8 kg
 24 hour Recall/Food Frequency
 From February 12th – February 20th per Patient Care, Pt’s average intake was 83%
 Shopping/Cooking Habits
 Pt resides at home with spouse; more recently she has relied on him to do the food shopping
and cooking due to her immobility
 Past MNT and Outcome
 Noncompliant with diet recommendations, energy and protein needs or supplement
suggestions
 NUTRITION ASSESSMENT CONTINUED
Date Na K BUN Creat Glu Alb Mg BNP Calcium
1/25/18 139 4.2 22 0.98  70 2.9 8.4

2/9/18 140 3.8 12 1.03 79 2.4 1.6 984 8.5

2/13/18 142 4.4 16 1.06 91 1.7 8.7
2/14/18 143 4.4 16 0.95 86 2.6 1.6 1430 8.5
2/15/18 142 4.4 16 0.95 86 1.6 8.6
2/16/18 139 4.2 15 0.89 78 1.6 8.6
2/18/18 142 4.0 15 0.82 82 1.7 8.7

Table 1: Patient’s lab values during admission.

NUTRITION DIAGNOSIS
 PES statements
 Increased nutrient needs as related to delayed wound
healing as evidenced by pressure ulcer/wound.

 Not ready diet/lifestyle as related to unwilling to

learn/apply information as evidenced by noncompliance
to diet.

 Overweight/obesity as related to excess energy intake as

evidenced by high BMI.
NUTRITION INTERVENTION
 Monitoring tools
 Food and/or Nutrient Delivery
 Ordered a Female CHO Controlled Standard Diet
 Initiated multiple nutrition supplements for patient
 Namely Juven and Ensure Enlive to promote would healing
and increase protein intake
 Nutrition Education
 Provided Pt with nutrition education regarding a Low Sodium and CHO Controlled Diet
 Nutrition Counseling
 Followed-up with patient several times during her admission; Pt was uninterested in
additional nutrition counseling and did not desire nutrition supplementation
 Coordination of Nutrition Care
 Encouraged patient to consider Outpatient Nutrition Counseling
NUTRITION INTERVENTION
CONTINUED
 Plans for f/u
 Pt was discharged to Quakertown Center for Short Stay
Rehabilitation on 2/20/18
 Cardionet monitor in place 3 times/week due to a fib
 IV diuretics to control edema and CHF
 Continue wound care follow-ups weekly along with home aid visits
3 times/week for assistance with cleaning
 DM agents discontinued due to significant weight loss since
admission; moving forward will be managed with diet alone (Sliding
Scale Insulin PRN)
SUMMARY & CONCLUSION
 Pt’s disinterest and inability to comply with wound care and
diet left her in a position with chronic wounds on her lower
extremities
 Anxiety and depression not acknowledged during her stay
 Spouse should be involved
 Limited mobility due to leg wounds and chronic pain,
minimal energy expenditure, diet of upmost importance
 From the beginning, Pt was resistant to try dietary
supplements, poor intake and noncompliance with diet order