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Case Study 1:

Encephalopathy/
Oncology
Karina Almanza, CSUN Dietetic Intern 2017-2018
Cedars-Sinai Medical Center
Alyssa Gong, Robyn Curran, Debrin Cohen, Stephanie Garcia
Dr. Annette Besnilian

Thursday, April 12, 2018


Dementia
Diet Implications of Dementia
Diet Implications of Encephalopathy
Dehydration
Diet Implications of Dehydration
Labs
Laboratory Value Response to Reference Range Patient’s Values (4/4)
Dehydration
Albumin ↑ 3.5-5.0 g/dL 2.9

Sodium ↑ 136-145 mEq/L 148


Blood Urea Nitrogen ↑ 10-20 mg/dL 15
(BUN)
Hemoglobin ↑ 14-18 g/dL 12.5
Hematocrit ↑ 42-52% NA
Chloride ↑ 98-106 mEq/L 108
About the Patient

Age: 77 yo

Gender: Male

Weight: 148# (67.1 kg)

BMI: 20.07 kg/m2


Initial Assessment
Initial Assessment: 4/4
Assessment:
Clinical nutrition screen for pressure ulcer on sacrum, pending WOCN consult
for staging. Attempted to meet with pt at bedside, no family/ CG present. Per
MD, pt has not eaten since 3/30, has been pocketing food in mouth and not
swallowing. Pt has been NPO since admission (4/2). Pt meets criteria for severe
malnutrition and wt loss.
Dx
Acute toxic/ Metabolic Encephalopathy (improving), Alzheimer’s Dementia
PMHx
Stage 3 Lymphoma s/p chemo 2015, Coronary Artery disease, Hyperlipidemia,
Hypertension, Coronary artery stent placement
Initial Assessment 4/4

Diet hx: Per MD note, pt has not


been eating since 3/30, has been
pocketing food in mouth and not
swallowing.
Physical Appearance: Mild fat loss
around orbital region with slightly
dark circles and hollow look. Mild
muscle loss in temporal region
with hollowing temporal bone.
Initial Assessment 4/4
Anthropometrics: I/O: +1051.8 for the last 24 hours
Height: 182.9 cm (6’0.01”) Skin: Pressure ulcer on medial sacrum
Weight: 67.1 kg (148#)- bed scale on (possible stage 3, 4 SDTI, Unstageable
4/2
(WOCN to Stage)); impaired skin
BMI: 20.07
Usual Weight: 171 to 182# (per wt hx) integrity on right elbow/ arm (intact)
% Usual Weight: 81-87% Edema: none documented
Labs: Glucose 149; K+ 3.2; Cl- 108; Cr
%Weight change: 14% loss in 5 0.7
months. Unknown Meds: IV Dextrose Saline, Continuous;
KCl 10 mEq/100 mL (completed 4/4)
GI: No BM during admission
Initial Assessment 4/4
Criteria Moderate Protein Energy Malnutrition Unspecified Severe Protein-Calorie
Malnutrition

Etiology/ Context Chronic Illness Chronic Illness

Weight loss that appears to be Defer due to other criteria met >10% in 6 months or less
associated with nutrition inadequate for
need; excluded weight loss due to fluid
status change (diuresis, HD, resolving
edema), amputation, or removal of body
equipment.

Energy Intake as percent of needs Insufficient information to assess 50% or less for 5 days or more

Body Fat Mild subcutaneous fat loss Defer due to other criteria met

Muscle Mass Mild loss Defer due to other criteria met

Fluid Accumulation Does not meet criteria Does not meet criteria

Reduced Grip Strength Does not apply Defer due to 2 other criteria identified
Initial Assessment: 4/4

Criteria
Underweight: BMI <19 and no
adult> 20 yrs
Morbid Obesity: BMI >40.0 not no
due to abnormal fluid collection

Loss of Weight: Refer to criteria Met for severe


in Table 1
Initial Assessment: 4/4
Interventions:
1. Coordination of Care: Nutrition care plan communicated with
team; discussed with RN, Loida. See recommendations box at
top of note.
2. Nutrition Education: Pt not appropriate for nutrition education
at this time d/t AMS. RD to continue to follow for discharge
planning needs as needed.
Nutrition discharge planning needs: to be determined.
Initial Assessment 4/4
Nutrition Diagnosis/ Problem:
Increased nutrient (Energy, Protein, Vit/Min) needs related to increased
physiological demands as evidence by Possible Stage III, Stage IV, SDTI,
Unstageable pressure ulcer and severe malnutrition.

Monitor/ Evaluate:
1. NPO diet <2 days. New goal.
2. Weight maintenance/ gain towards IBW. New goal.
3. No further skin breakdown. New goal.
4. BM 1-3 every 1-3 days. New goal.

Nutrition priority level is 3; RD to follow up within 5 days.


Reviewing Recommendations: 4/4

Recommendations
1. Suggest SLP for valuation of PO candidate
2. WOCN to evaluate stage of pressure ulcer
3. If safe for PO, consider the following supplementations for wound healing:
a. Multivitamin with minerals daily
b. Vitamin C 500 mg 2x daily for 10 days
c. Zinc Sulfate 220 mg daily for 10 days
d. Arginine 4.5 (1 pkt) 4x daily (total of 18 g arginine)
4. Monitor calibrated bed scale wt as able
5. Consider bowel regimen
Recommendations:4/4

Recommendations
1. Suggest SLP for valuation of PO candidate
2. WOCN to evaluate stage of pressure ulcer
3. If safe for PO, consider the following supplementations for wound healing:
a. Multivitamin with minerals daily
b. Vitamin C 500 mg 2x daily for 10 days
c. Zinc Sulfate 220 mg daily for 10 days
d. Arginine 4.5 (1 pkt) 4x daily (total of 18 g arginine)
4. Monitor calibrated bed scale wt as able
5. Consider bowel regimen
Pressure Ulcer
Initial Assessment → WOCN to assess

Stage III, Stage IV or STDI

Response to Consult → Per RD request, WOCN assessed

STDI

According to “SMC Nutrition Advisory and Support Committee 8/18/2014,”


recommendations for MVN, Vitamin C, Zinc, Arginine, Vitamin A
Why not Vitamin A?
Recommendations

Recommendations
1. Suggest SLP for valuation of PO candidate
2. WOCN to evaluate stage of pressure ulcer
3. If safe for PO, consider the following supplementations for wound healing:
a. Multivitamin with minerals daily
b. Vitamin C 500 mg 2x daily for 10 days
c. Zinc Sulfate 220 mg daily for 10 days
d. Arginine 4.5 (1 pkt) 4x daily (total of 18 g arginine)
4. Monitor calibrated bed scale wt as able
5. Consider bowel regimen
Response to Consult
Response to Consult: 4/6
Response to: Consult for pressure ulcer protocol

Comment: Per WOCN nurse assessment (4/5), pt has CAPU evolving SDTI with partial
thickness skin breakdown on medial sacrum/coccyn. Recommendations provided
above for wound healing. SLP categorized pt as Mild Oropharyngeal suggesting a
puree, nectar thick liquid diet; crushing medications into puree. Pt was started on
puree, nectar thick diet 4/5 PM. PO intake averages 83% per last 2 meals. Since RD
visit (4/4), no updated bed scale weight or BM documented. Will arrange for Nectar
Thick HCHP shake x1 daily to help meet nutrient needs.
Response to Consult: 4/6
Recommendations for Physicians:
1. Consider the following supplementations for wound
healing:
a. Multivitamin with minerals daily
b. Vitamin C 500 mg 2x daily for 10 days
c. Zinc Sulfate 220 mg daily for 10 days
d. Arginine 4.5 (1 pkt) 4x daily (total of 18 g arginine)
2. Monitor calibrated bed scale wt as able
3. Consider bowel regimen
Follow-Up
Follow-up: 4/10

Assessment:
Met pt and wife at bedside, requesting nutrition education regarding diet
for discharge. Discussed Nectar Thick Liquids and puree diet, handout
provided. Wife reports is responding well to nectar thick diet, increase in
appetite. PO intake averaging 92% for last 3 meals.
Per MD, pt has shown improvement; has increased food intake being
spoon fed by RN.
Per RN, pt is a good candidate for Mealtime Mates; referral made by
Dietetic Student to Alicia DTR.
Follow-up: 4/10
Diet history: Per wife, pt was on
Wt Readings from Last 15 Encounters: mechanical diet prior to admission in
04/02/18 67.1 kg (148 lb) assisted living facility (Silverado);
consuming partial or complete 3 meals
BMI (Calculated): 20.07 daily with 1 cookie in between meals.
IBW: 76.94 kg (170# at BMI of 23) During admission, pt drinks more
%IBW: 87% juices than water (apple and guava)
Usual weight: 165# (per wife 3/15) and has had an increased appetite,
%UBW: 90% consuming majority of meals provided
since on puree diet.
% Weight Change: 10% loss in 6 weeks.
Unknown
Follow-up: 4/10
Skin: Pressure Ulcer Sacrum Medial
(SDTI); Impaired skin integrity/ wound
GI: No BM noted since admission 4/2 arm. Pr RN, no further skin breakdown
since admission, using medihoney
Current diet Rx: Diet Modular dressing on PU (4/9)
Products Resource Arginaide, 1 Edema: none documented
packet 4x daily (provided with
Labs include: (4/10) Glucose 133; Na+
thickened water using "Thick It");
141; Cl- 105; Cr 0.7; Lymphocytes 0.7
Diet Nutritional Supplements HCHP
Milkshake (Nectar Thick); Diet Puree Meds include: Vitamin C tablet 500 mg;
Nectar Thick liquids 0.45% NaCl continuous IV infusion 75
ml/hr, continuous; rivastigmine 13.3 mg/
24 hr patch 13.3 mg; Zinc Sulfate capsule
220 mg
Follow-up: 4/10 Patient met criteria for unspecified
severe protein-calorie malnutrition
on 4/4.
Estimated Needs based on 148 lb (67.1
kg) bed scale (as of 4/2): Nutrition Diagnosis/Problem:
1873 to 2123 kcals 1. Increased nutrient (Energy,
(Mifflin RMR 1441 x 1.3 + 250 kcal for Protein, Vit/Min) needs related to
wt gain) increased physiological demands
101 to 134 g protein (1.5 to 2 g/kg per of wound healing and nutrition
SDTI PU and cancer hx) status as evidenced by SDTI pressure
~2000 ml fluids (~1 ml/kcal) ulcer and severe malnutrition.
Follow-up: 4/10
Interventions:
1. Coordination of Care: Nutrition care plan communicated with team. See
recommendations box at top of note.
2. Nutrition Education: With wife, provided nutrition education on Thickened
Liquid Nutrition Therapy; HO provided. Wife was responsive and engaged,
asking questions. Specific questions were referred to SLP for further
diagnosis.
3. RD to continue to follow for discharge planning needs as needed.
Nutrition discharge planning needs: continue on nectar thick diet.
Follow-up: 4/10
Monitor/Evaluate:
Recommendations for Physicians: 1. NPO diet < 2 days. Goal met, completed.
1. Monitor calibrated bed scale wt as able 2. No further skin breakdown. Ongoing.
2. Consider BM regimen (per RN, MD put in an 3.Weight maintenance/ gain towards IBW.
order for laxative) Ongoing.
3. Multivitamin with minerals daily for wound 4. BM 1-3 every 1-3 days. Ongoing.
healing
Nutrition priority level is 3; RD to follow up
within 5 days.
If I could go back in time...
1. Recommend MTM earlier (Response to Consult)
2. Contacted patient’s wife earlier (Initial Assessment)
3. Discussed with patient’s RNs about BM earlier (Initial Assessment)
4. Abbreviated words such as Meal Time Mates (MTM)
5. Would have recommended a range for 250 to 500 additional kcal intake for
wt gain (Initial Assessment)
6. Contacted RN personally to ask for updated calibrated bed scale weight
Questions?
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