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Holy Family Hospital

Clinical Case Study


Lauren Nickerson; KSC Dietetic Intern
About Holy Family Hospital – Methuen
• 385 bed acute full service hospital
• Two campuses – Methuen and
Haverhill
• Steward Family hospital
organization
• Collaborations with large
Massachusetts hospitals
• Units
Holy Family Hospital Awards and Recognitions:

• Gold Seal of Approval

• “A” in Hospital safety grade for Spring 2018

• Leapfrog Group Top General Hospital Award 2017

• Advanced Certification in Hip and Knee Replacement Surgery


The Role of the Dietitian at Holy Family Hospital:

• Dietitians are employed through Sodexo

• Dietitians receive consults for full assessments, malnutrition screening, wound


healing, diet education, TF or PPN/TPN recommendations, etc.

• Dietitians attend rounds in the ICU/ CCU with the interdisciplinary team

• Dietitians interact with different disciplinary teams on a daily basis

• Dietitians play an important part in the diagnosis of malnutrition through ASPEN


credentials providing further reimbursement to the hospital
Self – Disclosure:
Why I chose this case study to present:

• I was able to watch this patients out-patient modified barium swallow


while shadowing the Speech Language Pathologist.
• This patient was re-admitted to the medical floor during my rotation
with failure to thrive directly related to her nutritional status.
• This patient is who I gave my first TF recommendations to while in my
clinical rotation.

Lets get started:


Please feel free to ask questions throughout the remainder of this case study presentation!
About Polymyositis (PM)
• Uncommon inflammatory disease that
causes inflammation of the healthy
muscle causing muscle weakness

• Affects both sides of your body

• Muscles impacted can include the


high, thighs, upper arms, shoulders,
and neck

• Commonly affects people aged 30-50,


black, women

• There is no cure
Causes and Symptoms of PM
• Unknown cause, more research needs to be done
• Shares similar characteristics to an autoimmune disease

Symptoms include: Complications may include:


• Muscle weakness • Falls
• Arthritis • Failure to thrive
• Dysphagia • Aspiration pneumonia
• Fatigue • Irregular heartbeat
• Fever • Increased risk for cancers
• Changes in voice (hoarse)
• Shortness of breath
Medical Diagnosis:
• Rheumatologist or neurologist most commonly diagnosis. May still see PT/ OT or
SLP therapists for diagnosis.

• Clinical and physical exams are important for diagnosis


• Blood testing to measure for autoimmune and other inflammatory markers
• Creatinine kinase
• Aldolase
• ALT and AST
• LD (Lactate dehydrogenase)
• ANA (Antinuclear Antibodies panel)
• Imaging and tests
• MRI
• EMG (Electromyography)
• Muscle Biopsy
• Modified Barium Swallow
Courses of Treatment:
There is no cure for this disease. The goal of treatment is to manage the
inflammation by reducing it or eliminating it, and restore muscle performance.

• Corticosteroids
• Immunosuppressive drugs

• Nutrition support
About this patient:

Age: 74
Gender: Female
Admit weight: 187# (84.822kg)
Height: 5’3” (1.6m)
BMI: 33.1

Reason for admission: Lower extremity weakness, unable to


ambulate, poor PO intake, failure to thrive
Patient History

Medical history: Afib, hypothyroidism, HTN, chronic pedal edema, fatty liver, G-tube placed
6/2018, uterine CA

Social history: Lives alone, has 2 children

Family history: Mother with MS, breast CA and multitude of heart diseases. Father with
enlarged heart and rheumatoid arthritis. Brother with prostate CA. Sister with Parkinson’s
disease.

Weight history: Patient previously weighed 210# ~2 months ago, now she has a stated weight
of 187# upon admission. This indicates a 23# (11%) wt loss in 2 months.
5/25/18 Admission to Holy Family Hospital

• Transferred from Merrimack Valley Hospital for upper and lower extremity pain
and weakness as well as some difficulty swallowing ongoing for about 3 weeks.
• Describes her pain as going across her upper back and her shoulders, down her
elbows.
• Difficulty getting up and moving around.
• Limited range of motion in lifting her arms that is progressively getting worse.
• Inability to lift her legs to climb stairs, or get out of bed.
• Inability to flex at the elbow and feed herself.
• Weight loss of 14 pounds in 9 days per patient report, loss of appetite.
• Trouble swallowing, choking and gagging on foods. Has to drink water and
swallow 2-3 times for food to go down.
MD note: 5/29 tube feeds through NG tube. She will be
discharged to rehab and reevaluate with outpatient through
neurology and rheumatology. If patient continues to have trouble
with swallowing then she may require a PEG tube. I explained this
to the patient and she indicated understanding.
Diet history:
-This patient had always eaten a regular diet before her diagnosis, avoiding salt for heart health

-In June, upon a previous admission, SLP did not clear this patient for PO intake. During that admission she had a
PEG to placed and was to start continuous nutrition support via the PEG tube. Patient was discharged on Jevity 1.2
to rehab facility.

-On 7/6, I was able to watch her outpatient MBS where SLP recommended a dysphagia advanced diet with honey
thick liquids.

-Patients diet was advanced at rehab facility to soft foods, thin liquids without a follow up MBS, still using the PEG
tube with Jevity 1.2 for some feeding per patient report.

-Patient was discharged from rehab facility without nutrition support and now arrives to the ER via ambulance
with failure to thrive/ unable to ambulate directly related to nutritional status.

Modified Barium Swallow: https://www.youtube.com/watch?v=AOlOGW4svEE


Admission on 7/30; H&P

• Leg and arm weakness, elevated CPK labs


• Notes she was discharged from Wingate Haverhill 7/13 on soft foods, thin liquids
to home, swallowing ok. Was able to ambulate without her assistive device.
• Difficulty with appetite since 7/13, was supposed to be using the G-tube for
supplemental feeds but she was discharged home without any services. She
thought nutrition was going to come see her.
• She had been doing Equate x3 per day, but not eating by mouth because her
swallow diminished again.
• Has not had a bowel movement in a week, feels very constipated, home regimen
of milk of mag has not been helping.
• MD states that during this admission she does not need any imaging, this bout of
weakness is directly related to poor nutrition.
Plan of Care per MD admission note:

“The patient will be admitted to the Medical Floor. She will get a PT evaluation as she is
still unable to ambulate. We will consul neurology, and get a Nutrition consult for
calorie counts and feeds. She may need to supplement on what she is eating with
further G-tube feeds. I would like to give her a little bit of fluids overnight because she
has not been eating or drinking great, but she does have pedal edema, so I will
continue the Lasix as well. I would like to have speech see her because her MBS on 7/6,
based on that she was supposed to be on a dysphagia advanced with honey-thick
liquids, but now she is doing a soft diet with thin liquids and apparently there is no
coughing or choking per the ED nurse, but I would like to have speech follow up.
Patient understands plan of care.”
7/31:

RN noted that PEG did not seem to be in the right place, or perforating the
gastric remnant. KUB with contrast imaging was ordered.

Over the past month, this patient had developed a stage I pressure ulcer on her
coccyx, and stage I + II pressure ulcers on her right middle buttocks.
Nutrition Assessment:

Age: 74
Issues affecting oral intake: Weakness, Dysphagia
Gender: Female
Admit weight: 187# (84.822kg)
Wt Hx: All reported wt, no actual wt in EMR. Wt loss of 23# (11%)
Height: 5’3” (1.6m)
in 2 months
BMI: 33.1
UBW: 210# per pt report
%UBW: 89% Intake needs:
IBW: 115# 1813-2116kcal (30-35kcal/kg adj bw)
%IBW: 162% 79-90g (1.2-1.5g/kg adj bw)
ABW: 133# 2120mls (25mls/kg)
Will meet 100% of RDIs through nutrition support, recommend
250mg Vit C for wound healing

Reason for admission: Lower extremity weakness, unable to ambulate, poor PO intake, failure to thrive
PES statements:

• Increased nutrient needs related to stage 1 pressure ulcer on coccyx, stage


I + II pressure ulcers on right middle buttock as evidenced by 1813-
2116kcal (30-35kcal/kg adj bw), 79-90g (1.2-1.5g/kg adj bw).

• Inadequate oral intake related to dysphagia, advanced age, lack of support


as evidenced by pt PO intake likely not meeting adequate kcal/protein
needs.
7/31 Nutrition Consult Reply done by Dietetic Intern

Interventions:
1: Will provide TF recommendations to cover 100% of nutritional needs

Recommendations:
1. Recommend TF/ Oral diet w/ oral diet texture per SLP recs, liberalize diet to regular-
-Initiate TF to cover 100% of needs w/ encouraged PO intake at meals. Initiate Jevity 1.5 @ 25mls/hr,
increasing by 15mls q6h as tolerated to goal rate of 60mls/hr x24 hrs w/ 180ml free water flush q4h
@ goal to provide 1980kcal, 84g protein, 2083mls total free water.
-Please hold TF for 1 hour before and after Synthroid dosing
2. Recommend bowel regimen, monitor BMs
3. Obtain actual wt, all wt’s in EMR are stated
4. Recommend d/c MVI, pt to receive 100% RDIs through TF regimen
5. Recommend 250mg Vit C/ day for wound healing.
Nutrition related goals:
1. No further wt loss (+/-2%) – Established
2. Tolerated TF at goal rate –Established

Nutrition plan/ discharge recommendations:


At this time there was no discharge recommendations completed, this patient was
leveled as a 1 meaning I would see her in 3 days and have the ability to re-evaluate
the TF regimen to send her home with an adequate plan.
7/31: KUB- check for PEG placement

Indication: Patients G-tube determined to be out of the stomach and residing


within the tract of the abdominal wall.

Findings: Attempts to reposition the G-tube were unsuccessful. Informed


consent was obtained. Current G-tube was removed, replaced by a new tube
under fluoroscopic control to confirm good positioning. No complications, pt
tolerated procedure very well.
What is a KUB:
“A kidney, ureter, and bladder (KUB) study is an X-ray study that allows
your doctor to assess the organs of your urinary and gastrointestinal
systems. Doctors can use it to help them diagnose urinary disorders and
causes of abdominal pain. They can also use it to help them determine
the size and position of your bladder, kidneys, and ureter.” –Hopkins
Medicine
7/31 Neurology Consultation reply:

“Pt w/ hx of PM based on rash, generalized weakness including dysphagia


and initially elevated CPKs, which are all improved significantly under
prednisone therapy, currently at 60mg daily. For the past week, she has
been eating very little and apparently has a UTI. She has been getting
weaker over the past week. I suspect that at this time a poor nutrition and
UTI are the cause of her weakness in the setting of preexisting less than
normal strength related to PM rather than a reoccurrence of PM. Keep her
prednisone stable, treat her UTI and improve her nutrition status.”
Labs 8/30: Labs 8/31: Nutrition related medications:
Na 135L Cl 97L Lactinex
Cl 90L CO2 35H Caltrate 500mg daily
CO2 35H Albumin 3.4L Colace
Glucose 156H Lasix 40mg
Albumin 3.4L Synthroid
Creatine Kinase 20L Milk of Mag
MVI
KCl
Vit D
Zofran
8/1:

• Pt started on Jevity 1.5 @ 25mls/hr overnight. Tolerating TF without it


being advanced towards goal rate of 8/1. No residual.
• No actual wt was obtained
• Pt was able to have a bowel movement today.

• Pt was discharged today, unable to reassess, pt was not at tube feed


goal rate.
• Unsure if pt was sent home w/ VNA or a SLP recommended diet
• SLP was unable to see her and evaluate
Take away message:
• Pt should have had a longer stay. She was only at 25mls of her TF where the goal
rate is 60mls/hr.
• PM can significantly impact nutrition status.
• Nutrition support is very important in all patient, especially this patient, and
contributes to their energy levels/ can cause failure to thrive.
• CM and SW should be working with patients to ensure they are discharged with
the proper support system.
• Still unsure on how/why this patients diet was advanced so soon after a MBS that
provided significant consistency restraints.
References:
1. jointcommission.org. https://www.jointcommission.org/accreditation/goldseal_downloads.aspx. Accessed August 23,
2018.
2. About Us. Community Health & Outreach. https://www.holyfamily-hospital.org/about-us. Accessed August 23, 2018.
3. BUNCH THOMASW, WORTHINGTON JOHNW, COMBS JOSEPHJ, ILSTRUP DUANEM, ENGEL ANDREWG.
Azathioprine with Prednisone for Polymyositis: A Controlled, Clinical Trial. Annals of Internal Medicine.
http://annals.org/aim/fullarticle/693799/azathioprine-prednisone-polymyositis-controlled-clinical-trial. Published March 1,
1980. Accessed August 23, 2018.
4. How to Use and Care for Your PEG Tube (General Information). Kidney Transplant manual.
https://www.allinahealth.org/mdex/nd0554g.htm. Accessed August 23, 2018.
5. Leapfrog. Leapfrog. http://www.leapfroggroup.org/. Accessed August 23, 2018.
6. Mulder DW. Steroid Therapy in Patients with Polymyositis and Dermatomyositis. Annals of Internal Medicine.
1963;58(6):969. doi:10.7326/0003-4819-58-6-969.
7. Nutrition for Myositis Patients • Johns Hopkins Myositis Center. Johns Hopkins Myositis Center.
https://www.hopkinsmyositis.org/unique/nutrition-myositis-patients/. Accessed August 23, 2018.
8. Polymyositis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/polymyositis/symptoms-causes/syc-
20353208. Published July 21, 2017. Accessed August 23, 2018.
9. What are corticosteroids? Bundoo. https://www.bundoo.com/articles/what-are-corticosteroids/. Accessed August 23, 2018.
10. What is Polymyositis? Myositis Support and Understanding. https://understandingmyositis.org/myositis/polymyositis/.
Accessed August 23, 2018.
11. What You Should Know About Your KUB X-ray. Johns Hopkins Medicine Health Library.
https://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/kidney_ureter_and_bladder_x-ray_92,P07719.
Accessed August 23, 2018.