CASE STUDY - MRS .W ALLISON CALLAN KSDI 2014 WHAT WE ARE GOING TO DISCUSS TODAY Clinical Dietician’s role at Wing Memorial Thyroid function and Thyroid Storm Hyperosmolar Hyperglycemia Non-ketotic Syndrome (HHNS) Nutrition Support and Refeeding Syndrome WING MEMORIAL HOSPITAL AND MEDICAL CENTERS Located in Palmer, Mass Fully accredited by the Joint Commission Wing Memorial is a 74-bed hospital Established in 1913 Provides emergency, medical, surgical and psychiatric services to residents of Palmer, Monson, Wilbraham, Ludlow, Belchertown and nearby towns. ICU, Medical/Surgical, Parker North, Geriatric Psych Four additional medical centers were built to provide out patient services to the community RD ROLE AT WING MEMORIAL HOSPITAL One RD manager, part-time Manages RD’s Provides outpatient care Bariatric program Three part-time clinical RD’s Cover all four floors See every patient Daily triage Write diet order, w/ MD cosign ICE BREAKER Think of a health scenario that you, a family member or family friend had to go through? Were there a lot of surprises? Or did you know what to expect? Was it overwhelming? Did you feel like all of your questions were answered? Did you feel like you could support your loved one? Be an advocate for yourself? Were there things that you wished had gone differently? Better? The same? Share? Please keep these things in mind as I tell you the story of Mrs. W. THE STORY OF MRS. W Social History 85 year old widowed female Lives with daughter and son-in-law Uses a cane for assistance with ambulation Nonsmoker, no known alcohol or illicit drug use Has six children No recent known falls Past Medical History Extensive past medical history PATIENT INFORMATION CONTINUED Past Surgical History Laparoscopic cholecystectomy (2003) Home Medications Metoprolol tartrate, Keflex, Lisinopril/Hydrochlorothiazide Medication Allergies: ? Penicillin, Amoxicillin (allergies reported from childhood - unknown exact response) Diet History Does not follow a certain diet at home Food Allergies: chocolate, strawberries and seafood PATIENT INFORMATION Medical information prior to admission 12/20/13 Was seen by PCP for wound of left lower leg 12/20/13 Antibiotic therapy and pain medication were initiated Patient’s family were unaware of the details of the infection and medical history because the patient would not let her family in the room during doctor’s visits. HOSPITAL ADMISSION DAY (12/27/13) Admit DX in ED: HYPERGLYCEMIA, SEPSIS Patient not able to speak at the present time Patient presents with lethargy, altered mental status Chronic left leg wound infection According to the patient’s daughter: Reduced PO-drinking frequent Ensure supplementation Polydipsia Polyuria HOSPITAL ADMISSION DAY (12/27/13) Hypoxic 85% Fever 101 BP 110/90, low at times with systolic between 80-100 Atrial Fibrillation with rapid ventricular response up to 166 beats per minute Hyponatremia 132 (normal 136-145 mEq/dl) Hyperglycemia with an initial blood sugar of 1257 (normal 70-100 mg/dL) CPK 286 (normal value 30-135 units/L) WBC 13.6 (normal 5-10,000/ mm3) Creatinine 2.2 (normal 0.5-1.1 mg/dL) BUN 61 (normal 6-20 mg/dL) HOSPITAL ADMISSION DAY CONTINUED Chest x-ray Does not show any acute disease with large goiter Stabilized HR with Diltizem between 100-120 beats per minute IV fluids to improve BP, 90 systolic Blood sugars decreased to 400s with IV insulin Transferred to ICU CURRENT POSSIBLE DIAGNOSES Sepsis Hypotension Atrial Fibrillation (what was it triggered by?) Hyperosmolar Hyperglycemia Non-ketotic Syndrome (HHNS) Acute Kidney Injury Thyroid Storm THYROID GLAND REVIEW Normal Values TSH 0.4-4.0 mlU/L Thyroid function Role of T3 and T4 THYROID FUNCTION THYROID STORM What is it? Causes S/S Treatment HYPEROSMOLAR HYPERGLYCEMIA NONKETOTIC SYNDROME (HHNS) What is it? Causes Warning S/S Treatment RD’S ROLE IN CARE FOR MRS.W? Interview patient for information? Calculate nutrient needs Determine what form of nutrients PO, G-tube, TPN, NPO w/ IV fluids?( Po support vs Enteral support at Wing) Are there any skin wounds to consider? Chronic or acute illness that needs to be considered? NUTRITION ASSESSMENT Physical Assessment Breathing Alert Skin appearance Wounds present Odor present NUTRITION ASSESSMENT Current diet Swallow status determined IV fluids running? NUTRITION ASSESSMENT BP- WNL RR-not labored 20/minute TEMP- afebrile Anthropometrics HT 67” WT 147 KG 67 BMI 23 UBW ? DESIRED BODY WT 135LBS- WT DOES NOT NEED TO BE ADJUSTED NUTRITION ASSESSMENT Medications Humalog SS Propylthiouracil Inderal Solucortef Zosyn Lovenox Dilaudid Vancomycin Cardizem Lanoxin ASA INSULIN DRIP LABS Lab value Normal range Glucose 158 70-100 mg/dL BUN 40 6-20 mg/dL Creatinine 1.35 0.6-1.2 mg/dL Est GFR 37 90-120 mL/min or > 60 Sodium 149 136-145 mEq/L Potassium 3.9 3.5-5.2 mEq/L Magnesium 1.5 1.8-3 mg/dL Albumin 4.3 3.5-5 g/dL WBC 19.9 5-10,000 mm3 Chloride 117 95-105 mEq/L Phosphate 2.3 2.4-4.1 mg/dL HCT 43 36-44.1 % Hgb 14 12.1-15 gm/dL NUTRITION ASSESSMENT Level One Nutritional Risk Patients Needs include Protein: Minimum 67 grams of protein (1g/kg) Calorie: 1675-2010 kcals (25-30kcal/kg) Fluids: 1675-2010 ml (1ml/kcal) PES Inadequate oral food/beverage intake R/T DX , lethargy, DM and AKI as evidenced by patient is unable to take in PO at this time, elevated glucose, abnormal renal labs, open areas on left lower leg, heel and stage 11 skin ulcer on coccyx. Increased nutrient needs R/T increased demand for nutrient secondary to refeeding syndrome as evidenced by labs values indicating hypophosphatemia, hypomagnesaemia, and hypokalemia. NUTRITION ASSESSMENT Interventions: Inform kitchen of allergies (seafood, strawberries and chocolate) Monitor for PO feasibility and assess for nutritional supplements as feasible Diet Order: Diabetic/ Cardiac Recommend once daily MVI with minerals, (zinc ,vitamin C) due to open areas NUTRITION PROGRESS NOTE (12/30/13) Patient could not breath on own intubated and sedated Diet order: NPO Med Changes:Versed, Fentanyl, Kphos, Magnesium Current labs: BG 147, BUN and Creatinine improving, Phos 2.2 and Mag 1.6 being replaced, albumin 2.2 s/p IV fluids, H+H decreased ? Infectious process WT: increased 15.6 LBS since admission on 12/27/13- large positive fluid balance Abdominal CT scan showed an small bowel ileus Interventions: Monitor labs, replace electrolytes as indicated, if unable to extubate in next 2-3 days would consider tube feeds, pending resolution of ileus NUTRITION PROGRESS NOTE (12/31-1/2) Diet Order: NPO Intubation continues, weaning attempted Med: Lasix Labs: BG 314 w/ Humalog SS, NA WNL, Phosphate 2.0, will receive 1000 mg/day with KPHOS, K+ WNL , MG++ decreased 1.5, H+H decreased at 9.6, 29.4 WT: 161.6 LBS, (using 69 KG for calculations) INTERVENTION (12/31-1/2) Intervention: Tube feeding initiated Jevity 1.2 started at 30 ml/hr, tolerated without residuals Receives 100ml water flushes four times daily Goal Rate Jevity 1.2 60 ml/hr with 100 ml water flushes four times daily Provide 1728 kcal (25ml/hr ABW), 80 grams protein (1.1g/kg ABW), 1562 ml free water (22ml/kg ABW) Provide 1 tab of KPHOS four times daily (each tab: 250 mg Phos, 45mg K+, 298 mg NA), zinc, vit C Patient at high risk for refeeding syndrome, advance tube feed by 15 ml every 8 hours as tolerated to goal rate of 60 ml/hr Monitor wts, labs, follow refeeding syndrome, adjust water flushes as indicated REFEEDING SYNDROME What is it? Causes Treatment Prevention NUTRITION PROGRESS NOTE (1/3/14) Extubated, swallow evaluation pending at this time Diet Order: NPO, tube feed D/C’d, IV fluids D5 1/2 NS AT 100 ML/HR, ice chips are tolerated Labs: Indicate Refeeding Syndrome NA elevated 147, K+ decreased 3.3, Phos decreased 1.9, MG++ decreased 1.6 All with supplementation Glucose 216, A1C >15, prealbumin decreased 6.9 (wounds, sepsis, doxycycline added), H+H stable Intervention: 1. Follow swallow evaluation/PO feasibility, labs, weight change 2. Add nutrition supplements as able (vanilla only) 3. If PO not feasible, recommend start tube feed with Jevity 1.2 at 30 ml/hr and maintain at this rate until electrolytes normalize NUTRITION PROGRESS NOTE (1/4/14) Patient Diet: NPO, IVF D5W 75 ml/hr Breathing status change-currently on high flow nasal cannula Unable to swallow today Meeting set for consultation on transition to hospice/palliative (per patients wishes) RD consulted for TPN recommendations TPN 940 ml of 10% Aminosyn, 275 ml 50% Dextrose, 225ml sterile water and 250 mls 20% lipids would provide 1690 mls total volume (25ml/kg), 1344 kcals (20kcals/kg), 94 grams of protein (1.4 g/kg) Monitor phosphate, magnesium, potassium closely, when stable increase to 25kcal/kg 3. Use standard additives, provide extra phosphate, magnesium, potassium, via IV if necessary. If sodium level is still above normal limits, consider custom additives and omit sodium chloride from TPN. 4. Follow plan of care, (SLP consult?), labs REFERENCES Black, J. M., Hawks, J. H., & Keene, A. M. (2001). 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