BY: LAUREN MARTIN ARAMARK DIETETIC INTERN BRYN MAWR HOSPITAL APRIL 6 TH, 2012 Case Report:...
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Transcript of BY: LAUREN MARTIN ARAMARK DIETETIC INTERN BRYN MAWR HOSPITAL APRIL 6 TH, 2012 Case Report:...
BY: LAUREN MARTINARAMARK DIETETIC INTERN
BRYN MAWR HOSPITALAPRIL 6 T H , 2012
Case Report: Nutritional Management of Patient’s with Chronic Obstructive
Pulmonary Disease
Overview
Disease DescriptionEvidence-Based Nutrition
RecommendationsCase PresentationNutrition Care Process:
Assessment Diagnosis Interventions Monitoring & Evaluation
Conclusions
ETIOLOGYEPIDEMIOLOGY
PATHOLOGYCLINICAL SIGNS AND SYMPTOMS
RELATED CO-MORBIDITIES
COPD Disease Description
Etiology
COPD
Asthma
Smoking: emphysem
a or chronic
bronchitis
Pollution
Metabolic disorders
Alpha-1 antitrypsin deficiency
Epidemiology
Forth leading cause of deathAffects 32 million people6th leading cause of death worldwide~ 440,000 deaths/year due to smokingMen are more likely to have COPD >40 years old
Pathophysiology
COPD
Asthma Emphysema (Type I)*
Enlarged airspaces of the terminal bronchioles
Permanent destruction of
the alveoli
Chronic Bronchitis (Type II)
Inflammation of the bronchi
Additional lung changes
Emphysema Chronic Bronchtitis
Underweight and cachectic Hypoxia Normal hematocrit Cor pulmonale develops
much later SOB & wheezing Tissue destruction Chronic to mild coughing
Normal weight or overweight
Hypoxemia hematocrit Cor pulmonale Excess mucus production SOB Inflamed bronchial tubes
Clinical Signs & Symptoms
THE ACADEMY OF NUTRITION AND DIETETICS EVIDENCE ANALYSIS LIBRARY RECOMMENDATIONS
LITERATURE REVIEW
Evidence-Based Nutrition Recommendations
AND EAL Major Recommendations
COPD
Prevention of
weight loss
Assess quality of
life
Use BMI & weight changes
Article #1
“Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with individualized TPN”
Methods Retrospective observational study Purpose: To assess the use of individualized nutritional support in
severely malnourished patients n = 11 Inclusion Criteria:
Adult patients Moderate or severe malnutrition TPN >5 days between January 2003 – June 2006 At risk for developing refeeding syndrome
Description Individualized TPN + MVI + electrolytes Monitored for refeeding
Luque S, Berenguer N, Mateu de Antonio J, Grau S, Morales-Molina JA. Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with individualized total parenteral nutrition. Farmacia Hospitalaria. 2007;31(4):238-242.
Article #1
Results Albumin: in 4; constant in 7 Cholesterol: in 3; constant in 6; in 2 Lymphocytes: in 4; constant in 3; in 4 4 died All labs corrected by day 7
Conclusion Low levels of nutrition support Reestablish the anabolic metabolism Eliminate other mechanisms which may be leading to
starvations
Luque S, Berenguer N, Mateu de Antonio J, Grau S, Morales-Molina JA. Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with individualized total parenteral nutrition. Farmacia Hospitalaria. 2007;31(4):238-242.
Article #2
“Nutritional status and longer-term mortality in hospitalized patients with COPD”
Methods Prospective, observational study Purpose: assess the association between nutritional status and
long-term mortality in hospitalized COPD patients n = 261 Inclusion Criteria:
Acute hospital admission >24hrs Hospitalized consecutively for COPD Stage 1 or > for COPD
Description Anthropometric assessment; health status obtained 2 years post discharge assessed mortality
Cause of death: respiratory, cardiovascular, malignancy, otherHallin R, Gudmundsson G, Ulrik CS, et al. Nutritional status and longer-term mortality in hospitalized patients with chronic obstructive pulmonary disease. Respiratory Medicine. 2007;101:1954–1960.
Article #2
Results 19% underweight; 41% normal weight; 26%
overweight; 14% obese Underweight group 3x more likely to die Lowest mortality = overweight Diabetes
Conclusion Underweight COPD patients have a higher risk for
death in the next 2 years
Hallin R, Gudmundsson G, Ulrik CS, et al. Nutritional status and longer-term mortality in hospitalized patients with chronic obstructive pulmonary disease. Respiratory Medicine. 2007;101:1954–1960.
Article #3
“ Body mass and prognosis in patients hospitalized with acute exacerbation of COPD”
Methods Retrospective study Purpose: to assess the association between BMI and long-
term mortality in COPD patients after acute hospital care n = 968 Inclusion Criteria:
Hospitalization for acute COPD exacerbation February 2002 – June 2007
Description Patients were assessed for primary COPD diagnosis Followed up 3.26 years for mortality
Lainscak M, Haehling SV, Doehner W, et al. Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle. 2011;2:81-86.
Article #3
Results 22% BMI <21kg/m2
44% of patients died – lowest mortality in overweight group
BMI 1kg/m2 was associated with 5% less chance of death
GOLD stages decreased over BMI quartilesConclusion
A higher BMI predictive of better long-term survival Low BMI <21kg/m2 frequent in hospitalized COPD
patients
Lainscak M, Haehling SV, Doehner W, et al. Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle. 2011;2:81-86.
Case Presentation
84 year old, Caucasian women Diagnosis: SOB & COPD exacerbationRespiratory failure, intubation, sedation, extubation,
deathAdditional medical diagnosis:
Ischemic colitis Clostridium difficile colitis CHF Volume status GI bleed Malnutrition Severe aortic stenosis Severe mitral regurgitation Rate-controlled atrial fibrillation
Nutrition Care Process: Assessment
Client History Ex-smoker No drug or alcohol abuse Lives at home with
husband Recent swelling in
extremities Poor historian Family history
noncontributory
Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Assessment
Food/Nutrition-Related History No allergies, use of herbal supplements Refused Boost Minimal activity due to SOB Outpatient Medications:
Digoxin Coumadin Spiriva Lasix Potassium
Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Assessment
In-patient Medications Methylprednisolone Budesonide Heparin Vancomycin HCL Abuterol Acetylcysteine Florastor SSI Digoxin
Lopressor
Potassium Chloride Ducolax Senokot Maalox Colace Diprivan Sodium Chloride
Nutrition Care Process: Assessment
Anthropometric Measurements 5”; 72 lbs; BMI 14.06kg/m2
72% IBW of 100lbs 16# unintentional weight loss in past 8 months
Nutrition-Focused Physical Findings Generalized poor appetite Lungs with bilateral wheezing with rhonchi Extremities with mild edema Cachectic
Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Assessment
Biochemical Data, Medical Tests and Procedures Abnormal Labs on Admission:
Sodium: 129mEq/L - edema, diuretics, starvation, hyperglcemia
Creatinine: 0.8mg/dL- inadequate PO intake Glucose: 158mg/dL - Steroid use Total Bilirubin: 2.9mg/dL – prolonged fasting AST: 42U/L - Liver function BNP: 485pg/Ml – Heart failure
Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Assessment
Biochemical Data, Medical Tests & Procedures Respiratory acidosis, metabolic alkalosis
Nutrition Care Process: Assessment
Diagnosis-Related Group “Other Severe Protein Calorie Malnutrition”
ARAMARK Classification Status High – 20 points
Nutrient Needs
Nutrition Care Process: Nutrition Diagnosis
PES Statement: Underweight related to generalized poor appetite as
evidence by BMI 14.06 Unintended weight loss related to increased needs
from COPD as evidence by COPD, 16% weight loss in the past 8 months
Increased nutrient needs related to COPD exacerbation as evidence by underweight with BMI 14, estimated intake less than estimated energy requirements
Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Interventions
Enteral Nutrition Recommended: Fibersource HN 35mL/hr x 24 hours
with 1 scoop Promod once a day with 80mL free water flush q 6 Provided: 1,033kcals, 50.5g protein, 1,000mL free water
Parenteral Nutrition Recommended: Minimum volume, 50g Protein, 550
dextrose calories, 240 lipid calories Given: Minimum volume, 110g Protein (3.3g/kg), 800
dextrose calories, 500 lipid calories (52kcals/kg)Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Monitoring and Evaluation
Goals: Increase PO Intake Optimize enteral feedings to meet needs Decrease TPN to prevent refeeding syndrome
Significant weight gain Elevated glucose No refeeding
Assessment
Nutrition Diagnosis
Intervention
Monitor
Evaluation
Nutrition Care Process: Monitoring and Evaluation
Expiration March 4th, 2012Discharge Diagnosis
Hypoxemic respiratory failure Ischemic colitis Clostridium difficile Moraxella pneumonia Rate-controlled atrial fibrillation Profound malnutrition GI bleed Pulmonary HTN Severe mitral regurgitation Severe aortic stenosis Anemia
Malnutrition vs Age vs Other complications
Conclusions
High risk patientNutritional Problems:
Profound malnutrition/cachexia Respiratory acidosis/ metabolic alkalosis Respiratory failure GI bleeds/anemia
Nutrition Interventions Enteral/Parenteral nutrition support
Monitoring and Evaluation Individualized TPN Correcting of malnutrition/cachexia
References
1. Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 300-301.
2.Mueller, DH. Medical Nutrition Therapy for Pulmonary Disease. In: Mahan KL, Escott-Stump S eds. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders Elsevier; 2008: 899-918.
3. Chronic Obstructive Pulmonary Disease (COPD) Major Recommendations. Evidence Analysis Library: Academy of Nutrition and Dietetics. http://www.adaevidencelDibrary.com. Accessed March 20, 2012.
4. Luque S, Berenguer N, Mateu de Antonio J, Grau S, Morales-Molina JA. Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with individualized total parenteral nutrition. Farmacia Hospitalaria. 2007;31(4):238-242.
5. Hallin R, Gudmundsson G, Ulrik CS, et al. Nutritional status and longer-term mortality in hospitalized patients with chronic obstructive pulmonary disease. Respiratory Medicine. 2007;101:1954–1960.
6. Lainscak M, Haehling SV, Doehner W, et al. Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle. 2011;2:81-86.
7. Pronsky ZM, Crowe JP Sr. Food Medication Interactions. 16th ed. Birchrunville, PA: FOOD-MEDICATION INTERACTIONS; 2010.
8. Litchford MD. Assessment: Laboratory Data. In: Mahan KL, Escott-Stump S eds. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders Elsevier; 2008: 411 - 431.
9. ADA Nutrition Care Manual ®. www.nutritioncaremanual.org. Update October 2, 2010. Accessed March 6, 2012.
10. Nutrition Assessment: Patient Food Services Policies & Procedures ARAMARK Policy and Procedure. Updated March 10, 2010. Accessed March 13, 2012.
11. American Dietetic Association. Pocket Guide for International Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago, IL; 2011.
12 Kleinschmidt P, Brenner BE. Chronic Obstructive Pulmonary Disease and Emphysema in Emergency Medicine. Medscape Reference. http://emedicine.medscape.com/article/807143-overview#a0199. Updated January 4, 2011. Accessed March 30, 2012.