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Jillian O’NeilKNH 41109/17/13

Case Study #11 – Inflammatory Bowel Disease: Crohn’s Disease

1. What is inflammatory bowel disease? What does current medical literature

indicate regarding its etiology?

Inflammatory bowel disease, IBD, is an autoimmune, prolonged inflammatory condition of

the gastrointestinal tract. IDB is often associated with ulcerative colitis and Crohn’s disease.

Regarding it’s etiology, there is not current medical literature. Although, several

environmental factors could influence the disease – such as infectious agents, smoking,

intestinal flora, physiological changes in the small intestine and genetic associations.

(Nelms 415-417)

2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with

Crohn’s. How could this happen? What are the similarities and differences

between Crohn’s disease and ulcerative colitis?

Ulcerative colitis is a prolonged inflammatory bowel disease that mainly affects in the colon

and rectum. Crohn’s disease is a prolonged inflammatory bowel disease that mainly affects

the ileum and colon although it can affect the entire gastrointestinal tract. This could

happen if the initial diagnosis shown an infection, irritation, or abnormalities in the colon

and rectum. Once he was later diagnosed with Crohn’s, the disease may have traveled up

the digestive system, affecting the rest of his GI tract as well as causing further discomfort.

The similarities of Ulcerative Colitis and Crohn’s disease include: the etiology (abnormal

immune response which causes inflammatory damage of the GI mucosa; it is genetically

susceptibly and often associated with cigarette smoking); the epidemiology (commonly

found in both sexes equally, a higher prevalence in North America, northern Europe, the UK

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and with Jews). In regards to pathology, both diseases affect the GI tract. Similar signs and

symptoms include: abdominal and/or rectal pain and cramping, bloody stools, fever and

weight loss. Each disease has it’s own list of complications. The diagnosis of both include

an abdominal ultrasound, MRI, CT, ASCA/ANCA, and calprotectin, lactoferrin, and

polymorphonecular neutrophil elastase. The prognosis of both usually includes surgery.

For treatments, both use the drugs immunosuppressants, biologic therapies, antibiotics,

and steroids.

The differences include: Ulcerative Colitis usually has a peak onset of 20 to 30 years with a

secondary peak in the middle ages whereas Crohn’s disease has a peak age onset with teens

and those in their twenties. With pathology, Ulcerative Colitis mainly affects the colon and

rectum whereas Crohn’s disease mainly affects the ileum and colon. Signs and symptoms

specified for Ulcerative Colitis are: possibly constipation and rectal spasm, arthritis,

dermatological changes and ocular manifestations. Signs and symptoms of Crohn’s disease

include: chronic diarrhea, anorexia, malnutrition, and delayed growth in adolescents.

Complications of Ulcerative colitis include severe bleeding, toxic mega colon, toxic colitis,

strictures, perforation, intolerance to immunosuppression, colonic strictures, dysplasia and

carcinoma. Complications of Crohn’s disease includes malabsorption, malnutrition,

abdominal fistulas and abscesses, intestinal obstruction, gallstones, bacterial overgrowth,

kidney stones, urinary tract infections, thromboembolic complications, perianal disease

and neoplasia. Crohn’s disease also uses clinical presentation (CDAI score) to diagnosis the

patient. Drug treatment of Ulcerative colitis include adrenocorticosteroids, anti-

inflammatory, antidiarrheal. Surgery involves the colectomy. Drug treatment of Crohn’s

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disease includes methotrexate and surgery involves removing the affected area (ileoccolic

resections and segmental resections).

(Nelms 377, 416)

3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as

sever fulminant disease. CDAI score of 400. What does a CDAI score of 400

indicate? What does a classification of severe fulminant disease indicate?

Crohn’s Disease Activity Index, CDAI, is the way in which Crohn’s disease is described in

research and clinical trials. In order to determine the stage, factors are evaluated –

diarrhea, abdominal pain, abdominal mass, decreased sense of well-being, extra intestinal

manifestations, weight loss and laboratory features. A CDAI score of 400 indicates the stage

of “Moderate – Severe Disease.” A classification of severe fulminant disease indicates that

the patient has constant symptoms even though he or she was prescribed steroids or

biological agents. Those with a score about 450 also suffer from high fevers, persistent

vomiting, intestinal obstruction, rebound tenderness, cachexia as well as an abscess.

(Nelms 418, 419)

4. What did you find in Mr. Sims’ history and physical that is consistent with his

diagnosis of Crohn's? Explain.

In Mr. Sims history and physical reports, it states he had an abscess as well as acute disease

in the first 5cm of the ileum – both consistent with Crohn’s disease. In addition, abdominal

pain, chronic diarrhea, and a fever correspond to this disease. The report stated his general

appearance was “thin” and his calculated BMI is 20.8, putting him at the lower side of the

normal, healthy weight. Based on the Hamwi method, a healthy weight for a person of his

height would be 160 pounds yet he weighs twenty pounds less than that – signs of Crohn’s:

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weight loss, malnutrition and possibly anorexia. The stool consistency of “soft to liquid”

confirms the diarrhea. With the diagnosis of Crohn’s, Mr. Sims’ history includes orders for a

CT and Antiglycan antibodies. Previously, his clinical presentation was stated – a CDAI

score of 400.

Calculations:

Height: 5’9” = 69 inches = 1.75 m

Weight = 140 lbs / 2.2 = 63.6 kg

BMI = 63.6/(1.752) = 20.8

Hamwi method: 106 + 6(9) = 160 pounds ideally.

(Nelms 47, 48, 416)

5. Crohn’s patients often have extraintestinal symptoms of the disease. What are

some examples of these symptoms? Is there evidence of these in his history and

physical?

Crohn’s patients often have symptoms that occur outside of the intestines. Some symptoms

include: weight loss, fever, anorexia, malnutrition, and delayed growth in adolescents. In

his history and physical, there are evidence showing extraintestinal symptoms. As stated

above, Mr. Sims has had a significant amount of weight loss. In addition to the weight listed

with his vital signs, his general nutrition states he has lost more weight since his previous

hospitalization. This section confirms the weight loss and issue of malnutrition. In addition,

Mr. Sims has a temperature of 101.5 degrees – a fever to the normal body temperature of

98.6 degrees. Lastly, Extraintestinal manifestations may include arthritis, joint pain, ocular

manifestations, uvelitis, and episcleritis. (Nelms 416, American Academy of Family

Physicians)

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6. Mr. Sims has been treated previously with corticosteroids and mesalamine. His

physician had planned to start Humira prior to his admission. Explain the

mechanism for each of these medications in the treatment of Crohn’s.

Corticosteroids are used for patients with acute exacerbations. This drug aids in the

prevention of inflammatory responses as well as help with a quicker recovery. Mesalamine

treats the areas of the GI track that are affected by the disease. As an anti-inflammatory

agent, it works to eliminate pain or inflammation throughout the body – particular

inflamed bowels. Humira is the common name for the drug “Adalimumab.” It is used to

reduce the signs, symptoms and progression of moderate to severe rheumatoid arthritis for

adults. Arthritis is often a common symptom of ulcerative colitis. (Crohn’s and Colitis

Foundation of America, National institute of Health, American Academy of Family

Physicians)

7. Which laboratory values are consistent with an exacerbation of his Crohn’s

disease?

Although Crohn’s disease can’t be diagnosed through blood work, the laboratory values can

support the finings as well as aid in the monitoring of the disease. His protein value was

low – displaying a value of 5.5g/dL when the normal range is 6-8 g/dL. The Albumin and

prealbumin values were also low – values of 3.2g/dL and 11 mg/dL with normal ranges of

3.5-5 g/dL and 16-35 mg/dL. The antibody value, shown as + when the ASCA should be

negative, is a biomarker which indicates the patient suffers from Crohn’s. The C-reactive

protein value was high, 2.8 mg/dL, in relation to the reference range of less than 1.0mg/dL.

The C-reactive protein assesses for inflammation, infection, and disease. (Zonderman, Beth

Israel Deaconess Medical Center)

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8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why

he may be at risk for vitamin and mineral deficiencies.

Mr. Slims may be at risk for vitamin and mineral deficiencies even though he is taking

vitamin and mineral supplements. First, he may be deficient in iron due to blood loss and

malabsorption. A deficiency in magnesium and zinc may be due to the intestinal losses

from extreme diarrhea. Long-term steroid use and a decrease intake do dairy foods can

cause a deficiency in calcium and vitamin D. (Nelms 420)

9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel

syndrome, and provide a rationale for your answer.

Short bowel syndrome is the reduced digestion and absorptions due to a large resection of

the small intestine. Although his history chart stated he has not had a surgery in the past,

the orders indicate for Mr. Sims to consult with a surgeon. If he were to have surgery, then

he may be a likely candidate for short bowel syndrome. At this point, prior to any surgery,

he may only be at risk for short bowel syndrome due to the malabsorption of nutrients.

10.What type of adaption can the small intestine make after resection?

After surgery, the small intestine may develop adaptations. In particular, the resection may

help the intestine to absorb nutrients properly – if the procedure was successful. If the

procedure wasn’t successful in the direction it was intended, the extensive loss of surface

area will cause a major malabsorption of electrolytes, fluids and nutrients. (Nelms 420)

11.For what classic symptoms of short bowel syndrome should Mr. Sims’ health care

team monitor?

His health care team should monitor for the classic symptoms. Large volumes of diarrhea

cause deficiencies in sodium, iron, zinc, magnesium, calcium and selenium. In addition, they

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should monitor for dehydration, bloating, cramping and fatigue. Lastly, they should

monitor his blood work to review the levels of infection, inflammation and disease. (Nelms

425)

12.Mr. Sims is being evaluated for participation in a clinical trial using high-dose

immunosuppression and autologous peripheral blood stem cell transplantation

(autoPBSCT). How might this treatment help Mrs. Sims?

The immunosuppressant drug is used to help the body accept the transplant. Without this

drug, the immune system isn’t altered and the body will not corporate with the stem cell

transplant. The transplantation itself will aid in the inflammatory response the body has

been producing. For Mr. Sims, his body has been producing an inflammatory response due

to the Crohn’s disease. Therefore, the autologous peripheral blood stem cell

transplantation will encourage his body to reduce the inflammation and continue to

remission of the disease. (Nelms 554, Clinical Trials)

13.What are the potential nutritional consequences of Crohn’s disease?

The potential nutritional consequences of Crohn’s disease include the common deficiencies.

A deficiency in calories is due to the insufficient intake, increased energy requirements and

fear of abdominal pain along with diarrhea after eating. Protein deficiency is associated

with the increased protein needs, catabolism, and healing from surgery. The fluid and

electrolyte deficiency is due to short bowel syndrome and high volume diarrhea. There

may be a deficiency in iron due to blood loss and malabsorption. A deficiency in magnesium

and zinc may be due to the intestinal losses from extreme diarrhea. Long-term steroid use

and a decrease intake do dairy foods can cause a deficiency in calcium and vitamin D. A

deficiency in B12 and water-soluble vitamins is due to surgical resections (loss of ileum).

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Medications can cause a deficiency in folate and steatorrhea causes deficiency in fat-soluble

vitamins. (Nelms 420)

14.Mr. Sims underwent resection of 200 cm of jejunum and proximal ileum with

placement of jejunostomy. The ileocecal valve was preserved. Mr. Sims did not

have an ileostomy, and his entire colon remains intact. How long is the small

intestine, and how significant is this resection?

The small intestine is about 5.5 m to 6 m (550 – 600 cm) in length. The jejunum is about 2.5

meters in length (250cm). With a resection of 200 cm of the jejunum, the small intestine

was reduced to 350 to 400cm in length. This resection provides a major significant change

for Mr. Sims. The jejunum is responsible for the absorption of many vitamins and minerals

– including Thiamin, Riboflavin, Niacin, Pantothenate, Biotin, Folate, Vitamin B6, Vitamin C,

A, D, E, K, Calcium, Phosphorus, Magnesium, Iron, Zinc, Chromium, Manganese, and

Molybdenum. This resection will cause a decrease in the absorption of the important

nutrients Mr. Sims needs for a healthy, everyday diet. (Nelms 384)

15.What nutrients are normally digested and absorbed in the portion of the small

intestine that has been resected?

The portion of the small intestine that has been resected was the jejunum and proximal

ileum. The nutrients that are normally digested and absorbed in this restricted area

include: Thiamin, Riboflavin, Niacin, Pantothenate, Biotin, Folate, Vitamin B6, Vitamin C, A,

D, E, K, Calcium, Phosphorus, Magnesium, Iron, Zinc, Chromium, Manganese, and

Molybdenum. (Nelms 384)

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16.Evaluate Mr. Sims’ % UBW and BMI.

Mr. Sims’ percent Usual Body weight is 83.8%. Interpreting this result, he has a percent

weight change of 16.2%. He has a BMI of 20.8. (Nelms 47, 48)

Calculations:

%UBW= (current weight/usual body weight) * 100

(140/167)*100

%UBW = 83.8%

% weight change = 100-%UBW 100 – 83.8 = 16.2%

Height: 5’9” = 69 inches = 1.75 m

Weight = 140 lbs / 2.2 = 63.6 kg

BMI = 63.6/(1.752) = 20.8

17.Calculate Mr. Sims’ energy requirements.

Mr. Sims’ energy requirements were determined using the EEE equation with a physical

activity coefficient of 1.11 for low active. His daily caloric requirement is 2,000 calories.

Calculations:

Weight: 140 lbs / 2.2 = 63.6 kg

Height: 5’9” = 69 inches = 1.75 m

Age: 35 years old

TEE=662-9.53(age) + PA (15.91*weight + 539.6*height)

662-9.53(35) + 1.11(15.91*63.6 + 539.6*1.75)

662-333.55 + 1.11(1011.9 + 944)

328.45 + 2171 = 2500 calories

(Nelms 242)

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18.What would you estimate Mr. Sims’ protein requirements to be?

If Mr. Sims consumed 10% of his daily energy intake for proteins, this would be 250

calories of protein per day. This amount is equivalent to 62.5 grams of protein.

Calculations:

2500 calories/day *.10 =250 calories of protein/day (1g/4 cal) = 62.5g protein

(Nelms 243)

19.Identify any significant and/or abnormal laboratory measurements from both his

hematology and his chemistry labs.

In regards to his chemistry laboratory measurements, his protein value of 5.5g/dL is low

in reference to the normal range of 6-8 g/dL. The Albumin and prealbumin values were

also low – values of 3.2g/dL and 11 mg/dL with normal ranges of 3.5-5 g/dL and 16-35

mg/dL. The C-reactive protein value was high, 2.8 mg/dL, in relation to the reference range

of less than 1.0mg/dL. Mr. Sims’ HDL cholesterol count was low with a value of 38mg/dL in

comparison to the reference point of above 45 for males. The biomarker, antibody value

(ASCA) was displayed at a positive (+) when it s preferred to be negative. In regards to his

hematology laboratory measurements, the ideal hemoglobin range for males is 14-17g/dL.

Mr. Sims’ was low with a value of 12.9 g/dL. His Hematocrit value was also low with 38%

and the normal reference range for males of 40-54%. The transferrin and ferritin levels

were low with values of 180 mg/dL and 16 mg/mLL – the reference ranges for males are

215-365 mg/dL and 20-300 mg/ML. His zinc protoporphrin (ZPP) levels were high with a

value of 85 mol/mol – the reference range is 30 to 80 mol/mol. The labotory results for μ μ

hematology also showed a low value of Vitamin D 25 hydroxy – 22.7 ng/mL with the

reference range of 30-100. A decreased value of 17.2 g/dL was also shown for Free retinolμ

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(vitamin A) with the reference range of 20-80 g/dL. Lastly, the ascorbic acid range of 0.2-μ

2.0 mg/dL was shown to be low with a value of <0.1mg/dL.

(A Case Study Approach 119-121)

20.Select two nutrition problems and complete the PES statement for each.

A. Inadequate Calorie Intake

Inadequate caloric intake (NI-1.2) of 2,236 calories related to lifestyle-diet

choices as evidence by the recent dietary intake and a weight loss of 40

pounds.

B. Poor Eating Habits

Poor eating habits of processed foods and minimal fruit/vegetable intake

related to lifestyle-diet choices as evidence by the recent dietary intake and

laboratory results.

Mr. Sims energy intake is roughly 2,236 calories. His estimated needs is 2,500 calories.

(www.fitday.com)

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21.The surgeon notes Mr. Sims probably will not resume eating by mouth for at least

7-10 days. What information would the nutrition support team evaluate in

deciding the route for nutrition support.

When a patient is designated as NPO, the nutritional support team needs to assess the

situation and decide on a route to continue the essential nutritional support. The team

would choose the route of Total Parentarel Nutrition because of the circumstances of NPO.

TPN provides the patient with proper fluids and nutritional needs by way of intravenous

feeding. Seven to ten days is considered short term; so, this option would be best. The team

will also need to take into consideration that the patient will need to be supplied with

additional supplementations: zinc (12-15mg/L of stool output), calcium (10-25 mEq/day);

magnesium (15-30 mEq/day) and Copper (0.5 to 1.5 mg/day). (Nelms 422, 577)

22.The members of the nutrition support team note his serum phosphorus and

serum magnesium are at the low end of the normal range. Why might that be of

concern?

The low serum phosphorus and serum magnesium values are of concern because of the

ways in which it will further affect him. First, low serum phosphorus levels can lead to

fatigue, irregular breathing, loss of appetite, weight fluctuation, painful and fragile bones.

Secondly, low serum magnesium levels can be associated with anxiety, sleeping disorders,

vomiting and nausea, seizures, abnormal heart rhythm, confusion, muscle spasm, low blood

pressure and insomnia. Both levels are of concern to prevent further medical issues to the

patient. (University of Maryland Medical Center, Nelms 132)

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23.What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be

prevented?

Refeeding syndrome is the metabolic alterations that may occur due to the nutritional

repletion of starved patients. Mr. Sims is at risk for this problem because he has had a

record of low energy intake. In addition, the next seven to ten days of his hospitalization

will include a NPO diet. Lastly, as stated in Nelms, a drop in serum levels of phosphorus

mass result due to the refeeding syndrome. The nutritional support team has already

noticed the drop in these levels. This syndrome can be prevented by avoiding to overfeed

the patient as well as to begin the feedings slowly. (Nelms 81, 92, 93)

24.Mr. Sims was placed on parenteral nutrition support immediately

postoperatively, and a nutrition support consult was ordered. Initially, he was

prescribed to receive 200g dextrose/L, 42.5 g amino acids/L, and 30g lipid/L. His

parenteral nutrition was initiated at 50cc/hr with a goal rate of 85 cc/hr. Do you

agree with the team’s decision to initiate parenteral nutrition? Will this meet his

estimated nutrition needs? Explains. Calculate pro (g); CHO (g); lipid (g); and total

kcal from his PN.

I agree with the team’s decision to initiate parenteral nutrition. Mr. Sims has not only lost

weight recently but is also on an NPO diet for the next week or so. Therefore, it is crucial to

initiate a plan that guarantees for him to receive the nutrients needed. He will not meet his

nutrition needs with this amount of nutrients he was prescribed. With the prescription, he

would receive 240 g carbohydrates per day (816 kcalories), 48 grams of protein per day

(60 calories), and 36 grams of lipid per day (396 calories). In total, he will have a caloric

intake of 1,272 calories per day. This is a problem that he will not meet his nutritional

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needs because he is already in a form of deficit. His recent weight loss and diet habits have

influenced his point of medical treatment at this point. Therefore, the nutritional team will

need to increase intake. Once the goal rate of 85cc/hour, his total calories per day is 2155.

He will receive 408 g of carbohydrates, 87 grams of protein, and 60 grams of lipid per day.

Using the rate of 85cc/hour will be more beneficial to Mr. Sims because the calories are

closer to his initial calorie goal of 2500kcal. (Nelms 95, 96)

Calculations:

50 cc = 0.05 L ; 85 cc = 0.085 L

200 g dextrose/L (0.05L) = 10gCHO per hour * 24 = 240gCHO per day

240gCHO *3.4cal/g = 816 kcal of CHO per day

42.5 g amino acids/L (0.05L) = 2g pro per hour *24 = 48 g pro per day

48g pro (1kg/0.8g) = 60 kcal of Pro per day

30g lipid/L (0.05 L) = 1.5 g lipid per hour * 24 = 36 g lipid per day

36 g lipid (11kcal/gram) = 396 kcal of lipid per day

Total kcal = 816 + 60 + 396 = 1272 calories per day

200 g dextrose/L (0.085L) = 17gCHO per hour * 24 = 408gCHO per day

408gCHO *3.4cal/g = 1387 kcal of CHO per day

42.5 g amino acids/L (0.085L) = 3.6g pro per hour *24 = 87 g pro per day

87g pro (1kg/0.8g) = 108 kcal of Pro per day

30g lipid/L (0.085 L) = 2.5 g lipid per hour * 24 = 60 g lipid per day

60 g lipid (11kcal/gram) = 660 kcal of lipid per day

Total kcal = 816 + 600 + 396 = 2155 calories per day

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25.For each of the PES statements you have written, establish and ideal goal (based

on the signs and symptoms) and an appropriate intervention (based on the

etiology).

A. Ideal goal: increase overall body weight by improving on the lifestyle-diet choices

and increasing the daily caloric intake. For example, Mr. Sims would increase caloric

intake by choosing a calorie and nutrient dense snack instead of cola and crackers.

B. Ideal goal: increase intake of fruit and vegetables while decreasing the amount of

processed foods by improving on lifestyle-diet choices and knowledge on healthy

eating habits. For example, Mr. Sims could chose to have fruit as a snack, add

vegetable options to dinner and lunch, and make homemade potato chips rather

than snacking from the pre-packaged bag.

26.Indirect calorimetric revealed the following information:

Measure Mr. Sims’ dataOxygen consumption (mL/min) 295CO2 production (mL/min) 261RQ 0.88RMR 2022

What does this information tell you about Mr. Smith?

This information tells me that Mr. Sims’ Resting Metabolic rate is 2,022kcalories. This is the

amount of energy when he is at rest – not taking into consideration any extra activities. In

addition, his respiratory quotient of 0.88 indicates the level of protein used. This data tell

us that he uses 295 ml of oxygen per minute (oxygen consumption) and produces 261 ml of

carbon dioxide per minute (CO2 production). Mr. Sims’ cardiac input is greater than his

cardiac output. (National Library of Medicine)

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27.Would you make any changes to his prescribed nutrition support? What should

be monitored to ensure adequacy of his nutrition support? Explain.

I would not make changes to his prescribed nutrition support if he reaches the goal rate of

85cc/hour. If that goal has been obtained, I would increase it to 90cc/hours to reach the

desired energy intake and ultimately healthy weight for Mr. Sims. In order to ensure the

adequacy of his nutrition support, I suggest to continue with testing of indirect

calorimetric because it’s the main way to accurately estimate his calorie needs. This data

will notify the care team of an increase in caloric needs, which is affected by weight loss or

weight gain.

28.What should the nutrition support team monitor daily? What should be

monitored weekly? Explain your answers.

The nutrition support team should monitor the amount of ccs per day. This is important to

know when is the correct time to increase the amount of energy intake per day. When

beginning at 50cc/hour, it is important to slowly increase to 85cc/hour to prevent further

refeeding syndrome. The nutrition support team should monitor his caloric needs weekly

using indirect calorimetry. This is important to support or deny the weight gain as well as

assist the team in knowing when to continue to increase the ccs. Ultimately, the team wants

Mr. Sims to reach a full recovery by eating foods rather than through parenteral nutrition.

By monitoring daily and weekly, the team can assist in the recovery.

29. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is

now abnormal? What should be done about it?

A serum glucose level above 126 mg/dL is abnormal. His level of 145 mg/dL is high and

associated with high blood sugar as well as diabetes. Although he has a high level, I do not

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believe Mr. Sims has diabetes. I believe his high level is due to the 200g/L of dextrose that

is directly put into his bloodstream with parenteral nutrition. To lower his increased

glucose level, a lower dosage of dextrose can be used. Another option would be to use it at

60cc/hour while slightly increasing protein and lipid to 95cc/hour. (National Library of

Medicine)

30.Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20:

18.4 grams. By using the daily input/output record for 12/20 that records the

amount of PN received, calculate MR. Sims’ nitrogen balance on postoperative day

4. How would you interpret this information? Should you be concerned? Are

there problems with the accuracy of nitrogen balance studies? Explain.

The Urinary Nitrogen value of 18.4g is the amount of protein in the body during a

designated 24-hours. His total was 85 g. He is in a catabolic state with a negative nitrogen

balance of -8.8. This value puts him in the category of extreme stress. This is something to

be concerned with because he may need in increase intake to balance out the loss with the

intake levels. These numbers may be altered from improper I/O, the fudge factor of 4

grams that takes into account the nitrogen losses. (Nelms, Parenteral Nutrition)

Calculations:18.4g Urinary Nitrogen/L (0.05L) = 85 g protein on day 4

368g pro (1kg/4) = 93 kcal of Protein on day 4

nitrogen intake = 85/6.25=13.6

nitrogen loss = 18.4 + 4 grams = 22.4 grams

Balance = intake – loss – 13.6-22.4 = -8.8

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31.On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous

48 hours and had his first bowel movement. The nutrition support team

recommends consideration of an oral diet. What should Mr. Sims be allowed to

try first? What would you monitor for tolerance? If successful, when can the

parenteral nutrition be weaned?

First, he should be allowed to try sugar-free, isotonic clear liquids. I would monitor his

bowel function and sounds, his stool color and consistency, his temperature and his

respiration rate. If successful, parenteral nutrition can be weaned. This is a very slow

process and cannot be rushed. Only one food at a time should be added to the diet to

prevent further complications. If the GI symptoms are worsened, the food added will need

to be removed and gradually introduced again. (Nelms 426)

32.What would be the primary nutrition concerns as Mr. Sims prepares for

rehabilitation after discharge? Be sure to address his need for supplementation

of any vitamins and minerals. Identify two nutritional outcomes with specific

measurement for evaluation.

Primary nutrition concerns for Mr. Sims would be: if he can continue on the “slow

additions” of new foods into his diet, if he can choose foods that will not aggravate the

disease, if he can avoid processed foods and chew foods well, and if he can eat smaller

meals more often. In addition, he will need to take supplementation of vitamins and

minerals in liquid or chewable form. Iron supplements are needed to prevent anemia and

restore iron levels. A calcium and vitamin D supplement is important to prevent

osteoporosis because Chronis disease increases the risk of this disease. Lastly, I would

suggest a Vitamin B12 supplement for proper nerve function. The first nutritional outcome

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would be to increase Mr. Sims weight. An increase of 500 calories per day (3500 calories

per week) would increase his weight by 1 pound. If he can slowly increase his caloric

intake, he will be able to successfully gain weight. This can be measured for evaluation by

having a “weigh in” at every counseling session, once a week. The second nutritional

outcome would be to increase his knowledge about healthy lifestyle choices. By educating

Mr. Sims on these choices, he can improve his overall health as well as feel better during his

recovery process. I would first educate him and then provide him with a journal. In this, he

will create a log of all intakes. The measurement for this outcome would be to review the

progress of change at the weekly meeting. Also, by pointing out and suggesting where he

can improve in his diet, Mr. Sims will be able to reach a new goal for the following week’s

evaluation.

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