Running head: COPD

COPD Case Study

By June Saxton

10/22/2012

This case study concerns Mr. C who is a 72 year old male that was admitted to the

hospital 2 days ago complaining of shortness of breath. Mr. C. is 5’10” and 240 pounds. Mr. C

has COPD, HTN, depression, obesity, and sleep apnea. Mr. C has smoked since the time he was

a teenager. He is a retired auto-mechanic and is married. He is currently taking a diuretic, a blood

pressure medication, uses an inhaler when SOB, and also takes an anti-depressant. The patient

uses a breathing mask at night due to his sleep apnea history.

Condition, risk factors and common treatments

Chronic obstructive pulmonary disease (COPD) is a slow, progressive disease with

obstruction of the airways. There are two types. In Type 1 (emphysema), there is abnormal,

permanent enlargement and destruction of the alveoli. In Type II (chronic bronchitis) there is a

productive cough and inflammation of the bronchi and other lung changes (Mahan, Escott-Stump

& Raymond, 2012).

The main risk factors for COPD include smoking, being over the age of 40, exposure to

occupational dust and chemicals, long term exposure to wood or biomass smoke and exposure to

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indoor pollution. Some other factors which can cause an increased risk of COPD are having

allergies or asthma, being infected with HIV and eating cured meats (Harvard Health

Publications, 2010).

The goals for effective management of COPD include; assessing and monitoring the

disease, reducing the risk factors, managing stable COPD and managing any increase in the

severity of the disease. Treatment includes pulmonary rehabilitation programs, oxygen therapy

and medications such as bronchodilators, glucocorticosteroids, mucolytic agents and antibiotics

to manage any infections that may be present. Very advanced COPD may require lung

transplantation (Mahan, Escott-Stump & Raymond, 2012).

Patient’s current status

After Mr. C was admitted to the hospital his respiratory status declined to the point where

he needed to be incubated in order to be properly oxygenated. He has been started on IV fluids

with normal saline for hydration, is unable to talk and has been unable to consume an oral diet

for 4 days. His current lab values are within normal limits and the nursing notes reveal that he

has normal urine output and bowel sounds are present and normal. Mr. C. was incubated because

upon admission initiated his labs were abnormal. The affected labs were: CO2, BUN/Cr, pH, and

Na.

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Vent support can impact a patient by causing respiratory muscle weakness, ventilator

acquired pneumonia, lung injury, tracheal injury, increased secretions, general deconditioning

due to inactivity and the ability to communicate and nutrition. (Asher, n.d.).

The nutrition therapy goals for a patients with COPD receiving vent support to meet basic

nutritional requirements, preserve lean body mass, restore respiratory muscle mass and strength,

maintain fluid balance, improve resistance to infection and to provide enough energy to wean

them from oxygen support and vent support without exceeding the respiratory systems ability to

clear CO2 (Mahan, Escott-Stump & Raymond, 2012).

Current Nutritional Recommendations

Indirect calorimetry is the recommended method for determining calorie needs but

because we do not have the information necessary to apply this, I have chosen to use the Harris-

Benedict Formula.

At his current weight, Mr. C’s BMR is 1960 calories (BMI Calculator, n.d.). Using the

Harris-Benedict Formula, he would need 2352 calories to maintain his current weight, but since

Mr. C is overweight, I would recommend reducing his daily intake to 2200 calories It is

recommended that critical care patients receive a of 1.5 g/kg - 2.0 g/kg of dry body weight

(Mahan, Escott-Stump & Raymond, 2012). I would recommend average the protein intake to 1.8

g/kg. That would be 198 grams of protein. At 4 calories per gram of protein, that translates to

792 calories for protein with the rest of the calories being divided equally between fat and

carbohydrates which leaves 704 calories for each of them.

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At this point, because he cannot take oral nutrition and his calorie requirements are so

high, I would recommend that Mr. C. be started on EPN through gastric tube in order to meet the

calorie requirements mentioned above. This meets the recommendation that patients receiving

vent support meet basic nutritional requirements and preserve lean muscle mass (Mahan, Escott-

Stump & Raymond, 2012).

Nutritional recommendations upon discharge

If Mr. C’s condition improves and he is taken off the vent, I would recommend that Mr.

C. continue a 2200 calorie a day diet. I agree with the doctor’s recommendation that he follow a

heart healthy diet and recommend the DASH diet. Because he hasn’t been very good at

complying with the diet recommendations made in the past, it might be a good idea the

supplement with the Omega 3 multi-vitamin that Mrs. C. previously purchased for him. Also

depending on how well he does staying within his calorie limits, I might recommend Ensure

complete as a meal replacement at breakfast time or a high protein live food shake.

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References

Mahan, L., Escott-Stump, S. & Raymond, J. (2012). Krause’s Food & Nutrition Care Process.

13th Edition. St. Luis, Mo. Elsevier Inc.

Harvard Health Publications. (2010, April 10). Chronic obstructive lung disease - risk factors.

Retrieved from http://www.healthcentral.com/copd/copd-000070_6-145.html

Asher, A. (n.d.). Mechanical ventilation. Retrieved from

http://www.med.umich.edu/pmr/images/ppt/asher.ppt

BMI Calculator. (n.d.). Bmr calculator. Retrieved from http://www.bmi-calculator.net/bmr-

calculator/

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APPENDIX

Nutritional Care Plan for Mr. C.

A – A 72 year old man was admitted complaining of shortness of breath. He is 5’10

inches and weighs 240 pounds. His BMI is 34.8 and he is overweight. He has a history of COPD,

HTN, depression, obesity, and sleep apnea. His lab values for CO2, BUN/Cr, pH, and Na

were abnormal. He was put on vent support and is unable to communicate and has been NPO for

4 days with IV fluids of normal saline for hydration.

D – Increased energy expenditure (N1-1.2) due to being on vent support. Inadequate oral food or

beverage intake (N1-2.1), inadequate protein intake (N1-52.1), inadequate fat intake (N1-51.1),

inadequate carbohydrate intake (N1-53.1), inadequate vitamin intake (N1- 54.1) and inadequate

mineral intake (N1-55.1) due to being NPO for 4 days. In the past, patient has had limited

adherence to nutrition-related recommendations (NB-1.6).

I – It is recommended that Mr. C. have glucose added to his IV immediately and the doctor

consider preparing him to receive EN through gastric tube because he has not received any

nutrition for 4 days. The recommended formula would be 2200 calories with 198 grams of

protein, 176 grams of carbohydrate and 78 grams of lipids. This calorie recommendation is made

because of his overweight status and this amount of protein is recommended to maintain lean

muscle mass.

ME – Evaluate nutrition intake, urine and stool output and lab values for total protein and serum

albumin every two days as well as checking his weight and energy level. Follow up as long as he

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is in the hospital and on vent support with the goal in mind to proceed to a normal diet as soon as

he is exubated. In addition, to provide educational support to both Mr. and Mrs. C. about the

components of the DASH diet by providing handouts and answering any of their questions so

that they would be prepared to implement the diet on discharge.

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