Mini-Case Study Presentation

Hilary SmithNovember 17, 2014

Patient SL

84 y/o female Transported by EMS from home, pt

unsure who called 911 Admitted 11/2/14 with weakness,

UTI and signs of alcohol withdrawal Number of intern contacts: 3, 1 with

RD Number of RD contacts: 1

Social History Does not have a Primary Care Physician Lives at 2-story home with 50-year old

son who is wheelchair-bound and takes care of him, and 24 y/o grandson

SL using a wheelchair more often, was unable to get up 3 days prior to admission

Patient arrived unkept

Prior Medical History H/o alcohol use, unknown how

much/often Alcohol level 150 upon admission

Smokes 1 pack/day H/o L hip repair surgery, acute renal

failure, b/l lower extremity cellulitis, HTN

No home meds

Diet History

Upon first contact, was not able to obtain history Patient sleeping and no PO intake

Visited 2 days later Pt says she eats 2 meals/day at home Usually a bagel, sometimes with lox for

breakfast/lunch Used to cook but now eats pizza or Chinese food

for lunch or dinner Current intake: inconsistent ~50%, likes Ensure

CIWA Protocol Clinical Institute Withdrawal Assessment SL was put on protocol upon admit Measures 10 symptoms to assess pt risk for

withdrawal Assessment score

>8-10, minimal to mild withdrawal 8-15, moderate withdrawal 15+, severe withdrawal

Pt assigned detoxification program

Medications IV NS @ 120 ml/hr alternating with IV NS +

MVI + folic acid + thiamine @ 150ml/hr “Banana Bag”

Ceftriaxone – ABT for UTI Consider Na content with low Na diet; anorexia

Folic acid Thiamine Multivitamin w/ Minerals Diazepam – Alcohol withdrawal symptoms

Limit caffeine to <400-500 mg/day, caution with grapefruit

Ativan PRN – Alcohol withdrawal symptoms

Labs

K - 3.3 mmol/L – low Ref. range 3.5-5.1

Ca - 7.6 mg/dL – low Ref. Range 8.5-10.1

Albumin - 2.7 g/dL – low Ref. Range 3.4-5.0

Ethanol – 150 mg/dL - high

Nutrition History

Diet at time of assessment: Room Service, Heart Healthy (3-4g Na, low fat, low cholesterol)

Liberalized to House Menu, Regular on 11/9

Physical

Appearance: frail 2 Pressure ulcers: R ischium,

unstageable; L ischium Stage II, staged per wound care RN

Demeanor: lethargic; first visit pt was sound asleep (Ativan PRN)

Anthropometric Data Height: 152 cm Weight: 44.6 kg BMI: 19.3 IBW: 51 kg %IBW: 87% UBW: unknown per pt, thinks she

may have lost some weight prior to admission

Nutrition Needs Calorie needs – Mifflin St. Jeor Weight used: 44.6 kg (admit wt) Activity factor: 1.3-1.4 (pressure ulcers,

frail appearance) 1067-1149 kcal/day

Protein 1.5 g/kg (pressure ulcers) 67g/day

Fluid Needs: 1,338 ml/day 30 ml/kg (Age 55+)

PES Statement

Inadequate oral intake related to ETOH withdrawal as evidenced by patient not eating solid food

Plan/Recommendations Level: Severe Level 4 (1-4 scale)

Reassess every 2-4 days Poor PO intake averaging <25% of needs

Continue with current diet Add Ensure Complete BID to breakfast and

dinner (350 kcal, 13g protein) To increase potential for calorie intake and

promote wound healing Monitor diet tolerance, supplement

tolerance, labs, weight, intake and output

Goal

Increase oral intake to 50-75% of meals/supplements

Timeframe to achieve: 3 days

Hospital Course

11/2/14 Admission 11/3/14 1st visit and assessment with RD 11/5/14 Intern visit to obtain diet history,

UBW, encourage intake, assess appropriateness for education

11/6/14 Discharge to Sub-Acute Rehab unit at Northwest Hospital

11/8/14 2nd assessment by RD Added Magic Cup 1x/daily (290 kcal, 9g protein) Liberalized diet to regular to increase food

choices 11/9/14 Changed to House, Regular

Wound and Weight Status

Currently has unstageable pressure ulcer on R ischium and healing stage II pressure ulcer on L ischium

Current weight 46.5 kg gained 4.18 lbs since admission

Nutrition Literature Support

NPUAP-EPUAP (National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel) Guidelines All individuals should have nutrition assessment

upon admission and with each condition change

Provide sufficient calories 30-35 kcal/kg for pts under stress and pressure ulcer

Provide adequate protein for positive N balance 1.25-1.5 g/kg protein No evidence-based recommendation for Arginine or

Glutamine Provide and encourage daily fluid intake Provide adequate vitamins and minerals

Through diet; offer supplement if deficiency confirmed/suspected

Medical Literature Support Alcohol impairs wound healing and

increases incidence of infection EtOH intoxication at time of injury is a risk

factor for increased susceptibility to infection in a wound

Acute EtOH exposure can lead to impaired wound healing by weakening the early inflammatory response, preventing wound closure, angiogenesis, and collagen production, and changing the protease balance at the site of the wound.

Questions?

References

1. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper

2. Factors Affecting Wound Healing, Journal of Dental Research