NUTRITION SUPPORT

Cally Byrne
Francis Kozlowski MS. RD, CNSC, LD

CLIENT/SOCIAL HISTORY
S.S.
80 y/o male
Med Hx:
C3 tetraplegia 2 fall from step stool (2013)
Neurogenic bowel/bladder
2 Stage IV Sacral Pressure Ulcers
Chronic hyponatremia
HTN

TIMELINE
2/24/16
Scheduled admission to SCI for management of sacral
decubitus ulcer

2/25/16
Transferred to MICU for AMS and HTN
CT left basal ganglia hemorrhage w/ intraventricular
hemorrhage and mild hydrocephalus

2/26/16
Transferred to UH to be evaluated by neurosurgery

HEMORRHAGIC STROKE
Two types of stroke
Ischemic: Blood flow stopped by
blockage
Hemorrhagic: Weakened vessel tears
or ruptures, causing blood to leak in
and around brain

Two types of hemorrhagic

stroke
Intracerebral hemorrhage (ICH)
Basal ganglia hemorrhage
Subarachnoid Hemorrhage (SAH)

BASAL GANGLIA HEMORRHAGE

Most common cause
Hypertension

Signs and Symptoms

Headache, neck pain, double vision,
nausea or vomiting, loss of
consciousness or death
Body movement, sensation, vision,
personality, speech, ability to swallow

Treatment and therapy

Minimize injury and stabilize patient
Depends on severity of stroke and
range of symptoms

TIMELINE
2/24/16
Scheduled admission to SCI for management of sacral decubitus ulcer

2/25/16
Transferred to MICU for AMS and HTN; Intraventricular hemorrhage

2/26/16
Transferred to UH to be evaluated by neurosurgery

3/1/16
Transferred back to VA (SCI); Nutrition consult placed for TF recs.

3/2/16
Began TF via dobhoff
SLP NPO and TF via dobhoff until lethargy resolves
NUTRITION!

INTERVIEW
Chewing Problems: No
Dysphagia: No
However, 3/1/16 med note: "MBS was
performed which showed oropharyngeal
dysphagia.

Appetite: Fair
Nausea: No
Vomiting: No
Feeding Assistance Required: Yes
dependent during feeds
Diarrhea: No
Constipation: No
*However, 2/25/16 ntrn note: "Yes - chronic"

ANTHROPOMETRICS

Height: 59
Wt: 180.9 lbs
Target Wt: 147-153 lbs
adj for obesity and SCI

BMI not appropriate

Nutrition
Assessme
nt

MEDICATIONS
Ascorbic Acid
Nystatin
Omeprazole
Sodium Chloride
Zinc Sulfate

Bisacodyl
Hydralazine
Lidocaine
Nitroglycerin
Ondansetron
Piperacillin

BIOCHEMICAL DATA/MEDICAL TESTS

Date

Gluc

Na

BUN

Ca
(Correcte
d)

Cr

Mg

Phos

EGFR

Albumin

3/1/16

116

126 (L)

3.1

12

0.4 (L)

8.9

1.7 (L)

2.5

207

2.8 (L)

3/2/16

106

127 (L)

3.8

14

0.4 (L)

8.8

1.8

207

2.8 (L)

3/3/16

108

131 (L)

3.8

19

0.4 (L)

9.4

2.4 (L)

207

3.3 (L)

3/4/16

108

132 (L)

3.7

25 (H)

0.4 (L)

9.5

2.5

207

3 (L)

3/5/16

131

135 (L)

3.6

44 (H)

0.5

9.3

160

3 (L)

3/6/16

123

139

3.6

35 (H)

0.5

9.5

2.7

160

3.1 (L)

3/7/16

145

143

3.9

34 (H)

0.4 (L)

9.4

2.8

207

3.1 (L)

3/9/16

100

136

4.1

20

0.4 (L)

9.4

3.2

207

3.1 (L)

Prealbum
in

26

CRP

5.97

COMPARATIVE STANDARDS
Energy Requirements
2,055 kcal/day
30 kcal/kg
Target Body Weight

Protein Requirements
103 g/day
1.5 g/kg
Target Body Weight

Fluid Requirements
2,555 ml/day

NUTRITION DIAGNOSIS

Inadequate oral food/beverage intake

Related to: poor po intake, dysphagia
As evidenced by: need for TF and
dysphagia pureed diet

NUTRITION INTERVENTION

Follow SLP recommendations regarding po intake

TF through Dobhoff
No PO Impact 1.5 FS @55 cc/hr
1,980 kcals, 124 g pro, 0 g fiber, 1016 ml h2o, >100% RDIs vits/mins
PO Impact 1.5 FS starting at 55 cc/hr, increasing as tolerated to goal
rate of 80 cc/hr x 12 hrs (6p-6a)
1,440 kcals, 90 g pro, 0 g fiber, 739 ml water, <100% RDIs

NS flushes of 50-100 cc qshift adj for hydration needs

NUTRITION INTERVENTION

No education provided
Coordination of Care:
HOB elevated 45 degrees during TF
Requested psyllium be provided separate from TF
Please obtain prealb and CRP once TF @ goal x 3 days

NUTRITION MONITORING AND

EVALUATION
No nausea, vomiting, or abdominal distention
Prealb >15 w/ CRP wnl
Wt maintenance w/o significant gain or loss >5% in one month

PATIENT UPDATE

Diet:
3/3/16: Dysphagia pureed diet w/ honey thick liquids (only when patient is
alert)
3/7/16: Ensure+ TID
3/8/16: Transition to nocturnal TF
3/9/16: Dysphagia advanced diet w/ thin liquids

Labs: Hyponatremia resolved, Albumin improved and Prealb was at 26

mg/dl (3/9/16)

REFERENCES

The New Jersey Comprehensive Stroke Center at University

Hospital. Types of Stroke. University Hospital Newark, New
Jersey Web Page. http://www.uhnj.org/stroke/types.htm.
Accessed March 10, 2016.
Knipe H, Jones J, et al.. Radiopaedia.org.
http://radiopaedia.org/articles/intraventricular-haemorrhage.
Accessed March 10, 2016.