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Case Study Presentation: Chronic Obstructive Pulmonary Disease Copd
Case Study Presentation: Chronic Obstructive Pulmonary Disease Copd
Decramera, M et al. Systemic effects of COPD. Respiratory Medicine (2005) 99, S3S10
Chronic Bronchitis Emphysema Alveoli are enlarged and destroyed Bronchi are red and swollen, and congested with mucous secretions
Chronic cough and sputum production The sputum is usually clear and thick As bronchitis progress infections occur more frequently Periodic infections can cause fever, dyspnea, coughing, production of purulent sputum and wheezing
Household members: Husband, age 68. PMH of CAD. Ethnic background: Caucasian Referring physician: Debra Bradshaw, MD (pulmonology)
Pt refers that she is hardly able to do anything by herself right now. Even taking a bath or getting dressed makes her short of breath.
Heart: Regular rate and rhythm; mild jugular distension noted Extremities: 1+ bilateral pitting edema. No cyanosis or clubbing Neurologic: Alert, oriented; cranial nerves intact Skin: Warm, dry Chest/lungs: Decreased breath sounds, percussion hyperresonant; prolonged expiration with wheezing; ronchi throughout; using accessory muscles at rest Abdomen: Liver, spleen palpable; nontender, normal bowel sounds nondistended,
Pt values 15 4 11.5 35 83 5 10 3 1
Normal range 4.3-10 4-5 12-16 37-47 50-62 3-6 25-40 3-7 0-3
24h recall: c coffee with nondairy creamer, few sips of orange juice, c oatmeal with 1 tsp sugar, c chicken noodle soup, 2 saltine crackers, c coffee with nondairy creamer, 32oz of Pepsi per day.
ASSESSMENT
Food / Nutrition History Data
Pt intake x needs Pt needs 1592 kcal 49.55g 15.93g 300mg 2400mg 218.98g 22.30g --43.18g 1200mg 8mg --Usual intake 1440 kcal 36g 28g 55mg 1220mg 248g 8g 134g 24g 30% 40% 93.24mg 24h recall 1100 kcal 27g 25g 5mg 1070mg 200g 2g 130g 6g 4% 10% 93.24mg
ASSESSMENT
Anthropometric Data
Chemistry Labs
ASSESSMENT
Biochemical Data
Pt values 3.4g/dl 5.9g/dl 19mg/dl 219mg/dl Albumin Total protein Prealbumin Transferrin
Age: 62y Ht: 53 = 160cm IBW: 115lb = 52.3Kg UBW: 145-150lb = 65.9-68.1Kg Usual BMI: 25.75 = overweight ABW: 119lb = 54.0Kg Actual BMI: 21.14 = healthy range wt: 20.66% since COPD dx 5 years ago
Na 136
BUN 9 Cr 0.9
GLU 92
Hematology Labs WBC RBC HGB HCT SEGS BANDS LYMPHS MONOS EOS
Pt values
15x103mm3
ABGs Labs pH pCO2 pO2 SO2 CO2 content Carbonic acid Base excess Base deficit HCO3-
1d Pt values
Units
7.29
50.9
mmHg mmHg
77.7 92
31
5% 10% 3% 1%
2.4
3.6
1.2 6.0
24.7
29.6
ASSESSMENT
Physical Examination Data
Social history Head and neck Teeth: Poorly fitting dentures Skin Skin: dry Edema, peripheral: 1+ bilateral Vital Signs Temperature: 98.8F Respiratory Rate: 22 bpm Shortness of breath
ASSESSMENT
Client History Data
Physical activity, easy fatigue with increased activity; unable to achieve desired levels Medical/ Health history Chronic Obstructive Pulmonary Disease Upper respiratory infections or pneumonia Signs and symptoms Shortness of breath or dyspnea on exertion or at rest Meds and supplements Medications that cause anorexia: Albuterol sulfate
DIAGNOSIS RATIONAL
NI 2.1 Inadequate Oral/Food Beverage Intake Definition Less than established reference standards or recommendations based on physiological needs nutrient needs due to prolonged catabolic illness NC 3.2 Involuntary Weight Loss Decrease in body weight that is not planned nutrient needs due to prolonged catabolic illness Weight loss of 5% within 30 days, 7.5% in 90 days or 10% in 180 days Fever, heart rate, respiratory rate Normal or usual intake in face of illness Poor intake, change in eating habits, skipped meals, change in way clothes fit
Anthropometric Data
Etiology
Biochemical Data
Anthropometric
Weight loss
Physical Exam.
Dry skin
Food/Nutrition hx
Client hx
Conditions associated with a diagnosis or tx (COPD) Medications associated with weight loss
NUTRITIONAL DIAGNOSIS
PES STATEMENT
1.
INTERVENTION
FOOD AND/OR NUTRIENT DELIVERY MEALS AND SNACKS (ND-1)
Modify distribution, type, or amount of food and nutrients within meals or at specified time
GOALS Maintain actual body weight, recover plasma protein levels Decrease fatigue while eating Decrease early satiety Prevent fluid retention Prevent dehydration, which thickens mucus Decrease food-drug interaction MEANS BEE x 1.3 = 1530 Kcal PRO = 17% = 65g/d = 1.2g/Kg/d CHO = 48% = 183.6g/d LIP = 35% = 59.5g/d Use 6 small concentrated meals at frequent intervals Limit fluid intake with meals Limit salt intake, restrict Na and increase K intake Fluids = 30ml/Kg = 1620ml/d Decrease caffeine intake
INTERVENTION
2. NUTRITION EDUCATION INITIAL/BRIEF NUTRITION EDUCATION (E-1) Priority Modifications: Communicate relationship between nutrition and specific disease/health issue
GOALS Decrease food-drug interaction Avoid coughing spells Conserve energy during the day MEANS Provide knowledge: association between caffeine & bronchodilators Provide knowledge of caffeine high-content foods Avoid excessively hot or cold foods Encourage slow eating Give suggestions of foods that are easy to prepare Main meal early in the day to have more energy throughout the rest of the day Encourage rest periods before and after meals Encourage the patient to make small, attractive meals Overcome anorexia Explain how to concentrate protein and calories in small feedings Avoid distension from large meals or gaseous foods Ensure adequate flavor of foods Provide knowledge: no association between milk & mucus production Explaining the benefits of milk/Calcium intake Explain: relation between Ca, BMD, osteoporosis risk for post-menopausal women
INTERVENTION
3. COORDINATION OF NUTRITION CARE COORDINATION OF OTHER NUTRITION CARE (RC-1) CARE DURING
GOALS
MEANS
Schedule treatments to mobilize mucus 1 hour before and after meals to prevent nausea Improve ventilation before meals and overall physical Improve physical conditioning with planned exercises, especially conditioning to strengthen strengthening exercises respiratory muscles Make sure the oxygen cannula is worn during and after meals. Eating and digestion require energy, which causes the body to use more oxygen
DOCUMENTATION
ADIME FORMAT
A (Assessment): Review of data reveal a 62 year-old female with a medical dx of COPD with poor food choices comprised of high content of saturated fat, sugar and caffeine, although with insufficient caloric and micronutrient intake. Pt is 53, 119lb, BMI 21.14, although pt has been loosing wt since COPD dx 5yr ago (145-150lb). Labs reveal low albumin and total protein and pre-albumin has borderline values. Pt presents shortness of breath and cough which impair food intake. D (Diagnosis): Involuntary weight loss (NC-3.2) RT increased
nutrient needs 2 COPD AEB 20% of weight loss since COPD diagnosis.
DOCUMENTATION
ADIME FORMAT
I (Intervention): Nutrition Prescription Meals
and Snacks (ND-1) Recommend 1530 kcal diet providing 65g of protein, 184g of CHO, 60g of fat and 1620ml of fluid/d. Limit sodium and caffeine intake. Eat small meals at frequent intervals. Initial/Brief nutrition education (E-1) Provide knowledge and tips to decrease drug-nutrient interactions, conserve energy during the day, prevent coughing spells, overcome anorexia and increase milk intake. Coordination of Other Care During Nutrition Care (RC-1) Referral to Physical Therapist to improve ventilation before meals and overall physical conditioning to strengthen respiratory muscles.
THANK YOU
QUESTIONS?
M (Monitoring): Tolerance to diet, food diary, body weight, presence of peripheral edema, Labs (ABGs Labs, Alb, preAlb, H/H), pt understanding, sx of shortness of breath and fatigue while eating, appetite. E (Evaluation):Comparison of intake to estimated needs, change of dietary habits, and improvements in fatigue while eating