Patient Case Study

10/2/17-11/13/17
Lauren Lenk
 Background

❖  “JH”
❖  59 year old male
❖  History of DM, HTN, and HLD
❖  Severe motorcycle accident
❖  Traumatic brain injury
 Background continued

❖  First hospital admission on 8/20/17

❖  PEG tube placed 9/13
❖  NPO
❖  Transferred 10/2/17
 Nutrition Assessment
Food/Nutrition Related History

❖  NKFA
❖  Diet history unavailable
❖  First hospital: enteral nutrition-Pivot 1.5
❖  Second hospital: Jevity 1.2 ATC 30ml water 3 times/day
❖  This diet provided 1872 calories, 87 grams of protein and 1263ml of water.
 Anthropometric Data

Admission weight (10/2): 98.7kg (217lb) Height: 5’10 (70 inches

Current weight: 96.7kg (213lb) Weight change over time: 46lb loss 8/20-10/24 (42lb wt. loss at first hospital, ~4lb loss at second)

Usual body weight: 118 kg (260lb) % UBW: 78% moderate malnutrition

IBW: 75kg (165lb) Current body weight/ usual body weight x100

(92.6kg/118kg x 100=78.4)

BMI: 31 (classified as obese)

70x70=4900

4900/217(lb)x704.5= 31.19
 Weight Trend

10/4 10/7 10/14 10/21 10/24 10/28 11/11

98.7kg 98.8kg 97.8kg 93.3kg 92.6kg 96.8kg 96.7kg

bedscale bedscale Liko lift bedscale bedscale Liko lift Liko lift
 Biochemical Data

Dates Prealbumin Albumin Sodium BUN

10/2 - - 150 36

10/5 35 2.8 - -

10/9 - - 133 21

10/23 - 3.3 134 7

10/30 - - 134 8

11/6 - 3.5 134 9

 Biochemical Data-Blood Sugars
Date 12 midnight 6AM 12 noon

10/5 129 166 -

10/6 136 147 140

10/7 178 175 110

10/8 142 152 132

10/9 155 149 136

 Nutrition Focused Physical Findings
●  Overweight-abdominal area
●  Muscle wasting
●  Skin-dry, warm, pale
●  Wounds- unstageable located on coccyx, left ear, back of head, left toe
●  GI- rectal tube 9/13-10/5
 Client History
Personal Hx: Social Hx:

●  Divorced ●  3 children-2 sons, 1 daughter

●  lives alone ●  Ex-wife- power of attorney
●  runs their own printing company ●  Appears very independent
●  enjoys working on cars ●  Mildly religious
●  passion for motorcycles ●  Connecticare
 Primary Diagnosis
Traumatic Brain Injury (TBI)

●  Intracerebral hemorrhage (ICH)

●  Subarachnoid hemorrhage (SAH)
 Intracerebral hemorrhage (ICH)
A rupture of blood vessels around or in the brain causing bleeding in the skull

Epidemiology: 12-15 of every 100,000

Causes: physical trauma

signs/symptoms: headache, vomiting, dizziness, confusion, unequal pupil size, slurred speech, lethargy,
drowsiness, seizures, and loss of consciousness

Treatment: Intubation due to risk for aspiration, stabilizing vitals, surgical approaches such as craniotomy,
speech evaluations for swallow difficulties, initiating enteral feedings as soon as possible
 Subarachnoid hemorrhage (SAH)
Bleeding into the subarachnoid area of the brain, is usually distinguished from an intracerebral
hemorrhage that has been extended into the subarachnoid area.

Epidemiology: 9 per 100,000

Causes: most common-head trauma

signs/symptoms: onset severe headache (most common symptom), nausea/vomiting, visual changes,
neurologic deficits, loss of consciousness, seizures, elevated blood pressure, elevated temp, tachycardia

Treatment: antihypertensive medications to control blood pressure, fluid restrictions, and antihypertensive
therapy
 Secondary Diagnosis
Dysphagia- An impairment in the condition of swallowing

Causes- Traumatic brain injury

Signs/symptoms: Difficulty swallowing, coughing, choking, food stuck in throat, weight loss, changes in
eating habits, persistent pneumonia

Treatment: Diet modifications following the Dysphagia diet, exercise techniques, posturing while eating,
enteral nutrition
 Medical Tests
FEE’s test

10/11 Upgraded to: Puree, nectar

10/23 Upgraded to: Soft, thin

11/9 Upgraded to: Ground, thin

11/13 Upgraded to: Whole, thin

 Medical Treatment
●  Nutrition
●  Speech
●  Physical and Occupational Therapy
●  Respiratory
 Patient Diagnosis: Nutritional Consequences
●  Communicate nutritional needs-
○  hunger/satiety
○  Stomach pain
○  TF tolerance
○  Food preferences
○  Supplementation
●  Cannot feed self
●  Clinical judgement, trial and error, team efforts
 Estimated Needs
Estimated Energy Needs: Using desirable body weight of 70kg= 2100kcals.

30kcals/kg due to significant weight loss, trauma, and present wounds

(70kg x 30kcal/kg= 2100kcals needs).

Estimated Protein Needs: 98kg

1.4g/kg due to protein depletion and current wounds

(70kg x 14.4g/kg=98g protein needs)

Estimated Fluid Needs: 2100ml

30ml/kg- fluid need for the age of 55-65

(70kg x 30ml/kg= 2100ml fluid needs).

 Nutrition Diagnosis
PES statement: Inadequate enteral nutrition related to possible tube feed intolerance and trauma as evidence by 46-

pound weight loss x 2 months, mild protein depletion, and dehydration.

PES statement 2: Inadequate oral intake related to dysphagia and traumatic brain injury as evidence by poor po

intake (25%) and reliance on tube feed boluses.

 Nutrition Intervention
Goals

●  Stabilize weight to desired range

●  Improve protein levels to within normal limits
●  Maintain controlled blood sugars
●  Transition to po as medically appropriate
 Nutrition Intervention
Food/Nutrient Delivery
●  Jevity 1.2 ATC 30ml water 3x day This diet provided 1872 cals, 87g pro, 1263ml of water.
●  Switched to Nutren 1.5@ 75ml/hr x 16hrs, Nutren 1.5 240ml bolus at 12 noon, and 300ml water
bolus’s three times a day
●  Fiber supplement trial 3x day

●  2205 calories 98 grams of protein and 1994ml of water.

 Nutrition Intervention
●  10/11 FEE’s: started on po
●  Tube feed remained the same
●  History of diabetes-on insulin
●  Questioned nocturnal TF altering hunger
●  Post meal bolus <50% HS bolus
●  Eating 75-100%
 Nutrition Intervention
●  10/20 TF d/c
●  FEES 10/23-upgrade
●  Poor po-resume post meal boluses
●  Worsening wound-protein supplement
●  Po continued to be variable-continue post meal bolus
 Nutrition Intervention
Counseling/Education-n/a

Coordination of care-

●  Speech
●  Nursing
●  CNA’s
●  Social work
 Monitoring and Evaluate
●  Food/Nutrition Related History: Patient will consume 75-100% of meals po

●  Anthropometric Data: Weight maintenance at this time. Slow weight loss as medically appropriate (wounds should

heal before goal for weight loss).

●  Biochemical Data/Medical Tests: Request labs weekly to monitor, check Prealbumin and albumin every two weeks to

assess protein adequacy while wounds are present, blood sugars should be checked daily to monitor control.

●  Nutrition Focused Physical Findings: Right ear, left toe, and back of head wounds-healed. Stage 4 wound on coccyx-

continue protein supplement regimen 3x day.

 References
1. Torner JC. Epidemiology of Subarachnoid Hemorrhage . SEMINARS IN NEUROLOGY. 4. https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-2008-1041565.pdf. Accessed November 19, 2017

2. Emedicine.medscape.com. (2017). Subarachnoid Hemorrhage: Practice Essentials, Background, Pathophysiology. [online] Available at: https://emedicine.medscape.com/article/1164341-overview [Accessed 21
Nov. 2017]

3.. De Rooij NK, Linn FHH, van der Plas JA, Algra A, Rinkel GJE. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. Journal of Neurology,
Neurosurgery, and Psychiatry. 2007;78(12):1365-1372. doi:10.1136/jnnp.2007.117655.

4. Mayoclinic.org. (2017). Intracranial hematoma - Symptoms and causes - Mayo Clinic. [online] Available at: https://www.mayoclinic.org/diseases-conditions/intracranial-hematoma/symptoms-causes/
syc-20356145 [Accessed 21 Nov. 2017].

5. Emedicine.medscape.com. (2017). Intracranial Hemorrhage: Background, Pathophysiology, Epidemiology. [online] Available at: https://emedicine.medscape.com/article/1163977-overview [Accessed 21 Nov.
2017].

6. Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709.

7. Intracerebral Hemorrhage. Google Books. https://books.google.com/books?hl=en&lr=&id=YieKCwAAQBAJ&oi=fnd&pg=PA21&dq=incidence%2Bof%2BIntracerebral

%2Bhemorrhage&ots=gpoKFpx1bN&sig=IQW2-ulA6C4i0dqbbYelI-tZSZQ#v=onepage&q=incidence%20of%20Intracerebral%20hemorrhage&f=false. Accessed November 19, 2017.

8. Emedicine.medscape.com. (2017). Dysphagia: Practice Essentials, Background, Anatomy. [online] Available at: https://emedicine.medscape.com/article/2212409-overview [Accessed 22 Nov. 2017]

9. Nacci A, Ursino F, La Vela R, Matteucci F, Mallardi V, Fattori B. Fiberoptic endoscopic evaluation of swallowing (FEES): proposal for informed consent.Acta Otorhinolaryngologica Italica. 2008;28(4):206-211.

10. PubMed Health. (2017). PubMed Health - National Library of Medicine. [online] Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/ [Accessed 21 Nov. 2017].