Clinical Care Conference

Aimee Merkle-Scotland
Fall 2018
Backus Hospital
Introducing JS

55yo M
Admitted 9/4/18
With AMS and urinary retention 2/2 ARF

Admitting Dx:
● Alcohol withdrawal
● Acute renal failure with anion gap acidosis
● Metabolic encephalopathy (? Wernicke’s)
● Severe sepsis
About JS Social Hx:
● Lives alone- supportive
housing program
PMHx: ● Has no car
● Colchester Food Bank
● Alcohol abuse
● Hx of alcohol abuse
● Tobacco abuse
● Current smoker
● Orthopedic surgery
Anthropometry and weight changes

Ht: 6’
Wt: 154lb (70kg)
BMI: 20.93kg/m2 → Normal
IBW: 166lb
UBW: 180lb

(10/7/15) 79.8kg → (6/6/16) 86.8kg → (6/13/18) 83.1kg → (9/5/18) 70kg

★ Patient reported unintentional weight loss in the past 3wk-6mo
 NFPE

General appearance Wasting

● Alert and confused
● Disheveled look, with coarse
and thin hair
● Poor dentition
● Burn marks on fingertips
● Requires glasses
● Fat wasting-
○ Moderate orbital
○ Moderate buccal
● Muscle wasting-
○ Quadriceps
○ Gastrocnemius
○ Interosseous muscle
Biochemistry Taken 9/12

CBC: Electrolytes and Renal Labs:

● WBC: 8.0 ● Na: 146 H
● RBC: 3.51 L ● Cl: 109 H
● H/H: 3.51 L/12.3 L ● BUN: 7 L
● PLT: 153 ● K, Ca, CO2, Creatinine, Anion
● MCV: 103 H gap, Mg, Phosphorus, and
● MCH: 35 H GFR all WNL
● Albumin: 3.0 L
● Protein tot: 5.7 L

Liver labs:
ALP, AST, ALT, bilirubin all WNL
 ● Enoxaparin
Meds ● Fluconazole
● Quetiapine
● Ativan
● Thiamine
● Folic acid
Current Intake

● Decresaed PO intake in the past year to 3

weeks
● Normal alcohol intake is about a pint of
vodka and a 6 pack of beer/day

24 hour recall:

● Breakfast: eggs, fruit (if available), coffee

● No lunch Since his admission, the patient’s PO intake was
● Dinner: mac and cheese, mashed poor but had improved to 100% by the follow up
potatoes, or pot pie appointment
Diet order and needs
Kcal needs:
30-35kcal/kg → 2100-2450 kcal
Regular diet, modified Mifflin St. Jeor x 1.3 IF: 2032 kcal
consistency; soft
Protein: 1.3-1.5g/kg = 91-105g

Fluid:
Method 3: 1mL/kcal x 2450 = 2450
mL
For AKI: UO + 500mL = 3450mL +
500mL = 3950 mL
 PES Statement
Severe malnutrition RT inadequate oral intake AEB loss of >7.5%
of body weight in >3 months, severe muscle loss (temporal, calf,
and quadricep regions), and moderate subcutaneous fat loss
(tricep and orbital regions).
Intervention

● Increasing PO intake
○ In hospital: initiate 2 Ensure enlive daily between
meals
○ At home: education on adding kcal, fat, protein to
meals
● Education
○ Food assistance programs in the area
○ Tips to increase intake while on a budget
○ Encouraged to quit smoking and drinking
● Coordination of care
○ Assistance with meals
 Monitoring + Nutrition Education goals:

Evaluation 1. State the number for the help

● Monitor tolerance of diet
and supplements
● Monitor PO intake and
output
● Check folate and thiamine
labs
● Weekly weights
hotline for food assistance
2. State 3 ways to add
inexpensive sources of protein
and carbohydrates to his meals
3. State 3 ways to add
inexpensive sources of fruits
and vegetables to his meals
Sample Menu

Breakfast Snack Lunch Snack Dinner Snack

1 cup oatmeal 1c cream of ⅔ cup rice ½ cup canned 1 cup mashed 1 cup frozen or
½ cup canned wheat 1 cup frozen or frozen potatoes made canned fruit
peaches 1 T peanut (or canned) vegetables with 1T butter 1 cup whole
1 cup whole butter vegetables 2 eggs 3 oz of milk
milk 1 cup whole 1 cup refried ½ cup sausage or
2 hard boiled milk (or regular macaroni and chicken
eggs canned) beans cheese

Provides 2450 kcal

Thank you!
Any questions?
References
Academy of Nutrition and Dietetics. Nutrition Care Manual. https://www.nutritioncaremanual.org/ Accessed
[9/18/2018]

Ishihara, K., Szerlip, H.M. (1998) Anion Gap Acidosis. Seminars in Nephrology 18(1): 83-97.

Mahan, K.L., Raymond J.L. Krause’s Food & the Nutrition Care Process, 14th Edition. St. Louis, Missouri: Elsevier. 2017.
Print.

Nickel, J.C. “Urinary Retention.” National Institute of Diabetes and Digestive and Kidney Diseases. National Institute of Health.
August 2014. Web. September 15, 2018. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention

No Author. “What is Alcohol Withdrawal?” WebMD. WebMD. 2005. Web. September 15, 2018.
https://www.webmd.com/mental-health/addiction/alcohol-withdrawal-symptoms-treatments#1

Wedro, B., Davis, C.P. “Encephalopathy.” eMedicineHealth. WebMD. 2018. September 15, 2018.