Case-22-24 Ischemic Stroke – Medical Nutrition Therapy: A Case-Study Approach : Book Guide

This Document Contains Cases 22 to 24 Case 22 – Ischemic Stroke I. Understanding the Disease and Pathophysiology 1. Define stroke. Describe the differences between ischemic and hemorrhagic strokes. • Stroke is defined as a disruption of brain function caused by interruption of blood flow to the brain. • Ischemic stroke refers to a reduction in blood flow caused by atherosclerotic or damaged blood vessels that supply blood to the brain. A thrombotic stroke may also result via a plaque breaking off and occluding an already narrowed vessel. • Hemorrhagic stroke results from a weakened blood vessel that ruptures and bleeds into the surrounding brain; blood accumulates and compresses surrounding brain tissue. 2. The non-contrast CT confirmed that Mrs. Washington had suffered a lacunar ischemic stroke—NIH Stroke Scale Score of 14.What does Mrs. Washington’s score for the NIH stroke scale indicate? • Mrs. Washington was classified as a level 14. • A score over 22 is interpreted as severe neurological deficit. • She is classified as having a moderate neurological deficit. 3. What factors place an individual at risk for stroke? • Non-modifiable: Gender – female Ethnicity – African-American; Hispanic Age (risk doubles each decade after 55) Genetics • Modifiable: Hypertension (highest contribution) Cardiovascular disease Diabetes mellitus Dyslipidemia Asymptomatic carotid stenosis Cigarette smoking (second highest contribution) Alcohol use Illicit drug use Dietary intake (third highest contribution) Use of oral contraceptives High BMI Low Physical activity 4. What specific signs and symptoms noted with Mrs. Washington’s exam and history are consistent with her diagnosis? Which symptoms place Mrs. Washington at nutritional risk? Explain your rationale. • New-onset weakness of the right side involving the right arm and leg. • Difficulty speaking with changes in control of muscles and tongue. • Cranial nerves III, V, VII, and XII impaired. • Motor function tone and strength diminished on right side and for extremities. • Dysarthria may place Mrs. Washington at risk for difficulty with chewing and swallowing. • Her weakness indicates she may have problems with meal preparation and self-feeding skills. 5. What is rtPA? Why was it administered? • Tissue plasminogen activator (tPA) is an enzyme normally found on the surface of endothelial cells of veins, capillaries, the pulmonary artery, the heart, and the uterus. It is secreted after vascular injury. • Recombinant tPA (rtPA) is a tissue plasminogen activator produced by recombinant DNA technology. • It is administered to heart attack and stroke patients to help dissolve clots. II. Understanding the Nutrition Therapy 6. Define dysphagia. What is the primary nutrition implication of dysphagia? • Dysphagia is difficulty swallowing and is a common problem in neurogenic disease. • The primary nutrition implications are inadequate oral intake and risk of aspiration/choking. 7. Describe the four phases of swallowing: a. Oral preparation Food is manipulated in the mouth and masticated if necessary, reducing it to a consistency ready for bolus formation and swallowing b. Oral transit Tongue propels food posteriorly until the pharyngeal swallow is triggered c. Pharyngeal Pharyngeal swallow is triggered; the bolus is moved through the pharynx; and the cricopharyngeal sphincter (upper esophageal sphincter) opens to allow the bolus to enter the esophagus d. Esophageal Esophageal peristalsis carries the bolus through the cervical and thoracic esophagus and into the stomach 8. The National Dysphagia Diet defines three levels of solid foods and four levels of fluid consistency to be used when planning a diet for someone with dysphagia. Describe each of these levels of diet modifications. Diet Description Examples of foods NDD-1: Dysphagia Pureed • Designed for individuals with ○ severely reduced oral preparatory stage abilities ○ impaired lip and tongue control ○ delayed swallow reflex triggering ○ oral hypersensitivity ○ reduced pharyngeal peristalsis ○ and/or cricopharyngeal dysfunction • Pudding consistency – pureed smooth with no lumps. • Cream of wheat • Smooth yogurt • Smooth custard • Pudding NDD-2: Dysphagia Mechanically Altered • Designed for individuals who can tolerate a minimum amount of easily chewed foods. • May be appropriate for persons with ○ moderately impaired oral preparatory stage abilities ○ edentulous oral cavity ○ decreased pharyngeal peristalsis ○ and/or cricopharyngeal muscle dysfunction • No coarse textures, nuts, raw fruits or vegetables; meat is ground or finely diced or in casseroles. • Eggs • Pancake with syrup • Tuna salad • Canned peaches • Banana NDD-3: Dysphagia Advanced • Designed for pts who may have difficulty chewing, manipulating, & swallowing certain foods. • Based on a mechanical diet & consists of soft food items prepared w/out blenderizing or pureeing. • May be appropriate for persons beginning to chew or with mild oral preparatory stage deficits. • No hard fruits or vegetables, nuts, or crispy, raw, sticky, or stringy foods. • Vegetable soup • Ham sandwich • Cantaloupe Liquid type Liquid viscosity in cP (at shear rate of 50 s-1 and 25 degrees C) Thin liquid 1-50 Nectar-like 51-350 Honey-like 351-1750 Spoon-thick >1750 9. It is determined that Mrs. Washington’s dysphagia is centered in the esophageal transit phase and she has reduced esophageal peristalsis. Which dysphagia diet level is appropriate to try with Mrs. Washington? • Esophageal phase: Epiglottis does not close normally. Bolus remains in the esophagus. Avoid sticky and dry foods. Follow dense foods with liquids. • Stage 2: Ground/minced diet, but patient may be able to tolerate as high a level as Phase 4 since she has little difficulty with the oral stages of her diet. She must be sure to follow dense foods with liquids to wash food through the esophagus. Liquid type: Nectar-like 10. Describe a bedside swallowing assessment. What are the background and training requirements of a speech-language pathologist? • A bedside swallowing assessment involves a physical examination, including oropharyngeal motor function, signs and symptoms of dysphagia, and tolerance to various food and fluid consistencies. • It can be difficult to detect aspiration conclusively during this evaluation. • A speech-language pathologist (SLP) has a master’s degree that requires an additional clinical fellowship. • A SLP must additionally successfully pass a national exam for a certificate of clinical competence (CCC). 11. Describe a modified barium swallow or fiberoptic endoscopic evaluation of swallowing. • These are the preferred diagnostic tools for dysphagia. • Modified barium swallow: ○ Fluoroscopy allows observations of the oral cavity, pharynx, and esophagus during a swallow. ○ Barium is added to foods and liquids in order to observe the bolus. • Fiberoptic endoscopic evaluation of swallowing: ○ small, fiberoptic endoscope (inserted through the nose) used to observe the oral pharynx and larynx while the patient swallows different consistency foods and liquids • Results are used to identify: Absence/presence of dysphagia Percentage (estimated amount) of aspiration Bolus transit time Motility problems Pooling of food Efficiency of swallow Etiology of dysphagia Efficacy of various compensatory or therapeutic strategies • It also offers opportunity to assess and test the safety of different types, textures, and amounts of food. 12. Thickening agents and specialty food products are often used to provide texture changes needed for the dysphagia diet. Describe one of these products and how it may be incorporated into the diet. • Gelatin, pureed thick vegetables, pureed fruits or applesauce, baby rice cereal, and baby apple flakes can be used in addition to many commercial thickeners that are available for use (ThickIt®; Thick’N Easy®; Thixx®; NutraThick ThickenUp®, etc.). • ThickenUp® is 100% modified cornstarch. • It provides 15 kcal/tbsp and can be made to any consistency. • Following the instructions provided on the package or incremental adding of the product will allow one to increase the viscosity of the food/beverage, as desired III. Nutrition Assessment 13. Mrs. Washington’s usual body weight is approximately 165 lb. Calculate and interpret her BMI and %UBW. • BMI = 165/622  703 = 30.2. • This is classified as Grade 1 obesity. • Based upon her current body weight, her BMI is 33.9. • Generally, a healthy weight for most elderly falls between a BMI of 24 and 29. • A BMI greater than 29 can be associated with increased health problems. 14. Estimate Mrs. Washington’s energy and protein requirements. Should weight loss or weight gain be included in this estimation? What is your rationale? • Women: RMR = (9.99  84.1) + (6.25  157.48) – (4.92  77) – 161 RMR = 1349.2 kcal (AF 1.2) = 1619 or about 1500-1700 kcal • Protein requirements – 0.8-1.0 g/kg = 67-84 grams • Even though her BMI places her in the obese category, weight loss is not recommended at this time. • She is at risk for decreased oral intake so weight maintenance should be the goal at this time. 15. Using Mrs. Washington’s usual dietary intake, calculate the total number of kilocalories she consumed as well as the energy distribution of kilocalories for protein, carbohydrate, and fat. • Total kcal: 1938 kcal • 80g protein (16% kcal from protein) • 71 g fat (33% kcal from fat) • 257g carbohydrate (53% of total kcal) 16. Compare this to the nutrient recommendations for an individual with hyperlipidemia and hypertension. Should these recommendations apply for Mrs. Washington during this acute period after her stroke? • Current recommendations for treatment of hyperlipidemia use the Therapeutic Lifestyle Change Diet and the DASH diet recommendations. <30% total kcal from fat <7% from saturated fat <200 mg cholesterol <2400 mg sodium 20-30 g fiber per day • The DASH diet encourages 10-12 servings of fruits and vegetables in order to provide higher potassium, magnesium, and calcium in the diet with a reduced sodium intake. • Mrs. Washington’s diet provides: Nutrient Recommended amounts (based on 2000 kcal/day) Mrs. Washington’s Fat <30% of total kcal 33% Saturated fat <7% 10% Cholesterol <200 mg 181 mg Calcium 1240 mg 707 mg Potassium 4700 mg 3452 mg Sodium <2400 mg 2712 mg • Mrs. Washinton’s diet is really pretty close to the recommendations of both the TLC and DASH diets. • Her diet is slightly high in fat, low in potassium, high in sodium, low in calcium, and high in saturated fat. • Increasing the total quantity of fruits and vegetables will assist to reduce total energy and sodium intake with lower-fat food choices and increase potassium at the same time. Increasing her dairy intake through low-fat milk and yogurt can help improve her calcium intake while avoiding saturated fats that come from cheese sources. • Yes, these recommendations should apply to Mrs. Washington during this acute phase. 17. Estimate Mrs. Washington’s fluid needs. • Weight: 100 mL per kg body weight for 1st 10 kg 50 mL per kg body weight for next 10 kg 20 mL per kg body weight for each kg above 20 kg 1000 + 500 + 1100 = 2600 mL fluid • Age & weight: 55-65 years: 30 mL per kg body weight per day 30  75 = 2523 mL • Energy needs: 1 mL per kcal = 1619  1 ≈ 1600 mL 18. Review Mrs. Washington’s labs upon admission. Identify any that are abnormal. For each abnormal value, explain the reason for the abnormality and describe the clinical significance and nutritional implications for Mrs. Washington. Each of the following abnormal labs results from her hyperlipidemia, is consistent with cardiac risk, and requires nutrition therapy: • Cholesterol (ref. 59 mg/dL, pt 40 mg/dL) • LDL/HDL ratio (ref. 10%) is suggested of severe malnutrition due to chronic illness. 13. After examining Mrs. McCormick’s history and physical, identify any clinical signs and symptoms that may alert you to a nutrient deficiency. Describe the nutrition-focused physical examination and address the important components that may be used to fully assess Mrs. McCormick's nutritional status. • Weight loss/fat wasting: 20# weight loss over six months (>18% bodyweight) Underweight and orbital wasting also noted • Muscle wasting: Low protein intake: dry, dull hair, sunken cheeks, temporal wasting, muscle loss in quadriceps and gastrocnemius, low Braden score • Grip strength: Reduced strength in the extremities noted • Low albumin and prealbumin noted with no presence of inflammation • Riboflavin (B2) deficiency and B vitamin deficiency: fissured eyelid corners, cheilosis noted on lips, angular stomatitis; iron deficiency: koilonychias, pale skin, anemia • Dehydration: Dry mucous membranes in nose and throat, dry skin, poor skin turgor • This assessment information allows for the diagnosis of moderate to severe malnutrition associated with chronic disease. 14. Evaluate Mrs. McCormick’s laboratory values. List all abnormal values and explain the likely cause for each abnormal value. • Calcium (L): Low protein levels, especially albumin, which causes the bound calcium to be low; dietary calcium deficiency, malnutrition, possible hypoparathyroidism • Protein (L): Malnutrition – decreased visceral protein stores • Albumin (L): Malnutrition – decreased visceral protein stores • Prealbumin (L): Malnutrition – decreased visceral protein stores • Cholesterol (L): PEM, starvation • HDL (L): Family history of CAD, low physical activity • RBC (L): Anemia, iron deficiency • Hgb/Hct/MCV/MCH/MCHC (L): Prolonged iron deficiency/anemia • Transferrin (H): Chronic iron deficiency (body is trying to allocate iron to put into stores) • Ferritin (L): Iron deficiency (low iron stores) • WBC (H): Consistent with infection and possible pneumonia 15. Determine Mrs. McCormick’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements. • EER: 28-33 kcal/kg  50 kg = 1400-1700 kcal/day Because of this patient’s recent weight loss and underweight status, she will require more calories than needed to maintain weight (goal is to gain weight back to usual body weight) • EPR: 1.2-1.5 g protein/kg  50 kg = 60-75 g protein/day Because of the clinical and laboratory evidence of protein malnutrition, her needs over the long term are increased in order to see an improvement to these signs and symptoms 16. Assess Mrs. McCormick’s diet prior to having difficulty swallowing. Compare her energy and protein intakes to her estimated nutrient needs. • Energy Intake: 877 kcal • Protein Intake: 35 grams • EER: 1400-1700 kcal • EPR: 40-50 grams Based on these estimations, it appears that Mrs. McCormick was not meeting her calorie (63%) and protein (88%) needs on a daily basis before she developed problems swallowing. It is reasonable to state that with her underlying disease, she was most likely not consuming all of the food items listed on a daily basis, and consuming enough on a daily basis is a big struggle for her. IV. Nutrition Diagnosis 17. What criteria would you assess to determine if Mrs. McCormick meets the criteria for malnutrition using the proposed definitions of malnutrition associated with chronic disease? To assess if Mrs. McCormick meets the criteria for malnutrition associated with chronic disease, the following criteria should be considered: 1. Unintentional Weight Loss: Significant weight loss (usually >5% over 6 months) without trying. 2. Low Body Mass Index (BMI): A BMI of less than 18.5 kg/m² or low muscle mass. 3. Reduced Nutrient Intake: Chronic poor intake or inadequate dietary intake due to illness. 4. Inflammation: Evidence of chronic inflammation (e.g., elevated C-reactive protein). 5. Functional Decline: Reduced physical performance, strength, or endurance. These factors, based on clinical assessment, laboratory values, and patient history, help diagnose malnutrition in the context of chronic disease. 18. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses. • Malnutrition • Inadequate mineral intake (iron, calcium) • Inadequate vitamin intake (riboflavin) 19. Write your PES statement for each nutrition problem. • Malnutrition r/t inadequate oral intake AEB noted 20-pound weight loss, muscle wasting (temporal, quadriceps, gastrocnemius), and fat wasting (orbital). • Inadequate mineral intake (iron, calcium) r/t difficulty swallowing AEB diet recall stating a liquid-only diet due to trouble swallowing, abnormal lab values and physical sign of koilonychia, • Inadequate vitamin intake (B-vitamins) r/t inadequate oral intake/swallowing difficulty AEB liquid-only diet and physical signs of cheilosis, angular stomatitis, and fissured eyelid corners. V. Nutrition Intervention 20. The National Dysphagia Diet defines three levels of solid foods and four levels of fluid consistency to be used when planning a diet for someone with dysphagia. Describe each of these levels of diet modifications. Three levels of the dysphagia diet with four levels of liquid modifications: • Food textures: 1. Level 1 Pureed – all foods are smooth like mashed potatoes Blended, whipped, mashed Smooth and free of lumps Add gravy, sauce, vegetable juice, or milk Avoid raw fruits, vegetables, or nuts 2. Level 2 Soft (Mechanically altered) – foods are moist and bite-sized cooked vegetables and soft meats Blended, chopped, ground, mashed Gravies, sauces, vegetable or fruit juice, milk to help moisten foods Soft breads and cereals 3. Level 3 Advanced – most liberal, consists of regular textures except hard, sticky, or crunchy foods Bite-sized pieces (½ inch or smaller) Moisten meats by braising, stewing, or baking Avoid all raw vegetables except shredded lettuce Avoid apples and pears, or fruits with tough outer peals Avoid nuts, seeds, dried fruits, coconut, pineapple, and chunky peanut butter • Liquid consistencies: The purpose is to alter the thickness of the liquid in order to slow down its movement to prevent aspiration. Patients who have trouble swallowing or muscle dysfunction may be recommended for a barium swallowing test by an SLP to determine the need. This includes any liquid at room temperature, including ice cream, gelatin, raw apples, watermelon, etc. 1. Thin – Normal consistency 2. Nectar-Like 1. Slightly thicker than thin 2. Applesauce 3. Honey-Like – Consistency of honey 4. Spoon-Like (Pudding) – Thickest consistency 21. The Dysphagia Outcome and Severity Scale (DOSS) is used to determine the nutrition prescription for a patient. Discuss this scale and how it corresponds to the level of dysphagia diet that is recommended. • The DOSS is a simple, easy-to-use 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment. Its results are used to make recommendations for diet level, independence level, and type of nutrition. • The lowest level represents the most severe dysphagia, and the level increases as functional ability and independence increase. • The levels correspond to the type of diet recommended (normal diet, modified diet, or non-oral diet). 22. The FEES and MBS indicate the following: “Patient demonstrates difficulty initiating the swallow and bolus was held in the mouth for an excessive amount of time. Spillage into the larynx is noted with some aspiration.” Identify the diet you would recommend at this time. • Based on this assessment and using the DOSS, recommend a modified diet of Level 4 – moderate dysphagia: intermittent supervision/curing, one or two consistencies restricted This patient has no noted problems chewing, but stated that she feels food gets stuck in her throat – would benefit from a softer diet • Level 3 (advanced) for most liberal diet Only need to restrict liquid consistency to be thicker • Pt had penetration into the larynx with some aspiration Pt may need cueing, but with some tips, can learn to initiate on her own • Recommend: Level 3 advanced diet and nectar-thick liquids The thickness of the liquids/diet consistency depends on what the SLP recommends 23. Using the data collected during your nutrition assessment, what vitamin and mineral supplementation would you recommend? • Iron • B vitamins (limit vitamin B6 supplementation to less than 15 mg) • Calcium/vitamin D VI. Nutrition Monitoring and Evaluation 24. Identify factors that you will need to monitor to ensure adequacy of her nutrition intervention. • Intake by mouth with modified diet via diet recall Whether or not she is following recommendations/strategies • Protein modifications with medication use • Weight changes, GI motility/output, GERD • Functional capacity with UPDRS • Labs (albumin, iron status, hydration) • The need for alternative nutrition support (compliance with use/care of feeding tube) 25. What criteria would you use to determine whether Mrs. McCormick requires enteral feeding? • Patient is meeting 18% within 6 months and muscle/fat wasting) • Functional status/DOSS continues to decline • Risk of aspiration due to swallowing difficulty/GERD prohibits feeding into the stomach, alternative routes will be needed Case 24 – Adult Traumatic Brain Injury (TBI) I. Understanding the Disease and Pathophysiology 1. Define traumatic brain injury (TBI). What is the Glasgow coma scale? What was Mr. Walker's initial GCS score? What findings from the physical exam are consistent with this score? Traumatic brain injuries can be categorized as either penetrating brain injuries or closed head injuries. A penetrating brain injury involves puncturing of the skull and direct damage to brain tissue. The injury itself can be classified as either a primary or a secondary brain injury. Primary brain injury is the damage to the initial penetration of brain tissue or the mechanical thrashing of the brain inside of the skull, which can lead to lacerations or brain tissue death. Secondary injuries in both penetrating and closed head injuries are the physiological changes in the aftermath of the initial injury, including cerebral edema, hemorrhage, hematoma, and infection. It is the rise in intracranial pressure and impaired blood flow following TBI that can lead to additional CNS damage. Signs and symptoms can vary depending on the location and severity of brain injury. Mild TBI patients may or may not lose consciousness and may experience a headache, light-headedness, dizziness, blurred vision, fatigue, memory and concentration problems, and behavioral or mood changes. Moderate TBI patients may experience a worsening headache, seizures, slurred speech, dilated pupils, nausea, vomiting, confusion, agitation, and loss of consciousness. The Glasgow coma scale evaluates and ranks the severity of TBI. Eye opening response, verbal response, and motor response are measured for a combined score between 3 and 15. A severe head injury correlates with a score of 8 or less, a moderate head injury with a score of 9 to 12, and a mild head injury with a score of 13 to 15. Mr. Walker’s initial GCS score was a 9. He had a 2 eye opening response, a 3 verbal response, and a 4 motor response. This is consistent with his physical exam at that time because he had reactive pupils in response to painful stimuli (2 eye opening response). He exhibited no verbal responses and decreased awareness of surroundings, but would moan when touched for incomprehensive speech (2 verbal response). Finally, he would withdraw in response to pain (4 motor response). 2. Read the radiology reports and the MD progress note dated 6/7. What causes edema and bleeding after a traumatic brain injury? What general functions occur in the frontal lobe? How might Mr. Walker's injury affect him in the long term? Edema and bleeding in a traumatic brain injury are caused by the mechanical thrashing of the brain inside the enclosed skull. This can cause tissue damage and excessive bleeding. The tissue damage causes the inflammatory response to be activated. In other words, inflammation begins with the onset of cellular injury. Blood vessels dilate with increased blood flow to the area, resulting in redness, swelling, pain, heat, and an altered function. This is meant to supply additional oxygen and nutrients but also causes increased vascular permeability that allows proteins and immune cells to pass from blood to tissue spaces. Even though this is a natural response of the body to injury, it becomes a problem in an enclosed space like the skull. Intracranial pressure can build and lead to cell death by a decrease in blood flow, leading to destruction of nerves and decreased functioning of the brain. The frontal lobe is the area of the brain concerned with memory, intellect, and personality. Any trauma to the brain tissue causes loss of function to that specific area. Mr. Walker may experience loss in cognitive function or changes in personality. General fatigue, headaches, and memory loss are common. Because Mr. Walker did not lose consciousness for an extended period of time and the overall injury was only moderately severe, he probably has a good chance of full recovery. 3. Secondary effects for this type of injury result from teh complications initiated by the injury and may occur over days following the insult. These may include the following: inflammatory response, oxidative stress, ischemia, hypoxia and increased intracranial pressure. Discuss three of these complications and how they may impact Mr. Walker's hospitalization and recovery. • Inflammatory response: the inflammatory response results in beneficial and detrimental effects related to the roles of various inflammatory mediators and cytokines; results in increased intracranial pressure and impaired cerebral perfusion pressure cause these effects • Oxidative stress: leads to the secondary damage of neurons, glia, and axons • Ischemia: reduced blood flow to the neuronal tissue due to the increased cranial pressure can reduce the delivery of nutrients needed for recovery and decrease the removal of toxic metabolites from the damaged tissue • Hypoxia: this is related to the lack of blood flow and further damage may result due to the lack of oxygen to supply the energetic needs of the recovering damaged tissue • Increased intracranial pressure: the elevated intracranial pressure results in poor tissue perfusion which may lead to secondary damage to the brain tissue • If intracranial pressure can be minimized, tissue perfusion and delivery of nutrients to the sites of damage will help Mr. Walker's recovery. Additionally, if the inflammatory response can be controlled, damage due to oxidative stress and inflammatory cytokines may further hasten his recovery during his hospitalization. II. Understanding the Nutrition Therapy 4. Head trauma patients are significantly more catabolic. Describe this acute metabolic response to injury. A systemic inflammatory response occurs after a TBI and is similar to that of burns and sepsis. The increased levels of cortisol and catecholamines (norepinephrine and epinephrine) results in a hypermetabolic response associated with increased gluconeogenesis, glycogenolysis, lipolysis, and protein wasting. Hyperglycemia and insulin resistance are also common metabolic issues associated with this inflammatory response. Due to this extreme level of catabolism, it is important to aggressively feed TBI patients to prevent excessive loss in body weight. 5. Using the ASPEN and/or AND evidence-based guidelines, describe the role of nutrition support in the care of the TBI patient? According to ASPEN guidelines for nutrition in the critically ill (2009), enteral nutrition should be initiated within the first 48 hours of admission and is the preferred route over parenteral nutrition. If enteral nutrition alone is not meeting energy requirements after 7-10 days, then parenteral nutrition should be considered. Early enteral nutrition blunts the metabolic stress response, maintains gut integrity, and prevents translocation of bacteria. It has been observed that TBI patients that are not aggressively supported nutritionally have been estimated to lose as much as 15% of their body weight within one week. With potential issues for dysphagia and chewing difficulties coupled with the hypermetabolic needs of the patient, immediate nutrition support is strongly recommended. 6. Are there specific nutrients that are recommended to support the care of an individual with a TBI? A supplementation regimen specifically for TBI has not been established. But since TBI patients are considered to be patients who are not only critically ill but are some of the most hypercatabolic and hypermetabolic, using the critical care guidelines for these patients is appropriate. The ASPEN and SCCM guidelines for adults state that administration of a combination of antioxidant vitamins and trace minerals (specifically including selenium) has been demonstrated to result in reduced mortality. Glutamine has also been recommended for use in burn and trauma patients and may be beneficial for TBI patients as well. III. Nutrition Assessment 7. Assess Mr. Walker’s admitting height and weight. Calculate and evaluate his BMI. Ht. = 5"11"; Wt. = 172 lbs IBW = 106 lbs + 6 lbs/1" (after 5') x 11" = 172 lbs BMI = (172 lbs / 2.2 lbs/kg) / (71" x 2.54 cm/1" / 100 cm/m)2 = 24.0 kg/m2 Mr. Walker is 100% of his ideal body weight and has a BMI of 24.0, indicating he is of normal body weight. 8. Determine Mr. Walker's energy, protein, and fluid requirements. Provide a rationale for the method you have used to estimate his needs. Energy Requirements: American Chest Physicians 30-35 kcal/kg of current body weight: 2346-2737 kcal Protein Requirements: 1.5-2.0 g/kg (per extreme protein wasting/hypermetabolism) x 78.2 kg = 117-156 g/day Fluid Requirements: 35 mL/kg x 78.2 kg = 2737 mL/day ≈ 2700 mL/day Or 1 mL/kcal x 2747 kcal = 2737 mL/day≈ 2700 mL/day Fluid needs may need to be altered per I/O records and vital signs (e.g. blood pressure) 9. Mr. Walker was started on Pivot 1.5 @ 50 mL/hr. How much energy and protein will this provide? Does it meet his estimated protein and energy needs that you determined in question #8? 50 mL/hr x 24 hr = 1200 mL/day 1200 mL/day x 1.5 kcal/mL = 1800 kcal/day 1200 mL/day x 93.8 g pro/1000mL = 169 g protein/day Propofol (8.2 mL/hr) x 24 hr x 1.1 kcal/mL = 216 kcal 1800 + 216 mL = 2016 kcal This rate of infusion of Pivot 1.5 for nutrition support only provides74% of his energy needs, but exceeds his protein needs (13 g/day more than upper limit of estimated needs). 10. Using the intake/output record for 6/7-6/8, answer the following: a. What was the total volume of feeding for 6/7-6/8? 650 mL of formula. b. What was the nutritional value of his feeding? Calculate the total energy and protein that he received. 650 mL x 1.5 kcal/mL = 975 kcal 650 mL x 93.8 g pro/1000 mL = 61 g protein Propofol (8.2 mL/hr) x 24 hr x 1.1 kcal/mL = 216 kcal 975 + 216 mL = 1191 kcal c. What percentage of his needs was met? What factors may interfere with the patient receiving his prescribed nutrition support? What steps can be taken to assure adequate delivery of nutrition support to the critically ill patient? The nutrition support provided met only 43% and 52% of his energy and protein needs, respectively. Feedings are stopped frequently in the acute care setting for medications, procedures, therapies, or perceived intolerance to the formula. Frequent monitoring by the RD with documentation and discussion with the health care team can allow for maximum feeding to be provided. Adjusting rate or cycling the feeding over a certain amount of time can also help to maximize the amount of feeding she is receiving. For example, it is common to calculate the rate of infusion for enteral nutrition support based off of 22 hours instead of 24 hours, which will result in a higher calculated rate and hopefully account for stopped feedings throughout the course of the day. Recent recommendations using volume based feedings allows for nursing to make up for times off of feeding by adjusting rates accordingly to meet the daily volume requirement. 11. Assess Mr. Walker's laboratory values at admission and on 6/7. Explain any abnormal laboratory values. • Serum glucose (high): due to increased rates of gluconeogenesis and glycogenolysis from the elevated levels of cortisol and catecholamines due to injury • Lactate (high): due to increased anaerobic metabolism resulting from poor tissue perfusion or oxygen delivery to tissues • Phosphate/magnesium (slightly low): may be due to overhydration/fluid accumulation due to injury • ALT (high): elevated due to TBI trauma potentially causing hypoperfusion to hepatic tissue and thus causing some damage • CPK (high): elevated due to tissue damage and trauma • CRP (high): elevated because it is an acute phase protein and trauma/inflammation is present. • WBC, %Neutrophil, %Monocyte (high): elevated due to increased inflammatory/immune response • RBC, Hgb, Hct (low): due to blood loss and hemorrhagic edema in brain IV. Nutrition Diagnosis 12. Select two high priority nutrition problems and complete the PES statement for each. The following are possible PES statements. It may be helpful for students to initially write more than two nutrition diagnoses and then prioritize as to the ones that are most likely to have immediate nutrition interventions. • Increased energy expenditure related to hypermetabolism due to traumatic brain injury as evidenced by elevated laboratory values suggestive of acute illness/inflammation and hypermetabolic processes (glucose 125 mg/dL, lactate 2.8 mmol/L, and CRP 155 mg/dL) • Inadequate enteral nutrition infusion related to increased needs d/t TBI as evidenced by only 650 mL of formula provided per I/O chart and estimated receipt of only 43% and 52% of energy and protein needs, respectively. V. Nutrition Intervention 13. Mr. Walker's MD started enteral feeding on day 2 of the admission. As the RD in the neurointensive care unit, outline the nutrition support recommendations you would make for Mr. Walker. Impact Glutamine initiated at 20 mL/hr; advance by 20 mL/hr q 4-6 hrs until goal rate of 80 mL/hr is met. Provides 2496 kcal + 216 kcal (from propofol); total 2712 kcal/day, 178 g protein, and 1842 mL water. Flush feeding tube with water periodically for a total of 900 mL. 14. Mr. Walker has received propofol (diprivan) 25 mcg/kg/min or 8.2 ml/h. What is propofol? How many kcal would he receive from this prescription? Propofol is a lipid-based IV anaesthetic agent used for general anaesthesia. It provides 1.1 kcal/mL and the prescription of 8.2 mL/hr would provide 196.8 mL and 216 kcal/day. This should be taken into consideration when calculating the patients nutrition prescription and his daily caloric intake. VI. Nutrition Monitoring and Evaluation 15. Mr. Walker was extubated on day 4 of his admission. He received a swallowing evaluation that is described in the following report: *See Case Study book for report What is a FEES? What factors in the speech pathologist's report indicate the continued need for enteral feeding? • FEES stands for fiberoptic endoscopic evaluation of swallowing and is useful in examining swallowing disorders. A fiberoptic endoscope is passed through the nostril and obtain a few of the pharynx and esophagus to assess the patient's ability to properly coordinate his swallowing and pass the bolus of food into the esophagus. Risk of aspiration and "pocketing" of food is also assessed. • Factors that suggest continued need for EN include his reported choking on water and fatigue/lack of cooperation after a few swallows. This suggests inadequate oral intake would occur if placed on a PO diet. 16. When Mr. Walker is cleared for an oral diet by the SLP and physician, what information would you use to determine the appropriate oral diet order? What guidelines would you use to determine when Mr. Walker can be weaned from his enteral feeding? • Based upon the SLP's and physician's assessment/evaluation of the level of dysphagia Mr. Walker is experiencing, the RD should provide an appropriate diet to meet those needs. • Mr. Walker can be weaned from his enteral feeding when he meets 60% of his needs by mouth. 17. Mr. Walker will be transferred to the rehabilitation unit in the hospital for therapies with physical therapy, occupational therapy and speech therapy. Summarize the training that each of these professionals receives and describe their potential role in Mr. Walker's recovery. • Physical therapist - require a master's degree from an accredited program and must pass a national licensure exam; will help Mr. Walker with issues concerning mobility and reducing pain • Occupational therapist - require a master's degree and must meet state licensure requirements; can provide assistance in Mr. Walker's rehabilitation and reintroduction into a normal lifestyle and helping him meet his daily needs (e.g. cooking, dressing, etc.) • Speech therapist - requires a graduate degree from an accredited program and meet clinical certification standards; can help Mr. Walker with eating/swallowing issues and/or any speech difficulties he may be experiencing from his trauma Solution Manual for Medical Nutrition Therapy: A Case-Study Approach Marcia Nahikian Nelms 9781305628663, 9780534524104, 9781133593157