Group Teaching - Malnutritrion - Nutrition Case Studies Flashcards
Case 1
Gladys, an 84 year old woman, has been admitted to hospital as an emergency with shortness of breath and fevers. She is subsequently diagnosed with community acquired pneumonia (CAP) and treated with IV fluids and antibiotics.
Her past medical history (PMHx) includes: Advanced dementia; Two emergency admissions with CAP in the past year; Pernicious anaemia; Type 2 diabetes; Hypercholesterolemia; Hypertension; Osteoporosis; and two falls in the past year.
Social Hx: She is a nursing home resident.
Medications: Hydroxocobalamin; Adcal D3; Atorvastatin; Bisoprolol; Metformin.
Weight at assessment on this admission: 47 kg.
Weight 3 months ago: 55 kg.
Height: 1.55 m.
Nutrition:
1. The care home healthcare assistant reports that there has been a decline in her oral intake over the past three months. He also says that she has been ‘pocketing’ food in her mouth and has a preference for sweeter foods.
2. She fails a bedside swallow screen so is referred to a speech and language therapist, who diagnoses dysphagia. She is therefore deemed to be at a high risk of aspirating both food and fluid.
3. Members of her family, who visit her regularly in her nursing home, have expressed concern at her decline in oral intake and her recent weight loss, and are asking for tube feeding to start.
What is Gladys’s BMI?
19.6 kg/m2
Case 1
Gladys, an 84 year old woman, has been admitted to hospital as an emergency with shortness of breath and fevers. She is subsequently diagnosed with community acquired pneumonia (CAP) and treated with IV fluids and antibiotics.
Her past medical history (PMHx) includes: Advanced dementia; Two emergency admissions with CAP in the past year; Pernicious anaemia; Type 2 diabetes; Hypercholesterolemia; Hypertension; Osteoporosis; and two falls in the past year.
Social Hx: She is a nursing home resident.
Medications: Hydroxocobalamin; Adcal D3; Atorvastatin; Bisoprolol; Metformin.
Weight at assessment on this admission: 47 kg.
Weight 3 months ago: 55 kg.
Height: 1.55 m.
Nutrition:
1. The care home healthcare assistant reports that there has been a decline in her oral intake over the past three months. He also says that she has been ‘pocketing’ food in her mouth and has a preference for sweeter foods.
2. She fails a bedside swallow screen so is referred to a speech and language therapist, who diagnoses dysphagia. She is therefore deemed to be at a high risk of aspirating both food and fluid.
3. Members of her family, who visit her regularly in her nursing home, have expressed concern at her decline in oral intake and her recent weight loss, and are asking for tube feeding to start.
What is her percentage weight loss? What is the timeframe for these losses? Is this clinically significant?
14.5% in 3 months
Not clinically significant (must be above 15% weight loss)
Case 1
Gladys, an 84 year old woman, has been admitted to hospital as an emergency with shortness of breath and fevers. She is subsequently diagnosed with community acquired pneumonia (CAP) and treated with IV fluids and antibiotics.
Her past medical history (PMHx) includes: Advanced dementia; Two emergency admissions with CAP in the past year; Pernicious anaemia; Type 2 diabetes; Hypercholesterolemia; Hypertension; Osteoporosis; and two falls in the past year.
Social Hx: She is a nursing home resident.
Medications: Hydroxocobalamin; Adcal D3; Atorvastatin; Bisoprolol; Metformin.
Weight at assessment on this admission: 47 kg.
Weight 3 months ago: 55 kg.
Height: 1.55 m.
Nutrition:
1. The care home healthcare assistant reports that there has been a decline in her oral intake over the past three months. He also says that she has been ‘pocketing’ food in her mouth and has a preference for sweeter foods.
2. She fails a bedside swallow screen so is referred to a speech and language therapist, who diagnoses dysphagia. She is therefore deemed to be at a high risk of aspirating both food and fluid.
3. Members of her family, who visit her regularly in her nursing home, have expressed concern at her decline in oral intake and her recent weight loss, and are asking for tube feeding to start.
Describe the indication for each of her medications.
- Hydroxocobalamin: Treat VB12 anaemia
- Adcal D3: Treat hypocalcaemia / osteoporosis / Vit D deficiency
- Atorvastatin: Decrease cholesterol
- Bisoprolol: Treat hypertension
- Metformin: Decrease blood glucose
Case 1
Gladys, an 84 year old woman, has been admitted to hospital as an emergency with shortness of breath and fevers. She is subsequently diagnosed with community acquired pneumonia (CAP) and treated with IV fluids and antibiotics.
Her past medical history (PMHx) includes: Advanced dementia; Two emergency admissions with CAP in the past year; Pernicious anaemia; Type 2 diabetes; Hypercholesterolemia; Hypertension; Osteoporosis; and two falls in the past year.
Social Hx: She is a nursing home resident.
Medications: Hydroxocobalamin; Adcal D3; Atorvastatin; Bisoprolol; Metformin.
Weight at assessment on this admission: 47 kg.
Weight 3 months ago: 55 kg.
Height: 1.55 m.
Nutrition:
1. The care home healthcare assistant reports that there has been a decline in her oral intake over the past three months. He also says that she has been ‘pocketing’ food in her mouth and has a preference for sweeter foods.
2. She fails a bedside swallow screen so is referred to a speech and language therapist, who diagnoses dysphagia. She is therefore deemed to be at a high risk of aspirating both food and fluid.
3. Members of her family, who visit her regularly in her nursing home, have expressed concern at her decline in oral intake and her recent weight loss, and are asking for tube feeding to start.
How would you feed this patient?
Enteral nutrtion (EN) possibly NG tube
Case 1
Gladys, an 84 year old woman, has been admitted to hospital as an emergency with shortness of breath and fevers. She is subsequently diagnosed with community acquired pneumonia (CAP) and treated with IV fluids and antibiotics.
Her past medical history (PMHx) includes: Advanced dementia; Two emergency admissions with CAP in the past year; Pernicious anaemia; Type 2 diabetes; Hypercholesterolemia; Hypertension; Osteoporosis; and two falls in the past year.
Social Hx: She is a nursing home resident.
Medications: Hydroxocobalamin; Adcal D3; Atorvastatin; Bisoprolol; Metformin.
Weight at assessment on this admission: 47 kg.
Weight 3 months ago: 55 kg.
Height: 1.55 m.
Nutrition:
1. The care home healthcare assistant reports that there has been a decline in her oral intake over the past three months. He also says that she has been ‘pocketing’ food in her mouth and has a preference for sweeter foods.
2. She fails a bedside swallow screen so is referred to a speech and language therapist, who diagnoses dysphagia. She is therefore deemed to be at a high risk of aspirating both food and fluid.
3. Members of her family, who visit her regularly in her nursing home, have expressed concern at her decline in oral intake and her recent weight loss, and are asking for tube feeding to start.
Describe the moral and ethical challenges of feeding this patient.
- Informed consent: Ensuring that the patient or their surrogate decision maker fully understands the procedure and any potential risks and benefits before giving consent.
- Autonomy: Respecting the patient’s right to make decisions about their own healthcare and not coercing or forcing them into receiving enteral nutrition against their will.
- Beneficence: Balancing the potential benefits of enteral nutrition with any harm it may cause, such as discomfort or infection.
- Non-maleficence: Avoiding causing harm to the patient and monitoring for any negative side effects from the enteral nutrition.
- Justice: Allocating healthcare resources in an equitable manner and considering the impact of enteral nutrition on the patient’s quality of life and overall well-being.
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
What is his BMI?
25.6 kg/m2
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
What is the difference between clear and free fluids?
- Clear fluids: These are fluids that are transparent and free of particles, such as water, ice chips, clear broths, frozen water or ice pops, clear fruit juices without pulp, clear gelatins, and clear sports drinks (such as Gatorade).
- Free fluids: These are fluids that do not have any caloric or nutritional value and do not add to a person’s daily caloric intake. They are usually clear liquids and are typically used for hydration or for flushing out the body. Examples include water, tea, coffee, and clear broths.
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
According to NICE CG32 2006 Guidelines, should this patient receive nutrition support? If so, what would be your nutrition plan? Give a rationale for your plan.
* Do not feed patient – this will allow the pancreas to ‘rest’
* Encourage the patient to increase ‘free fluids’ intake
* Start enteral tube feeding following naso-gastric tube (NGT) insertion(replacing the Ryles wide bore tube)
* Start parenteral nutrition (PN) – provide nutrition without ‘stimulating’ the pancreas
Start enteral tube feeding following naso-gastric tube (NGT) insertion(replacing the Ryles wide bore tube)
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
Is the patient at risk of refeeding syndrome?
Yes, he is:
* Very little / no nutrition > 5 days
* PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics)
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
Is refeeding syndrome only considered when artificial nutrition support is to start, or is it also a risk with oral nutrition support?
Both oral and artificial
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
How would you manage refeeding syndrome?
- Correct and monitor electrolytes
- Administer thiamine & pabrinex
- Monitor fluid & food intake (10-20kcal/kg)
Case 2
George, an 84 year old man, has been admitted to hospital as an emergency following two days of severe epigastric pain associated with vomiting. He was subsequently diagnosed with acute pancreatitis secondary to alcohol and treated with IV resuscitation fluids; pain relief; IV potassium (K+) and phosphate (PO4) replacement and IV anti-emetics. A Ryles wide bore tube is also placed.
PMHx: He admits to drinking 94 units of alcohol per week.
Investigations: a CT Scan of his abdomen shows extensive inflammatory changes involving head & neck of his pancreas consistent with acute pancreatitis.
Part A
It is now day 5 of hospital admission and his acute pancreatitis is increasing in severity.
His vomiting stopped on the second day of his admission so his Ryles tube has been spigotted (blocked). Aspirates from the tube indicate acceptable/low volume gastric residual volumes.
Nutrition: Although he’s now allowed to take free fluids, his actual intake has been very little over the past 7 days. He is currently only managing sips of water due to disease related anorexia (lack of appetite) and pain.
Height: 1.71 m; Weight: 75 kg.
He reported no weight loss prior to his admission.
Part B
Day 15: An NG feeding tube has been sited (replacing the Ryles wide bore tube) and he’s been receiving and tolerating enteral nutrition, he’s also been managing sips of oral fluids.
Unfortunately he has now started to complain of increased nausea and nursing staff, who are aspirating his NG feeding tube every four hours, report that the volumes of aspirate are trending upwards. Prokinetics are started but his gastric residual volumes continue to increase.
Imaging identifies inflammation causing duodenal stenosis.
What route of nutrition would you now recommend? Give a rationale for your plan.
* NGT feeding at a reduced rate, underfeeding the patient.
* Trial naso-jejunal tube (NJT) feeding.
* Start parenteral nutrition.
- Trial naso-jejunal tube (NJT) feeding.
It bypasses the stomach to avoid possible aspirations and nausea, still using the gastric system (unlike the PN)
