Nikki Finkenthal

KNH 411
Professor Matuszak
Final Exam Case Study (# 21 Paper Copy)
1. Mr. Sims has had a 200-cm resection of his jejunum and proximal ileum. How
long is the small intestine, and how significant is the resection?
-The small intestine is divided into the duodenum, which is approximately 0.5 m
long, the jejune is 2 to 3 m and the ileum is 3 to 4 m. Most of the digestive
process is completed in the duodenum and upper jejunum sections of the small
intestine. This was significant resection because it is 30% of his small intestine is
being removed. Any resection is significant because it affects the function,
absorption and distribution of how nutrients work (Krause, 2012, p. 9).

2. What nutrients are normally digested and absorbed in the portion of the small
intestine that has been resected?
-On average each day the small intestine absorbs 150 to 300 grams of
monosaccharides, 60 to 100 grams of fatty acids, 60 to 120 grams of amino acids
and peptides and 50 to 100 grams of ions. In the small intestine all but 1 to 1.5
liters of the 7 or 8 liters secreted for the upper portions of the GIT in addition to
dietary fluids, is absorbed by the time the contents reach the end of the small
intestine (Krause, 2012, p. 9).

3. What would be the optimal method of determining Mr. Sims energy and protein
needs?
-In order to determine the optimal method of determining Mr. Sims energy and
protein the physicians say 25-35 kcal x weight (kg) if the BMI is between 16-25
use the usual body weight for the patient (Nelms, 2016, p. 109).

4. Evaluate the anthropometric data available for Mr. Sims.

Mr. Sims currently has a height of 59, a current weight of 137 lbs or 62.2 kg at
admission, 15 months ago he weighed 140 lbs and he has a UBW of 166-168, he
currently has a BMI of 20.2 kg/m2.

5. Evaluate Mr. Sims admission labs for nutritional significance.

The day of admission Mr. Sims had low levels of albumin, total protein,
prealbumin and transferrin. The low levels found in Mr. Sims labs can be related
to his state of malnutrition from the inability to eat and due to the fact that his
body is not properly absorbing and digesting protein which is a common issue
with patients who have Crohns disease and inflammatory bowel disease. His low
level of transferrin also indicates that he has low levels of iron and is also an
indicator of protein status in his system (Nelms, 2016, p. 59).

6. The members of the nutrition support team note that his serum phosphorous and
serum magnesium are at the low end of the normal range. Why might that be of
concern?
 -The low levels of serum phosphorus can result from a vitamin D deficiency or
decreased activation of vitamin D, which decreases intestinal absorption. Since
Mr. Sims has intestinal issues its understandable that he has lower levels of serum
phosphorus, but it is a concern because if untreated or levels continue to decrease
it can lead to osteomalacia, rickets and/ or metabolic acidosis. The low levels of
serum magnesium are related to the low serum phosphorus levels because it
assists in maintaining phosphorous homeostasis and is also partly controlled by
the intake of vitamin D. Approximately 50% of the magnesium found in an
individuals diet is absorbed in the small intestine, which as we know Mr. Sims is
currently having problems with. If untreated it can cause personality changes,
depression, anorexia, nausea/ vomiting and ileus (Nelms, 2016, p. 140).

7. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
-Refeeding syndrome is several common metabolic alterations that may occur
during nutritional repletion of patients who are malnourished or in a state of
starvation. If a patient has been given parenteral nutrition they can be at risk for
refeeding syndrome if they had present signs of malnutrition, have had long-term
inadequate oral intake and have had minimal overall intake as a result of an NPO
status or poor appetite. Mr. Sims can be at risk for this syndrome due to the fact
that he had a very poor appetite and was NPO after his surgery. In order for it to
be prevented clinicians begin feedings slowly and avoid overfeeding as the go to
strategy in over to prevent refeeding syndrome. Also in the early phases in
refeeding the nutrition prescription should be moderate in carbohydrates and
supplemented with phosphorus, potassium and magnesium (Nelms, 2016, p. 103)
(Krause, 2012, p. 321).

8. Calculate Mr. Sims energy requirements. Compare the Harris-Benedict equation

with appropriate activity and stress factors to calculations with the Ireton-Jones
equation.
Harris- Benedict: 66.5 + (13.75 x 75.0 kg) + (5 x 175.2 cm) (6.78 x 37 years) x
1.2 PAL = 2067 (2100-2200 kcals per day)

Ireton-Jones: (5 x 75 kg) (11 x 37 years) + 244 + 239 + 1784 = 2235 kcal/ day
(2200-2300 kcals per day)

9. Which numbers would you use as a goal for Mr. Sims nutrition support? Explain.
I would use the goal intake of 2100-2200 kcal daily intakes for Mr. Sims nutrition
support because it takes into account his height, weight, age and the PAL/ stress
his body is going through after his surgery. I would also make sure he received a
protein intake of 113 grams of protein. I would also suggest that he has a fluid
intake of 2100-2200 cc of fluid a day in order to maintain his hydration status
based on 1mL/ kcal.

10. What would you estimate Mr. Sims protein requirements to be?
 -Based on the fact that Mr. Sims just recently underwent a major surgery and had
a weight loss I decided to use a 1.5 grams/ protein/ kg factor.
(75 kg) x (1.5)= 113 g of protein

11. The surgeon notes that Mr. Sims probably will not resume eating by mouth for at
least 7-10 days. What information would the nutrition support team evaluate in
deciding the route for nutrition support?
-The nutrition support team would need to mainly address the fact that due to Mr.
Sims bowel resection and Crohns that his body will have the inability to properly
digest and absorb nutrients, so the most successful approach for nutrition support
would be parenteral. The nutrition support team also needs to consider the patients
nutrition assessment, the length of time that Mr. Sims will need the nutrition
support, his overall diagnosis and the current medical condition (Nelms, 2016, p.
101-102).

12. Mr. Sims was started on parenteral nutrition postoperatively. Initially, he was
prescribed to receive 200 g dextrose/L, 42.5 g amino acids/L, 30 g lipid/L. His
parenteral nutrition was initiated at 50 cc/hr with a goal rate of 85 cc/hr. Do you
agree with the teams decision to initiate parenteral nutrition? Will this meet his
estimated nutritional needs? Explain. Calculate: pro (g); CHO (g); lipid (g); total
kcal from his PN. Then write a TPN order.
-Based on Mr. Sims current medical state, overall diagnosis and his inability to
properly absorb and digest his daily needed nutrients I agree with the teams to
decision to choose parenteral nutrition as his form of nutrition support. This TPN
prescription wont meet his nutritional needs based on his estimated energy needs
from the Harris- Benedict equation that states he needs roughly a minimum of
2100 kcal/ day.
200 g dextrose/ L x 3.4 kcal/ gram = 680 kcals from CHO

42.5 g AA/ L x 4 kcal/ gram = 170 kcals from protein

30 g lipid/ L x 9 kcal/ gram = 270 kcals from lipids

Total TPN= 1120 kcals per day

13. Indirect calorimetry revealed the following information:

Data Mr. Sims Data

Oxygen consumption (mL/ min) 295
CO2 production (mL/ min) 261
RQ 0.88
RMR 2022
What does this information tell you about Mr. Sims?
-Mr. Sims oxygen consumption values and CO2 production are values that are
within a normal range, which can help indicate that his energy requirements are
being met and he is not overfed. RQ is the respiratory quotient, which is found by
CO2 production/ Oxygen consumption that indicates that he has a mixed diet of
 carbohydrates and proteins. His RMR is his resting metabolic rate and it indicates
that based on his calculated resting energy expenditure that he is slightly low, but
within the suggested amount of kcal per day (Nelms, 2016, p. 23).

14. Would you make any changes in his prescribed nutrition support? What should be
monitored to assure adequacy of his nutrition support? Explain.
-I would change the prescribed nutrition support that has been put in place by his
nutrition support team to an increased daily caloric intake of 2100-2200 kcals/ day
based on the estimated energy requirement. I would also monitor his weight,
hydration status; prealbumin, albumin, total protein and transferrin due to the fact
that those lab levels were previously low. I would also want to monitor his serum
levels, input/ outputs and make sure to check for any signs of infection.

15. What should the nutrition support team monitor daily? What should be monitored
weekly? Explain your answers.
Mr. Sims inputs and outputs should be monitored daily as well as testing for
hyperglycemia should be done 3 to 4 times a day as well. Measurements of his
serum electrolytes, BUN and creatinine, magnesium and phosphorus should also
be completed daily. At the initiation of nutrition support Mr. Sims lipid tolerance
needs to be addressed and if he has an abnormal result then it should be taken
weekly following the initial test. In addition Mr. Sims weight, hydration and signs
of infection should be carefully looked at (Nelms, 2016, p. 110).

16. Evaluate the following 24-hour urine data; 24-hour urinary nitrogen for 12/20:
18.4 grams. By using the daily nursing record that records the amount of PN
received, calculate Mr. Sims nitrogen balance on postoperative day 4. How
would you interpret this information? Should you be concerned? Are there
problems with the accuracy of nitrogen balance studies? Explain.
Nitrogen balance is a measure of the daily intake of the daily intake of nitrogen
minus the daily excretion. The urinary nitrogen balance is used to accurately
interpret the protein catabolic response during disease state and as a response to
nutritional support. Based on the value that Mr. Sims has he is a catabolic state
and this is a concern because he can be classified as protein-energy malnutrition.
There are some problems with the accuracy of nitrogen balance studies because
there are certain limitations in the measurement due to the inherent error of 24-
hour urine collection, failure to account renal impairment and the inability to
measure nitrogen losses from wounds, burns, diarrhea and vomiting (Nelms,
2016, p. 58) (Krause, 2016, p. 55).

Nitrogen balance= (dietary protein intake / 6.25) UUN 4

(113/ 6.25) 18.4 4= -4 nitrogen balance

17. Is Mr. Sims a likely candidate for short bowel syndrome?

Short bowel syndrome is defined as inadequate absorptive capacity that results
from the reduced length or decreased function of bowels after resection. A loss of
 70% to 75% of small bowel usually results in short bowel syndrome. It also is the
inability to maintain nutrition and hydration needs with normal fluid and food
intake, regardless of bowel length. Based on the fact that Mr. Sims recently had a
200 cm resection of his bowel and has the inability to maintain proper nutrition
and hydration without the assistance of nutrition support will make him a likely
candidate for short bowel syndrome (Krause, 2012, p. 637).

18. What type of adaptation can the small intestine make after resection?
The small intestine can make various adaptions and changes after a resection
occurs. The small intestine needs to readjust the absorption and digestion of
nutrients. The resection of a duodenum is rare and if resection occurs the
digestion and absorption needs to readjust because it the portal of entry for
pancreatic enzymes and bile salts. A jejunal resection results in reduced surface
area and faster intestinal transit, the function reserve for absorption of
micronutrients, excess amounts of sugars and lipids is reduced. An ileal resection
is significant because it produces the most complications such as malabsorption
and malnutrition (Krause, 2012, p. 637)