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CLINICAL CASE STUDY

STEPHANIE BUSH
KEENE STATE COLLEGE DI
FEBRUARY 8, 2017
OUTLINE

Pathophysiology - SBO

Hospital Admission- RF

Nutrition Care Process/Clinical Course

Summary
CONCORD HOSPITAL

Community hospital in Concord, NH


295 beds
6 floors
~20,000 patients

5 Centers
Center for Cardiac Care
Center for Urologic Care
Payson Center for Cancer Care
The Orthopaedic Institute
Women's Health Services
SMALL BOWEL
OBSTRUCTION1
Interruption of the normal flow
of bowel contents.
Causes
Mechanical: high, low, closed,
open, high grade, low grade,
simple, complicated
Functional
Symptoms
Distention
Constipation/Obstipation
Vomiting: bilious or feculant
Pain/Abd cramping
ETIOLOGY OF SBO

Misc
11%
Hernia
2%

Malignancies
5%

Crohn's Disease
7%

Adhesions
75%
SMALL BOWEL OBSTRUCTION: PROGRESSION & COMPLICATIONS1

Ischemia
Necrosis
Perforation
Sepsis
Electrolyte
imbalances &
hypotension
Edema

https://www.youtube.com/watch?v=sBm12CkNtAo
DIAGNOSIS AND TREATMENT1

Medical diagnosis
Presenting symptoms, PMH
Confirmed w/ X-ray, CT scan,
luminal contrast studies, or ultrasound

Treatment options
Surgical vs non surgical treatments
IVF, NPO, NG tube, e-, pain meds
Laparotomy
http://link.springer.com/article/10.1007/ s00268-014-2733-6

webmd medscape
MNT RECOMMENDATIONS

SBO/GI surgery reccs include:


NPO for bowel rest
Advance diet
Clear liquids minimal bowel activity
Full liquidstransitioning to solids,
increasing bowel activity
Buzzle.com Low residue diet
MR. RF: Presented to the ER 1/07/17 c/o:

65 year old male Inc abd pain and bloating x 24 hrs


Bloating and distention x2 weeks
Frail and cachectic
No BM last 9 days
looking
Vomiting green bile emesis
Decreased urine output
ADMIT DATE 1/07/17
CT of abd and pelvis w/ IV & oral contrast
Indicated SBO and large hiatal hernia
Aggressively hydrate, Zofran, NG tube placed for decompression
NPO
Repeat imaging w/ contrast on 1/8
No role, at present, for surgical intervention for this patients
obstruction
ASSESSMENT 1/08/17
Client Hx
Anthropometrics
Food and Nutrition Related Hx
Biochemical
Nutrition Focused Physical
Findings

Dallasbehavioral.com
Medical Hx (from med rec) Social Hx (from med rec and pt, family)

HTN Mechanic--retired
ASSESSMENT 1/08/17 Hyperlipidemia Wife and sister
Asthma Part of Dana Farber
Client Hx Reflux experimental
Anthropometrics Major depression, Anxiety chemotherapy trial
Osteoarthritis
Food and Nutrition Related
Claudication
Hx Previous Surgeries (from med
TIA rec)

Biochemical Hernia repair SB resection &


Hx ETOH, ex smoker inguinal hernia repair
Nutrition Focused Physical
Metastatic squamous cell 2014
Findings
carcinoma of the head and Resection of neck
neck lesion
Height: 59 (69in)

ASSESSMENT Weight: 53.9kg standing (118.6lbs)


Client Hx
Anthropometrics
BMI: 17.5g/m2

Food and Nutrition Related Hx UBW: 66.4kg (146 lbs) as of July 2016
Biochemical
%UBW: 81%
Nutrition Focused Physical
Findings
Weight Loss: 12.5kg in 6 mos

% Weight Loss: 19%


Current Diet: NPO, inadequate

Inadequate intake PTA


ASSESSMENT Nausea 2-14 d, Vomiting 3-7 d
Tolerating water, coffee and Coke for 1
Client Hx
week
Anthropometrics Before last week, intake was limited
Drinks 2 CIB/day at home
Food and Nutrition Related Hx
Dysphagia
Biochemical
Medications:
Nutrition Focused Physical
Beclomethasone-asthma
Findings
Montelukast-asthma
Fluticasone-sal-asthma
Tiotropium Br- anticholinergic
bronchodilator
Heparin-anticoagulant
Labs 1/7/17 Value (range)
Serum Osml 264 L (285-295 mOsm/kg)
Sodium 126 L (136-145 mmol/L)

ASSESSMENT Chloride 86 L (98-107mmol/L)


BUN 24 H (7-22 mg/dL)
Client Hx
WBC 13,880 H
Anthropometrics H&H 11 L & 34 L
Food and Nutrition Related Hx
Biochemical
Labs 1/8/17 Value (range)
Nutrition Focused Physical
Serum Glucose 83 mg/dL (70-107)
Findings
Sodium 132 L (136-145)
Chloride 92 L (98-107mmol/L)
BUN 21H (7-22mg/dL)
Frail and cachectic looking
Looks older than stated age
ASSESSMENT Severe muscle wasting
SubQ fat loss
Client Hx
Difficulty swallowing and chewing
Anthropometrics Poor appetite currently
Food and Nutrition Related Hx
Biochemical
Nutrition Focused Physical
Findings

http://www.cancertherapyadvisor.com/
1620 kcals (30kcal/g)
65-76g protein (1.2-1.4g/kg)
PATIENT NEEDS Recommendations for HNCA are:
30-35kcal/kg
1-1.5g pro/kg
Escott Stump & UK Natl Multidisciplinary Guidelines
NUTRITION DIAGNOSIS

Malnutrition RT catabolic illness AEB appetite poor, BMI


<18.5, inadequate intake, muscle wasting, subcutaneous
fat loss, weight loss of 19% in 6 months
INTERVENTION

Goals: Await diet advancement


Meet nutrition needs of Offer mechanical soft, soft veggies, extra
1620kcals, 65-75g protein, gravy
hydration needs Strawberry CIB w/ whole milk and BP
*Increase intake via PO food, powder
supplements, and/or nutrition TID w/ meals
support
Assist ordering and w/ choice
Increase and/or maintain weight
Recommend nutrition support
http://journals.sagepub.com/doi/full/10.1177/0148607109341804
MONITOR AND EVALUATE

Intake: PO, tolerance, transition to PO


Biochem: BG, K+, Na, Cl, BUN/creat
Anthros: weight, weight change, BMI
Nutrition Focused Physical Findings: n/v, appetite, bowel function,
swallowing, subQ fat loss, muscle wasting
NG TUBE DIDNT HELP, NEW IMAGING SHOWED A HIGH
GRADE SBO REQUIRING SURGERY ON 1/9
Surgeries Performed:
Exploratory Laparotomy
SB resection w/ primary
anastomosis
Abd washout
Post-op Diagnoses
Adhesive band @ prior SB
resection
Mid lower abdomen 80cm
from ileocecal valve

http://slideplayer.com/slide/6493752/
DAY 4: 1/10/17

s/p lysis of adhesions, SB resection


Meds 1 L ClinimixE 4.25/10 @ 40ml/hr Continuous
Ketorolac-NSAID Nutrients Grams Kcals % needs

TPN to start today via PICC CHO 96 326


Pro 41 326 53-63%
Educated on TPN
Fat (daily 50 500
Total fluids 100ml/hr lipids)
Thiamine, MVI, Trace Minerals, Pepcid
High risk refeeding
Totals 990 61%
NICE Guidelines

Meets one of the following criteria

BMI <16 Unintentional weight loss <15% in 3-6 mos Little intake <10 d K<2.5,
P<1.5, s
Mg<1
Or: Two of the following criteria:

BMI<18.5 Wt loss >10% 3-6 mos Little intake <5 d Hx


ETOH/drugs
NICE Guidelines

Meets one of the following criteria

BMI <16 Unintentional weight loss <15% in 3-6 mos Little intake <10 d K<2.5,
P<1.5, s
Mg<1
Or: Two of the following criteria:

BMI<18.5 Wt loss >10% 3-6 mos Little intake <5 d Hx


ETOH/drugs
Days 5-7: 1/11/17-1/13/17 TPN Days # 2-4

2 L ClinimixE 4.25/10 @ 80ml/hr 1.4 L ClinimixE 5/20 @ 60ml/hr


Nutrient G Kcals % needs Nutrient G Kcals % needs
CHO 192 653 CHO 288 979
Pro 82 326 107% Pro 72 288 94%
Fat (daily 500 Fat (daily 500
lipids) lipids)
Thiamine, MVI, Trace Minerals, Pepcid Thiamine, MVI, Trace Minerals, Pepcid
Totals 1479 91% Totals 1767 109%
Adv to cl lq, sips
Serum Glu: 128 H Diet: Clear Liquids
Na: 129 Ladd 50mL/h NS
Na: 134 L 10Mm bolus Encouraging broth intake for Na level
Goal to inc Na, avoid custom
Creat: .58 L Ensure clear berry
Cl: 91 L
Phos: 2.4 L 10Mm bolus Na: 127 L
K+: 3.7
NS @ 20ml/h Cl: 91 L KCl Bolus
Mg: 1.4 L
K+: 3.3 L
Phos: 2.7
DAY 8: 1/14/17
DAY # 5 TPN

@ Goal
1.4 L ClinimixE 5/20 @ 60ml/hr
Plan to stop TPN 1/15
Advanced to fulls
Medications:
Kcal count initiated:
Atorvastatin-statin
488 kcal (30%) Escitalopram-antidepressant
Heparin-anticoagulant
18 g protein (27%) Oxycodone-narcotic
Did low residue ed, sending
CIB TID
DAY 9: 1/15/17
DAY # 6 TPN 1.4 L ClinimixE 5/20 @60ml/hr

Delayed Ileus
Rising WBC
Nausea, increased distention
No longer advancing diet
Labs: Creat: .50 L
Kcal count Glu: 126 WBC: 15.69H
136 kcal (8%) Na: 128 L HGB: 8.4 L
Cl: 93 L HCT: 25.2 L
4 g pro (6%)
DAY 10: 1/16/17
DAY # 7 TPN

1 L ClinimixE 5/25 @40ml/hr


CT scan today
Labs:
Hypoactive bowel sounds Nutrient G Kcals % needs
Na 125 L
Concentrate TPN for Na goals Cl: 90 L CHO 240 816
Alb: 1.7 L Pro 48 192 73%
Kcal count: Mg: 1.5 L 2 g bolus
WBC: 16.22 H Fat (daily 500
129 kcal (7%)
HGB: 8.4 L lipids)
1 g pro
HCT: 25.5 L MVI, Trace Minerals
Totals 1508 93%
DAY 11: 1/17/17
TPN DAY #8

Labs:
Diet: NPO
Na 124 L
? anastomotic leak Cl 89 L
Creat: .89 L
Custom TPN for Na goals (doc) & increase protein
WBC 17.42 H
closer to actual needs (RD) HGB 7.9 L
HCT: 23.8 L
CUSTOM TPN @ 45 ML/HR W/ DAILY LIPIDS, NA @
NS IN TPN
Macronutrient mL Grams Kcals Percent kcals
15% AA 450 ml 68g 270kcal 1.2 g/kg 16%
70% Dex 350 ml 245 g 833kcal 3.1 mg/kg/min 51%
20% Lip 250 ml 50g 500kcal .9g/kg, 31%
104 ml/hr max rate
1,050 ml 1603kcal
DAY 12: 1/18/17
DAY # 9 TPN

OR today
Found adhesive partial SBO
Tried to place NG tube
Hiatal hernia
Decompression

UTI
Days 13-18 1/19/17- 1/24/17

TPN Days #10-15

Continue Custom TPN, @ goal 1/20 Advanced to clears, then fulls (w/ toast,
Na trending up crackers, muffins??), dysphagia
128 136 worsening
Other labs 240-480ml/d intake
WBC: 20 15 Generally getting 5-6% kcals, 0-6%
BUN High 19th-21st pro orally
Ux Na Random: 14mMol/L (20th) Consulted for PEG placement

Meds added:
Cipro-abx, Ketolorac-NSAID, Ondansetron-n/v, Pantoprazole- GI prophylaxis, Megestrol appetite stimulant
DAY 19-20: 1/25/17-1/26/17
TPN DAY # 16

Increasing to 100ml/hr, 2.4 L same macros, IVF to stop


Na increased in TPN to 180mEq
Palliative care meeting Couldnt place PEG , no surgical g tube
Progressed to solids, trialing pureed diet surgical soft/low res (100% bfast)
Mirtazapine antidepressant
Na: 134 L
K: 3.4 L bolus 30mEq
DAY 21: 1/27/17

DC day!
Weight: 59.9kg
Recc DC on oral & TPN 2L, NS, w/ Flintstones MVI
Followed by NELC, weekly labs, VNA, wife and sister helping
Will begin cycle at home
Surgical soft/low res diet, 100% lunch
SUMMARY

Maintained weight
Increased Na at least for a while
Whole team encouraged food intake
tried multiple diets, supplements, app
stimulants

Coordinated w/ doctors, nurses,


pharmacy, care management
REFERENCES

Kulaylat MN, Doerr RJ. Surgical Treatment: Evidence-Based and Problem-Oriented. Small bowel obstruction. 2001.
https://www.ncbi.nlm.nih.gov/books/NBK6873/
Attard JP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg. 2007 Aug; 50(4):
291300. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386166/
Hasudungan A. Small Bowel Obstruction. Armando Hasudungan Biology and Medicine videos.
https://www.youtube.com/watch?v=sBm12CkNtAo.
Meier, R.P.H., de Saussure,W.O., Orci, L.A. et al. Clinical Outcome in Acute Small Bowel Obstruction after Surgical or
Conservative Management. World J Surg (2014) 38: 3082. http://link.springer.com/article/10.1007/s00268-014-2733-6.
August DA, Huhmann MB. A.S.P.E.N Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Support Therapy During Adult
Anticancer Treatment and in Hematopoietic Cell Transplantation. First Published January 5, 2017
Escott-Stump. Nutrition Diagnosis and Related Care. 8th ed. Pg 754.
THANK YOU !

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