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KNH 411
CHELSIE FELLMAN
SEPTEMBER 15, 2015
2014).
4. What did you find in Mr. Sims history and physical that is
consistent with the diagnosis of Crohns? Explain.
Prior to now, Mr. Sims was hospitalized due to the
diagnosis of IBD almost 3 years ago. The initial
diagnosis was UC and then later identified as Crohns
CD are:
o Osteoporosis
o Inflammatory arthropathies
o Scleritis
o Nephrolithiasis
o Cholelithiasis
o Erythema nodosum
(NIH, 2014).
There is not sufficient evidence in his history/physical of
any of any extraintestinal symptoms but Mr. Sims does
suffer from severe abdominal pain and frequent
diarrhea.
6. Mr. Sims has been treated previously with corticosteroids and
Mesalamine. His physician has planned to start Humira prior to
this admission. Explain the mechanism for each of these
medications in the treatment for Crohns Disease.
According to Crohns and Colitis Foundation of America
(CCFA), the number one goal for Crohns disease is to
achieve remission (absence of symptoms) and maintain
remission. Corticosteroids are fast-acting antiinflammatory drugs that have been the mainstay of
treatment for acute flare-ups of disease. Corticosteroids
are also immunosuppressive which means they
decrease the activity of the immune system (CCFA,
2009).
Humira reduces the effects of a substance in the body
that can cause inflammation (NIH, 2014).
Ref. Range
6-8
3.5-5
16-35
<1.0
2/15 1952
5.5 (low)
3.2 (low)
11 (low)
2.8 (low)
<45 M
30-100
20-80
38 (low)
22.7 (low)
17.2 (low)
0.2-2.0
0.1 (low)
The values listed above are all low due Mr. Sims Crohns
Disease not allowing him to absorb all the nutrients he
needs in his diet in order to sustain his health.
Malabsorbtion is a major contributing factor to these
laboratory values all being lower than they should be. The
intestines are unable to absorb the nutrients as the food
passes through the GI tract due to the chronic
inflammation, which inevitably means the nutrients are
getting lost and arent being absorbed into his blood
stream. The vitamin D, for example, is low because
patients with CD decrease their intake of dairy foods as a
result of the lactose-restricted diet they are on. His calcium
levels were 9.1mg/dL and so there is also a high chance for
his calcium intake to be deficient in the future as well (p.
420).
426).
Mr. Sims is a potential candidate for SBS because he has
not had any of his intestines removed according to his
medical record, but he does have CD which lead to
resection?
According to Nelms, it is understood that 50% of the
duodenum and jejunum can be resected without
significant nutrition deficits (p. 426). The body can
adapt to only have 50% of the intestines left, however,
if less than 100 cm of the small intestine is left,
11.
disease?
Insufficient intake of calories
Anorexia
Fear of abdominal pain and diarrhea after eating
Protein deficiencies
Fluid and electrolyte deficiency
Iron, magnesium, zinc, calcium, vitamin D, B12, folate
deficiencies
Water soluble vitamin deficiencies
10
14.
(p. 420)
Mr. Sims underwent resection of 200 cm of jejunum and
15.
protein
11
It
is
crucial
that
directly
following
the
medical
16.
Nutrition Assessment
17.
unintentionally.
Calculate Mr. Sims energy requirements:
Using the Mifflin method:
o EER= 10(63.6)+6.25(175.3)-5(35)+5 = 1,562
kcal/day
o 1,562 kcal X 1.6 PAL = 2,498 kcal
12
kcal/day
What would you calculate Mr. Sims protein requirements
to be?
1.0-1.5 g/kg
63.6 kg X 1.0 = 64 g Pro
63.6 kg X 1.5 = 95 g Pro
Range: 64g-95g Pro daily
(p. 421)
19.
12.9 (low)
38 (low)
180 (low)
Ferritin (mg/mL)
16 (low)
ZPP (micromole/mol)
85 (high)
22.7 (low)
17.2 (low)
<.1 (low)
Nutrition Diagnosis
13
20.
Nutrition Intervention
21.
14
22.
15
(MedlinePlus, 2015).
Adequate amounts of serum magnesium for Mr. Sims
are important because magnesium serves many
functions in the body. Magnesium is needed for nearly
all chemical processes in the body. It helps maintain
normal muscle and nerve function, and keeps the bones
strong and it is also needed in order for the heart to
function normally (MedlinePlus, 2015).
23.
16
Moledina, 2008).
Mr. Sims is most definitely at risk for this syndrome
seeing as he has just undergone a surgery that will
result in him being unable to consume food for 7-10
days. He will be forced to go onto a TPN for the time
24.
17
1,800-1,900 kcal/day.
I do agree with the teams decision to initiate parenteral
nutrition for the reason that Mr. Sims body will not be
capable of consuming food orally for at least 7 days
post-operatively. He will need the PN in order to reach
his daily caloric goal of 1,800-1,900. The PN initiated by
the team will indeed meet his nutritional needs. The
total kcal provided from the PN is 1,976 kcal and this
total does in fact fall into the range of his goal of 1,800-
1,900 kcal/day.
To calculate the grams of all three macronutrients, I set
up an equation of ratios:
o Pro (g): 42.5g/50cc/hr = x/85cc/hr =72.25g
72.25g X 4.3 kcal/g = 310 kcal Pro
o CHO (g): 200g/50cc/hr = x/85cc/hr = 340g
340g X 3.4 kcal/g = 1,156 kcal CHO
o Lipids (g): 30g/50cc/hr = x/85cc/hr = 51g
51g X 10kcal/g = 510 kcal Lipid
o TOTAL kcal from PN = 310 kcal pro + 1,156 kcal
CHO + 510 kcal lipid = 1,976 kcal
(p. 109)
18
25.
body.
Inadequate oral intake (NI- 2.1) related to patients
inability to maintain weight as evidenced by a 27 lb.
weight loss in a 6-month period.
o Encourage Mr. Sims to document his weight at the
beginning of each week when he returns home to
note any further fluctuations in his body weight.
Ensuring that he does not go below 18.5 for a BMI
(NIH, 2014) is important for him to maintain his
health status with a healthy BMI of 20.7.
Measure
295
261
19
RQ
RMR
0.88
2022
regarding that.
The hydration status of Mr. Sims will need to be
monitored for the reason that it is very easy for
20
28. What should the nutrition support team monitor daily? What
should be monitored weekly? Explain your answers.
21
22
31. On post-op day 10, Mr. Sims team notes he has had bowel
sounds for the previous 48 hours and had his first bowel
movement. The nutrition support team recommends
consideration of an oral diet. What should Mr. Sims be allowed to
try first? What would you monitor for tolerance? If successful,
when can the parenteral nutrition be weaned?
23
taken.
Monitor would be a monthly lab test to evaluate his
bowel movement.
Multi-vitamin consumed daily once a day with a meal.
25
References
Best,WR,Becktel,JM,Singleton,JW.Rederivedvaluesoftheeightcoefficientsofthe
CrohnsDiseaseActivityIndex(CDAI).Gastroenterology77(4Pt2),843846
(1999).
26
Crohn's&ColitisFoundationofAmerica(CCFA).(2009,October29).Retrieved
September10,2015.
Crohn'sdisease.MayoClinic(2010,May13).RetrievedSeptember10,2015.
Dretzke,J.(2014,September3).RetrievedSeptember10,2015.
Internationaldieteticsandnutritionterminology(IDNT)referencemanual:Standardized
languageforthenutritioncareprocess.(3rded.).(2011).Chicago,IL:American
DieteticAssociation.
Mehanna,H.,Moledina,J.,&Travis,J.(2008,April4).Refeedingsyndrome:Whatitis,
andhowtopreventandtreatit.RetrievedSeptember9,2015.
NationalInstitutesofHealth(NIH).(2014,July16).RetreivedSeptember10,2015
Nelms,M.(2011).Nutritiontherapyandpathophysiology(2nded.).Belmont,CA:
Wadsworth,CengageLearning.
Nelms,M.,&Roth,S.(2004).Medicalnutritiontherapy:Acasestudyapproach(4th
ed.).Belmont,CA:Wadsworth/ThomsonLearning.
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Phosphorusbloodtest:MedlinePlusMedicalEncyclopedia.(2015,April9).Retrieved
September13,2015.
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