Patient 

36 y.o. WM adm. 2/3/04 w/ Crohn’s dx. C/O lower ab pain, N/V x 5d

3 mo’s earlier told should have sx but refused and put himself on liquid diet

PMH               

Crohns x 17y                      PSH: smoker/ caffeine

 

Procedures & Dx’s                                        

2/3

2/5

 

 

 

2/11

 

 

 

2/12

Abdominal and CT Scan:  dilated and thickened small intestine w/ streaking and gas

Exploratory Laparotomy, Ileocolic Resectionàend to end anastomosis

(found ascites, distended loops, lg palpable mass of pus and fecal material, severe crohns/perforation: terminal ileum-cecum; Est. 400cc blood loss)

Dx: Crohn disease, Perforated ileum

CT scan: bowel distention, fluid collection right abdomen, right lobe lung infiltrate

Chest X-ray: atelectasis right lung

Dx: Right lower lobe pneumonia w/ atelectasis

PICC line IV catheter

Rising Leukocytosis; fever 2/10 – 2/13

 

Diet Order

2/2 – 2/16 NPO; 2/16 lunch CL; 2/20 FL; 2/21 Soft Bland; 2/22 Soft Bland/Lactose int.

 

 

Anthropometrics

& TPN order

 

Ht: 5’5” (165 cm)      

IBW: 136# (62kg)       

BMI: 25

BMI: 22.7

 

Wt: 150#  (68kg)

à 137# (62.19kg)

Wt loss:

 8% x 2.5wk (Severe)

TPN

AA

Dex

Lip

2/13

50g

150g

10% @10cc/h

2/15

90g

250g

65g

2/19

90g

275g

65

}

 

 

@ 80 cc/h

 

 

 

kcal

974

1795

1860

 

Nutritional Requirements

Calories = BEE (1586) x 1.4 (infection, post op, fever) = >2200 kcal

PRO = >100g (1.5 x admit wt)

Jennifer Duvall
 

RD Chart Notes

2/4  

Min po x several days and probable need for NPO x several days post-op. Recommend TPN

2/6

Pt still awaits NG tube.  No plans for diet adv.  Consider TPN if no adv 72h.

2/9  

NG tube clamped today.  Anticipate adv diet.

2/11

Left note on front of chart for MD recommending TPN.  Will follow plan of tx closely

2/12

Pt started on TPN – tol.  2/15-2/17 Tol TPN

2/20

Pt on last TPN bag; some soup for lunch.  Pt concerned about diet and crohn’s after d/c.  Educ Provided     

 

Diet Order

NPO

NPO

NPO

NPO

NPO

TPN

TPN/CL

TPN/FL

 

Labs

2/3

2/4

2/5

2/10

2/11

2/12

2/17

2/20

Normal Range

BUN

12

9

6

<5

<5

5

12

11

5-25 mg/dl

Na

134

131

131

132

133

132

136

135

135-146 mmol/L

CO2

17.6

WNL

18-32 mmols/L

Glucose

166

115

126

WNL

70-115 mg/dl

Uric Acid

 

 

 

 

 

3.7

1.9

 

3.7-7.8 mg/dl

Albumin

 

 

 

 

 

2.5

2.8

 

3.5-5.0 g/dl

2/9 Total Iron 19;        Iron Binding 147;           %Saturation 13;                 B12 134.7;            Folic Acid 8.1

Cholesterol

 

 

 

 

 

100

107

 

120-199 mg/dl

Triglycerid

 

 

 

 

 

85

151

117

20-150 mg/dl

WBC

13.9

12

16

11

14

21.9

20.4

8

7

4.8-10.8 k/cmm

RBC

5.8

5

5

3.7

3.8

4.1

4.0

3.6

4.1-5.3 m/cmm

Hgb

15.3

15

12

10

9

10

9

9.5

13.5-17.1 g/dl

Hct

45.7

45

40

30

29

31

29

28

41-51%

MCV

78.4

x

x

x

x

x

x

78.2

81.0-99.0 fl

MCH

26.3

x

x

x

x

x

x

26.2

28.0-32.0 pg

Platelet ct

424

x

x

x

x

743

x

618

150-350 k/cmm

MPV

7.4

x

x

x

x

6.7

x

x

7.4-10.4

 

Meds

 

Jan

Feb wk 1

Feb wk 2

Feb wk 3

Acetaminophen (analgesic, antipyretic: pain)

Bisacodyl (laxative)

*

 

************

     

************

        *        ***      

*****

*****

Cepacol Lozenge

Cyanocabalamin (vitamin B12)

 

 

      *********

                   *

************

                   *

*****

Dextrose 5% in 0.9%

Dextrose 5% in Water

 

      *********

              *****

**

************

 

****

Fat Emulsion 10%

Fluconazole (oral candidiasis, poss. yeast in abd)

 

 

  **

  ***********

 

*****

Heparin Lock Solution (anti-coagulant)

Hydromorphone (narcotic often suppository)

 

          *

 

 

 *     *

Hyperalimentation Sol

Potassium Chloride

 

   

    **********

  ***********

**

**

Ketorolac NSAID contraind. w/ recent GI perforation ??

Levofloxacin (IV - antibiotic)

 

*

 

************

 

**                     

****

Meperidine HCl (analgesic)

Mesalamine (anti-inflammatory suppository)

 

     *

 

 

                  ***

 

*****

Metronidazole (IV – antibiotic)

Midazolam (sedative)

*

************

     *

************

*****

Morphine Sulfate (pain)

Sodium Chloride 0.9%

*

*

**********  *

****

***  *  ******

*****

Naloxone (pure narcotic antagonist)

Nicotine Transermal

 

    **********

          *******

***********

************

 

*****

Nystatin (oral candidiasis, poss. yeast in abd)

Ondansetron Inj (anti-emetic)

 

 

      *********

  ***********

************

**

*****

Pantoprazole (antiGERD)

Piperacillin-Tazobac (antibiotic-pneumonia)

*

****

 

  ***********

 

*****

Premix IV Solution

Promethazine (anti-histamine, anti-emetic)

*

*

************************

************

************

*****

*****

Ranitidine (IV antiulcer, anti-gerd, antisecretory)

Vancomycin (IV antibiotic; bact ID’d from sx)

 

    **********

            ******

************

************

**

****

Zolpidem Tartrate (sleep aid)

 

 

 

*****

 

9/20 Pre-consult interview:  Pt had a lot of fears, concerns, and misconceptions

·        Is lactose intolerant;  eats everything other than regular milk

·        Reportedly had been asymptomatic and ate anything he wanted until just recently; “all happened overnight”

·        Believed he did this to himself through denial and eating habits over the years

·        Thought this was God’s way of warning him not to be in denial of his disease

·        Wanted to know what he had to eat; would do anything not to be in this situation again

·        Didn’t understand why hospital would give him OJ, apple juice, etc…b/c after working with specialist at Johns Hopkins was told these juices were harmful.

·        Concerned about use spices, especially salt and pepper.

 

9/20 F/U consult/education:

Goals: 

·        Alleviate fears associated with food intake and self-blame

·        Provide diet information for asymptomatic periods and during periods of inflammation.

·        Address issues specific to patient concerns.

Education

 

When inflammation does occur, many foods may become irritating and should be avoided until symptoms resolve.  Dietary recommendations are individualized to each patient b/c food tolerance varies depending on the part of the intestine which is affected.  Key point is to strive for a well-balanced, healthy diet and learn what individual adjustments can help during periods of disease flares.

 

Tips

 

Specifics

 

Provided handout and business card.

 

 

References:

 

Escott-Stump S. 2002. Nutrition and Diagnosis Related Care. Lippincott Williams & Wilkins: New York.

 

Mahan LK. & S. Escott-Stump. 2000. Krause’s Food, Nutrition & Diet Therapy. W.B. Saunders Co.: New York.