Krause\'s Food and the Nutrition Care Process 14th edition Chapter 27 Case Study

Question

Krause's Food and the Nutrition Care Process 14th edition Chapter 27 Case Study

Jane is a 42-year-old female who presents with acute onset of epigastric abdominal pain associated with nausea and bilious vomiting, poor appetite, and 20-pound (9-kg) unintentional weight loss over the past 3 months. A nutrition consult is requested for assessment of nutritional status and strategies for treating nutritional issues associated with gastroparesis.

Nutrition Assessment

Past medical history is significant for type I DM, GERD, gastroparesis, hypertension, chronic low back pain, and recent back surgery 3 months ago. Jane was discharged on narcotics, and then was recently hospital- ized for similar symptoms that were attributed to diabetic gastroparesis exacerbated by narcotics use.

Her medications on admission include insulin, Zofran, Prilosec, Reglan, lisinopril, Ultram.

Oral intake has gradually decreased over the last 3 months to sips of liquids (water, soup, tea), and toast or crackers for the past 2 weeks. Upon further questioning, Jane reports frequent hypoglycemia after meals, early satiety, chronic constipation, and often wakes up in the morning feeling full. She has persistent epigastric abdominal pain accompanied by vomiting.

Anthropometrics: Ht: 162.5 cm (64 inches); Wt: 72.7 kg (160 lb); BMI : 27.5 kg/m2

Usual body weight: 81.8 kg (180 lbs); weight change: 11% change in 3 months (significant weight loss).

Jane’s nutrition-focused physical examination (NFPE) reveals the following: No evidence of muscle loss; stomach is smaller per patient report but otherwise no visible evidence of fat loss; no upper or lower extremity edema. Tongue is beefy red and swollen for the past few weeks (glossitis resulting from possible iron, folate, and vitamin B12 deficiency).

Functional capacity: Little energy or motivation to do anything for past 3 months. Dizzy and lightheaded for past 1 week.

Laboratory data: Hb A1C (glycosylated hemoglobin) level: 9.5% (high), blood pressure: 178/95 (high), blood glucose: 293 mg/dl (high)

Nutrition Diagnostic Statements (PES Statements):

• Suboptimal oral intake (P) related to inability to consume sufficient calories (E) as evidenced by report of nausea, vomiting, and persistent abdominal pain (S).

• Unintended weight loss (P) related to altered GI function (E) as evidenced by 11% weight loss over past 3 months (S).

1- What test can be used to test Jane’s gastric emptying rate?

2- How do pro-kinetic medications work?

3- What can affect nutritional status with gastroparesis?

4- What is considered ”normal” gastric emptying time?

5- What foods will Jane want to avoid?

6- What foods lower LES pressure?

7- How can Jane prevent benzoar formation?

8- What are dietary recommendations for Jane’s diabetes and hypertension?

9- What factors could contribute to GERD?

10- List what to monitor in Jane’s follow-up visits

Explanation / Answer

1- What test can be used to test Jane’s gastric emptying rate?

To test Jane’s gastric emptying rate she has to be subjected to gastric emptying scintigraphy test. This is gold slandered test to diagnosed delaying in gastric empting. It is generally tested when doubts about the abnormal delayed empting of food form stomach. It mainly caused due to two reason gastric outlet obstruction and gastroparesis. Due to abnormal gastric delay following complications arrive- uneasy conditions after meals, nausea, vomiting.

2- How do pro-kinetic medications work?

Pro-kinetic medications are used to stimulate contractions of the stomach muscles in case of gastro-oesophageal reflux disease (GERD).During GERD acid moves up from the stomach into the oesophagus resulting heartburn and damaging the tissue. In healthy people, the lower oesophageal sphincter (LES) is located at the junction of the stomach and the oesophagus. This valves stops digestive acids to come out to oesophagus. In GERD patients this is not functional properly which causes the reflux of acid to oesophagus. Pro-kinetic medications help to tightening LES, thus prevent acid from refluxing from the stomach into the oesophagus. It also helps to increase the rate of stomach empting, which ultimately reduces the reflux of stomach acid.

Example: Cisapride, metoclopramide Etc.

3- What can affect nutritional status with gastroparesis?

Following factors affect the nutritional status gastroparesis condition

·         Eat in small volume but frequent meals: small eating volume each time, 6 times small meal per day. Over eating caused nausea and vomiting. Try to take liquid between meals not with meals.

·         Properly chew meals for easier digestion

·         Seat upright for at least 1 hour after eating and thus using gravity to speed up stomach emptying and reduce symptoms of reflux.

·         Avoid high food diet, avoid alcohol.

·         Diet supplements with vitamin and minerals.

4- What is considered”normal” gastric emptying time?

In healthy adult individuals normal gastric retention at time interval 1,2, and 4 hour after finishing a consistent radio tagged low fat meal are 90%, 60% and 10% respectively.

5- What foods will Jane want to avoid?

·         High fat food like fried food, cream, cheeses, sausages etc should be avoided.

·         Methylxanthine containing food like Coffee, chocolate should be avoided.

·         Carbonated beverages along with alcohol should be avoided.

6- What foods lower LES pressure?

High fat containing foods, methylxanthine containing food have been found to delay gastric emptying as well as decrease the LES pressure. Thus they are increasing the oesophageal exposure time to stomach acid and the volume available for reflux.

7- How can Jane prevent benzoar formation?

According to compositions Bezoars are 4 types.

Phytobezoars (indigestible food particles that are found in vegetable or fruit fibers), Trichobezoars(conglomeration of hair and food particles)

Lactobezoars (milk protein)

Pharmacobezoars (concretions of various medications)

Food-grade fat emulsifier helps to reduce the size of a bezoar, allowing it to pass from the digestive tract. Also Usage of protease along fat emulsifier with also helps to reducing the bezoar. Combined use of cellulase and Diet Coke also helpful.

8- What are dietary recommendations for Jane’s diabetes and hypertension.

·         Maximum Sodium intake is 1,500 mg/day. From total diet carbohydrates=55 %, protein=18% and fat=27%

·         Saturated fat and dietary cholesterol are very limited.

·         nuts, legumes and sweets are limited

·         Increase intake of fresh green vegetables.

9- What factors could contribute to GERD?

Following factors could contribute to GERD:

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