Neuro Cs

Name:
__Ziying Tan______________________
Winter 2015

Mini Case Study #3

Present illness: LM is a 75 yo M presenting with L sided weakness, slurred speech, and
difficult swallowing. The speech pathologist has completed a swallow evaluation that
reveals severe oropharyngeal dysphagia. He must be kept NP0. Patients spouse is at
bedside and reports everything being fine until 2 days ago when patient lost function of
his left side and was slurring his speech. She called 911 and brought him to the ED and was
admitted right away. She says he has always been a big guy and loves his food and wine.
His activity consisted of overseeing their winery and playing 18 holes of golf on the
weekend.

Dx: acute CVA
PMH: HTN
Anthropometrics: Height 6, Weight 240#
Labs: Albumin: 3.8 g/dL
Na: 134 mEq/dL
Cl: 101 mEq/dL

K: 3.6 mEq/dL

CO2: 26 mg/dL
Cr: 0.8 mg/dL

Glu: 276 mg/dL

Total Cholesterol: 245mg/dL
Meds: Toprol, coumadin

Diet: NPO

1. Using IBW, calculate LMs nutritional needs, including calories, protein and fluids.
(show calculations) (6 points)

IBW=106 lbs. for first 5 plus 6 lbs for every inch
= 106 lbs + (6 x12)
=178 lbs/ 2.2lb/kg = 80.9kg
Using Mifflin: Men: RMR=(9.99 x weight) + (6.25 x height) (4.92 x age) +5 (PR p.3)

= (9.99 x 80.9kg) + (6.25 x 182.9cm) (4.92 x 75) +5

=1587.3 kcal/day
Activity Factor: 1.2-1.3: confined to bed~out of bed (PR p.9)
NO injury factor in this case
Therefore, LMs kcal needs:
1587.3kcal/day x 1.2 = 1904.8 kcal/day=1905kcal/day
1587.3kcal/day x 1.3=2063.5 kcal/day=2064kcal/day

Protein requirement: 0.8~1.0 gm/kg/day (PR p.10)
80.9kg x 0.8 g/kg=64.7g protein/day=65g protein/day
80.9kg x 1.0g/kg=80.9g protein/day=81g protein/day

Fluid requirement: 1ml/kcal

1905~2064kcal/day x 1ml/kcal=1905~2064ml

2. What micronutrient and food sources need to be considered for a patient on Coumadin?
(2 points)

Coumadin is used to prevent heart attacks, strokes, and blood clots in veins and arteries.
People who take Coumadin may not receive sufficient vitamin K for optimal function of
vitamin K-dependent protein, which are important to maintain long-term health.
Therefore, vitamin K needs to be considered for a patient on Coumadin. Three food sources
of vitamin K: kale (green leafy vegetable), Spring onions (salad vegetables), Brussels
sprouts (brassica vegetables)

Resource:
http://www.wellnessresources.com/studies/entry/how_coumadin_affects_vitamin_k_func
tion/
http://www.healthaliciousness.com/articles/food-sources-of-vitamin-k.php

3. Define dysphagia and how it impacts your nutrition intervention. (2 point)

Dysphagia- difficulty swallowing due to oropharyngeal or esophageal problems. Therefore,
the diet should be modified due to the patient has swallowing difficulty. I need to make
sure the foods that wont increase risk of choking, and how to obtain adequate nutrition
and hydration in order to avoid dehydration and undernutrition. Moreover, dysphagia
increases the risk of aspiration, so this needs to take as a consideration when deciding the
route of tube feeding. This is because aspiration can lead to choking, shortness of breath,
discomfort and pneumonia, etc. Furthermore, nutrition intervention needs to make
decision based on what the speech pathologists evaluation.

4. Name and describe the 3 levels of the National Dysphagia Diets. (3 point)

Level 1: Dysphagia pureed-foods that are very cohesive, pudding-like, homogenous,
and requiring very little chewing ability.
Level 2: Dysphagia mechanically altered characteristics- foods that are mechanical altered,
cohesive, moist, semisolid foods, and requiring some chewing.
Level 3: Dysphagia advanced-Soft foods that require more chewing ability.

Resource: NUT116BL_Agiing and Dysphagia Lecture slides

5. The referring physician is recommending the placement of a PEG tube. What are your
formula recommendations? List type of formula, volume and rate that best matches
your calculated calorie and protein goals. (show calculations) (4 points)

Based on the needs of LW, I would recommend Osmolite 1 CAL (Abbott). This patient has
no GI problem, so whole protein is recommended to meet the protein requirement.
Additionally, I would recommend low residue for him because I am worrying about he
would get GI upset, and I have to be careful with fiber content in NPO patients.

Estimated energy requirement from #1: 1905-2064kcal/day

Using standard formula of Osmolite 1CAL (Abbott): 1.06kcal/mL
1905kcal/1.06kcal/ml=1797.2mL
1797.2mL/24hr=74.8mL/hr, which should be rounded up to 75mL/hr
Total volume of formula: 75mL/hr x 24hr= 1800mL
Energy from this formula: 1800mL x 1.06kcal/mL=1908kcal

Hourly rate for delivery:
Using standard formula of Osmolite 1CAL (Abbott): 1.06kcal/mL
1905kcal/1.06kcal/ml=1797.2mL
1797.2mL/24hr=74.8mL/hr, which should be rounded up to 75mL/hr

Protein goals:
Total volume of formula: 1800mL/1000=1.8L
1.8L x 44g=79.2g protein

6. Is this volume of tube feeding adequate to meet his fluid needs? If not, indicate what
else is needed and how it would be added to the current tube feeding. (show
calculations) (2 points)

Using standard formula of Osmolite 1CAL (Abbott): 84% of water
Free water: 1800mL formula x 0.84 = 1512mL
Fluid requirement is 1905~2064ml
Water flushes: 1905mL-1512mL=393mL
393mL/4=98.25, which should be rounded to 100mL of water by every 6
hours in a day.

7. Write 1 appropriate PES statement for the patients nutrition problems. (1 points)
Inadequate oral intake (NI-2.1) related to severe oropharyngeal dysphagia as evidenced by
speech pathologists evaluation and the prescribed diet of NPO by the MD.

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Estimated energy requirement from #1: 1905-2064kcal/day

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