Principles and Practices of Enteral and Parenteral Nutrition

Principles and Practices of Enteral and Parenteral Nutrition

CD is a 28-year-old administrative hospital worker who presented to the emergency room  complaining of headaches and shortness of breath. She was admitted to the hospital for  evaluation

when she was found to have a blood pressure of 170/110 mm Hg and mild congestive heart  failure

(CHF) by chest X-ray. CD reports that over the past year, her weight has increased about 10  pounds

(4.5 kg), although her dietary intake has remained unchanged or even lower due to desire for  weight

loss.

Past Medical History 

CD has had no recent viral illness, sore throat, or upper respiratory infections but did report  frequent sore throats treated with antibiotics as a child. She has never had rheumatologic  symptoms,

and has no knowledge of a family history of renal disease. She is currently not taking any  medications, vitamins, minerals, or herbal supplements and has no known drug or food  allergies.

Social History 

CD has her own apartment and lives alone. She occasionally drinks alcohol but denies tobacco and intravenous or oral drug use.

CD’s 24-Hour Dietary Recall 

Breakfast (home) 

Tea 8 ounces (240 mL)

Orange juice 8 ounces

Non-dairy creamer 2 Tbsp.

_Bagel Frozen, store bought, eating

½

_{Cream cheese} 1 Tbsp. on whole bagel,

eating ½

Skim milk 8 ounces

Lunch (grocery store) 

Salad with scoop of tuna or

_{chicken salad} 1 cup, eating ⅓

Iced tea (unsweetend) 16 ounces (480 mL)

Orange or grapes 1 medium orang

Dinner (home) 

_{Chicken breast, broiled} 3.5 ounces (eating maybe

almost ¾)

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Principles and Practices of Enteral and Parenteral Nutrition

Broccoli, spinach 1/2 cup each

Margarine 1 tsp total for 2 vegetables

_Salt 1 tsp total for vegetables

and chicken consumed

Diet cola soda 16 ounces (480 mL)

Snack (movies) 

Salted nuts 2 small 1 ounce bags

Diet cola soda 16 ounces (480 mL)

Total calories: 1122 kcal

Protein: 68 g

Fat: 72 g

Carbohydrate: 118 g

Potassium: 2974 mg

Sodium: 1650 mg

Calcium: 819 mg

Phosphorus: 1095 mg

Review of Systems 

General: Fatigue, weakness, shortness of breath

GI: Anorexia

Physical Examination 

Vital Signs 

Temperature: 97 °F (36 °C)

Heart rate: 96 BPM

Respiration: 24 BPM

Blood pressure: 170/110 mm Hg

Height: 5′4″ (162 cm)

Current weight: 130 lb (59 kg)

Usual weight: 120 lb (54.5 kg) 6 months ago (Use for estimated “dry” weight)

Exam 

General: Well-developed female

Lungs: Decreased breath sounds with faint crackles at the right base Cardiac: Regular rate and rhythm, systolic murmur at the apex, S3 gallop Abdomen: Soft, non-tender, no hepatomegaly

Extremities: 2+ peripheral edema on both legs, ring tight on finger Skin: Warm to touch

Neurologic: Intact, mild asterixis

Initial Laboratory Data 

Patient’s Values Normal Values 

Sodium: 132 mEq/L 133-143 mEq/L

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Principles and Practices of Enteral and Parenteral Nutrition Case Analysis 2

Potassium: 6.4 mEq/L 3.5-5.3 mEq/L

Chloride: 111 mEq/L 98-108 mEq/L

CO2: 15 mEq/L 24-32 mEq/L

Calcium: 7.5 mg/dL 9-11 mg/dL

Adjusted calcium: 8.1 mg/dL 9-11 mg/dL

Phosphorus: 7.2 mg/dL 2.5-4.6 mg/dL

BUN: 90 mg/dL 7-18 mg/dL

Creatinine: 8.0 mg/dL 0.6-1.2 mg/dL

Albumin: 3.2 g/dL 3.5-5.8 g/dL

Hemoglobin: 7.3 g/dL 13.5-17.5 g/dL

Hematocrit: 21.9% 41-53%

Transferrin saturation: 18% 20-50%

Ferritin: 142 ng/mL 20-300 ng/mL

Mean corpuscular volume:

_{70 fL} 80-100 fL

White blood cells

(WBC): 5.7 × 109/L 4.5-11 × 109/L

Urinalysis: 3+ heme by

dipstick, 1+ protein by

dipstick

Sediment: 15-20 red blood

cells (RBC)/HPF, 3-5

WBC/HPF, 2-4 red blood

cell casts and broad

waxy casts/HPF

Electrocardiogram: Normal

sinus rhythm at 100, no

ischemic changes

Chest X-ray: Cardiomegaly,

CHF

Dialysis Treatment Plans 

CD received a temporary dialysis catheter and underwent two hemodialysis treatments in the hospital. During her hospitalization she was educated on all dialysis modalities available and  chose

peritoneal dialysis (PD). She was discharged from the hospital with plans for a peritoneal  dialysis

catheter to be inserted the following week. She was educated on a “renal” diet by the hospital  dietitian and medications were prescribed as well. She was to dialyze in the in-center dialysis  facility

close to the hospital.

Laboratory Data #2 (after 1 Week on HD) 

Patient’s Values Normal Values

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Principles and Practices of Enteral and Parenteral Nutrition Case Analysis 2

Sodium: 136 mEq/L 133-143 mEq/L

Potassium: 4.9 mEq/L 3.5-5.3 mEq/L

Chloride: 102 mEq/L 98-108 mEq/L

CO2: 18 mEq/L 24-32 mEq/L

Calcium: 8.8 mg/dL 9-11 mg/dL (8.4-9.5)*

Corrected calcium: 9.4

_mg/dL 9-11 mg/dL (8.4-9.5)*

Phosphorus: 6.0 mg/dL 2.5-4.6 mg/dL (3.5-5.5)*

BUN: 70 mg/dL 7-18 mg/dL

Creatinine: 6.2 mg/dL 0.6-1.2 mg/dL

Albumin: 3.3 g/dL 3.5-5.8 g/dL

_{Hemoglobin: 9.8 g/dL} 13.5-17.5 g/dL (11-12

g/mL)*

Hematocrit: 27% 41-53% (33-36%)*

*These are guidelines established for patients with chronic kidney disease (CKD) by the National Kidney Foundation Kidney Disease Outcomes Quality Initiatives (NKF K/DOQI) committees, but not currently utilized due to CMS requirements for lower doses of EPO.