Unit outcomes addressed in this Assignment:
• Explain the impact that ventilator support has on a person’s nutritional requirements.
• Explain the role that dietary intake plays in the management of COPD.
Course outcome(s) addressed in this Project:
NS335-3: Create a nutrition care plan for a specific disease state using the nutrition care process.
NS335-6: Choose the appropriate type of nutrition support for a patient who is unable to consume a normal oral diet
Review the following case study details for a patient with COPD and respiratory failure:
Mr. C is a 72-year-old male who was admitted to the hospital 2 days ago complaining of shortness of breath. Mr. C has a complicated medical history that includes: COPD, HTN, depression, obesity, and sleep apnea. Mr. C has smoked since the time he was a teenager. He is a retired auto-mechanic and is married to his wife, Mrs. C. Mr. C is 5’10″
and 240 pounds. He has been instructed to follow a heart healthy diet and to lose weight, but his wife reports that he is non-compliant with any dietary therapy. He is currently taking a diuretic, a blood pressure medication, and an anti-depressant, and he uses an inhaler when SOB (shortness of breath). The patient uses a breathing mask at night due to his sleep apnea history. His wife reports that she recently bought him a
special multi-vitamin containing omega 3 fatty acids. It is designed to help older men’s hearts and other medical issues.
Upon admission to the hospital, Mr. C’s respiratory status declines, and the ER physician decides to intubate the patient in order to deliver proper oxygenation. The MD also starts the patient on IV fluids consisting of NS (normal saline) for hydration. While on ventilator support, the patient is sedated and is unable to talk or consume an oral diet. The medical chart notes from the pulmonologist reveal that there are no immediate plans to extubate the patient (wean from the ventilator). Currently, the laboratory lab values of the patient are all within normal limits (WNL). However, upon admission and before vent support was initiated, his labs were abnormal. Some affected lab values were: CO2, BUN/Cr, pH, and Na. The patient has had an NPO (nothing by mouth) diet order status for 4 days and has only received IV fluids for intake. The nursing notes
reveal that he has normal urine output and bowel sounds are present and normal.
As a nutrition professional working at this hospital, you are to start the nutrition care process on this patient. Your hospital has a protocol to see all patients that have NPO diet orders and/or are on the ventilator for more than 4 days. You have NOT received a doctor’s consult for a tube feeding (enteral) order; however, it is imperative that this the patient is assessed and appropriate nutrition recommendations are made.
For this Assignment, you will write a descriptive essay concerning COPD. You will explain the disease itself and how you will develop a nutrition care plan for the case study patient. Your descriptive essay should include the following:
- Describe COPD, its risk factors, and its common treatments.
- Explain Mr. C’s current status. Describe why he was intubated and how vent support can impact a patient.
- What are the nutrition therapy goals for a patient with COPD receiving vent support?
- What are your specific nutrition therapy recommendations for Mr. C while he is on ventilator support? Include estimated calorie and protein requirements and the method(s) for how he should receive these nutrients (enteral, parenteral, or oral diet/supplements). You do not need to include details of specific brands, amounts/serving sizes and/or infusion rates.
- When the condition of the patient improves and he is taken off the vent, what are your recommendations for nutrition therapy for Mr. C upon discharge from the hospital? What are some specific diet plans, oral drink supplements, or vitamin/herbal therapies that may benefit Mr. C?
- Appendix: Write a Nutrition Care Plan/Chart note on this COPD patient, addressing the current clinical situation of the patient. Write this note as though you were the nutrition professional caring for this patient in a hospital setting. Please refer to Box 11-1 for Nutrition diagnoses terms and to Tables 11-3 and 11-4 in your textbook for information on the ADIME chart note process.
- Your descriptive essay should be written in paragraph format, including an introduction, body, and conclusion. Refer to the structure provided below. The viewpoint and purpose of this essay should be clearly established and sustained. Your writing should be well ordered, logical and unified, as well as original and insightful. Your work should display superior content, organization, style, and mechanics.
Your writing should:
- Follow the conventions of Standard American English (correct grammar, punctuation, etc.).
- Include a title page and reference page.
- Follow APA style format and citations guidelines, including Times New Roman 12-point font and double spacing. The minimum page requirement is 2 pages not including the title page, reference page, and appendix.
- Include at least 4 references. References may include your textbook, other textbooks, and scholarly websites and journal articles. Use APA style for all citations, including course materials.
Please organize your essay in the following paragraph format.
Section 1: Introductory paragraph(s) (incorporate your response to question 1)
Section 2: Body paragraph(s) (incorporate your response to question 2)
Section 3: Body paragraph(s) (incorporate your response to question 3)
Section 4: Body paragraph(s) (incorporate your response to question 4)
Section 5: Concluding paragraph(s) (incorporate your response to question 5)
Appendix: Nutrition Care Plan/Chart note
COPD Case Study – Mr. C
The case of Mr. C is reviewed. Mr. C, a 72-year old man has been admitted to hospital 2 days ago. He complained of shortness of breath. He weighs 240 pounds, at a height of 5’ 10”. He suffers from HTN, depression, obesity and sleep apnea. A retired auto-mechanic, he is married to Mrs. C, and has smoked since he was a teenager. He is non-compliant with dietary therapy, and is currently on diuretic, blood pressure medication and anti-depressant. He uses a breathing mask while sleeping due to his history of sleep apnea.
COPD – Risk Factors and Common treatments
COPD refers to Chronic obstructive pulmonary disease. It is a slow but progressive chronic inflammatory lung disease. The COPD foundation points out that the term is an umbrella term that describes a number of progressive lung diseases (COPD Foundation 2016). Increasing breathlessness is one of its characteristics. COPD has two types. Type 1 is referred to as emphysema and is characterized by an abnormal enlarging and destruction of the alveoli. For type II, on the other hand, which is chronic bronchitis, patients exhibit a productive cough and inflammation of bronchi (Mahan, Escott-Stump & Raymond, 2012). There are also other lung changes.
Risk factors for COPD include age – being over 40, smoking, exposure to occupational dust and chemicals, exposure to indoor pollution and an extended exposure to wood or biomass smoke. The risk of COPD is further elevated by conditions such as allergies and asthmas, and consumption of cured meats (Harvard Health Publications, 2010).
Treatment methods for COPD normally vary based on how advanced the disease is. The main of COPD management is to reduce the risk factors, assess and monitor the disease and to manage stable COPD as well as any increase in its severity. The different treatment methods available include the use of oxygen therapy, pulmonary rehabilitation programs and medications such as bronchodilators, steroids (inhaled), combination inhalators and antibiotics to treat any infections (Mayo Clinic Staff 2015). In highly advanced cases, lung transplants may be the only solution.
Mr. C’s Current Status
Mr. C has been intubated so that proper oxygenation is delivered. This is because upon admission, his respiratory status declined. Moreover, he has also been started on IV fluids, which include NS for hydration. He is sedated, hence unable to talk or consume an oral diet for four days. Mr. C’s lab values are within the normal limits and nursing notes reveal that his output urine is normal, with the report of present and normal bowel sounds. His intubation has to do with abnormal initial lab reports, whereby CO2, BUN/Cr, pH and Na had been affected.
Vent support has a number of impacts on a patient, including respiratory muscle weakness, lung injury and tracheal injury. Other effects include ventilator acquired pneumonia, increased secretions and general deconditioning.
For a patient with COPD who is receiving vent support, the main goals of nutritional therapy are to satisfy basic nutritional requirements, preserve lean body mass, restore the mass and strength of respiratory muscles, and to maintain the balance of fluids. Other essential goals are to boost immunity against infections, and to provide the patient with sufficient energy that will allow weaning from oxygen and vent support without exceeding the ability of the respiratory system to clear CO2.
Nutritional Therapy Recommendations During Ventilator Support
Calorie needs are best determined through indirect calorimetry. Due to lack of sufficient information, however, the Harris-Benedict Formula is applied.
Mr. C weighs 240 pounds, therefore his BMR is 1960 calories (BMI Calculator, n.d.). he requires 2352 calories to maintain his current weight, based on the Harris benedict Formula. However, since he is obese, a daily intake of 2150 calories would be better. Mahan, Escott-Stump & Raymond (2012) recommend that critical care patients should receive 1.5 – 2.0 g/kg of their dry body weight.
For protein, I would recommend that the average intake be 1.8g/kg, totaling 198 grams of protein and 792 calories of protein at 4 calories per gram. The rest of the calories should be divided between carbohydrates and fats at 684 calories each. Despite his high calorie requirements, Mr. C cannot consume orally. Consequently, I recommend that he be started on EPN through the gastric tube. This way, the recommendation for basic nutritional requirements and preservation of lean muscle mass will be met.
Nutritional Therapy Recommendations Upon discharge
Once discharged, Mr. C should maintain the 2150 calories a
day diet. He should adhere to a heart-healthy diet, and I recommend the DASH
diet. Mr. C’s non-compliance when it comes to following budgetary guidelines is
quite worrying and as such, it might be a good idea to retain the Omega-3
multivitamin supplement. Ensure Complete would be an appropriate replacement
for breakfast time, but this will depend on how well he is able to stick to the
BMI Calculator. (n.d.). BMR calculator. Accessed April 4, 2016. http://www.bmi-calculator.net/bmr-calculator/
COPD Foundation. 2016. What is COPD? Accessed April 4, 2016. http://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx.
Harvard Health Publications. (2010, April 10). Chronic obstructive lung disease – risk factors. Accessed April 4, 2016. http://www.healthcentral.com/copd/copd-000070_6-145.html
Mahan, L., Escott-Stump, S. & Raymond, J. (2012). Krause’s Food & Nutrition Care Process. 13th Edition. St. Luis, Mo. Elsevier Inc.
Mayo Clinic Staff. 2015. Treatments and drugs. July 21. Accessed March 4, 2016. http://www.mayoclinic.org/diseases-conditions/copd/basics/treatment/con-20032017.
Appendix – Nutritional Care Plan
A – Mr. C., a 72-year old man, was admitted to hospital complaining of shortness of breath. He weighs 240 pounds, and is 5’ 10” tall. He has a BMI of 34.4, making him obese. Mr. C has a history of several diseases and conditions, including COPD, HTN, obesity, depression and sleep apnea. Upon admission, lab values for CO2, BUN/Cr, pH, and Na were abnormal. He was then put on vent support and has not been able to communicate or consume orally, being NPO for four days. He has also been intubated with IV fluids of normal saline for hydration.
D – Due to vent support, Mr. C has increased energy expenditure (N1-1.2). He also has inadequate intake of the following due to being NPO for four days: inadequate oral food or beverage intake (N1-2.1), protein (N1-52.1), fat (N1-51.1), carbohydrate (N1-53.1), vitamin (N1- 54.1) and mineral (N1-55.1). The patient’s adherence to nutrition-related recommendations has been limited.
I – Glucose should immediately be added to Mr. C’s IV. Additionally, the doctor should prepare him for EN through the gastric tube, seeing as he has not received any nutrition for four days. The formula for this is 2150 calories with 198 grams of protein, 171 grams of carbohydrates and 76 grams of lipid. The amount of protein is needed to retain lean muscle mass. Moreover, the calorie recommendation is due to his status as obese.
ME – nutrition intake, urine and stool output as well as lab values for total protein and serum albumin should be evaluated every two days. Weight and energy level should also be checked. For as long as he is in the hospital and on the vent support, it is necessary to follow up. Normal diet should proceed once he is extubated. Furthermore, educational support on the components of the DASH diet to be provided to both Mr. and Mrs. C. support will be through handouts and answering any questions they may have.