1. Mini-Case Study Presentation Hilary Smith November 17, 2014

2. Patient SL 84 y/o female Transported by EMS from home, pt unsure who called 911 Admitted 11/2/14 with weakness, UTI and signs of alcohol withdrawal Number of intern contacts: 3, 1 with RD Number of RD contacts: 1

3. Social History Does not have a Primary Care Physician Lives at 2-story home with 50-year old son who is wheelchair-bound and takes care of him, and 24 y/o grandson SL using a wheelchair more often, was unable to get up 3 days prior to admission Patient arrived unkept

4. Prior Medical History H/o alcohol use, unknown how much/often Alcohol level 150 upon admission Smokes 1 pack/day H/o L hip repair surgery, acute renal failure, b/l lower extremity cellulitis, HTN No home meds

5. Diet History Upon first contact, was not able to obtain history Patient sleeping and no PO intake Visited 2 days later Pt says she eats 2 meals/day at home Usually a bagel, sometimes with lox for breakfast/lunch Used to cook but now eats pizza or Chinese food for lunch or dinner Current intake: inconsistent ~50%, likes Ensure

6. CIWA Protocol Clinical Institute Withdrawal Assessment SL was put on protocol upon admit Measures 10 symptoms to assess pt risk for withdrawal Assessment score >8-10, minimal to mild withdrawal 8-15, moderate withdrawal 15+, severe withdrawal Pt assigned detoxification program

7. Medications IV NS @ 120 ml/hr alternating with IV NS + MVI + folic acid + thiamine @ 150ml/hr “Banana Bag” Ceftriaxone – ABT for UTI Consider Na content with low Na diet; anorexia Folic acid Thiamine Multivitamin w/ Minerals Diazepam – Alcohol withdrawal symptoms Limit caffeine to <400-500 mg/day, caution with grapefruit Ativan PRN – Alcohol withdrawal symptoms

8. Labs K - 3.3 mmol/L – low Ref. range 3.5-5.1 Ca - 7.6 mg/dL – low Ref. Range 8.5-10.1 Albumin - 2.7 g/dL – low Ref. Range 3.4-5.0 Ethanol – 150 mg/dL - high

9. Nutrition History Diet at time of assessment: Room Service, Heart Healthy (3-4g Na, low fat, low cholesterol) Liberalized to House Menu, Regular on 11/9

10. Physical Appearance: frail 2 Pressure ulcers: R ischium, unstageable; L ischium Stage II, staged per wound care RN Demeanor: lethargic; first visit pt was sound asleep (Ativan PRN)

11. Anthropometric Data Height: 152 cm Weight: 44.6 kg BMI: 19.3 IBW: 51 kg %IBW: 87% UBW: unknown per pt, thinks she may have lost some weight prior to admission

12. Nutrition Needs Calorie needs – Mifflin St. Jeor Weight used: 44.6 kg (admit wt) Activity factor: 1.3-1.4 (pressure ulcers, frail appearance) 1067-1149 kcal/day Protein 1.5 g/kg (pressure ulcers) 67g/day Fluid Needs: 1,338 ml/day 30 ml/kg (Age 55+)

13. PES Statement Inadequate oral intake related to ETOH withdrawal as evidenced by patient not eating solid food

14. Plan/Recommendations Level: Severe Level 4 (1-4 scale) Reassess every 2-4 days Poor PO intake averaging <25% of needs Continue with current diet Add Ensure Complete BID to breakfast and dinner (350 kcal, 13g protein) To increase potential for calorie intake and promote wound healing Monitor diet tolerance, supplement tolerance, labs, weight, intake and output

15. Goal Increase oral intake to 50-75% of meals/supplements Timeframe to achieve: 3 days

16. Hospital Course 11/2/14 Admission 11/3/14 1 st visit and assessment with RD 11/5/14 Intern visit to obtain diet history, UBW, encourage intake, assess appropriateness for education 11/6/14 Discharge to Sub-Acute Rehab unit at Northwest Hospital 11/8/14 2 nd assessment by RD Added Magic Cup 1x/daily (290 kcal, 9g protein) Liberalized diet to regular to increase food choices 11/9/14 Changed to House, Regular

17. Wound and Weight Status Currently has unstageable pressure ulcer on R ischium and healing stage II pressure ulcer on L ischium Current weight 46.5 kg gained 4.18 lbs since admission

18. Nutrition Literature Support NPUAP-EPUAP (National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel) Guidelines All individuals should have nutrition assessment upon admission and with each condition change Provide sufficient calories 30-35 kcal/kg for pts under stress and pressure ulcer Provide adequate protein for positive N balance 1.25-1.5 g/kg protein No evidence-based recommendation for Arginine or Glutamine Provide and encourage daily fluid intake Provide adequate vitamins and minerals Through diet; offer supplement if deficiency confirmed/suspected

19. Medical Literature Support Alcohol impairs wound healing and increases incidence of infection EtOH intoxication at time of injury is a risk factor for increased susceptibility to infection in a wound Acute EtOH exposure can lead to impaired wound healing by weakening the early inflammatory response, preventing wound closure, angiogenesis, and collagen production, and changing the protease balance at the site of the wound.

20. Questions?

21. References 1. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper 2. Factors Affecting Wound Healing, Journal of Dental Research