Medical Nutrition Therapy Portfolio



Alexa AngeloKNH 411 Case Study #9I. Understanding the Disease and Pathophysiology1. How is acid produced and controlled within the gastrointestinal tract?Through protein digestion, acid is produced and controlled within the gastrointestinal tract. First, dietary and endogeneous proteins are hydrolyzed into their constituent amino acids and a few small peptide fragments by gastric pepsin and the pancreatic enzymes. Then, many small peptides are converted into their respective amico acids by the aminopeptidases located in the brush borders of the small-intestine epithelial cells. Next, the amino acids are absorbed by the Na+ and energy dependent secondary active transport via a symporter. These amino acids are transported by carriers specific to each of them. Some of the smaller peptides are absorbed by a different kind of symporter that is driven by H+, Na+-, and energy-dependent tertiary active transport. Most absorbed small peptides are broken down into their amino acids by intracellular peptidases. Finally, amino acids exit the cell at the basal membrane via various passive carriers, and enter the blood stream through simple diffusion. (Text 382)2. What role does the lower esophageal sphincter (LES) pressure play in the etiology of gastroesophageal reflux disease? What factors affect LES pressure?The LES normally serves as a barrier between the esophagus and the stomach. Under normal conditions, the atmospheric pressure in the esophagus is greater than that in the stomach, and this pressure differential prevents reflux of gastric contents. The signs and symptoms experienced with GERD are attributed to the reflux of gastric acid and pepsin and occur during transient LES relaxations. Factors that affect LES and may help lower them are 1) increased secretion of the hormones gastrin, estrogen, and progesterone; 2) presence of other medical conditions, such as hiatal hernia, scleroderma, or obesity; 3) cigarette smoking; 4) use of medications, including dopamine, morphine, and theophylline; 5) specific foods such as those high in fat, cholesterol, spearmint, peppermint, alcohol, and caffeine may all lower LES pressure. (Text 352)3. What are the complications of gastroesophageal reflux disease?Complications of untreated GERD may include impaired swallowing, aspiration of gastric contents into the lungs, ulceration, and perforation or stricture of the esophagus. Barrett’s disease is considered a complication also. Barrett’s disease involves a change in the epithelial cells of the esophageal mucosa. With Barrett’s disease, the normal squamous cell epithelium of the espophagus changes to metaplastic columnar cell epithelium. This dysplastic cellular change is considered to be a precursor to malignancy. (Text 352, 353)4. What is H. pylori, and why did the physician want to biopsy the patient for H. plyori? H. pylori is a type of bacteria that is very common. It causes more than half of peptic ulcers worldwide. H. pylori damages the mucous coating that protects the stomach and duodenum. Damage to the mucous coating allows powerful stomach acid to get through to the sensitive lining beneath. Together, the stomach acid and H. pylori irritate the lining of the stomach or duodenum and cause an ulcer. The physician may want to biopsy for H. pylori because the presence of it increases the chance of a peptic ulcer. H. pylori and Peptic Ulcers - National Digestive Diseases Information Clearinghouse. Home - National Digestive Diseases Information Clearinghouse. Web. 10 Sept. 2012. <. Identify the patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal reflux disease. The first concerning symptom that Mr. Nelson has is his complaints about heartburn and indigestion. It used to be only at night, but it has increased to almost constantly. His obesity is a factor that may contribute to lowering the pressure of the LES, causing an increased risk for GERD. Mr. Nelson takes aspirin daily and this may lead to an increase in the chances for GERD. He also has hypertension, which is a sign that could suggest the diagnosis of GERD.6. Describe the diagnostic tests performed for this patient. A barium swallow radiograph was used on Mr. Nelson, which uses X-rays to help spot abnormalities in the esophagus such as a hiatal hernia and other structural problems. A pH monitoring was also used. This involves a tube being inserted into the esophagus or clipping a small device that to the esophagus that will stay there for 24 to 48 hours. This device will measure when and how much acid comes up into the esophagus daily. It is helpful to use a food diary while being administered this test to help doctors relate what the person is eating with their levels of acid. An endoscopy with biopsy measured the amount of H. pylori in the patient. This test is done by sending an endoscope down the patients throat which allows the doctor to see the surface of the esophagus. The biopsy is done by passing forceps through the endoscope to allow the doctor to remove small pieces of tissue from the esophagus. The tissue is then looked at with a microscope to look for damage caused by acid reflux. Diagnosing GERD. The Ohio State University Wexner Medical Center. Retrieved September 10, 2012, . What risk factors does the patient present with that might contribute to his diagnosis? (Be sure to consider lifestyle, medical, and nutritional factors.)Obesity is a risk factor that Mr. Nelson possesses. He is not physically active enough and needs to start exercising, which will help lower his blood pressure levels as well as aid him in losing weight. He has a family history of heart disease which is a risk factor. He also drinks more alcohol than he used to, which is a risk factor for GERD.Gastroesophageal Reflux Disease and Heartburn - Risk Factors. University of Maryland Medical Center | Home. Retrieved September 10, 2012, from . The MD has decreased this patient’s dose of daily aspirin and recommended discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect GERD?The MD decreased the patient’s dose of daily aspirin and discontinued his use of ibuprofen because the use of these medications weaken the LES. This causes acid from the stomach to come up into the esophagus, causing discomfort. Acetaminophen is a good pain alternative pain reliever. Gastroesophageal Reflux Disease and Heartburn - Risk Factors. University of Maryland Medical Center | Home. Retrieved September 10, 2012, from . The MD has prescribed lansoprazole. What class of medication is this? What is the basic mechanism of the drug? What other drugs are available in this class? What other groups of medications are used to treat GERD?Lansoprazole (Prevacid) is a proton pump inhibitor. It blacks the H+, K+-ATP enzyme, a component in HCL production. Other drugs in this class include omeprazole (Prilosec, Zegrid), pantoprazole (Protonix), rabeprazole (Aciphec), and esomeprazole (Nexium), which are all available by prescription. Prilosec has an OTC strength version available also. Antacids are another group of medications used to treat GERD. These medicines use different combinations of three basic salts- magnesium, calcium, and aluminum- with hydroxide, or bicarbonate ions to help neutralize HCL. Examples of these include Alka-Seltzer, Maalox, Pepto-Bismol, Rolaids, and Riopan. Foaming agents are also combinations of aluminum, magnesium, and sodium bicarbonate that reduce symptoms associated with heartburn and indigestion. Examples of foaming agents include Gaviscon and Foamicon. H2 antagonists block histamine receptors that are a component of one of the stimulatory paths for acid secretion. These include cimetidine (Tagament HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75). All are available prescription strength and over the counter. Last, proinetics help strengthen the pyloric sphincter and increase the speed of gastric emptying. These include bethanechol (Urecholine) and metoclopramide (Reglan). (Text 353)II. Understanding the Nutrition Therapy10. Are there specific foods that may contribute to GERD? Why or why not?Some foods relax the lower esophageal sphincter, which contributes to GERD. These foods include peppermint or spearmint, chocolate, friend foods or those with high amounts of added fat, alcohol, and coffee (both caffeinated and decaffeinated). Coffee, alcohol, and pepper may increase gastric acid secretion. (Text 355)11. Summarize the current recommendations for nutrition therapy in GERD. Food GroupFoods to Avoid (if symptomatic)BeveragesCarbonated beverages, caffeinated and decaffeinated coffee and tea, cocoa, alcohol.Milk and milk products2% milk, whole milk, cream, high0fat yogurts, chocolate milkEggsFried or scrambled using high-fat cooking methodsCereals/grainsHigh-fat choices such as pastriesMeat and protein sourcesFried meats, bacon, sausage, pepperoni, salami, bologna, frankfurters/hotdogsVegetables and FruitsOnly those that aggravate individual problemsFatLess than 8 teaspoons dailyDessertsThose considered high in fat or those that are friedMiscellaneousPepper(Text 355)III. Nutrition AssessmentA. Evaluation of Weight/Body Composition12. Calculate this patient’s percent UBW and BMI. What does this assessment of weight tell you? In what ways does this contribute to his diagnoses?Mr. Nelson weighs 215 pounds and is 5’9”. By using the equation weight (kg/[height (m)]2, I found his BMI to be 31.7, which is in the obese category. The range of BMI’s are: <18.5= underweight, 18.5- 24.9= normal weight, 25 to 29.9= overweight, and a BMI of 30 or above is considered obese. Mr. Nelson’s BMI attributes to his diagnosis because obesity is a big risk factor for GERD.(Text 47)B. Calculations of Nutrient Requirements13. Calculate energy and protein requirements for Mr. Nelson. Identify the formula/nutrient calculation method you used, and explain the rationale for using it.Using the Harris Benedict equation, I found Mr. Nelson’s energy requirements. I used this equation because it seemed appropriate. Men: 66.5 + (13.8*97.5 kg) +( 5*175cm)- (6.78*48)= 66.5 + 1345.5 + 875 – 325.44= ~1961 KcalFor Mr. Nelson to receive the RDA of protein in his diet (.8g/kg of body weight), would give him:.8kg*97.5kg= 78 grams of protein a day(Text 60, 61)C. Intake Domain14. Complete a computerized nutrient analysis for this patient’s usual intake and 24-hour recall. How does his caloric intake compare to your calculated requirements?Mr. Nelson’s energy intake for the usual intake was 3,146 kcal and his protein intake was 121.1 grams . His energy intake for the 24-hour recall was 3,743kcal and 167.6 grams of protein. Mr. Nelson is over 1,000 kilocalories than I calculated. This is a huge risk factor because he needs to be losing weight, not eating more. Fit Day Free Calorie Counter and Diet Journal (See Attached)15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term.Mr. Nelson’s excessive energy intake is far above his recommended energy intake that is contributing to his obesity. He is consuming more protein than recommended also, which may put strain on his kidneys.D. Clinical Domain16. Are there any abnormal labs that should be addressed to improve Mr. Nelson’s overall cardiac health? Explain.Mr. Nelson’s LDL cholesterol levels are too high and his HDL cholesterol levels are too low. LDL cholesterol is “bad” cholesterol, and when these levels escalate, it causes hypertension which significantly increases the risk for cardiovascular disease. 17. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term.Mr. Nelson’s intake of foods high in saturated fat have led to high LDL cholesterol levels and low HDL cholesterol levels. Because of this, he developed hypertension and his risk of developing cardiovascular disease increased. He also drinks a lot of caffeine which is a food that can trigger GERD.E. Behavioral –Environmental Domain18. What other components of lifestyle modification would you address in order to help in treating his disorder?Along with addressing his eating habits, I would tell Mr. Nelson to increase his exercise and try to decrease some of the stress in his life. By increasing exercise, it can help lessen stress and also aid in weight loss. Exercise helps to decrease LDL cholesterol levels as well. I would ask Mr. Nelson to stop drinking alcohol as well.19. From the information gathered within the behavior-environmental domain, list possible nutrition problems using the diagnostic form.Mr. Nelson’s continuous consumption of foods high in saturated fats has led to an increase in LDL cholesterol levels and a decrease in HDL cholesterol levels, which led to hypertension and increased his chances for developing CVD. His excessive use of alcohol has led to an increased list of GERD as well as his high stress levels from work and his lack of exercise.20. Select two high-priority nutrition problems and complete PES statements for each.Excessive calorie intake related to a diet high in fats as evidenced by his daily caloric intake levels of over 1000 kcal more than recommended energy intake and 35-pound weight gain since his knee surgery.Increased risk for GERD related to a diet full in caffeine and fried foods related to a diet high in tea and processed fast foods as evidenced by the 24-hour diet recall exceeding recommendations for caffeine and high fat processed foods with an increase in heartburn due to these choices.V. Nutrition Intervention21. For each PES statement that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).Excessive calorie intake related to a diet high in fats as evidenced by his daily caloric intake levels of over 1000 kcal more than recommended energy intake and 35-pound weight gain since his knee surgery.For this PES statement, I recommend a goal of approximately a 24 pound weight loss over the next two months, allowing Mr. Nelson to lose approximately 2 pounds per week. This would mean that he would have to cut down his calorie intake about 500kcal per day, allowing his goal of 24 pounds to actually be attainable.Increased risk for GERD related to a diet full in caffeine and fried foods related to a diet high in tea and processed fast foods as evidenced by the 24-hour diet recall exceeding recommendations for caffeine and high fat processed foods with an increase in heartburn due to these choices.For this PES statement, I recommend a goal of lessening his heartburn through a diet with less saturated fats and caffeine in it to help with his heartburn symptoms. 22. Outline necessary modifications for him within his 24-hour recall that you could use as a teaching tool.Food ItemModificationRationaleCrispix1 cupThis is the actual serving size for Crispix and will allow for Mr. Nelson to cut down on the amount of calories in his diet.Skim MilkNoneOrange Juice1 cupThis is the actual serving size for orange juice and will help Mr. Nelson cut back on the amount of sugar he is bringing into his diet, allowing him to lose more weight.Diet PepsiSwitch to waterWater will help Mr. Nelson stay hydrated which will help with his heartburn, and water is overall beneficial.Fried chicken sandwichSwitch to baked or grilled chicken breast on a whole wheat bunFried foods are very bad for GERD and aid in indigestion. French FriesBaked sweet potatoComplex carbohydrates will help Mr. Nelson stay fuller longer and aid in his weight loss process. He needs to stay away from fried foods that will trigger his GERD.Iced TeaSwitch to water, or cut down significantly on the tea drinkingWater is the best drink to help Mr. Nelson stay hydrated. ChipsSwitch to whole-wheat crackersChips are very high in fat, which leads to high cholesterol and heart disease.BeerSwitch to waterBy eliminating beer from the diet, Mr. Nelson will help lower his symptoms of GERD.Fried chickenSwitch to baked or grilled chicken, or another baked or grilled type of lean meatFried foods bring on the symptoms of GERD and also lead to an increased risk for CVD.Potato SaladSwitch to a salad full with different vegetables and a vinaigrette dressingPotato salad can be very high in fat. If Mr. Nelson switches to a normal salad, he will get all of the benefits of the fiber and antioxidants that come with the vegetables.Green bean casseroleSwitch to regular cooked green beansCasseroles may be high in fat, that can lead to indigestion and also high cholesterol.Fruit saladNo modificationBaked BeansSwitch to edamame beansBaked beans may sometimes be cooked with bacon and brown sugar, which can make them very high in caloric value as well as fat.MilkshakeIf Mr. Nelson must eat dessert, switch to baked apples with cinnamon or eat the fruit salad as dessert.The fruit salad should be enough to serve as a dessert for Mr. Nelson. He needs to significantly cut back on his calories.References:Nelms, M. N. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning. ................
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