Jillian M. O'Neil - Home



Jillian O’NeilKNH 41109/17/13Case Study #11 – Inflammatory Bowel Disease: Crohn’s DiseaseWhat is inflammatory bowel disease? What does current medical literature indicate regarding its etiology?Inflammatory bowel disease, IBD, is an autoimmune, prolonged inflammatory condition of the gastrointestinal tract. IDB is often associated with ulcerative colitis and Crohn’s disease. Regarding it’s etiology, there is not current medical literature. Although, several environmental factors could influence the disease – such as infectious agents, smoking, intestinal flora, physiological changes in the small intestine and genetic associations. (Nelms 415-417)Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohn’s. How could this happen? What are the similarities and differences between Crohn’s disease and ulcerative colitis?Ulcerative colitis is a prolonged inflammatory bowel disease that mainly affects in the colon and rectum. Crohn’s disease is a prolonged inflammatory bowel disease that mainly affects the ileum and colon although it can affect the entire gastrointestinal tract. This could happen if the initial diagnosis shown an infection, irritation, or abnormalities in the colon and rectum. Once he was later diagnosed with Crohn’s, the disease may have traveled up the digestive system, affecting the rest of his GI tract as well as causing further discomfort. The similarities of Ulcerative Colitis and Crohn’s disease include: the etiology (abnormal immune response which causes inflammatory damage of the GI mucosa; it is genetically susceptibly and often associated with cigarette smoking); the epidemiology (commonly found in both sexes equally, a higher prevalence in North America, northern Europe, the UK and with Jews). In regards to pathology, both diseases affect the GI tract. Similar signs and symptoms include: abdominal and/or rectal pain and cramping, bloody stools, fever and weight loss. Each disease has it’s own list of complications. The diagnosis of both include an abdominal ultrasound, MRI, CT, ASCA/ANCA, and calprotectin, lactoferrin, and polymorphonecular neutrophil elastase. The prognosis of both usually includes surgery. For treatments, both use the drugs immunosuppressants, biologic therapies, antibiotics, and steroids. The differences include: Ulcerative Colitis usually has a peak onset of 20 to 30 years with a secondary peak in the middle ages whereas Crohn’s disease has a peak age onset with teens and those in their twenties. With pathology, Ulcerative Colitis mainly affects the colon and rectum whereas Crohn’s disease mainly affects the ileum and colon. Signs and symptoms specified for Ulcerative Colitis are: possibly constipation and rectal spasm, arthritis, dermatological changes and ocular manifestations. Signs and symptoms of Crohn’s disease include: chronic diarrhea, anorexia, malnutrition, and delayed growth in adolescents. Complications of Ulcerative colitis include severe bleeding, toxic mega colon, toxic colitis, strictures, perforation, intolerance to immunosuppression, colonic strictures, dysplasia and carcinoma. Complications of Crohn’s disease includes malabsorption, malnutrition, abdominal fistulas and abscesses, intestinal obstruction, gallstones, bacterial overgrowth, kidney stones, urinary tract infections, thromboembolic complications, perianal disease and neoplasia. Crohn’s disease also uses clinical presentation (CDAI score) to diagnosis the patient. Drug treatment of Ulcerative colitis include adrenocorticosteroids, anti-inflammatory, antidiarrheal. Surgery involves the colectomy. Drug treatment of Crohn’s disease includes methotrexate and surgery involves removing the affected area (ileoccolic resections and segmental resections). (Nelms 377, 416)A CT scan indicated bowel obstruction and the Crohn’s disease was classified as sever fulminant disease. CDAI score of 400. What does a CDAI score of 400 indicate? What does a classification of severe fulminant disease indicate?Crohn’s Disease Activity Index, CDAI, is the way in which Crohn’s disease is described in research and clinical trials. In order to determine the stage, factors are evaluated – diarrhea, abdominal pain, abdominal mass, decreased sense of well-being, extra intestinal manifestations, weight loss and laboratory features. A CDAI score of 400 indicates the stage of “Moderate – Severe Disease.” A classification of severe fulminant disease indicates that the patient has constant symptoms even though he or she was prescribed steroids or biological agents. Those with a score about 450 also suffer from high fevers, persistent vomiting, intestinal obstruction, rebound tenderness, cachexia as well as an abscess. (Nelms 418, 419)What did you find in Mr. Sims’ history and physical that is consistent with his diagnosis of Crohn's? Explain. In Mr. Sims history and physical reports, it states he had an abscess as well as acute disease in the first 5cm of the ileum – both consistent with Crohn’s disease. In addition, abdominal pain, chronic diarrhea, and a fever correspond to this disease. The report stated his general appearance was “thin” and his calculated BMI is 20.8, putting him at the lower side of the normal, healthy weight. Based on the Hamwi method, a healthy weight for a person of his height would be 160 pounds yet he weighs twenty pounds less than that – signs of Crohn’s: weight loss, malnutrition and possibly anorexia. The stool consistency of “soft to liquid” confirms the diarrhea. With the diagnosis of Crohn’s, Mr. Sims’ history includes orders for a CT and Antiglycan antibodies. Previously, his clinical presentation was stated – a CDAI score of 400. Calculations:Height: 5’9” = 69 inches = 1.75 mWeight = 140 lbs / 2.2 = 63.6 kgBMI = 63.6/(1.752) = 20.8Hamwi method: 106 + 6(9) = 160 pounds ideally. (Nelms 47, 48, 416)Crohn’s patients often have extraintestinal symptoms of the disease. What are some examples of these symptoms? Is there evidence of these in his history and physical? Crohn’s patients often have symptoms that occur outside of the intestines. Some symptoms include: weight loss, fever, anorexia, malnutrition, and delayed growth in adolescents. In his history and physical, there are evidence showing extraintestinal symptoms. As stated above, Mr. Sims has had a significant amount of weight loss. In addition to the weight listed with his vital signs, his general nutrition states he has lost more weight since his previous hospitalization. This section confirms the weight loss and issue of malnutrition. In addition, Mr. Sims has a temperature of 101.5 degrees – a fever to the normal body temperature of 98.6 degrees. Lastly, Extraintestinal manifestations may include arthritis, joint pain, ocular manifestations, uvelitis, and episcleritis. (Nelms 416, American Academy of Family Physicians)Mr. Sims has been treated previously with corticosteroids and mesalamine. His physician had planned to start Humira prior to his admission. Explain the mechanism for each of these medications in the treatment of Crohn’s.Corticosteroids are used for patients with acute exacerbations. This drug aids in the prevention of inflammatory responses as well as help with a quicker recovery. Mesalamine treats the areas of the GI track that are affected by the disease. As an anti-inflammatory agent, it works to eliminate pain or inflammation throughout the body – particular inflamed bowels. Humira is the common name for the drug “Adalimumab.” It is used to reduce the signs, symptoms and progression of moderate to severe rheumatoid arthritis for adults. Arthritis is often a common symptom of ulcerative colitis. (Crohn’s and Colitis Foundation of America, National institute of Health, American Academy of Family Physicians)Which laboratory values are consistent with an exacerbation of his Crohn’s disease?Although Crohn’s disease can’t be diagnosed through blood work, the laboratory values can support the finings as well as aid in the monitoring of the disease. His protein value was low – displaying a value of 5.5g/dL when the normal range is 6-8 g/dL. The Albumin and prealbumin values were also low – values of 3.2g/dL and 11 mg/dL with normal ranges of 3.5-5 g/dL and 16-35 mg/dL. The antibody value, shown as + when the ASCA should be negative, is a biomarker which indicates the patient suffers from Crohn’s. The C-reactive protein value was high, 2.8 mg/dL, in relation to the reference range of less than 1.0mg/dL. The C-reactive protein assesses for inflammation, infection, and disease. (Zonderman, Beth Israel Deaconess Medical Center)Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies.Mr. Slims may be at risk for vitamin and mineral deficiencies even though he is taking vitamin and mineral supplements. First, he may be deficient in iron due to blood loss and malabsorption. A deficiency in magnesium and zinc may be due to the intestinal losses from extreme diarrhea. Long-term steroid use and a decrease intake do dairy foods can cause a deficiency in calcium and vitamin D. (Nelms 420)Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide a rationale for your answer. Short bowel syndrome is the reduced digestion and absorptions due to a large resection of the small intestine. Although his history chart stated he has not had a surgery in the past, the orders indicate for Mr. Sims to consult with a surgeon. If he were to have surgery, then he may be a likely candidate for short bowel syndrome. At this point, prior to any surgery, he may only be at risk for short bowel syndrome due to the malabsorption of nutrients. What type of adaption can the small intestine make after resection?After surgery, the small intestine may develop adaptations. In particular, the resection may help the intestine to absorb nutrients properly – if the procedure was successful. If the procedure wasn’t successful in the direction it was intended, the extensive loss of surface area will cause a major malabsorption of electrolytes, fluids and nutrients. (Nelms 420)For what classic symptoms of short bowel syndrome should Mr. Sims’ health care team monitor? His health care team should monitor for the classic symptoms. Large volumes of diarrhea cause deficiencies in sodium, iron, zinc, magnesium, calcium and selenium. In addition, they should monitor for dehydration, bloating, cramping and fatigue. Lastly, they should monitor his blood work to review the levels of infection, inflammation and disease. (Nelms 425)Mr. Sims is being evaluated for participation in a clinical trial using high-dose immunosuppression and autologous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment help Mrs. Sims?The immunosuppressant drug is used to help the body accept the transplant. Without this drug, the immune system isn’t altered and the body will not corporate with the stem cell transplant. The transplantation itself will aid in the inflammatory response the body has been producing. For Mr. Sims, his body has been producing an inflammatory response due to the Crohn’s disease. Therefore, the autologous peripheral blood stem cell transplantation will encourage his body to reduce the inflammation and continue to remission of the disease. (Nelms 554, Clinical Trials)What are the potential nutritional consequences of Crohn’s disease?The potential nutritional consequences of Crohn’s disease include the common deficiencies. A deficiency in calories is due to the insufficient intake, increased energy requirements and fear of abdominal pain along with diarrhea after eating. Protein deficiency is associated with the increased protein needs, catabolism, and healing from surgery. The fluid and electrolyte deficiency is due to short bowel syndrome and high volume diarrhea. There may be a deficiency in iron due to blood loss and malabsorption. A deficiency in magnesium and zinc may be due to the intestinal losses from extreme diarrhea. Long-term steroid use and a decrease intake do dairy foods can cause a deficiency in calcium and vitamin D. A deficiency in B12 and water-soluble vitamins is due to surgical resections (loss of ileum). Medications can cause a deficiency in folate and steatorrhea causes deficiency in fat-soluble vitamins. (Nelms 420)Mr. Sims underwent resection of 200 cm of jejunum and proximal ileum with placement of jejunostomy. The ileocecal valve was preserved. Mr. Sims did not have an ileostomy, and his entire colon remains intact. How long is the small intestine, and how significant is this resection?The small intestine is about 5.5 m to 6 m (550 – 600 cm) in length. The jejunum is about 2.5 meters in length (250cm). With a resection of 200 cm of the jejunum, the small intestine was reduced to 350 to 400cm in length. This resection provides a major significant change for Mr. Sims. The jejunum is responsible for the absorption of many vitamins and minerals – including Thiamin, Riboflavin, Niacin, Pantothenate, Biotin, Folate, Vitamin B6, Vitamin C, A, D, E, K, Calcium, Phosphorus, Magnesium, Iron, Zinc, Chromium, Manganese, and Molybdenum. This resection will cause a decrease in the absorption of the important nutrients Mr. Sims needs for a healthy, everyday diet. (Nelms 384)What nutrients are normally digested and absorbed in the portion of the small intestine that has been resected?The portion of the small intestine that has been resected was the jejunum and proximal ileum. The nutrients that are normally digested and absorbed in this restricted area include: Thiamin, Riboflavin, Niacin, Pantothenate, Biotin, Folate, Vitamin B6, Vitamin C, A, D, E, K, Calcium, Phosphorus, Magnesium, Iron, Zinc, Chromium, Manganese, and Molybdenum. (Nelms 384)Evaluate Mr. Sims’ % UBW and BMI.Mr. Sims’ percent Usual Body weight is 83.8%. Interpreting this result, he has a percent weight change of 16.2%. He has a BMI of 20.8. (Nelms 47, 48)Calculations:%UBW= (current weight/usual body weight) * 100 (140/167)*100 %UBW = 83.8%% weight change = 100-%UBW100 – 83.8 = 16.2%Height: 5’9” = 69 inches = 1.75 mWeight = 140 lbs / 2.2 = 63.6 kgBMI = 63.6/(1.752) = 20.8Calculate Mr. Sims’ energy requirements. Mr. Sims’ energy requirements were determined using the EEE equation with a physical activity coefficient of 1.11 for low active. His daily caloric requirement is 2,000 calories. Calculations:Weight: 140 lbs / 2.2 = 63.6 kgHeight: 5’9” = 69 inches = 1.75 mAge: 35 years oldTEE=662-9.53(age) + PA (15.91*weight + 539.6*height)662-9.53(35) + 1.11(15.91*63.6 + 539.6*1.75)662-333.55 + 1.11(1011.9 + 944)328.45 + 2171 = 2500 calories(Nelms 242)What would you estimate Mr. Sims’ protein requirements to be?If Mr. Sims consumed 10% of his daily energy intake for proteins, this would be 250 calories of protein per day. This amount is equivalent to 62.5 grams of protein. Calculations:2500 calories/day *.10 =250 calories of protein/day (1g/4 cal) = 62.5g protein(Nelms 243)Identify any significant and/or abnormal laboratory measurements from both his hematology and his chemistry labs. In regards to his chemistry laboratory measurements, his protein value of 5.5g/dL is low in reference to the normal range of 6-8 g/dL. The Albumin and prealbumin values were also low – values of 3.2g/dL and 11 mg/dL with normal ranges of 3.5-5 g/dL and 16-35 mg/dL. The C-reactive protein value was high, 2.8 mg/dL, in relation to the reference range of less than 1.0mg/dL. Mr. Sims’ HDL cholesterol count was low with a value of 38mg/dL in comparison to the reference point of above 45 for males. The biomarker, antibody value (ASCA) was displayed at a positive (+) when it s preferred to be negative. In regards to his hematology laboratory measurements, the ideal hemoglobin range for males is 14-17g/dL. Mr. Sims’ was low with a value of 12.9 g/dL. His Hematocrit value was also low with 38% and the normal reference range for males of 40-54%. The transferrin and ferritin levels were low with values of 180 mg/dL and 16 mg/mLL – the reference ranges for males are 215-365 mg/dL and 20-300 mg/ML. His zinc protoporphrin (ZPP) levels were high with a value of 85 μmol/mol – the reference range is 30 to 80 μmol/mol. The labotory results for hematology also showed a low value of Vitamin D 25 hydroxy – 22.7 ng/mL with the reference range of 30-100. A decreased value of 17.2 μg/dL was also shown for Free retinol (vitamin A) with the reference range of 20-80 μg/dL. Lastly, the ascorbic acid range of 0.2-2.0 mg/dL was shown to be low with a value of <0.1mg/dL. (A Case Study Approach 119-121)Select two nutrition problems and complete the PES statement for each. Inadequate Calorie IntakeInadequate caloric intake (NI-1.2) of 2,236 calories related to lifestyle-diet choices as evidence by the recent dietary intake and a weight loss of 40 pounds. Poor Eating HabitsPoor eating habits of processed foods and minimal fruit/vegetable intake related to lifestyle-diet choices as evidence by the recent dietary intake and laboratory results. Mr. Sims energy intake is roughly 2,236 calories. His estimated needs is 2,500 calories. ()The surgeon notes Mr. Sims probably will not resume eating by mouth for at least 7-10 days. What information would the nutrition support team evaluate in deciding the route for nutrition support.When a patient is designated as NPO, the nutritional support team needs to assess the situation and decide on a route to continue the essential nutritional support. The team would choose the route of Total Parentarel Nutrition because of the circumstances of NPO. TPN provides the patient with proper fluids and nutritional needs by way of intravenous feeding. Seven to ten days is considered short term; so, this option would be best. The team will also need to take into consideration that the patient will need to be supplied with additional supplementations: zinc (12-15mg/L of stool output), calcium (10-25 mEq/day); magnesium (15-30 mEq/day) and Copper (0.5 to 1.5 mg/day). (Nelms 422, 577) The members of the nutrition support team note his serum phosphorus and serum magnesium are at the low end of the normal range. Why might that be of concern?The low serum phosphorus and serum magnesium values are of concern because of the ways in which it will further affect him. First, low serum phosphorus levels can lead to fatigue, irregular breathing, loss of appetite, weight fluctuation, painful and fragile bones. Secondly, low serum magnesium levels can be associated with anxiety, sleeping disorders, vomiting and nausea, seizures, abnormal heart rhythm, confusion, muscle spasm, low blood pressure and insomnia. Both levels are of concern to prevent further medical issues to the patient. (University of Maryland Medical Center, Nelms 132)What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be prevented?Refeeding syndrome is the metabolic alterations that may occur due to the nutritional repletion of starved patients. Mr. Sims is at risk for this problem because he has had a record of low energy intake. In addition, the next seven to ten days of his hospitalization will include a NPO diet. Lastly, as stated in Nelms, a drop in serum levels of phosphorus mass result due to the refeeding syndrome. The nutritional support team has already noticed the drop in these levels. This syndrome can be prevented by avoiding to overfeed the patient as well as to begin the feedings slowly. (Nelms 81, 92, 93)Mr. Sims was placed on parenteral nutrition support immediately postoperatively, and a nutrition support consult was ordered. Initially, he was prescribed to receive 200g dextrose/L, 42.5 g amino acids/L, and 30g lipid/L. His parenteral nutrition was initiated at 50cc/hr with a goal rate of 85 cc/hr. Do you agree with the team’s decision to initiate parenteral nutrition? Will this meet his estimated nutrition needs? Explains. Calculate pro (g); CHO (g); lipid (g); and total kcal from his PN. I agree with the team’s decision to initiate parenteral nutrition. Mr. Sims has not only lost weight recently but is also on an NPO diet for the next week or so. Therefore, it is crucial to initiate a plan that guarantees for him to receive the nutrients needed. He will not meet his nutrition needs with this amount of nutrients he was prescribed. With the prescription, he would receive 240 g carbohydrates per day (816 kcalories), 48 grams of protein per day (60 calories), and 36 grams of lipid per day (396 calories). In total, he will have a caloric intake of 1,272 calories per day. This is a problem that he will not meet his nutritional needs because he is already in a form of deficit. His recent weight loss and diet habits have influenced his point of medical treatment at this point. Therefore, the nutritional team will need to increase intake. Once the goal rate of 85cc/hour, his total calories per day is 2155. He will receive 408 g of carbohydrates, 87 grams of protein, and 60 grams of lipid per day. Using the rate of 85cc/hour will be more beneficial to Mr. Sims because the calories are closer to his initial calorie goal of 2500kcal. (Nelms 95, 96)Calculations:50 cc = 0.05 L ; 85 cc = 0.085 L200 g dextrose/L (0.05L) = 10gCHO per hour * 24 = 240gCHO per day240gCHO *3.4cal/g = 816 kcal of CHO per day42.5 g amino acids/L (0.05L) = 2g pro per hour *24 = 48 g pro per day48g pro (1kg/0.8g) = 60 kcal of Pro per day30g lipid/L (0.05 L) = 1.5 g lipid per hour * 24 = 36 g lipid per day36 g lipid (11kcal/gram) = 396 kcal of lipid per dayTotal kcal = 816 + 60 + 396 = 1272 calories per day200 g dextrose/L (0.085L) = 17gCHO per hour * 24 = 408gCHO per day408gCHO *3.4cal/g = 1387 kcal of CHO per day42.5 g amino acids/L (0.085L) = 3.6g pro per hour *24 = 87 g pro per day87g pro (1kg/0.8g) = 108 kcal of Pro per day30g lipid/L (0.085 L) = 2.5 g lipid per hour * 24 = 60 g lipid per day60 g lipid (11kcal/gram) = 660 kcal of lipid per dayTotal kcal = 816 + 600 + 396 = 2155 calories per dayFor each of the PES statements you have written, establish and ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).Ideal goal: increase overall body weight by improving on the lifestyle-diet choices and increasing the daily caloric intake. For example, Mr. Sims would increase caloric intake by choosing a calorie and nutrient dense snack instead of cola and crackers.Ideal goal: increase intake of fruit and vegetables while decreasing the amount of processed foods by improving on lifestyle-diet choices and knowledge on healthy eating habits. For example, Mr. Sims could chose to have fruit as a snack, add vegetable options to dinner and lunch, and make homemade potato chips rather than snacking from the pre-packaged bag. Indirect calorimetric revealed the following information: MeasureMr. Sims’ dataOxygen consumption (mL/min)295CO2 production (mL/min)261RQ0.88RMR2022What does this information tell you about Mr. Smith?This information tells me that Mr. Sims’ Resting Metabolic rate is 2,022kcalories. This is the amount of energy when he is at rest – not taking into consideration any extra activities. In addition, his respiratory quotient of 0.88 indicates the level of protein used. This data tell us that he uses 295 ml of oxygen per minute (oxygen consumption) and produces 261 ml of carbon dioxide per minute (CO2 production). Mr. Sims’ cardiac input is greater than his cardiac output. (National Library of Medicine)Would you make any changes to his prescribed nutrition support? What should be monitored to ensure adequacy of his nutrition support? Explain. I would not make changes to his prescribed nutrition support if he reaches the goal rate of 85cc/hour. If that goal has been obtained, I would increase it to 90cc/hours to reach the desired energy intake and ultimately healthy weight for Mr. Sims. In order to ensure the adequacy of his nutrition support, I suggest to continue with testing of indirect calorimetric because it’s the main way to accurately estimate his calorie needs. This data will notify the care team of an increase in caloric needs, which is affected by weight loss or weight gain. What should the nutrition support team monitor daily? What should be monitored weekly? Explain your answers.The nutrition support team should monitor the amount of ccs per day. This is important to know when is the correct time to increase the amount of energy intake per day. When beginning at 50cc/hour, it is important to slowly increase to 85cc/hour to prevent further refeeding syndrome. The nutrition support team should monitor his caloric needs weekly using indirect calorimetry. This is important to support or deny the weight gain as well as assist the team in knowing when to continue to increase the ccs. Ultimately, the team wants Mr. Sims to reach a full recovery by eating foods rather than through parenteral nutrition. By monitoring daily and weekly, the team can assist in the recovery. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is now abnormal? What should be done about it?A serum glucose level above 126 mg/dL is abnormal. His level of 145 mg/dL is high and associated with high blood sugar as well as diabetes. Although he has a high level, I do not believe Mr. Sims has diabetes. I believe his high level is due to the 200g/L of dextrose that is directly put into his bloodstream with parenteral nutrition. To lower his increased glucose level, a lower dosage of dextrose can be used. Another option would be to use it at 60cc/hour while slightly increasing protein and lipid to 95cc/hour. (National Library of Medicine)Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4 grams. By using the daily input/output record for 12/20 that records the amount of PN received, calculate MR. Sims’ nitrogen balance on postoperative day 4. How would you interpret this information? Should you be concerned? Are there problems with the accuracy of nitrogen balance studies? Explain.The Urinary Nitrogen value of 18.4g is the amount of protein in the body during a designated 24-hours. His total was 85 g. He is in a catabolic state with a negative nitrogen balance of -8.8. This value puts him in the category of extreme stress. This is something to be concerned with because he may need in increase intake to balance out the loss with the intake levels. These numbers may be altered from improper I/O, the fudge factor of 4 grams that takes into account the nitrogen losses. (Nelms, Parenteral Nutrition)Calculations:18.4g Urinary Nitrogen/L (0.05L) = 85 g protein on day 4368g pro (1kg/4) = 93 kcal of Protein on day 4nitrogen intake = 85/6.25=13.6nitrogen loss = 18.4 + 4 grams = 22.4 gramsBalance = intake – loss – 13.6-22.4 = -8.8On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous 48 hours and had his first bowel movement. The nutrition support team recommends consideration of an oral diet. What should Mr. Sims be allowed to try first? What would you monitor for tolerance? If successful, when can the parenteral nutrition be weaned?First, he should be allowed to try sugar-free, isotonic clear liquids. I would monitor his bowel function and sounds, his stool color and consistency, his temperature and his respiration rate. If successful, parenteral nutrition can be weaned. This is a very slow process and cannot be rushed. Only one food at a time should be added to the diet to prevent further complications. If the GI symptoms are worsened, the food added will need to be removed and gradually introduced again. (Nelms 426)What would be the primary nutrition concerns as Mr. Sims prepares for rehabilitation after discharge? Be sure to address his need for supplementation of any vitamins and minerals. Identify two nutritional outcomes with specific measurement for evaluation. Primary nutrition concerns for Mr. Sims would be: if he can continue on the “slow additions” of new foods into his diet, if he can choose foods that will not aggravate the disease, if he can avoid processed foods and chew foods well, and if he can eat smaller meals more often. In addition, he will need to take supplementation of vitamins and minerals in liquid or chewable form. Iron supplements are needed to prevent anemia and restore iron levels. A calcium and vitamin D supplement is important to prevent osteoporosis because Chronis disease increases the risk of this disease. Lastly, I would suggest a Vitamin B12 supplement for proper nerve function. The first nutritional outcome would be to increase Mr. Sims weight. An increase of 500 calories per day (3500 calories per week) would increase his weight by 1 pound. If he can slowly increase his caloric intake, he will be able to successfully gain weight. This can be measured for evaluation by having a “weigh in” at every counseling session, once a week. The second nutritional outcome would be to increase his knowledge about healthy lifestyle choices. By educating Mr. Sims on these choices, he can improve his overall health as well as feel better during his recovery process. I would first educate him and then provide him with a journal. In this, he will create a log of all intakes. The measurement for this outcome would be to review the progress of change at the weekly meeting. Also, by pointing out and suggesting where he can improve in his diet, Mr. Sims will be able to reach a new goal for the following week’s evaluation. References"Autologous Stem Cell Transplantation for Crohn's Disease - Full Text View -."?Home - . N.p., n.d. Web. 13 Sept. 2013. <;."CCFA: Corticosteroids."?CCFA: Crohn's | Colitis | IBD. N.p., n.d. Web. 15 Sept. 2013. <;."Glucose test - blood: MedlinePlus Medical Encyclopedia."?National Library of Medicine - National Institutes of Health. N.p., n.d. Web. 12 Sept. 2013. <;."How do you diagnose Crohn's disease?."Beth Israel Deaconess Medical Center. N.p., n.d. Web. 14 Sept. 2013. <;."Management of Crohn's Disease--A Practical Approach - American Family Physician."?Home -- American Academy of Family Physicians. N.p., n.d. Web. 14 Sept. 2013. <;."Mesalamine: MedlinePlus Drug Information."?National Library of Medicine - National Institutes of Health. N.p., n.d. Web. 14 Sept. 2013. <, Marcia.?Medical nutrition therapy: a case study approach. 4th ed. Stamford, Connecticut: Cengage Learning, 2013. Print.Nelms, Marcia Nahikian.?Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print."Phosphorus in diet: MedlinePlus Medical Encyclopedia."?National Library of Medicine - National Institutes of Health. N.p., n.d. Web. 13 Sept. 2013. <;."Phosphorus | University of Maryland Medical Center."?Home | University of Maryland Medical Center. N.p., n.d. Web. 14 Sept. 2013. <, Jon, and Ronald Vender.Understanding Crohn disease and ulcerative colitis. Jackson, Miss.: University Press of Mississippi, 2000. Print. ................
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