Natalie Rohr

KNH 411
Prof Matuszak
Case Study #11: Inflammatory Bowel Disease: Crohns Disease
1. What is inflammatory bowel disease? What does current
medical literature indicate regarding its etiology?
Inflammatory bowel disease (IBD) is am autoimmune, chronic
inflammatory condition of the gastrointestinal tract. The disease has
two diagnoses: ulcerative colitis and Crohns disease and while they
both fall until the IBD category, they both have very distinct
differences. Current medical literature indicates that the exact etiology
for IBD is still unknown however; the current hypothesis states that its
a combination of environmental and clinical factors that cause an
inappropriate immune response in genetically predisposed individuals.
Some of the environmental factors include smoking, infectious agents,
intestinal flora, diet, and physiological changes in the small intestine.
There is also a strong genetic association with IBD with a percent value
of 5-15% of patients, (Nelms, 418).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
2. Mr. Sims was initially diagnosed with ulcerative colitis and
then diagnosed with Crohns. How could this happen? What
are the similarities and differences between Crohns disease
and ulcerative colitis?
Ulcerative colitis (UC) and Crohns disease are both considered an IBD
so they have similarities between the two diseases but they also have
very distinct differences. Both sexes are affected equally in UC and
Crohns disease. Both diseases mainly develop in teenage years to

young adults, yet they can both occur at any point in a persons life.
The symptoms for both UC and Crohns are also very similar with the
symptoms including abdominal pain, tenesmus (urgency for
defecation), and diarrhea (although the diarrhea with UC is often
bloody). The treatment for Crohns and UC are very similar and include
antibiotics, immunosuppressive medications, immunomodulators, and
biologic therapies. In over 60% of patients with either UC or Crohns, a
surgical intervention is required. UC is chronic with repeated
exacerbations and remissions, while Crohns is rarely ever cured. With
these similarities, Mr. Sims was inappropriately diagnosed the first
time. With many aspects that are similar, the differences between the
two diagnoses are more important. UC is limited to the colon while
Crohns disease can occur anywhere between the mouth and anus. UC
is a constant inflammation of the colon; while in Crohns there can be
healthy parts of the intestine mixed in between inflamed areas, which
are commonly the ileum and colon. Serological markers that include
antibody testing have been used to distinguish between UC and
Crohns disease. Lastly, Crohns disease can occur in all layers of the
bowel walls while UC only affects the inner most lining of the colon,
(Nelms, 418-419).
Cited: Ulcerative Colitis vs Crohn's Disease |Center for Inflammatory
Bowel Diseases. (n.d.). Retrieved September 13, 2015, from
http://gastro.ucla.edu/body.cfm?id=169
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
3. A CT scan indicated bowel obstruction and the Crohns
disease was classified as severe-fulminant disease, CDAI score

of 400. What does CDAI score of 400 indicate? What does a

classification of severe-fulminant disease indicate?
A Crohns Disease Activity Index, or CDAI, score between 220 and 450
indicates that the patient is experiencing the moderate-severe stage of
the disease. If the patient is in the severe stage of Crohns disease,
then that individual has bowel movements frequent enough to need
strong anti-diarrheal medication. Most of the symptoms of Crohns,
including abdominal pain, are more severe than in the milder stage.
The patient will experience complications such as weight loss, joint
pain, inflammation in the eyes, reddened or ulcerated skin, fistulas,
abscesses, fever, elevated white blood cell count and a low red blood
cell count.
Cited: Crohn's disease. (2012, December 12). Retrieved September 13,
2015, from http://umm.edu/health/medical/reports/articles/crohnsdisease
4. What did you find in Mr. Sims history and physical that is
consistent with his diagnosis of Crohns? Explain.
Within Mr. Sims history report, it indicated acute disease within 5-7 cm
of jejunum and first 5 cm of ileum. Since the disease is in multiple
portions of the intestine, this stays true to the fact that Crohns disease
can skip around and affect multiple portions of the GI tract at once.
Also in his report, he stated having severe abdominal pain along with
diarrhea. Since his diarrhea shows no presence of blood, these
symptoms stay true to the symptoms of Crohns. Based on his physical
results, Mr. Sims is underweight for his height with a height of 59 and
a weight of 140 lbs. He also is experiencing a major fever of 101.5
degrees F along with abdominal pain and tenderness. His excessive
weight loss, major fever, and abdominal pain/tenderness stay true to
the description of a severe Crohns diagnosis, (Nelms 418-419).

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
5. Crohns 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?
Crohns patients can often experience extraintestinal symptoms of the
disease or disease manifestations outside of the GI tract. These
symptoms include osteopenia and osteoporosis, dermatitis,
rheumatological conditions such as ankylosing spondylitis, ocular
symptoms, and hepatobiliary complications. Based on Mr. Sims history
and physical information, he does not show signs of any of these so he
is not experiencing any extraintestinal symptoms, (Nelms 420).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
6. Mr. Sims has been treated previously with corticosteroids
and mesalamine. His physician had planned to start Humira
prior to this admission. Explain the mechanism for each of
these medications in the treatment of Crohns.
Mesalamine is commonly used among Crohns patients and it works to
inhibit inflammatory cell proliferation by interrupting cellular RNA and
by inhibiting the overall immune response. Mesalamine is used with
Crohns disease when the ileal and colon are involved. Corticosteriods
are also anti-inflammatory medications that work to inhibit the overall
inflammatory response. Corticosteriods are often used to treat acute
exacerbations, especially in Mr. Sims case (severe-fulminant), however

patients are at risk of becoming steroid dependent, (Nelms 420).

Humira is a tumor necrosis factor (TNF) blocker and it is used to reduce
signs/symptoms of RA, JIA, PsA, AS, and CD (Crohns). Patients with
Crohns produce too much TNF, which is what attacks the GI tract.
Humira helps provide TNF blockers to bind to the excess TNF and help
reduce inflammation. Humira is only used for Crohns patients when
other treatments have not worked well enough.
Cited: Humira: Medication Guide. (n.d.). Retrieved September 13,
2015, from
http://www.fda.gov/downloads/Drugs/DrugSafety/ucm088611.pdf
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
7. Which laboratory values were consistent with an
exacerbation of his Crohns disease? Identify and explain these
values.
According to Mr. Sims laboratory results, his albumin, hemoglobin, and
hematocrit levels were depressed. In severe cases of Crohns, there are
commonly low levels of albumin, hemoglobin, and hematocrit, which
are consistent with his diagnosis. The low hemoglobin and hematocrit
levels confirm anemia. His levels of ASCA and C-reactive protein were
high based on his lab values. These are acute-phase reactants and
high levels of them show the presence of Crohns, (Nelms 419).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.

8. Mr. Sims is currently on several vitamin and mineral

supplements. Explain why he may be at risk for vitamin and
mineral deficiencies.
For people with Crohns disease, they have to be very conscious with
what they are eating. They tend to have malnutrition, especially
protein-malnutrition. Protein needs are increased due to the higher
need of energy caused by the infection. Mr. Sims is not getting all of his
protein based on his low laboratory values (5.5 when the
recommended is 6-8). He is also at risk for vitamin and mineral
deficiencies especially in calcium, vitamin D, vitamin B12, iron, zinc,
and magnesium due to malabsorption and losses in blood and
diarrhea. Symptoms such as severe diarrhea and abdominal pain and
decrease the oral intake of the patient as well. Since Mr. Sims had a
history of abdominal pain and diarrhea, he is at a higher risk of these
vitamin and mineral deficiencies, (Nelms 421).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
9. Is Mr. Sims a likely candidate for short bowel syndrome?
Define short bowel syndrome and provide a rationale for your
answer.
Short bowel syndrome (SBS) is decreased digestion and absorption
that result from a large resection of the small intestine. Incidence of
SBS is estimated to be approximately two to three cases per million
individuals per year. One of the most common causes of SBS is Crohns
disease with resulting multiple resections. Mr. Sims has yet to undergo
any type of surgery regarding his Crohns disease, therefore the full
length of his intestines is still there. Since he is now experiencing
severe symptoms and his Crohns has exacerbated being a candidate

for the procedure seems likely, however based on his laboratory

values, the only nutritional deficiency he is experiencing is in protein
and vitamin D. I would suggest putting him on a higher protein and
vitamin D diet and monitoring these values. If they continue to
decrease or if other deficiencies become present, then I would consider
him a good candidate for short bowel syndrome, (Nelms, 426).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
10. What type of adaptation can the small intestine make after
resection?
Although each case is highly individualized, most research agrees that
a resection of more than 70% of the GI tract (or >100 cm) will result in
severe nutritional and metabolic complications. After resection, the
small intestine undergoes three phases. The first phase ranges from 710 days and in this phase extensive fluid and electrolyte losses are in
large volume of diarrhea. Patients are very dependent on parenteral
nutrition in this phase. The second post-op phase may last for several
months and within this phase there is a reduction in diarrhea volume
within the remaining bowel. Enteral nutrition is introduced in this
phase. Lastly, during the third phase there is continued adaptation of
the remaining bowel. The remaining intestine increases in diameter
and starts to allow for increased absorptive surface area. This also
includes increased blood flow, secretions, and mucosal cell growth.
This phase can range from 1-2 years and enteral feeding supports
successful adaptation, (Nelms, 427).

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
11. For what classic symptoms of short bowel syndrome should
Mr. Sims health care team monitor?
A classic symptom of short bowel syndrome that Mr. Sims health care
team should monitor is diarrhea. The team needs to monitor his
vitamin and mineral losses since the intestine is unable to absorb
adequate amounts of vitamins A, D, E, and K. Other nutrients that can
become deficient as well are sodium, magnesium, iron, zinc, selenium,
and calcium because they are often lost in large amounts in the
diarrhea, (Nelms, 427).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
12. 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 Mr. Sims?
Over the years there has been much controversy on the safety and
efficacy of using high-dose immunosuppression and autologous
peripheral blood stem cell transplantation. Many patients with severe
Crohns disease remain refractory to conventional treatment and this
treatment may help induce remission in these patients. Upon doing
limited trials and research, it has been shown that autoPBSCT is safe
and appears to be effective among patients in order to induce
remission however; the treatment should be further evaluated in
following trials.

Cited:
Hasselblatt, P. (2012, September 2). Remission of refractory Crohn's
disease by high-dose cyclophosphamide and autologous peripheral
blood stem cell transplantation. Retrieved September 13, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/22937722
13. What are the potential nutritional consequences of Crohns
disease?
Crohns disease affects normal digestion and absorption; therefore
many nutritional consequences can come into play. Some nutrition
diagnoses related to Crohns include malnutrition, inadequate energy
intake, inadequate oral intake, increased nutrient needs, inadequate
vitamin/mineral intake, impaired nutrient utilization, food medication
interaction, and altered nutrition-related laboratory values. Malnutrition
can always be an issue, even when the patient has entered remission.
Protein-calorie malnutrition and other deficiencies can be caused by
decreased nutrient intake, malabsorption, drug-nutrient interactions,
anorexia, and protein-losing enteropathy. The severe abdominal pain
can cause patients to not want to eat and the excessive diarrhea can
cause patients to become calorie deficient and malnourished. When
there is inflammation or infection, protein needs are increased, in some
cases they go up to 150% of daily energy needs. Crohns patients are
also at risk for deficiency of micronutrients including calcium, vitamin
D, vitamin B12, iron, zinc, and magnesium. These micronutrients need
to be monitored due to malabsorption and losses in diarrhea. If the
Crohns patient decides to undergo new medication or surgery, these
nutritional risks compound those of the disease process. The use of
corticosteroids can result in hyperglycemia, nitrogen wasting, and
osteoporosis. The use of sulfasalazine can interfere with folate

metabolism and surgery will increase the protein and calorie needs
along with the need for additional nutrients, (Nelms, 421).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
14. 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 7 meters or 22 feet on average making it
the longest section of the digestive tube. The organ is made up of
three segments: the duodenum, the jejunum, and the ileum. The
duodenum is the shortest portion of the intestine (0.5m) and continues
the digestion process from your stomach. The jejunum (2-3m) rapidly
carries the food with wave-like contractions towards the ileum. The last
section of the intestine, the ileum, is the longest part (3-4m) and this is
where most nutrients from the food are absorbed. Fortunately for Mr.
Sims, no resection was done regarding his ileum and his ileocecal valve
was preserved and his colon remains intact. With his jejunum being
shorter, the surface area is reduced so the transit from the jejunum to
the ileum will be shorter than normal. However, with the ileum being
untouched, this is good news for Mr. Sims so that he can absorb the
nutrients needed. The preservation of his ileocecal valve is also
beneficial in order to absorb vitamin B12 and bile acid.
Cited: Organs: Small and Large Intestine. (n.d.). Retrieved September
13, 2015, from http://www.chp.edu/CHP/organs intestine

15. What nutrients are normally digested and absorbed in the

portion of the small intestine that has been resected?
Most of the digestion and absorption process begins in the first 100 cm
of the small intestine. Most carbohydrate and protein absorption takes
places in the duodenum and jejunum. The ileum is responsible for
absorbing fates bound to bile salts, fat-soluble vitamins and vitamin
B12. Therefore, since the jejunum underwent a resection, Mr. Sims
carbohydrate and protein absorption will be decreased but not fully
deceased considering the duodenum also absorbs these nutrients. The
ileum is also able to take over for the jejunum, and digest/absorb any
nutrients left over.
Cited: Jeejeebhoy, K. (2002, May 14). Short bowel syndrome: A
nutritional and medical approach. Retrieved September 14, 2015, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/
16. Evaluate Mr. Sims percent UBW and BMI.
UBW = 83-84%
UBW = (current weight/usual body weight) x 100
(140lb/166lb) x 100 = 84%
(140lb/168lb) x 100 = 83%
BMI = 20.3 kg/m2
BMI = weight (kg)/ [height (m)]2
140 lbs/(2.2 kg/lb) = 63.6 kg
59 = 69 in / (39 in/m) = 1.77 m
BMI = 63.6 kg/(1.77m)2 = 20.3 kg/m2
Percent weight change = 16-17%
Percent change = 100 - %UBW
100 - 83 = 17%
100 84 = 16%
Mr. Sims has lost around 16.5% of his usual body weight, which is
considered severe which also goes along with the Crohns diagnosis of
lost body weight. His BMI
was calculated to be 20.3, which is a low BMI for a male of his height.

17. Calculate Mr. Sims energy requirements.

Mifflin-St. Jeor REE for men: 10 (W in kg) + 6.25 (H in cm) 5 (age in
years) + 5
1.5 = stress factor
REE = 10 (63.6 kg) + 6.25 (177cm) 5(35) + 5 = 1,572 kcal
TEE = 1,572 x 1.5 = 2,358 kcal
Recommended Energy Requirements = 2,358 kcal (2,3002,400)
18. What would you estimate Mr. Sims protein requirements to
be?
(63.6 kg) x 1.5g 1.75 of protein/kg) (Nelms, 421)
Protein requirement is estimated to be about 95-111 g of
protein/day (95-110)
After looking over Mr. Sims laboratory results, it is sufficient to say that
his protein, albumin, and prealbumin status are below the
recommended range.
Cited Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
19. Identify any significant and/or abnormal laboratory
measurements from both his hematology and his
chemistry labs.
Chemistry
Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
C-reactive protein (mg/dL)
HDL-C (mg/dL)
ASCA
Hematology
Hemoglobin (Hgb, g/dL)
Hematocrit (Hct, %)
Transferrin (mg/dL)
Ferritin (mg/dL)
ZPP
Vitamin D 25 hydroxy

Reference
Range
6-8
3.5 - 5
16-35
< 1.0
>45 M
Neg

2/15 1952

14-17 M
40-54 M
215-365 M
20-300 M
30-80
30-100

12.9 (low)
38 (low)
180 (low)
16 (low)
85 (high)
22.7 (low)

5.5 (low)
3.2 (low)
11 (low)
2.8 (high)
38 (low)
+ (low)

(ng/mL)
Free retinol (vitamin A)
20-80
17.2 (low)
Ascorbic acid (mg/dL)
0.2 2.0
<0.1 (low)
Above are significant values regarding Mr. Sims laboratory results.
20. Select two nutritional problems and complete a PES
statement for each.
Inadequate protein intake (NI-5.7.1) related to decreased ability to
consume sufficient amounts due to Crohns diagnosis as evidenced by
a clients history of Crohns, a total protein level of 5.5 g/dL, an
albumin level of 3.2 g/dL, and a prealbumin level of 11 mg/dL.
Inadequate energy intake (NI-1.2) related to decreased ability to
consume foods due to Crohns disease as evidenced by weight loss of
16% in the past 6 months, history of Crohns, severe abdominal pain,
and diarrhea.
21. 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?
The nutrition support team should evaluate his fluid and electrolyte
levels as well as his required nutrient intake. Since he will be in the first
phase of pre-op SBS, he will be experiencing large volumes of diarrhea
which will contribute to fluid and electrolyte losses. Mr. Sims will be
dependent on the parental nutrition in this phase. After several
months, Mr. Sims should slowly be moved to an enteral nutrition. There
will be a reduction in his diarrhea volume but fluids and electrolytes
should still be watched. Around this time there should be a gradual
transition to an oral diet as well. Since they did a resection of the
jejunum, his nutrients such as carbohydrates and protein, should be
watched to make sure they are getting absorbed at the proper
amounts. Since his lab values for protein have been low, these should

be watched very carefully. Adequate protein intake will be necessary

after surgery to help give Mr. Sims more energy and help the wound
heal, (Nelms, 427).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
22. 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 this be of concern?
If serum magnesium and serum phosphate levels are low while the
patient is reliant on parenteral nutrition, this can be somewhat of a
concern. Levels at the low end of the normal range can indicate
malnutrition, malabsorption of nutrients, dehydration from diarrhea,
hypercalcemia and hemodialysis. Electrolyte imbalance can also be of
concern. When there are low levels of electrolytes in the body,
especially such as magnesium and phosphate, this can indicate
refeeding syndrome, which can be another concern while Mr. Sims is
undergoing parenteral nutrition, (Nelms, 103).
Cited: Phosphorus blood test: MedlinePlus Medical Encyclopedia.
(2013, October 29). Retrieved September 13, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003478.htm
Serum magnesium - test: MedlinePlus Medical Encyclopedia. (2013,
January 22). Retrieved September 13, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003487.htm
23. What is refeeding syndrome? Is Mr. Sims at risk for this
syndrome? How can it be prevented?

Refeeding syndrome is characterized by several common metabolic

alterations that may occur during nutritional repletion of patients who
are malnourished or in a state of starvation. When a patient is on
parenteral nutrition, refeeding can often be dramatic and sometimes
be fatal. When a person is in starvation, liver gluconeogenesis slows,
fatty free acids are used to produce energy in the form of ketones and
basal metabolic rate declines. When foods are slowly introduced again
to the body, whether in oral, enteral, or parenteral, a shift in ketones to
glucose as the primary energy source occurs. Glucose metabolism
requires large amounts of phosphorous. Along phosphorous, there may
be an increased need for magnesium, potassium, and thiamin as well.
This is why Mr. Sims phosphorous and magnesium levels should be
monitored. If there is a drop in these levels, it may result in hemolysis,
impaired cardiac function, impaired respiratory function, and even
death. Low serum magnesium may result in tremor, muscle twitching,
cardiac arrhythmias, and eve paralysis. Mr. Sims is at risk for this
syndrome because he has had a history of malnutrition, long-term
inadequate oral intake and his minimal intake due to loss of appetite.
He will need to be closely monitored to make sure his serum levels
dont get too low and supplementation can be provided as needed. If
the clinician begins feedings slowly and avoids overfeeding, this
syndrome may be able to be prevented, (Nelms, 103).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.

24. Mr. Sims was placed on parenteral nutrition support

immediately postoperatively, and a nutrition consult was
ordered. Initially, he was prescribed to receive 200g

dextrose/L, 42.5g amino acids/L, and 30g lipid/L. His parenteral

nutrition was initiated at 50 cc/hr with a goal rate of 85 cc/hr.
Do you agree with the teams decision to initiate parenteral
nutrition? Will this meet his estimated nutritional needs?
Explain. Calculate: pro (g); CHO (g); lipid (g); and total kcal
from his PN.
I do agree with the nutrition teams decision to initiate parenteral
nutrition. After undergoing a resection, Mr. Sims bowel needs time to
adapt to the change, therefore starting him on a lower caloric diet for
the time being is a good idea to let the bowel get back to its normal
job. When I calculated Mr. Sims estimated energy requirements, I found
that he needs roughly 2,300-2,400 kcal/day and 95-110g of protein per
day as well. His initial PN of 50cc/hr will be under his estimated energy
and protein needs, however this is okay for the time being while his
bowels heal. The goal PN of 85cc/hr will be almost identical to his
estimated energy intake with his protein levels still being lower than
they should be at 87 grams per day.
50cc/hr = 1,200 cc/day = 1.2 L/day

(200g dextrose/L) x 1.2 L = 240g dextrose/day

o (240g)(3.4kcal/g) = 816 kcal

(42.5g amino acids/L) x 1.2 L = 51g amino acid/day

o (51g)(4.3 kcal/g) = 219 kcal

(30g lipid/L) x 1.2 L = 36g lipid

o (36g)(10 kcal/g) = 360 kcal

Total kcal/day = 1,395 kcal

85cc/hr = 2,040cc/day = 2.04 L/day

(200g dextrose/L) x 2.04 L = 408g dextrose/day

o (408g)(3.4 kcal/g) = 1,387 kcal

(42.5g amino acids/L) x 2.04 L = 87g amino acid/day

o (87g)(4.3 kcal/g) = 374 kcal

(30g lipid/L) x 2.04 L = 61g lipid/day

o (61g)(10 kcal/g) = 610 kcal

Total kcal/day = 2,371 kcal

25. For each of the PES statements you have written, establish
an ideal goal (based on the signs and symptoms) and an
appropriate intervention (based on the etiology).
Based on my first PES statement, I recommended that Mr. Sims start to
intake more protein through the PN diet and hopefully begin to take in
more protein orally within the next few months. He can do this by
either taking protein supplements or by increasing his consumption of
protein-based foods such as meat, chicken, and/or eggs. His daily
protein levels are below average and I would like his protein levels to
be around the recommended value of 95-110 g.
Based on my second PES statement, I would like Mr. Sims to start
increasing his energy intake. His recommended energy intake is
between 2,300 and 2,400 kcal/day. If he starts consuming more
calories with the PN support, this will help increase his intake, therefore
help him gain the weight that he lost back. I would like to see him gain
enough weight to be back to the recommended weight for a male his
height/age, 166 lbs. By increasing his caloric intake, monitoring his lab
values to make sure he is absorbing the right amount of nutrients and
watching his abdominal pain/diarrhea, he should be able to gain at
least 1 pound a week.
26. Indirect calorimetry revealed the following information:
Measure
Oxygen consumption (mL/min)
CO2 production (mL/min)
RQ

Mr. Sims data

295
261
0.88

RMR
2022
What does this information tell you about Mr. Sims?
Indirect calorimetry is a technique that provides accurate estimates of
energy expenditure by using measurements of CO2 production and
oxygen consumption during rest and then again at steady-exercise.
Based on Mr. Sims results, his oxygen consumption is 295 mL/min,
which above the average of 250 mL/min. When that value is divided by
his CO2 production value of 261 mL/min (average 200 mL/min), his
respiratory quotient was calculated to be 0.88. Based on all of this
information, it shows that Mr. Sims is burning his protein stores during
metabolism. Lastly, it shows that his resting energy intake should be
2022 kcal/day, (Nelms, 105).
Cited: Robergs, R. (2010). Indirect Calorimetry. Retrieved September
13, 2015, from http://www.unm.edu/~rrobergs/426L11IndCalorim.pdf
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
27. Would you make any changes to his prescribed nutrition
support? What should be monitored to ensure adequacy of his
nutrition support? Explain.
I would make a few changes to Mr. Sims prescribed nutrition support.
As calculated in questions 17-18, his estimated energy requirements
and protein requirements are 2,358 kcal/day and 95-110 g/day
respectively. I would increase his amino acids that so that was
receiving at least 95 grams of protein a day. With his goal PN, he is
only receiving roughly 87 grams per day. This is needed to make sure
his level of protein doesnt fall below the recommended daily amount
and to help aid in the healing process from his resection. I would keep

his PN at 85cc/hr because with that, he is receiving roughly 2,300

calories, which is what he needs to intake in order to start gaining his
weight back. Throughout the process, his lab results will be closely
monitored. This includes tracking his protein absorption, input/output,
vitamin and mineral levels, antioxidant levels (vitamin E, vitamin C,
and beta-carotene), and his weight, (Nelms, 421-422).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.

28. What should the nutrition support team monitor daily?

What should be monitored weekly? Explain your answers.
Monitoring is intense for the first few days, and then it decreases as
the patient reaches goal infusions and becomes stable. Intake and
output levels should be monitored first. Testing for hyperglycemia
should be monitored 3-4 times a day and daily measurements of serum
electrolytes, BUN and creatinine, magnesium, and phosphorous. Serum
triglycerides need to be tested weekly to assess lipid tolerance and if
they appear to be abnormal, they may be tested each week thereafter.
Weight, hydration/fluid status, bowel function, and intake/output should
be monitored daily. A patient should also be monitored in order to
prevent possible complications such as electrolyte imbalance,
underfeeding/overfeeding, hyperglycemia, and refeeding syndrome. If
the patient continues on PN for several weeks, transient elevations in
liver enzymes should be noted. Lastly, the nutrition support team
needs to monitor the patient closely to prevent any serious infections
that can occur while on PN, (Nelms, 110-111).

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
29. Mr. Sims serum glucose increased to 145 mg/dL. Why do
you think this level is now abnormal? What should be done
about it?
Increased serum glucose can result from metabolic stress, dehydration,
or parenteral nutrition overfeeding. A complication from PN is
hyperglycemia and patients are usually at high risk. His daily dosage of
dextrose that he is receiving from PN should be reduced until the blood
sugars stabilize. He should be closely monitored until his lab results
can be evaluated and returned to normal.
Cited: Adult Enteral Feeding Policy. (2015, February 1). Retrieved
September 13, 2015, from
https://www.ashfordstpeters.info/images/policies/PAT108.pdf
30. 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.
N2 balance = (dietary protein intake/6.25) urine urea nitrogen 4
(Nelms, 58)
N2 balance = (86.7 g/6.25) 18.4g 4 = -8.5g
Mr. Sims nitrogen balance was calculated to be a -8.5g. This is
interpreted at Mr. Sims currently being in a negative nitrogen balance.
A negative nitrogen balance develops when nitrogen excretion is

greater than nitrogen intake, indicating catabolism or inadequate

nitrogen intake. Measuring nitrogen balance assesses overall protein
status. Yes, I would be concerned with his negative value nitrogen
balance because this could indicate inadequate protein consumption,
malnutrition, and/or an infection. There are multiple limitations
regarding nitrogen balance including the inherent error of 24-hour
urine collection, failure to account for renal impairment, and inability to
measure nitrogen losses from wounds, burns, diarrhea, and vomiting.
Since Mr. Sims has been having heavy diarrhea lately, this would be
something to monitor. Nitrogen intake is also hard to account for and
can be difficult to measure when the patient is on PN support. Oral
protein intake can also be difficult to measure when the patient is on
EN or PN, (Nelms, 57-58).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
31. On 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?
If oral intake is recommended, a low-residue, lactose-free diet with
small, frequent meals is best tolerated initially. If steatorrhea is
present, then the amount of fat should be reduced. As the patient
starts to respond to medical therapy, small amounts of fiber and
lactose can gradually be added. Fiber and lactose intake should be
monitored for tolerance, as each patient will respond differently.
Initially restricted foods should include gas-producing foods, spicy or

fried foods, caffeinated beverages, or any other food the individual

patient identifies as problematic. Parenteral nutrition can be weaned
immediately as long as his levels are stabilized and oral intake is
successful, (Nelms, 421).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
32. What would be the primary nutrition concerns as Mr. Sims
prepares for rehabilitation after his discharge? Be sure to
address his need for supplementation of any vitamins and
minerals. Identify two nutritional outcomes with specific
measurements for evaluation.
His primary nutrition concerns when Mr. Sims prepares for
rehabilitation should be maximizing his energy and protein intake.
Weight gain along with proper exercise will ensure rebuilding of protein
stores and muscle mass. Its always a good idea to monitor dietary
patterns and encourage a variety of all foods as long as the patient can
tolerate them. In order to protect against inflammation, he should
consume foods high in antioxidants such as carotenoids, vitamin E,
vitamin C, and selenium (examples include fruits, vegetables,
vegetable oils, nuts) and foods rich in omega-3 fatty acids, such as
tuna or salmon. These are important therapeutic alternatives in the
management of inflammatory bowel diseases. Foods high in oxalate
(such as cocoa, tea, strawberries, wheat germ, etc) can cause
increased risk for urolithiasis or kidney stones. High doses of vitamin C
supplements, > 2g/day, should be avoided as well in order to prevent
these risks. The use of probiotics and prebiotics have been associated
with reducing symptoms in patients with IBD and a positive change in
anti-inflammatory markers. I would like Mr. Sims to keep a food log in

order to monitor his daily intake and also to reevaluate his weight and
BMI to make sure he gets back to the normal range of 166-168 lbs. His
lab results will also need to be reevaluated to ensure that he is getting
adequate protein, albumin, and prealbumin intake (Nelms, 422-423).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.

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