SCI Case Presentation

Preceptor: Lisa Plungas, MS, RD, LD

Intern: Mike Daniels
9/11/15

Client History

*Patient: C.B
*Ward: W6B - SCI
*Attending Physician: Mary Henzel, MD
*Age: 67
*Gender: Male
*Race: White

Social History

*Married - lives with wife and step son

*History of PTSD and Depression
*HHA assists with ADLs and IADLS receives 14 hours a week.
* Wife provides assistance with catheter and bowel care.

*Smokes around 10 cigarettes per day and is not interested in

quitting.
*Barriers:
* Paraplegic
* Tremors that occasionally hinder ability to eat
* At home, pt sits for long periods of time and doesnt turn
regularly

PMH/Active Problems

*Paraplegia from transverse myelitis

*Neurogenic bowel and bladder
*COPD
*OSA
*CKD Stage II
*Dyslipidemia
*UTI vs. suspected wound infection
*Delirium
*Recurring fever
*Chronic stage IV pressure ulcers (2) and deep tissue injuries (2)

Chief Complaint

*8/21 Transferred from OSH for fever, wound care,

and suspected wound infection vs. UTI
*Started on antibiotics

Outpatient
Medications/Supplements1
Antihypertensives
* Lisinopril - ACE Inhibitor Hypertension
Avoid natural licorice
* Metoprolol Beta Blocker
Hypertension

*
*
*
*

Anticonvulsants/Mood
Stabilizers/Antidepressants
Clonazepam Benzodiazepine
Avoid SJW and alcohol
Gabapentin Neuropathic Pain
Valproic Acid Mood Stabilizer
May increase appetite and
weight
Sertaline PTSD Avoid SJW and
alcohol

COPD
* Tiotropium Bronchodilator COPD
* Albuterol Bronchodilator COPD
Limit caffeine intake.

*
*
*
*
*
*
*

Miscellaneous
Simvastatin Dyslipidemia Avoid grapefruit
and SJW
Calcium Polycarbophil Bulk-forming laxative
Adequate fluid intake
Pantoprazole PPI GERD B12 and iron
absorption
Simethicone Antiflatulent
Ferrous Gluconate 324-325 mg
Vitamin D 1000 IU
Wound care supplies

Inpatient Medications1
Anticonvulsants/Mood
Stabilizers/Antidepressants/Antipsy
chotics
* Clonazepam Benzodiazepine
Avoid SJW and alcohol
* Gabapentin Neuropathic Pain
* Divalproex Mood Stabilizer
May increase appetite and
weight
* Sertaline PTSD Avoid SJW and
alcohol
* Aripiprazole Agitation
COPD
* Tiotropium Bronchodilator COPD
* Albuterol Bronchodilator COPD
Limit caffeine intake.
* Budesonide Corticosteroid COPD
Ca/Vit D recommended

*
*
*
*
*
*
*
*

Miscellaneous
Simvastatin Dyslipidemia Avoid grapefruit
and SJW
Pantoprazole PPI GERD B12 and iron
absorption
Simethicone Antiflatulent
Vitamin D 3000 IU
Lisinopril - ACE Inhibitor Hypertension
Avoid natural licorice
Cephazolin Cephalosporin Alcohol
Docusate Laxative Adequate fluid
Wound care supplies

Biochemical Data
/Anthropometric Measures
Labs

Values

Measures

Values

Albumin

2.0 g/dL (L)

Height

61 (185 cm)

Prealbumin

7 mg/dL (L)

Weight

CRP

110 mg/L (H)

254.6 lbs
(115.7kg)

HGB and HCT

10 g/dL (L) and 33% (L)

LDL Cholesterol

113 (H) mg/dL

HDL Cholesterol
Triglycerides

Target Weight
(Adj. for Obesity
and SCI)

188-195 lbs (85.588.6 kg)

131-135%

23 (L) mg/dL

Target Weight %
(Adj. for
Obesity)

218 (H) mg/dL

BMI

Not appropriate
for SCI

Weight History

*Lost 8.5 lbs

(unplanned, nonsig (3%) from
5/15/15-8/21/15
*Weight has been
stable since 8/28/15

Food/Nutrition-Related History

*Diminished appetite worsened with delirium

*SUBJECTIVE: Reported eating on average 20% of
breakfast, 75% of lunch, and 75% of dinner during stay.
*200% of Boost+.

*OBJECTIVE: Pt. is consuming on average around 2050% of meals.

Pressure Ulcers2-3

* Definition: Localized injury to the

skin and/or underlying tissue as a
result of pressure or pressure in
combination with shear.
*
*
*
*

Stage 0: DTI
Stage I: Non-blanchable redness
Stage II: Partial thickness
Stage III: Full thickness
subcutaneous fat
* Stage IV: Full thickness bone,
muscle, and tendons
* Stage ?: Unstageable

* Causes: Age, sensory perception,

increased skin moisture, nutrition,
perfusion-related, compression, and
immobility.

Pressure Ulcers on Pt.

Pressure
Ulcer

Location

1. Stage IV

Coccyx

2. Stage IV

Right
Ischium

3. DTI

Right
Lateral Leg

4. DTI

Left Lateral
Malleolus

5. DTI
(resolved)

Perineum

2013 NCM Pressure Ulcers3

*Energy Recommendations: 30-35 kcals/kg/day

*NPUAP recommends 35-40 kcals/kg/day

*Protein Recommendations: 1.5-2.0 g/kg/day

*Zinc supplementation is not recommended.
*Arginine, glutamine, and HMB mixtures might provide
benefit, but more research is needed.

Timeline

*8/21/15: Transferred from OSH and admitted to W6B-SCI

*Tagged WBC Scan ruled out osteomyelitis
*8/28-8/29 Fever returned
*9/2/15: OR debridement of right ischial wound
*9/3/15: Delirium
*9/9/15: Nutrition Follow-Up
* Lingering delirium is still impacting pts intake.

*Seen by Psych, Nutrition, ID, Respiratory Care, OT, PT, Wound

Care, SW, Surgery, and others.

Comparative Standards

*Energy Requirements: 2565-2645 kcals/day

*Based on 30 kcals/kg and Adj. target body weight

*Protein Requirements: 128-132 grams/day

*Adj. target body weight and protein level of 1.5

*Fluid Requirements: 3065-3145 ml/day

*1 ml/kcal +500 ml

Nutrition Diagnosis

*Inadequate protein-energy intake related to

hypermetabolism secondary to pressure ulcers,
delirium, history of depression as evidenced by
nursing ADL notes, interdisciplinary team meeting,
meal rounds, and decreased prealbumin with
decreased CRP

Nutrition Intervention

*Food and/or Nutrient Delivery:

*DIET: Continue regular diet
*Medical/Nutritional Supplements:
*Continue with Beneprotein BID (50 kcals, 12 g pro per
serving)
*Continue with Boost Plus 1xday (360 kcals, 14 g pro per
serving)
*Trying chocolate magic cup (290 kcals, 9 g pro per serving)

Nutrition Education

*Discussed the importance of adequate kcals and

protein for wound healing.
*Discussed supplement usage and tolerance.

Nutrition Monitoring & Evaluation

*I. Adequate PO intake greater 75%

meals/supplements (not met)
*II. Evidence of up trending prealbumin with down
trending CRP (not met)
*III. Weight maintenance without documented
significant weight gain or weight loss (met)

References

*1. Pronsky Z, Elbe D, Ayoob K. Food Medication Interactions.

18th Ed. Birchrunville, PA: Food-Medication Interactions;
2015.
*2. European Pressure Ulcer Advisory Panel and National
Pressure Ulcer Advisory Panel PPPIA. Prevention and
Treatment of Pressure Ulcers: Quick Reference Guide.; 2014.
Accessed 9/9/15.
*3. Academy of Nutrition and Dietetics. Nutrition Care
Manual. Pressure Ulcers. Accessed 9/9/15.
*4.https://www.studyblue.com/notes/note/n/anatomical
-position/deck/7530913. Accessed 9/9/15.