TW Case Study

By: Ruchi Shah

Case Study

● 36-year-old, Hispanic female well known to the hospital service for the last 17
years.
● hx: end-stage renal disease, poorly controlled diabetes mellitus and obesity,
hyperglycemia, hypertension, hyperlipidemia, currently on peritoneal dialysis
(PD) and a right leg below the knee amputation.
Prior to Readmission
● Discharged 6 days prior to readmission.
○ Last admission: cellulitis of the abdominal wall, abscess collection near PD site,
● Day before readmission
○ Left flank pain and generalized weakness
Reason for Admission

● Day of readmission
○ Pain radiated to PD site, chills, dizziness, lightheadedness
● Admitted to ED
○ UTI, chills, weakness, nausea, and vomiting
○ Chronic loose stools
○ Left heel wound
● TW has complex medical issues with poor control. She remains at high risk for
adverse outcomes including worsening of infection that can possibly lead to death.
Food and Nutrition Related History
● no known food allergies

● follows a general diet at home including fast food items at least once a day

● Hospital diet - renal; carbohydrate counting 60 g/meal 1600-1900 calorie

restriction; 2 gm sodium (low sodium); 1 gm potassium (low potassium);

800-1000 mg phosphorous (low phosphorous) diet.

 Anthropometric Measures
Admit Weight - 107 kg Usual Body Weight (UBW) - 115 kg

Current Weight 109 kg UBW% - 95%

Weight Change Over Time - fluctuates Ideal Body Weight (IBW) - 58 kg

from 105kg - 125kg (adjusting for
%IBW - 188%
amputation which was 6% of body weight)
BMI = 37.3
Height 1.702m (5’7”)
Biochemical Data
Nutrition Focused Physical Findings
Appearance Symptoms

● Female ● Nausea
● Obese ● Vomiting
● Below the knee amputation - right leg ● Loose stools
● Soft bowel sounds present ● Abdominal pain
● Left heel wound
● Abscess collection near PD site
Personal History
● Well known to the hospital service for non-compliance
● Often comes in with her mother
● Has two children - taken by social services
● No occupation
● Opiate, drug, and alcohol use
Type 2 Diabetes Mellitus
● Worldwide epidemic caused mainly by lifestyle habits
● Pathophysiology:
○ genetics, decrease in beta cell function, decreased insulin secretion insulin resistance, poor glucose
control
● Insulin resistance often caused by obesity
● Dysregulation of carbohydrate, protein, and lipid metabolism
● Microvascular complications
○ Neuropathy, retinopathy
● Macrovascular complications
○ Metabolic syndrome, hyperglycemia, cardiovascular disease
● Medications/Treatment: insulin, medications that increase insulin secretion,
insulin sensitized, etc. , preventing hypoglycemic events
Medical/Health History
● Type 2 Diabetes Mellitus
○ Diagnosed in 1997
○ First diagnosis that begin her continuous admissions
○ Her non compliance has led to a variety of other diagnoses such as:
■ Diabetic polyneuropathy
■ Tremors likely due to gabapentin toxicity
■ Metabolic acidosis
■ Peritonitis
■ Cellulitis of the abdominal wall
■ Below the knee amputation
End Stage Renal Disease
● Often the result of chronic kidney failure, diabetes and/or hypertension
● Treatments:
○ Dialysis - most common form of management, opioids - phosphate binders, kidney transplant
● Risk for malnutrition, gastrointestinal symptoms, and encephalopathy
● Symptoms of fatigue
● 38% five year survival rate of patients with stage V CKD in combination with end
stage renal disease
Medical/Health History
● End Stage Renal Disease
○ With a history of:
■ Arteriovenous dialysis fistula
■ Acute kidney failure
■ Chronic kidney failure
■ Anemia with chronic kidney disease
■ Secondary hyperparathyroidism with chronic disease
○ Currently on peritoneal dialysis
Tests performed and Medical Treatment
● Tests performed
○ Cystoscopy
○ Bladder cystometrogram
○ Bilateral retrogrades
○ Insertion of bilateral ureteral stent
○ Tested for bowel obstructions due to nausea and vomiting
● On peritoneal dialysis
● Fingerstick blood glucose
Medical Treatment - Nutritional Consequences
● Diabetes
○ Hyperglycemia
○ Hpoglycemia
○ Diabetic ketoacidosis
- Stress the need for: insulin, weight management, physical activity, lowering caloric
intake, and improving nutritional intake

● End Stage Renal Disease

○ Lower serum albumin, amino acids, prealbumin, transferrin, and creatinine
○ Higher BUN
○ Electrolyte imbalances: phosphorous, sodium, and potassium
- Nutritional status: malnourished
Medications
- Atorvastatin (Lipitor) - lipid lowering agent
- Amlodipine (Norvasc) - hypertension and hyperlipidemia
- Calcium Acetate (PHOSLO) - hyperphosphatemia
- Clonidine (Catapress) - antihypertensive
- Dicyclomine (Bentyl) - gut antispasmodic
- Diphenoxylateatropine (Lomitil) - diarrhea
- Doxazosin (Cardura) - urinary retention and antihypertensive
- Escitalopram (Lexapro) - selective serotonin reuptake inhibitor
- Gabapentin (Neurontin) - nerve pain and anticonvulsant
- Insulin Glargine (Lantus) - insulin to treat diabetes
- Insulin Lispro (Humalog) - insulin to treat diabetes
- Losartan (Cozaar) - antihypertensive
- Metoclopramide (Reglan) - gut motility stimulator
Medications Continued

● Metoprolol Tartrate (Lopressor) - beta blocker

● Ondansetron (Zofran) - prevents nausea and vomiting
● Pantoprazole (Protonix) - proton pump inhibitor for GERD, damaged esophagus,
high levels of stomach acid
● Phenytoin (Dilantin) - anticonvulsant
● Potassium Chloride (Klor-con) - treats low levels of potassium
● Sevelamer (Renvela) - lowers phosphorous in blood of patients on kidney dialysis
● Topiramate (Topomax) - nerve pain and anticonvulsant
● Trazadone (Desyrel) - sedative and antidepressant
● Furosemide (Lasix) - Diuretic
Social History
● No occupation
● Lives with her mother
● Hispanic
● Follow Catholicism
● Two children - taken by social services
● Insurance: Medicaid Connecticut
● Negative for dentures, glasses, hearing aids
● History of drug, opiate, and alcohol use
● No smoking history
● General diet - including fast food often
● Understands her noncompliance
● Spends 75% of the year in the hospital
● Possible new addiction to pain medications
Comparative Standards
● Daily caloric requirements
○ 14kcal/kg - 20 kcal/kg x 109 kg (current weight) = 1526 kcal - 2180 kcal
● Daily protein requirements
○ 0.6 gm/kg - 0.8 gm/kg x 109 kg = 65.4 gm - 87.2 gm protein
● Daily fluid requirements
○ 1562 kcal = ~ 1600 kcal
● Daily carbohydrate requirements
○ 1600-1900 kcal restriction therefore a 200-240 gm CHO/day or 60 CHO/meal
Nutrition Diagnosis - PES Statement 1

Inadequate oral intake related to cellulitis of the abdominal wall as evidence by poor
po intake prior to admission, po intake of 0-25% after admission, nausea, vomiting,
abdominal pain, chronic kidney disease
PES statement 2

Not ready for diet/lifestyle change related to history of non-compliance as evidence by

denial of need for food and nutrition related changes, failure to take advantage of
outpatient help, hostility, inability to understand required change, reported to have
fast food on a daily basis when feeling okay
Intervention - Food and/or Nutrient Delivery
● Encouraged patient to consume 50-100% of meals
● Spoke to kitchen to provide alternatives to the patients liking
● High phosphorous lab value upon admission - recommended low phosphorous
diet
● Calorie restricted diet
● Carbohydrate restricted diet
Intervention - Nutrition Education and Counseling
● 17 year history with the hospital - education has been provided numerous times
● Patient and mother asked for no education
● Instead discussed diet on grocery shopping habits, fast food choices, carbohydrate
counting and low sodium
Intervention - Coordination of Care
● Provided information regarding diabetes outpatient services
● Spoke with the hospital isn't regarding recommendation of low phosphorous diet
● Discussed with dietary staff to provide alternatives
● Spoke with CNA to encourage the patient’s po intake
● Spoke with MDs, dietitians, and nurses who have worked with her for years to
gather information
Interventions - Goals
● Encourage po intake due to current poor po
● Long term goal: improve diet choices and compliance
● Main goal: prevent any further complications
Monitoring and Evaluation
1. Food and/or Nutrition Related History
● Follow calorie restriction; carbohydrate; renal; low phosphorus diet
● Monitor and encourage po intake
● Monitor fast food intake
2. Anthropometric Data
● Maintain +/- 5 pounds of admission weight
3. Biochemical Data, Medical Tests and Procedures
● glucose, phosphorus, and electrolytes will return to within normal limits
4. Nutrition Focused Physical Findings
● Relieve nausea, vomiting, loose stools, and abdominal pain
 References
1. Kratz A, Ferraro M, Sluss PM, Lewandrowski KB. Normal reference laboratory values. N Engl J Med. 2004;351(15):1548-1563.

2. DeFronzo RA, Ferrannini E, Groop L, et al. Type 2 diabetes mellitus. Nature Reviews Disease Primers. 2015;1:nrdp201519.

3. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014;37(Supplement 1):S90.

4. Foley RN, Collins AJ. End-stage renal disease in the united states: An update from the united states renal data system. Journal of the American
Society of Nephrology. 2007;18(10):2644-2648.

5. O'connor NR, Corcoran AM. End-stage renal disease: Symptom management and advance care planning. Am Fam Physician. 2012;85(7).

6. Zanetti M. Consequences of diabetes on nutritional status topic 21. . 2017.

7. Ikizler TA, Hakim RM. Nutrition in end-stage renal disease. Kidney Int. 1996;50(2):343-357.

8. Goldman R, Bassett SH. Phosphorus excretion in renal failure. J Clin Invest. 1954;33(12):1623.

9. Wing RR, Blair EH, Bononi P, Marcus MD, Watanabe R, Bergman RN. Caloric restriction per se is a significant factor in improvements in glycemic
control and insulin sensitivity during weight loss in obese NIDDM patients. Diabetes Care. 1994;17(1):30-36.