Professional Documents
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Prevalence of COPD
3rd leading cause of death in the United States About 13.5 million people have been diagnosed with COPD in the United States It is estimated an equal number are undiagnosed (1) Kills more women than breast cancer or diabetes (1) COPD is responsible for more than 120,000 deaths per year
(In
13.1
10.5
What is COPD?
COPD is an umbrella term used to characterize a group of abnormal inflammatory response in the lungs and partially obstruct airflow
COPD develops over time and continually worsens, lifestyle and medication can slow the progression but the damage is not reversible
Key Signs of COPD - Chronic cough - Increased mucous - Short of breath during physical activities
10/16/2013
Chronic Bronchitis
Definition: Inflammation of the bronchial mucous membrane, characterized by cough, hypersecretion of mucus, and expectoration of sputum over a long period of time and associated with increased vulnerability to bronchial infection.
Inflammation of the bronchial results in the production of mucus Mucus clogs the airway making it difficult to breath This results in chronic coughing which causes more damage to the bronchial tubes
http://medical-dictionary.thefreedictionary.com/chronic+bronchitis
Carbon dioxide goes through the capillary membrane and into the alveolar membrane Carbon dioxide continues on through the alveoli to the bronchioles
Through the alveolar membrane to the capillary membrane and into the blood
Emphysema
Definition: Emphysema is a chronic respiratory disease where there is overinflation of the air sacs (alveoli) in the lungs, causing a decrease in lung function, and often, breathlessness.
The walls of the alveoli become damaged and lose there elasticity, pockets of air called bullae are formed in damaged areas The damaged areas cause narrowing of the airways, making breathing difficult
Affecting the ability to exhale first and progressively the ability to inhale
http://medical-dictionary.thefreedictionary.com/emphysema
Symptoms
Cough Wheezing Hemoptysis Chest pain Anorexia Early satiety Weight loss Dyspnea Tachypnea
Anemia Altered taste Fatigue Malaise Depression
Assessing COPD
Preparing Meals Quality of life should be looked into as it pertains to the inability to cook and prepare meals (EAL).
Assessing Body Composition Can be done with BMI as a starting point, should not be the only indicator used for a patients status (EAL).
Assessing Calorie Needs Inflammation increases REE so more calories are needed for the patient (EAL).
http://andevidencelibrary.com/topic.cfm?cat=3708
10/16/2013
X-ray ABG
http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm http://copdcanada.ca/understanding_your_numbers.htm
Surgery to remove a damaged part of the lung can be done to help the non-damaged part function normally.
http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm
Respiratory Quotient
Amount of CO2 produced/ amount of O2 consumed For glucose 1.0 For fat 0.7 For protein 0.8 RQ for conversion of glucose to fat >1.0
Vitamin C Supplementation
Micronutrients: Vitamin C
Grade A Study: Randomized double-blind study done with COPD patients. Experiment: One control group given placebo, One experimental group given ascorbic acid for 14 days; Patients required to write daily symptoms of COPD in diaries Results: Severity of symptoms decreased as experiment went on; Vitamin C supplementation may work to decrease symptoms of COPD
http://web.ebscohost.com.mantis.csuchico.edu/ehost/detail?sid=5a1d0df0-0935-42ef-802d8f2c32193ce6%40sessionmgr113&vid=1&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=65430245
10/16/2013
Vitamin D Supplementation
Micronutrients:Vitamin D Grade C Study: Randomized case-control study done with COPD patients and patients w/out COPD Experiment: COPD patients and non-COPD patients were split into two groups and Vitamin D levels were measured in both Results: COPD patients had severely lower levels of Vitamin D compared to patients w/out COPD
Micronutrients
Smoker: Vitamin C Prevent Osteoporosis: Mg & Ca Mg & Phos (Monitor & supplement if low) Malnutrition & Meds: Vitamin D & K If Cor Pulmonale is present: Fluid restriction
http://web.ebscohost.com.mantis.csuchico.edu/ehost/pdfviewer/pdfviewer?sid=6e2b4b7b-fcde-49cd-afe3a4477db40541%40sessionmgr115&vid=2&hid=122
Patient Information
Patient: Daishi Hayato Age: 65 Sex: Male
Ethnic background: Asian American Household Members: Wife Occupation: Retired manager of local grocery store
Chief Complaint
Patient was working in the yard and became very short of breath. Patients wife then called the doctor and was told to take him to the emergency room immediately.
Medical Diagnosis
COPD
10/16/2013
Step 1: Assessment
Medical History: COPD secondary to chronic tobacco use, 2 packs per day for 50 years Limited exercise capacity due to dyspnea on exertion Intermittent claudication
Diagnosis
Total dental extraction 5 years ago Emphysema >10 years ago Cholecystectomy 20 years ago
Intervention
Step 1: Assessment
Medication Prior to Hospitalization: Combivent: 2 inhalations 4 times/day Lasix: daily Oxygen: L/hour via nasal cannula at night Risk Screening: Current Smoker: 2 packs per day for 50 years Allergies: Penicillin
Step 1: Assessment
Patient Report: General appetite is only fair Breakfast is normally his largest meal Appetite has decreased for past several weeks
Usual Dietary Intake: AM: Egg, hot cereal or muffin, and hot tea with milk and sugar Lunch: Soup, sandwich, and hot tea with milk and sugar Dinner: Small amount of meat, rice, 2-3 kinds of vegetables, and hot tea with milk and sugar
24-Hour Recall: 2 scrambled eggs, few bites of Cream of Wheat, sips of hot tea, bite of toast Ate nothing rest of day- sips of hot tea
Anthropometric Data
Weight: 122lbs 55kg Height: 54 64in. 163cm Usual Body Weight: 135lbs Ideal Body Weight: 130lbs 59kg Body Mass Index: 21 (Normal) Percent Ideal Body Weight: 90%(Adequate E stores) Percent Usual Body Weight: 94% (Normal)
Calories: 66.5+(13.8x59kg)+(5x163cm) (6.8x65)= 1253.5 1253.5 X 1.3 X 1.4= 2281 kcals/day Based on Body Weight 1,475 2065 Kcals
10/16/2013
Laboratory Analysis
Acidosis Anemia Hemoglobin = 13.2(L) Anemia Hematocrit= 39(L) Anemia Transferrin 173(L) Result of low pH Anemia
Serum Protein Albumin= 3.5 (Low end) PEM Prealbumin= 17 (Low end) PEM
ph = 7.22(L) Acidosis pCO2 = 66(H) Hypoventilation Acidosis pO2 = 57(L) Respiratory Failure HCO3(bicarbonate) = 37(H)
Step 2: Diagnosis
Step 3: Intervention
Nutrition Education: Recommended modifications (E-1.4) - Increase fat and protein, decrease carbohydrate - Small frequent meals
Inadequate energy intake (NI-1.4) related to shortness of breath and early satiety as evidenced by unintended weight loss, 24-hour recall, and patient report.
Nutrition Education: Nutrition relationship to health/ disease (E-1.4) - Education on smoking, exercise, & nutrition
Coordination of Nutrition Care: Referral to community agencies (RC-1.4) -COPD support group/ Smoking support group
Nutrition Counseling: Social support (C-2.4) - Educate & Counsel patients wife on important modifications
Implementing Intervention
Recommended Modifications
We educated the patient on the importance of small frequent meals throughout the day to increase oral intake. Also educating the patient on the importance of high fat & protein and low carbohydrate to help manage oxygen levels.
Patients Goals
After educating the patient and his wife on the importance of nutrition and lifestyle modifications the patient set personal goals to achieve such modifications. Goal 1: The patient and his wife agreed that every two hours she would offer a calorie dense meal, using the handout of high calorie recipes. Goal 2: The patient also decided to attend COPD & smoking support groups every other week for one month. Barriers: The patients primary barrier was giving up smoking and does not wish to modify behavior at this time, but will supplement vitamin C as long as he continues to smoke. The patient was also concerned with tolerance of additional feedings, and agreed to trying oxygen support during meals if needed.
Social Support
Educated the wife about the importance of nutrition and calorie dense food choice Answering any questions or concerns she had
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Action goals
Small frequent meals High fat & protein Low carbohydrate COPD/Smoking support group If trouble tolerating increased meals add oxygen during meal If continues smoking supplement vitamin C
Education Materials
Simple recipes for increasing fat & protein Tips for decreasing dyspnea
Scope ofIs Practice Tree This In Our Scope Requested Act or Service Of Practice?
1. Is it permitted? No or Not Sure Yes
Yes 3. Would it be reasonable for a dietetics practitioner to do? No 5. Can I demonstrate the knowledge, skill, and competence? Yes No
Yes
No
STOP Until additiona l educatio n acquired Proceed if authorization documented
STOP Performance of activity or service may place dietetics practitioner and client at risk!
No
10/16/2013
Follow up Recommendations
Follow up biweekly with outpatient RD Support groups available weekly for COPD Support & Smoking sensation support
References
http://pats.atsjournals.org/content/8/4/363.full http://www.sciencedirect.com/science/article/pii/S095528631100132X
http://andevidencelibrary.com/topic.cfm?cat=3708
http://web.ebscohost.com.mantis.csuchico.edu/ehost/pdfviewer/pdfviewer?sid=6e2b4b7b-fcde-49cd-afe3a4477db40541%40sessionmgr115&vid=2&hid=122
http://web.ebscohost.com.mantis.csuchico.edu/ehost/detail?sid=5a1d0df0-0935-42ef-802d8f2c32193ce6%40sessionmgr113&vid=1&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=65430245 http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm http://copdcanada.ca/understanding_your_numbers.htm http://medical-dictionary.thefreedictionary.com/emphysema