Medications (Appendix E)
W. F. was on many medications during his stay in hospital but most are of no nutritional concern. Only the use of octreotide to block exocrine excretion for the promotion of wound healing has any direct effect on the digestive process.
Evaluation of Care Plan
In retrospect, the upper range of W. F.?s assessed nutritional requirements should have been used to start with since he experienced weight loss through most of his stay. The maximum rate was only placed at 90 ml/hr by the doctor giving less than was calculated originally which compounded the effect of the initial under assessment.
The sepsis experienced by W. F. did however make his requirements higher than were initially calculated and this event could not be accounted for in advance and could only be dealt with as it occurred.
Osmolite HN was an appropriate choice as there were no contraindications to using an intact nutrient formula. As well the patients assessment did not show a special requirement such as a high protein intake that could not be met by Osmolite HN. Since there were no special needs, the nutritional content of Osmolite HN was in an adequate proportion to the patient?s needs for energy and protein. This allowed for subsequent reassessed needs to be met with changes in the flow rate without modification of the formula.
Since the lab values showed no obvious signs of insufficiency, the subsequent increases in the rate of tube feed only began after the patient was able to be weighed in order to assess the inadequacy of the intake. Monitoring of the weight followed to assess need for further adjustments which were made as necessary.
There was no need for enzyme therapy as no steatorrhea or evidence of pancreatitis was present during the patient?s stay in hospital.
The GST?s showed slightly elevated values but these could be explained by the presence of the extreme sepsis the patient experienced. As well some increase in blood sugars from the delayed response to glucose from a loss of insulinotropic factors is expected (12). Therefore no need for diabetic intervention was indicated.
The meal plan and diet education given to W. F. to follow were appropriate for a post Whipple?s procedure patient and the follow-up appointment verified this by the fact that W. F.?s weight was stable over the weeks since his discharge.
Conclusion
While there are many possible nutritional concerns for a patient undergoing a Whipple?s Procedure, they are dependent on the degree of resection of the various components of the digestive tract and associated systems. The only problem W.F. experienced was the infection which may have temporarily increased his needs and caused him discomfort. This however did not cause him to develop any of the deleterious nutritional complications that are possible with this procedure.
The upper end of the patient?s assessed requirements should have been recommended to help ensure adequacy, however as previously discused there were unforseeable occurrences that affected W. F.?s requirements as well.
The long term prognosis looks good for W. F. since there was no evidence of metastases in the lymph nodes surrounding the cancer and W. F. seems to be adapting to his new diet and maintaining his weight which indicates that there is probably no concern for nutritional inadequacies at this time. Since he was booked for chemotherapy in January, problems could arise as a result of that treatment.
Appendix D
LABS
Date
(norm) WBC
4-11 Hgb
13.5-18 Na
135-146 K
3.5-5.1 Cl
100-110 Urea
3.7-7.0 Creat
45-125 Glu
3.6-5.5
17/09 6.0 152 139 4.3 105 5.3 80 5.1
26/09 20.4H 148 136 4.9 106 4.3 94 -
27/09 15.3H 130L 137 4.7 110 4.9 96 6.7H
28/09 15.8H 107L 138 3.8 108 3.6L 81 -
29/09 16.1H 103L 141 3.7 109 3.4L 85 -
01/10 19.8H 106L 135 4.0 101 3.2 97 -
? 20.3H 110L – - – - – -
02/10 11.4H 100L – - – - – -
04/10 14.5H 86L 137 4.0 102 2.6L 75 -
06/10 13.9H 89L 139 4.1 104 1.5L 70 -
? – - 137 4.2 104 1.7L 79 -
10/10 – - 134L 4.3 101 2.9L 82 -
18/10 10.3 106L – - – - – -
Chem Strips
Date
27/09 6.7 6.7 6.5 5.7 5.4 6.1 6.5
28/09 8.1
04/10 9.1 7.9 8.3 9.2
05/10 13.8 11.4
06/10 10.6 8.6 6.7
07/10 -
08/10 7.5
09/10 10.4
Appendix E
Medications
· Inhibitors of digestive secretions:
- Octreotide, Famotidine, Ranitidine
· Antibiotics:
- Cefuroxime, Ampicillin, Gentamycin, Cefotaxime,
Clindamycin, Chlordiazepoxide,
· Analgesics:
- Morphine, Indocid, Acetaminophen
· Anticoagulant:
- Heparin, Warfarin
· Antipsychotics & relaxants:
- Haloperidol, Halidol, Librium, Lorazepam,
· Diuretic:
- Lasix
· Antiemetic:
- gravol
· Cardiotonic:
- Digoxin
32b