The supervising dietitian has informed you that a new patient was admitted overnight from the nearby hospital and is recovering from a skin graft surgery due to a severe pressure ulcer (bed sore). Imagine that you are asked to review the patient’s chart notes and provide a nutrition assessment summary along with some ideas about what type of therapeutic diet or nutrition therapy she requires.
Patient information from the hospital medical chart:
Age: 6-year-old female
Height: 43 inches
Weight: 38 pounds
Admitting Diagnosis (Dx): Cerebral Palsy, bedridden, stage 3 pressure ulcer on sacrum, food allergy to eggs
Surgery: Skin graft performed to increase healing and reduce further infection risk.
Diet order: Thickened liquids and pureed foods with precautions due to dysphagia (swallowing deficiencies) associated with CP. No eggs: Severe Egg Allergy.Speech/Cognitive: Patient receives speech and swallowing therapy due to CP. Her speech and cognitive abilities were reported to be around that of a 2-year-old.
Cindy normally resides at home with her family. She qualifies for state-funded home medical assistance due to the CP diagnosis. She is bedridden and relies on the home health nursing assistants for care. Her parents have three other children and involve her in as many family activities as possible, but the actual care is provided by the in-home medical team. Cindy has had a gastrostomy feeding tube (G-tube) since she was just a few months old. In recent years, it has only been used nocturnally if her oral intake of the pureed/soft diet foods fell below the 50% mark for two or more meals. She received a specialized enteral formula that did not have eggs as any source of the protein.
For many years, Cindy was cared for by the same team of nurses and nursing assistants, and she did not have any major medical or nutrition-related problems. However, about 6 months ago, the state funded program changed home care contract companies and a new company began to provide care. Cindy’s parents felt that the care was sub-standard and reported it numerous times, but without any improvements. It was not until Cindy’s quarterly check-up that these problems were identified. Her weight had dropped by 15% in just 3 months, her albumin was low, and her lean muscle mass and strength had decreased. Most alarmingly, she had developed a pressure ulcer on the sacrum. The MD immediately admitted Cindy into the hospital.
Upon further investigation, the new home health company had been administering nocturnal tube feedings with a formula that contained egg as one of the partial sources of protein. They thought that it was a comparable substitute for the previous brand. Additionally, they had misread the original nutrition order to only give night enteral feedings (via the G-tube) if her oral intake was insufficient. Until the issues were discovered, Cindy went several months receiving a full night of tube feedings that provided a feeling of fullness to her. She also was suffering from chronic diarrhea and associated malabsorption. Subsequently, she would not feel well enough to eat the next day and the cycle repeated itself daily. She also started having many more nasal and respiratory symptoms, which the new care providers explained away as being typical seasonal allergies. She was prescribed an antihistamine. Her parents were unaware of the nocturnal tube feedings because the nursing staff would run them about 8–10 hours while the patient was asleep.
Questions to address:
1. Why was Cindy at risk for a pressure ulcer? What were some of the contributing factors, and why?
2. Whatarethesymptomsofaneggallergy?Whydoyouthinkherallergywasnot ever life threatening when she was receiving the nightly tube feedings at home?
3. Takeintoconsiderationhermultiplemedicalconditionsofcerebralpalsy,egg allergy, and recent pressure ulcer, and calculate her estimated calorie needs and protein needs.
4. Recommendanappropriatetubefeedingformulabrandnameortypethathasno albumin from egg protein (for the days that she does not have adequate oral intake of her meals).
5. Appendix:Designafull-daymealplanforCindythatincludespureed/softfoods. This diet needs to fully address her CP-related chewing/swallowing challenges. Be sure to consider her protein needs for wound healing promotion and future prevention, but without foods containing eggs or egg by-products. Oral protein drink supplements can be considered. Include the total calories, carbohydrates, fats, protein, and any micronutrients that are important in this case.