1. Anorexia Nervosa
Case Study Presentation
Roanna Martin, WVU Dietetic Intern
November 29, 2012
1

2. Outline
• Anorexia Nervosa
• Assessment
• Diagnosis
• Intervention
• Monitor/Evaluate
• Conclusion
2

3. An Diagnostic Criteria
• Refusal to maintain body weight at or above a
minimally normal weight for age and height (< 85%
IBW)
• Intense fear of gaining weight
• Disturbed perception of body shape and/or size
• Amenorrhea (absence of at least 3 consecutive
periods)
• Restricting Type: Accomplishes weight loss through
dieting, fasting, or excessive exercise.
• Binge-Eating/Purging Type: Regularly engages in
binge-eating or purging behavior
3

4. Physical Findings
• Skin and Extremities • Cardiovascular
• Cold hands & feet • Bradycardia
• Dry skin • Hypotension
• Lanugo • Orthostatic
• Alopecia hypotension
• Acrocyanosis • Cardiac
arrhythmiaas
• Dependent Edema
• Electrocardiograph
ic abnormalities
4

5. Physical
Findings, continued
• Gastrointestinal • Plasma/serum values
• Salivary gland • Elevated BUN
enlargement &creatinine
• Delayed gastric • Hyponatremia
emptying
• Constipation
• Hypokalemia
• Hypercholesterolemi
• Bone a
• Decreased bone • Hypoglycemia
mineral density • Low T3
• Reproductive • Low-normal T4
• Amenorrhea • Hypophosphatemi
a(during refeeding)
5

6. Prognosis
• 50% of those diagnosed with anorexia will have full
recovery with treatment
• Mortality is 0-21%
• Death results from complications of
starvation, including:
• Pneumonia
• Weakened immune system
• Heart, kidney, or multiple organ failure
6

7. Care Team
• Physician
• Nurse
• RD
• Mental health professional
(psychiatrist, psychologist)
• Other professionals as indicated
7

8. Primary goal: Medical
stabilization
• Close monitoring of electrolytes
• Fluid balance
• Other blood levels
• Weight regain
• Prescription of psychoactive medication
8

9. Recommended nutrition
Prescription
• Initiate at 1,200 kcal to 1,400 kcal
• Energy gradually by 100 kcal to 200 kcal increments.
• Protein: 0.8-1.2 g/kg of recommended body weight.
• Goal: Weight gain of 1-2 lbs/week.
• Small, frequent meals. Vitamin, mineral supplements.
• Tube feeding may be necessary for severely
malnourished patients (especially if refusing po intake).
9

10. Assessment
• Food and eating history
• Biochemical laboratory values
• Anthropometric indices of nutritional status
10

11. Patient
• 25 year old female
• Frequent hospitalizations
• 5’ 2” (157.48 cm)
• 82.72 lb (37.6 kg ) on 10/27
• BMI: 15.2
• IBW: 110.2 lb (50.1 kg)
• 75% IBW
• Edentulous
11

12. Admission 10/27
• Chief complaint “Weakness” and positive blood
cultures
• Assessment and Plan
• Fungemia/bacteremia
• gram negative organisms in bladder
• yeast in blood
• CKD
• GERD
• Pulmonary Fibrosis
• DVT Prophylaxis
12

13. Microbiology
• Candida tropicalis (yeast)
• Enterococcusfaecium
• Stenotrophomonasmaltophilia
• Klebsiellapneumoniae
13

14. Past Medical History
• Anorexia Nervosa (Lowest Weight: 58.3 lb (26.5 kg), BMI 10.7 on 5/31/11)
• Malnutrition
• CKD stage IV
• Liver disease
• Pulmonary fibrosis
• Right heart failure
• Hypothyroidism
• Depression
• Pancytopenia
14

15. Past surgical history
• Cholecystectomy
• PEG placement and removal
• Tracheostomy placement and removal
• Infuse-A-Port placement and removal
15

16. Social History
• 25 year old female
• Lives with both parents
• Smoker, 10 pack-year history
• Denies current alcohol or drug use
• Admits previous history of IV drug use
• Sought treatment from eating disorder specialist.
Dismissed for noncompliance.
16

17. Relevant Supplements &
Medications
• Calcium (Caltrate) • Epoetin
• Vitamin D • Heparin
• Synthroid • Lasix
• Protonix • Prevacid
• Phoslo
17

18. Nutrition Diagnosis
• Malnutrition related to long history of
anorexia nervosa as evidenced by BMI
of 15.2, muscle wasting, and refusal to
eat sufficient energy/protein to maintain
a healthy weight.
18

19. 11/1: Initial Assessment
• Subjective: Pt. reported eating some breakfast and lunch.
Snacks in bed with her, and she did not like chocolate Ensure
at last admission.
• Objective: 37.6 kg, BMI 15.2 (PEM Grade III)
• No skin breakdown.
• Calcium, Vitamin D, Diflucan, Synthroid, Protonix, Celexa
• Order: Regular
• Assessment:
• 1233-1850 kcal (30-45 kcal/kg)
• 53-78 gm protein (1.3-1.9 gm/kg)
• Plan:
• Goal: Improve protein status, intake 50% or greater, promote
weight gain.
• Intervention: Continue to provide regular diet, catering
assistant will visit, encourage intake.
19

20. Patient Interview 11/5
• (Fiancée present in room, bag of Cheetos in bed)
• Today I ate:
• All of macaroni & cheese (except shared 4 Tbsp)
• Typical day:
• Breakfast: Bowl of cereal, ½ sausage sandwich or egg
with sausage and toast, snacks
• Lunch: Sandwich and chips, water and an orange
• Dinner: whatever Mom cooks
• Snack: dry cereal
20

21. 11/6: Consult
• Subjective: Visited with patient and patient’s fiancee for
extended amount of time. Discussed eating complex
carbohydrates.
• Objective: 37.6 kg, BMI 15.2
• No skin breakdown.
• Calcium, Vitamin D,Phoslo, Heparin, Protonix
• Order: Regular, with high protein milk shake, low volume every 6
hours.
• Assessment
• 1233-1850 kcal (30-45 kcal/kg)
• 53-78 gm protein (1.3-1.9 gm/kg)
• Plan: If intake does not improve, recommend enteral nutrition.
21

22. 11/9: Follow Up
• Subjective: Patient transferred to ICU. Spoke with physician.
• TF on hold secondary to being placed on CPAP. Possible CRRT.
• Objective:
• No skin breakdown.
• D10 NS w/ 3 amps NaBicarb @ 25 mL/hr = 204 kcal
• Calcium, Vitamin D,Lasix, Synthroid, Protonix
• Order:Suplena @ 5 mL/hr = 215 kcal, 5 gram protein, 89 mL free
water
• Assessment: Total protein, albumin levels low. Elevated
BUN/Creatinine. Hyperphosphatemia, Hypoglycemia noted (pt on
D10NS).
• Plan: Recommend Suplena @ goal 35 mL/hr = 1512 kcal, 38 gm
protein, 622 mL free water. 22

23. Nephrology Consult
• 11/10/12 08:58
• Acute on chronic renal failure, Metabolic acidosis
• Hypoxia, PO2 = 44 (Normal range 80-100)
• Urine output 225 mL
• Trace to minimal edema.
• No strong indication for dialysis at this point
23

24. Respiratory Arrest
& Metabolic Acidosis
• 17:15
• pH 6.98 (7.35-7.45)
• pCO2 69 (35-45)
• O2 Saturation 34% (95-100%)
• 17:34
• Endotracheal intubation
• Subsequent insertion of OG tube
24

25. 11/14: Follow Up
• Subjective: Patient remains intubated with TF at goal rate via OG tube.
No residual noted.
• Objective: 44 kg, BMI 17.7 (PEM Grade I)
• Stage II breakdown on sacrum.
• D10 NS @ 25 mL/hr = 204 kcal
• Lasix, Synthroid, Prevacid
• Order: Suplena @ 35 mL/hr
• Assessment
• 1170-2340 kcal (30-60 kcal/kg)
• 31-55 gm protein (.8-1.4 gm/kg)
• BUN 57, Cr 2.9, eGFR 20, Phosphorus: 3.6 (WNL)
• Plan: Increase rate of Suplena @ goal 40 mL/hr = 1435 kcal, 43 gm
pro, 688 mL free water.
25

26. 11/19: Consult/ follow Up
• Subjective: Patient extubated since last assessment, but
remains on TF. Oral diet started this am. Consult secondary to
diarrhea from current TF. Diarrhea improving 11/18 per
physician note.
• Objective: 40.2 kg, BMI 16.2 (PEM Grade II)
• No new breakdown noted.
• None.
• Caltrate, Prevacid
• Order: Mechanical soft chopped diet, Ensure Plus at 35 mL/hr
• Assessment
• 1170-2340 kcal (30-60 kcal/kg)
• 31-55 gm protein (.8-1.4 gm/kg)
• Plan: Recommend continue TF, Suplena @ 40 mL/hr
26

27. Calorie Count
Estimated Needs: 1700 kcal, 50 gm protein
11/21 11/22 11/23
Breakfast Kcal 630 205 560
Protein (gm) 13 7 20
Lunch Kcal 580 270 275
Protein (gm) 20 8 10
Dinner Kcal 725 120
Protein (gm) 26 4
Total Kcal 1935 (114%) 595 (35%)
Total Protein (gm) 59 (118%) 19 (38%)
27
*Food reported by patient’s mother

28. Operations
• 10/29: Removal of infected right femoral AV graft
• 10/31: Transesophageal echocardiogram
• No vegetations, mural thrombus or shunt
• Biventricular systolic dysfunction noted
• 11/6: Incision and drainage of abscess with evacuation of hematoma right
thigh.
• 11/8: Insertion of Dobhoff feeding tube
• 11/10: Endotracheal intubation
• Indications: respiratory arrest, hypoxia in low 30’s.
• 11/13: Insertion of triple lumen catheter in right internal jugular vein
• 11/15: Vent removed
28

29. Nutrition Interventions
• 10/27-11/9 Regular Diet
• 11/9-11/16: Suplena
• Initiate @ 5 mL/hr = 215 kcal, 5 gm protein, 89 mL free water
• Increase 5 mL every 8 hours to goal of 30 mL/hr
• 35 mL/hr = 1512 kcal, 38 gm protein, 622 mL free water
• 11/16-11/19: Suplena out of stock, change to Ensure Plus
@ 35 mL/hr = 1260 kcal, 45 gm protein, 605 mL free
water.
• Some diarrhea, improving per physician note on 11/18
• 11/19: Diet: mechanical soft, chopped
29

30. Refeeding Syndrome
• Hypophosphatemia (11/18: 2.5)
• Drops in potassium and magnesium
• Glucose intolerance
• Hypokalemia
• GI dysfunction
• Cardiac arrhythmias
• Congestive heart failure
30

31. Cardiac Function
• EKG on 11/21
• Left atrial abnormality
• Right ventricular hypertrophy.
• Lateral T wave inversions are new since previous
EKG,
• Ischemia should be considered
• 11/22: BNP >10000
• Indicator for CHF
31

32. Monitoring and Evaluation
• Critical Labs
• Intake
• Weight Change
32

33. Blood Glucose
Date Value
11/7 143,42, 129, 56,34, 152, 97, 65, 72, 72
11/8 67, 60, 159, 78, 72, 71, 65, 159, 75, 49, 212, 118
11/9 47, 54, 53, 166, 94, 121, 58, 71, 61, 78
11/12 91, 101, 81, 106, 75, 95, 102, 90, 114, 131, 108,
114
11/13 92, 111, 92, 108, 94, 67
Normal Glucose: 70-
108
33

34. Critical Labs
Labs Normal 27-Oct 3-Nov 9-Nov 17-Nov 24-Nov
Glucose 70-108 128 33 68 101 61
Na 136-146 139 133 137 137 138
K 3.5-5.1 3.9 5.1 5.4 3.5 4.8
Albumin 3.5-5.0 1.7 1.5 2
Ca 8.4-10.2 7.1 7.5 7.6 8.2 7.7
34

35. Renal Labs
Labs Normal 27-Oct 3-Nov 9-Nov 17-Nov 24-Nov
BUN 7-18 20 21 39 55 58
Cre 0.5-1.2 2.1 1.9 3.2 2.7 2.5
eGFR >60 29 32 18 21 23
35

36. Weight Change
IBW:
50
50.1 kg
45 44.444 43.1 (110.2 lb)
42.3
40 39.340.5 40.240.939.2
37.637 36.91
35
Weight (Kg)
33 31.33
30
25
20
15
10
5
0
Date
36

37. Clinical Notes
• 11/23: “Explained importance of eating protein.
encouraged patient to eat eggs, when turned my
back to wash hands patient was throwing food from
tray in trash, then stated she had eaten her eggs…
will continue to monitor patient while eating.” - RN
37

38. Source: Nationaleatingdisorders.org
38

39. Sources
• Nelms, Sucher, Long, “Nutrition Therapy and
Pathophysiology.”
• Academy of Nutrition and Dietetics. “Nutrition Care
Manual”
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