I. UNDERSTANDING THE DISEASE AND PATHOPHYSIOLOGY
1. How is acid produced and controlled within the gastrointestinal tract?
The production of acid occurs in the stomach by cells that are therein. The cells found in the stomach produce intrinsic factors and hydrochloric acid. There are chemical messengers that help during the activity. They are histamine, gastrin and acetylcholine. Gastrin helps in stimulating the cells to produce secretions when food enters the stomach. An enzyme somatostatin inhibits the secretions when needed. The digestion takes place in three phases; the cephalic phase, gastric phase and the intestinal phase. It is in the gastric gland that the parietal cells, responsible for secretion of hydrochloric acid, are found. In which case, the secreted hydrochloric acid triggers pepsinogen into action, kills microorganism and function in protein denaturization. The production and secretion of the acid occurs in the cephalic phases, also known as the first phase, whereby taste, smell or sight of food stimulates the release of pepsinogen and HCL (George et al, 2012, 80).
2. What role does lower esophageal sphincter (LES) pressure play in the etiology of gastroesophageal reflux disease? What factors affect LES pressure?
Given that the atmospheric pressure is much higher in the esophagus as compared to the stomach, this will hinder reflux of gastric substances. The lower esophageal sphincter (LES) ceases to act as anobstruction between the stomach and the esophagus because of weakening caused by gastroesophageal reflux disease. The reflux’s etiology is influenced by several aspects; among them include physical and lifestyle aspects. Among the facts that serve in lowering pressure of LES are hormones’ increase, bodily conditions such as hernia, medication and foods that are high in fat percentage (George et al, 2012, 51).
3. What are the complications of gastroesophageal reflux disease?
If not treated, complications of the disease include impaired swallowing, esophagus perforation, aspiration and ulceration.Barrett’s Esophagus normally causes the cells to change therein in the esophagus from normal squamous cell epithelium to metaplastic columnar cell epithelium. If the condition impairs swallowing, the patient should be given a restricted diet. The major complication that comes as a result of the condition is swallowing (Academy of Nutrition and Dietetics, 2014, 38).
4. The physician biopsied for H. pylori. What is this?
H. pylori stands for helicobacter pylori. It is a bacterium that causes ulcers and inflammation in the stomach. The bacteria can also serve in disorienting the stomach’s coating. A large number of symptoms associated with H. pylori are also projected by GERD. With a biopsy, the physician was able to exhaust all the relevant areas and be sure of what he was doing (Roth & Long, 2013, 47).
5. Identify the patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal reflux disease.
Severe indigestion reported by the patient, and his fear of having a heart attack. Other symptoms of the disease include heartburn and an increase in salivation. A person is likely to be belching more often when they have the condition. Increase in weight gain and heme in the respiratory tract may be present in some patients with the same condition (George et al, 2012, 34).
6. Describe the diagnostic tests performed for this patient.
Having been admitted to hospital, diagnosis for gastroesophageal reflux diseases is performed by intraesophageal ph monitoring and barium esophagram. pH monitoringinvolves putting an acid sensing probe contained in a capsule, battery and a transmitter inside. In which case, acid contained in the esophagus is monitored by probe and transfers the data to a recorder. The patient usually wears the recorder in form of a belt. The capsule functions for two days and after which the batter goes off. After a week, the capsule is then passed with the stool. The resulting information is entered into the computer in the process of determining the pH. For barium esophageal, a barium sulphate mixture is given to Mr. Nelson so that he can drink. The barium is visualized by use of fluoroscopy. This is essential in the process of accessing movement and swallowing occurring via the stomach to the duodenum (George et al, 2012, 72).
7. What risk factors does the patient present with that might contribute to his diagnosis? (Be sure to consider lifestyle, medical, and nutritional factors.)
8. The MD has decreased the patient’s dose of daily aspirin and recommended discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect gastroesophageal disease?
Some medications are known to block control pathways. Example of these is ibuprofen and aspirin. Despite providing the patient short-term relief, they should not be used for longer periods, not on daily basis. The drugs can serve in disorienting LES thereby leading to prevalence of GERD occurrence. (Roth & Long, 2013, 17).
9. The MD has prescribed omeprazole. What class of medication is this? What is the basic mechanism of the drug? What other drugs are available in this class? What other groups of medications are used to treat GERD?
Omeprazole acts as a barrier to proton pump with its working mechanism relying on suppressing molecules considered responsible for release of stomach acid. The protons inhibited include K+-ATPase enzyme, H+. Besides lansoprazole, omeprazole,
pantoprazole, rabepraxole and esomepraxoleare other proton pump inhibitors that are only availed on prescription. Further, GERD can be treated by antiacids, foaming agents, prokinetics, and prokinetics. (Roth & Long, 2013, 28).
II. UNDERSTANDING THE NUTRITION THERAPY
10. Summarize the current recommendations for nutrition therapy for GERD.
Among the recommendations include avoidance of alcohol, pepper (both black and red), avoiding coffee, reducing intake of food for each meal, chocolate and foods high in fat. Another recommendation is to increase intake of calcium and iron. On the other hand, the clients should increase the intake of foods rich in fiber to boost the digestion. Fiber increases the bulk in the stomach thereby aiding in digestion in the gastrointestinal tract (Academy of Nutrition and Dietetics, 2014, 83).
III. NUTRITION ASSESSMENT
11. Calculate the patient’s percentage UBW and BMI. What does this assessment of weight tell you? In what ways may this contribute to his diagnosis?
UBW = (100 x 215) /180 = 119%
BMI= weight/ heinght2 (97.7/ (1.75)2
BMI = 31.7
He is considered obese because of a high BMI with a weight above the 95th percentile (Academy of Nutrition and Dietetics, 2014, 78).
12. Calculate energy and protein requirements for Mr. Nelson. How would this recommendation be modified to support a gradual weight loss?
Energy requirement is 2970 k/cal while protein requirement is 111 g/day.
662 – 9.53 x age + physical activity x (15.91 x weight + 539.6 x height)
662 - 9.53 x 48 + 1.11 x (15.91 x 97.7 + 539.6 x 1.75) = 2970
Based on the 24-hour recall, the client uses 2970 kcal per day. Most of the food that he eats is high in calories. It would be rife is he cuts by around 500 kilocalories daily to have a normal BMI. He can go through this by cooking food so that he avoids the fatty food eaten as snacks. If he must eat out, he should go for the grilled foods because they have less fat. Secondly, he is taking in more of the carbonated drinks; he should limit the amount to one soda a day if he must take the carbonated drinks. Drinking a lot of water will help in the scenarios since it reduces the amount of carbonated drinks that he will take. He gets more energy from the snacking and is required to more to healthier eating options. When he takes such options, the amount of fat and calories in the diet will significantly reduce (Roth & Long, 2013, 40).
13. Complete a computerized nutrient analysis for this patient’s usual intake and 24-hour recall. How does his caloric intake compare to your calculated requirements?
I utilized MyPramid program in analysis of Mr Nelson’s 24hr recall. The analysis showed that Mr. Nelson took 3746 calories plus protein of 154.4 grams. His usual calories intake was 3610 and 112.3 grams for protein. All of these amounts are far above the calculated requirements. Consequently, this is a confirmation of his present condition
(Academy of Nutrition and Dietetics, 2014, 93).
14. Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s overall
health? Explain.
His cholesterol is considered to be off. This is punctuated by very high LDL and low HDL. This makes his total cholesterol to be very high, 220, and between 120 and 199 when normal. Through adapting a practice of lowering his weight, helping to improve his cholesterol, Mr. Nelson tan improve his general health. This includes cardiovascular health improvement.
15. What other components of lifestyle modification would you address in order to help in treating his disorder?
One of the strategies is to breakdown his meals by having him eat five smaller amount meals rather than the usual three large meals. Reduce the amount of soda drank. Make water drinking an important part of his diet. He should reduce the amount of alcohol intake and start exercising for better health. When he starts exercising, the BMI will fall in the normal category and the weight will be in the recommended bracket. The steps campaign will make sure that he walks and get active in the end.
IV. NUTRITION DIAGNOSIS
16. Identify pertinent nutrition problems and corresponding nutrition diagnoses and write at least two PES statements for them.
Excessive energy intake: This is as shown by the inappropriate weight gain
Elevated triglycerides levels: This is as shown by the high cholesterol levels of the patient.
PES 1: Excessive energy intake
Problem: Excessive energy intake. This is the problem that the nutrition intervention will be applied to.
Etiology: The client is associated with taking foods high on fats, which are known to be less healthy.
Signs and symptoms: The patient gained 35 pounds within the period and a BMI of 31.7 indicating he is obesity class 1.
PES 2: Elevated triglycerides levels
Problem: Elevated triglycerides levels. Nutrition intervention is required to solve this.
Etiology: The patient is reported of not taking proper diet as evidenced by high cholesterol and high LDL.
Signs and symptoms: High cholesterol and high Triglyceride levels of around 200 mg/dL (Roth & Long, 2013, 24).
V. NUTRITION INTERVENTION
17. Determine the appropriate intervention for each nutritional diagnosis.
For excessive weight gain:
An appropriate intervention is to try to reduce soda intake to one a day and consider taking water instead. He can then gradually try to reduce the soda amount taken.
He should cut his intake by 500 kcal per day for close to three months. In that regard, he will be able to lose one pound in every week. He will be put on diet for intervention that will include a follow up of measuring weight and monitoring through the 24-hour recall method. If there is no change in his caloric intake, it would be dropped by a further 400 kcal so that he gets to the normal BMI. Education is provided on how to cook food in order to retain the nutrients and remove more fat from his diet.
For elevated triglycerides levels:
For this nutritional diagnosis, the client would be introduced to some physical activities so that they burn the excess calories that are in the body. Mr. Nelson would be referred to a physiotherapist to undergo counseling on how to carry out the exercises very well. On the other hand, a step plan would be appropriate for Nelson. Making 3000 steps in a day will make sure that he remains active and shuns the dormant life. In so doing, Nelson will be active and able to reduce a number of calories.
18. Using Mr. Nelson’s 24-hour recall, outline necessary modifications you could use as a teaching tool.
References
Roth, Long (2013-05-13). Medical Nutrition Therapy: A Case Study Approach.
Academy of Nutrition and Dietetics (2014). Pocket guide for international dietetics & nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, Ill: Academy of Nutrition and Dietetics.
George F. Longstreth. Medline Plus. (2012). Esophageal pH Monitoring. Rockville Pike,
Bethesda, MD.
