Case Study #1: General Nutritional Assessment Matthew Thomas

Fall 13 Case Study #1: General Nutritional Assessment Matthew Thomas September 17, 2013 Professor Dray DIE 3213

2 1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW, % UBW, and BMI. Interpret her weight and weight change based on these parameters. (5 points) HEIGHT: (67inches) x (2.5)= 170 cm 1 WEIGHT: (140 lbs.) / (2.2)= 63.6 kg 1 % IBW: (5ft = 100) + (6 x 5= 30) = 130 [140/130] x 100 = 108% %UBW: (140/ 160) x 100= 87.5% BMI: (140/ 67)= 2.09 (2.09/67)= 0.03 (0.03x 703)= 22 According to the anthropometric data above, the patient current weight is within the normal BMI range. Her actual weight of 160 lbs. would give her a BMI of 26 that is categorized as overweight. The patients IBW is 130 and her %IBW is 108% which is within normal range as well. One aspect to take into account is her weight loss. The patient s history shows that her usual weight is 160 six months ago. However since the loss of her husband over the previous six months as well as having poorly fitting upper and lower dentures may be contributing factors toward her weight loss. The patient s %weight loss is 12.5% that is classified as severe weight loss. With this anthropometric data, it is important to monitor her food completion status while in hospital as well as place her on a mechanical soft diet. It is also important to counsel her on healthy weight maintenance by: suggesting a variety of foods that are relatively soft, Meals on Wheels government funded program so she does not have to rely on cooking and inform a family member of her severe weight loss so the weight loss does not continue. References: 1. Manore MM, Thompson JL, Vaughan LA. The Science of Nutrition. 2 nd ed. San Francisco, CA: Pearson Highered: 2011: D- 1, D- 2 2. Calculate her nutritional requirements (calories, protein, and fluid) and compare her current intake to her needs. (5 points) According to Food/Nutrition- Related History being inputted in USDA: SuperTracker program provides the following information: The Pt is on a 1,600 kcal based on current wt. Pt calories consumed based on usual diet is 1254 kcal. Pt RDA protein is 46 g but consumed 51g. Pt fluid intake is 28 oz. (828 ml). 1 When the recommended fluid/beverage intake is approx.101 oz. (3000 ml). 2 This data shows that the patient has suboptimal calorie and fluid intake but her protein levels are adequate. Harris- Benedict [655.1 + 9.6(63.6) + 1.85(170) 4.7(76)] 655.1 + 610.56 + 314.5 357.2 = 1,222.96(1.2) = 1,467.552 BEE=1,467.522 kcal/day

3 References: 1. USDA: SuperTracker. Website Assessed: September 15, 2013 https://www.supertracker.usda.gov/foodtracker.aspx (Printout attached) 2. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (INDT) Reference Manual. 4 th ed. Chicago, IL: The Academy of Nutrition & Dietetics: 2013: 96 3. Are any major food groups and nutrients obviously missing from her diet? Explain your answer. (5 points) Yes, the major food groups absent from her diet are: dairy, fruits, and vegetables. According to her usual diet, the Pt is not receiving any dairy whatsoever. The Pt only consumed approximately ½ cup of vegetables of the recommended 2 cups. The Pt has suboptimal fruit consumption consuming 1 cup (of that ½ cup is fruit juice) of the recommended 1.5 cups. The Pt consumed adequate grains however the majority of those grains were refined. 1 The absence of these food groups results in nutrient deficiencies. Some of the obvious nutrients missing from the Pt diet are: calcium, potassium, magnesium, and fiber. Consuming the recommended daily allowance of calcium is essential for this Pt because of he gender and age, she is susceptible for osteopenia (hence osteoporosis). Given the reason for her hospitalization, calcium levels should be monitored and crosschecked with a bone- density test to test for bone loss. According to the Pt diet, she only consumed 197 mg of Ca that is well below the target intake 1200 mg. 1 Ca is found in various dairy sources and leafy green vegetables sources both of which the Pt is also lacking. 2 The Pt daily Mg intake is 169 mg that is suboptimal to the recommended intake of 320 mg. Another suboptimal nutrient is K, the Pt K intake is 1344 mg which is under the recommended intake of 4700 mg. Another inadequate nutrient in the Pt diet is fiber. The Pt dietary fiber intake is 7 grams versus the target intake of 21 grams. 1 Reference: 1. USDA: SuperTracker. Website Assessed: September 15, 2013 https://www.supertracker.usda.gov/foodtracker.aspx (Printout attached) 2. Manore MM, Thompson JL, Vaughan LA. The Science of Nutrition. 2 nd ed. San Francisco, CA: Pearson Highered: 2011: 414. 4. Do you think she could be experiencing any drug nutrient interactions? If so, what dietary suggestions would you make? (5 points) According to the Pt chart, the only medications the Pt is currently taking is Furosemide @ 20mg/day. Furosemide is classified as a loop diuretic that is administered as a result of the Pt history of hypertension. Furosemide acting as a loop diuretic compromise the patient s K, Mg, and fluid levels.1 Furosemide function is to increases urinary excretion to decrease sodium levels blood (hypertension). The increased urinary excretion also causes K, Mg and fluids (water) to be lost in

4 urine thus causing suboptimal levels. According to the Pt Biochemical data, the Pt K value is 3.5 meq/l that is below the normal range of 3.5-5.0 meq/l. The combination of the Pt on Furosemide and consuming suboptimal amounts of K through diet puts the P at risk for adverse consequences due to K deficiency. I would counsel the Pt about Na and K interactions, the importance of K in diet and health and how to acquire K in diet by consuming K rich foods. 1 Another option is to encourage the Pt doctor or nurse to change medications and have the Pt be placed on aldactone: a potassium- sparing diuretic so K is not compromised for the Pt. References: 1. Crowe JP, Pronsky ZM. Food Medication Interactions. 17 th ed. Birchrunville, PA: Food- Medication Interactions: 2012: 114,152. 5. Interpret her serum albumin and prealbumin. In addition to nutritional intake, what factors can cause these indices to drop? What factors would cause them to be elevated? (5 points) According to the Pt biochemical data, the visceral protein albumin is 3.2 g/dl that is below the normal range of 3.5-5.5 g/dl and prealbumin is also subpar measuring 11 mg/dl that is significantly below the normal range of 16-40 mg/dl. These are common markers used in the acute care setting due to their short half- life. It is evident from 3 weeks ago through two days since the biochemical test was administered; the Pt visceral protein markers are low. Since both visceral proteins are negative- acute phase reactants, the serum levels decrease during inflammatory stress, injury and illness. Since the Pt is admitted into the hospital as a result of a femur fracture along which some ongoing psychological stressors is evidence of why these markers are inadequate. 1 On the other hand, these visceral proteins can increase if the Pt is pregnant or has hypoproteinemia, or proteinuria. For our Pt none of these factors are applicable. 2 References: 1. Emery E. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones and Barlett: 2012: 164. 2. Mahan LK, Escott- Stump S, Raymond JL. Krause s Food and the Nutrition Care Process. 13 th ed. St. Louis MO: Elsevier Saunders: 2012: 198. 6. Describe how factors in her anthropometric, biochemical, clinical, and dietary nutritional assessment data all fit together to form a picture of her nutritional health. (5 points) Taking into account the Pt anthropometric, biochemical, clinical and dietary nutritional assessment data results in a Pt whom is dehydrated and is in need or nutritional education about weight loss/maintenance. The Pt. reason for hospitalization is evidence of possible bone loss thus osteopenia in which a RD

5 should see if Pt is aware of the importance of calcium in diet especially for her age. The Pt food and nutrition- related history is evidence of here suboptimal Ca intake. The Pt physical findings also note that the pt has oral mucose dry and a decreased skin turgor. These are markers for dehydration which is supported by the Pt diet and medications. He pt. Food history shows a consumption of only 28 fl. Oz which is much below the normal beverage consumption. As a result of the Pt history of HTN, they are placed on Furosemide medication that is classified as a loop diuretic, which promotes fluid loss via urine that is good to controlling the HTN. However, this is causing the Pt to be dehydrated. The Pt diet shows a lack in optimal amounts of fruits, vegetables, and dairy. Serum test show that the Pt is low K levels due to the Furosemide as well as not obtaining enough dietary K in foods. Other nutrients also compromised by Furosemide is Mg. In sum, the Pt. is experiencing severe wt loss over the pass 6 months as a result from a combination of factors such as: the passing of her husband, living alone, FFT, loose fitting upper and lower dentures and bed confinement. 7. Write a PES statement based on the nutritional assessment data available. (5 points) Suboptimal energy intake related to poor food/nutrient intake as evidence by physical examination findings and Pt history. 8. What dietary and social changes would you suggest to improve her nutritional intake? (5 points) There are many dietary and social changes that I would suggest to promote her nutritional intake. The first dietary change I would do is to consult her and measure her nutritional knowledge. Then I would educate her on the importance of weight maintenance so she can maintain a healthy weight. The following thing I would educate her is the importance of calcium in her diet to prevent osteopenia (thus osteoporosis) as a result of her age and the rate of bone loss. I would encourage to incorporate more calcium rich food sources into her diet. Although she does not like eggs and milk, it would be encouraged that she tries soy milk as well as yogurt and soft cheeses such as ricotta or Swiss cheese because of its easy preparation and it is a soft cheese (easy with her loose dentures). I would also promote the consumption of leafy greens cannot only fill her vegetable deprivation but leafy greens such as kale, broccoli and collard greens contain calcium as well. I would also recommend the replacement of traditional OJ with fortified OJ with calcium and vitamin D. I would provide the Pt with education materials such as a low sodium diet due to her HTN. I would show the Pt her lab scores and show how a increase in K rich foods is essential to prevent her K levels from decreasing even further especially while on Furosemide. I would also address her hydration status and

6 explain why she is having skin turgor and encourage her to increase hydration status. While consulting with the Pt I would see if it is possible to also meet with the Pt primary care giver (family member) and relay the information onto them because they are most likely doing the grocery shopping and the food prep. I would also be the liaison between the caregiver and a social worker to see if the Pt is eligible for government assistance programs such as Meals on Wheels to ensure the Pt is receiving adequate nutrition to prevent further wt loss and increase K, Mg and Ca levels. Finally I would immediately place the Pt on a mechanically soft diet to encourage food consumption as a result of her poor fitting dentures. 9. What are your nutritional goals for her, and how would you monitor the effectiveness of your interventions from question #8? (5 points) My nutritional goals for this Pt are to increase calorie, K, Mg, Ca, Mg and hydration levels and decrease Na levels. I would also like to see the increase in whole grains, dairy and fresh or frozen fruits and vegetables. I would monitor the effectiveness of my intervention by defining where the Pt is in terms of expected outcome and to measure her desired outcomes. I would f/u with the patient and check for an updated f/u prealbumin reading and look in her chart to see if meal completion status is available (while in hospital). Resources: 1. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (INDT) Reference Manual. 4 th ed. Chicago, IL: The Academy of Nutrition & Dietetics: 2013: 69 10. Write a note documenting your assessment in SOAP or ADIME format. (5 points) Assessment: 76 y/o female at adequate wt for ht, at 103% IBW. Pt has history of HTN and put on furosemide @ 20 mg/day. Physical assessment shows oral mucosa dry and skin turgor decreased. Lab data shows PAB and alb below normal range. Pt is at high nutritional risk as a result of 12.5% wt loss over past 6 months and skin integrity and diet history. Estimated energy requirements: 1400-1600 kcal (25-30 kcal/kg) and ~50.4 g protein (.8g/ kg) Diagnosis: Suboptimal energy intake related to poor food/nutrient intake as evidence by physical examination findings and Pt history. Intervention: Recheck prealbumin within 48-72 hours

7 Consult/educate Pt and caregiver about wt maintenance, increase Ca, K, Mg and beverage consumption and its impact on health. The importance of maintaining bone health. Implement a diet that is mechanically soft foods. Provide Pt and caregiver with education materials about a low sodium diet. Monitoring: Monitor meal completion status Monitor visceral proteins Monitor adherence and comprehension to nutrition education Monitor expected and desired outcomes Evaluation: Prealbumin between 16-40 mg/dl Skin turgor status Oral dry mucosa status Bone density status

8 Resources USDA: SuperTracker Nurtient Report- Case Study 1 Assessed: September 16, 2013 https://www.supertracker.usda.gov/foodtracker.aspx MNT-1's Nutrients Report 09/16/13-09/16/13 Your plan is based on a 1600 Calorie allowance. Nutrients Target Average Eaten Status Total Calories 1600 Calories 1254 Calories Under Protein (g)*** 46 g 51 g OK Protein (% Calories)*** 10-35% Calories 16% Calories OK Carbohydrate (g)*** 130 g 152 g OK Carbohydrate (% Calories)*** 45-65% Calories 49% Calories OK Dietary Fiber 21 g 7 g Under Total Fat 20-35% Calories 37% Calories Over Saturated Fat < 10% Calories 9% Calories OK Monounsaturated Fat Polyunsaturated Fat No Daily Target No Daily Target 16% Calories No Daily Target 9% Calories No Daily Target Linoleic Acid (g)*** 11 g 12 g OK Linoleic Acid (% Calories)*** 5-10% Calories 9% Calories OK α-linolenic Acid (g)*** 1.1 g 0.7 g Under α-linolenic Acid (% Calories)*** 0.6-1.2% Calories Omega 3 - EPA Omega 3 - DHA No Daily Target No Daily Target 0.5% Calories Under 13 mg No Daily Target 51 mg No Daily Target Cholesterol < 300 mg 137 mg OK Minerals Target Average Eaten Status Calcium 1200 mg 197 mg Under Potassium 4700 mg 1344 mg Under

9 Sodium** 1500 mg 1832 mg Over Copper 900 µg 802 µg Under Iron 8 mg 8 mg OK Magnesium 320 mg 169 mg Under Phosphorus 700 mg 607 mg Under Selenium 55 µg 55 µg OK Zinc 8 mg 6 mg Under Vitamins Target Average Eaten Status Vitamin A 700 µg RAE 304 µg RAE Under Vitamin B6 1.5 mg 0.8 mg Under Vitamin B12 2.4 µg 0.5 µg Under Vitamin C 75 mg 51 mg Under Vitamin D 15 µg 0 µg Under Vitamin E 15 mg AT 6 mg AT Under Vitamin K 90 µg 92 µg OK Folate 400 µg DFE 329 µg DFE Under Thiamin 1.1 mg 0.7 mg Under Riboflavin 1.1 mg 1.0 mg Under Niacin 14 mg 16 mg OK Choline 425 mg 149 mg Under Information about dietary supplements. ** If you are African American, hypertensive, diabetic, or have chronic kidney disease, reduce your sodium to 1500 mg a day. In addition, people who are age 51 and older need to reduce sodium to 1500 mg a day. All others need to reduce sodium to less than 2300 mg a day. *** Nutrients that appear twice (protein, carbohydrate, linoleic acid, and α-linolenic acid) have two separate recommendations: 1) Amount eaten (in grams) compared to your minimum recommended intake. 2) Percent of Calories eaten from that nutrient compared to the recommended range. You may see different messages in the status column for these 2 different recommendations.