Karen Hudson

Case Study # 1
Nutrition Therapy 1: DIE 3213 CRN 81573; T & R 1:40 p.m.

9/17/2013

(Note: The following data was taken from the following source: EZ Emery Burlington, Clinical Case Studies for the Nutrition Care Process. Burlington, MA. Jones & Bartlett Learning, LLC, an Ascend Learning Company; 2012: pp. 5-8). Client is a 76 year old woman with a history of hypertension. She had fallen after tripping over her cat and fractured her femur and is confined to bed at this time. ANTHROPOMETRIC MEASUREMENTS: Height: 67 (67 x2.54cm = 170.18 cm) Weight: 140 lbs (140 x 0.45 kg = 63.64 kg) Usual weight: 160 lbs 6 months ago. She has been unmotivated to cook since losing her husband 6 months ago BIOCHEMICAL DATA, MEDICAL TESTS, AND PROCEDURES LABS:

Parameter

Value

Normal Range* (may vary by age, sex, & lab)

135-147 mEq/L 3.5-5.0 mEq/L 98-106 mEq/L 21-30 mEq/L 8-23mg/dL 0.7-1.5 mg/dL 70-110 mg/dL 12-16 g/dL 36-47 % 3.5-5.5 g/dL 16-40 mg/dL

Sodium Potassium Chloride Carbon dioxide BUN Creatinine Glucose Hemoglobin Hematocrit Albumin Prealbumin
Test results:

140 mEq/L 3.2 mEq/L 103 mEq/L 29 mEq/L 19 mg/dL 1.0 mg/dL 108 mg/dL 12.0 g/dL 38.1% 3.2 g/dL 11 mg/dL

X-ray indicates fracture of left femoral neck.

NUTRITION-FOCUSED PHYSICAL FINDINGS: Blood pressure: 128/65 mm Hg Oral mucosa dry. Has upper and lower dentures which are poorly fitting. Skin turgor decreased. CLIENT HISTORY Social History: No smoking or alcohol Husband died 6 months ago and patient has lost weight since that time Family History: N/A FOOD/NUTRITION-RELATED HISTORY Usual Diet: Breakfast 1 cup (8 oz) decaffeinated tea with 1 tbs half and half and 1 tsp sugar 1 slice white toast with 1 tsp margarine and 1 tsp jelly or 1 frozen pancake with 1 tbs syrup cup orange juice Lunch Canned soup, usually chicken noodle, 1 cup 4 unsalted crackers with 2 tbs peanut butter cup sliced peaches in light syrup Sweetened iced tea, 1 cup Dinner Chicken thigh with skin, stewed cup rice or potato with 1 tsp margarine
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 cup spinach or carrots 1 cup (8 oz) decaffeinated tea with 1 tbs cream and 1 tsp sugar Notes Rarely eats or drinks between meals. Avoids eggs and milk due to food preferences Medications Furosemide 20 mg daily Supplements None BMI, IBW & UBW calculation: BMI= 140 lbs (67 in. x 67 in.) x 703 = 140 4489 x 703 = 21.92 Or BMI= 63.64 kg (1.7018 m x 1.7018 m) = 63.64 kg 2.90 m2 = 21.97 1(p 167) Normal BMI for the pt would be 18.5-24.9. BMI at 18.5= 18.5 x 2.90 = 53.65 kg or 118.03 lbs1 (p 167) BMI at 24.9 = 24.9 x 2.90 = 72.21 kg or 158.86 lbs1 (p 167) The patients Ideal Body Weight (IBW) according to the Hamwi Equation: IBW = 100 lbs + 5 lbs (7 in.) = 135 lbs 1 (p 166) -The patients current % of IBW = 140 lbs/135 lbs x 100 = 103.7% (abov e IBW) UBW (Usual Body Weight) -The patients current % of UBW = 140 lbs/160 lbs x 100 = 87.5% (a loss of 12.5 %) -This BMI score falls within the healthy weight category for adults. However, the 20 lb weight loss is a significant weight loss in 6 months and should be addressed. The following tool was used to determine nutritional status: Mini Nutritional Assessment (MNA), downloaded from the Nestle Nutrition Institute at http://www.mna-elderly.com/forms/MNA_english.pdf on September 14, 2013. It was determined that the patient is malnourished.

-Also, by the Malnutrition Universal Screening Tool (MUST) for adults, the BMI score = 0, the Weight loss score (12.5% lost in 6 months) = 2 and Acute disease effect score = 0. Together, these scores indicate a high risk of malnutrition and needs to be treated. 1(p 134) Nutrition requirements: -Caloric intake, protein requirements and fluid needs were calculated by using the SuperTracker tool from the USDA website. According to the Centers for Disease Control and Prevention, the healthy weight range for this individual is 119-158 lbs and double-checked by the calculations above at 118.03-158.86 lbs. Her usual weight of 160 lbs was above this weight range, so in calculating a 5% weight loss from 160 lbs resulted in a goal weight of 152 lbs, which falls within the intended weight range and at a healthy weight loss from the 160 lbs. The caloric needs for this patient is calculated at 1711 calories per day to achieve this goal weight. This was calculated using the EER formula for women 19 years and older (BMI 18.5-25 kg/m2.1(p 27) Also, The following calculations were obtained from the Self.com Nutrition Facts and Analysis web page at http://nutritiondata.self.com/facts/. (See spreadsheet below for calculations.) Her current caloric intake ranges between 1193.5-1401.3 calories per day. -Also, The Dietary Reference intake for females >50 years old for protein is 0.8 g/kg/day. However, with her increased needs due to injury, her current requirement is 1.2-1.5 g/kg or 7796 g/day. 1 (p 455) & 2 (p 168) Her current protein intake ranges between 33.5-42 g/day, well below the recommended amount. -The Dietary Reference Intake for females >70 years old for water is at least 1.5 L/d or 1(p 455) & 2(p
168)

Her current water/liquid intake ranges between 45.61-52.22 fl. Oz. per day (1.351.54L/d)[1L=33.8 fl. Oz.), lower than the recommended amount or at the lower end of the recommended amount. -There is an obvious lack of foods from the dairy group in this patients current diet (3 cups/day recommended)3. Inclusion of dairy in her diet would increase caloric, protein and liquid intake, depending on the dairy products chosen. She doesnt like milk, so other dairy products like yogurt or cheeses can be added.

-6 ounces of grains/day are also recommended for this patient.3 However, she ranges from 11.8 ounces per day. The grain choices are also refined and it is recommended that she switch from refined grains to whole grain products. -2.5 cups/day of vegetables are recommended for this patient.3 However, she consumes 1.5 cup/day, with no legumes. -1.5 cups/day of fruits are recommended for this patient.3 1 cup/ day is currently being consumed. -5 oz./day of protein foods are recommended for this patient.3 (4.5 oz/day are being consumed). Possible Drug-Nutrient Interactions This patient is currently taking 20 mg of Furosemide daily. Furosemide is prescribed for hypertension. It is a diuretic (K depleting) and an antihypertensive. It is recommended that when a patient is taking Furosemide, that they take K and Mg supplements or increase the K and Mg in the diet.4(p 114) In viewing the Biochemical lab data obtained for this patient, her K level is 3.2 mEq/L, which is below the normal range of 3.5-5.0 mEq/L. Additional dietetic intake of vegetables, fruits, seafood and dairy products, as well as legumes is recommended to add K to the diet. Furosemide may also decrease Blood Serum levels of Mg, Na, Cl and Ca and may increase glucose, BUN, Creatinine, uric acid, dyscrasias, anemia, cholesterol, LDL, VLDL and TG. Levels of Na, Cl, CO2, BUN, Creatinine, Glucose, Hemoglobin, and Hematocrit are all within normal levels. However, Glucose is close to the upper limit of normal and Hemoglobin is at the lower level of normal. Continuous monitoring is recommended. Albumin and Prealbumin Serum Albumin is below normal levels. It is measured at 3.2 g/dL, while the normal range is 3.5-5.5 g/dL. Serum Prealbumin is also below normal levels. It is measured at 11 mg/dL, while the normal range is 16-40 mg/dL. Prealbumin is a negative acute-phase protein, whose levels go down during times of trauma.2(p 54-55) Prealbumin does have a short half-life (2 days), so it can be used as an indicator of protein status1(p198), but the stress and trauma of the broken femur lowers serum levels of prealbumin. A zinc deficiency can also cause lower serum prealbumin levels, so a test for a zinc deficiency is recommended at this time. In reviewing the patients diet, it is determined that she consumes less than half of the zinc that is required for a healthy dietary intake. For women > 70 years old, 8 mg of zinc are recommended per day.2 (Dietary Reference Intake
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Table)

This patient consumes < 6.4 mg/day. This zinc deficiency could contribute to the low levels of prealbumin. The patient has a broken femur, which would be accompanied by acute inflammation. Transport protein synthesis is inhibited when the acute-phase protein synthesis rate is increased in response to inflammation, stress, or trauma. Thus, using transport proteins to measure protein status becomes difficult. Albumin also has a long half-life (approximately 20 days), which decreases its sensitivity to short-term changes in protein status or short-term interventions to improve protein status.2 (p 54-55) Continuous monitoring is recommended
Review Decreased skin turgor is a late sign in dehydration. It occurs with moderate to severe dehydration. Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate, and 15% or more is severe dehydration.5 Her dietary intake indicates malnutrition, together with dehydration. She takes the antihypertensive, diuretic drug Furosemide, which can decrease serum K levels, which the biochemical panel indicates is below normal levels. Her low potassium levels may also be a result of her current state of malnutrition. Furosemide may also contribute to hypotension, but with a BP of 128/65, she is not hypotensive. Her albumin and prealbumin levels are below normal, which may be an indicator of malnutrition, but the trauma of her broken femur may also be the reason why her levels are low. She is confined to bed, which can contribute to muscle wasting. She has lost twenty pounds (12.5%) of her body weight in the last 6 months, due to the lack of desire to cook, since her husband died. This is also an indicator of malnutrition. Situational depression may play a role in her not eating. She also has poor fitting dentures and dry oral mucosa, which may contribute to her lack of desire to eat. The dry mucosa may be attributed to a combination of her advanced age, her dehydration, and also the intake of Furosemide.

PES Statement The patient has significant involuntary weight loss in the last 6 months related to depression and poor oral food and beverage consumption as evidenced by weight loss of 20 lb. Intervention Short-term Goals -The patient will maintain her current weight while hospitalized by eating nutrient dense foods.
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-After hospitalization, the patient will slowly gain wait up to a target weight of 152 lbs. -A dental appointment is recommended for the patient to obtain properly fitting dentures. Long-term Goals -The patient will modify her diet to include adequate calories, protein and liquids by using nutrient-dense foods to prevent weight loss. Special focus is also needed on potassium and zinc intake. A repeat of the biochemical tests is recommended in 1 month in order to monitor serum potassium, albumin and prealbumin levels. These need to be brought up into the normal range. A test for zinc levels is also recommended to be added to the test panel. -A follow-up appointment with an RD is also recommended in 1 month in order to monitor eating habits, nutritional intake, anthropometric data and biochemical data. -The patient is recommended to seek mental health counseling in order to deal with the death of her husband. Also volunteering or visiting a senior center is also recommended. Chart Note Using ADIME Nutrition Assessment Pt is a 76 year old woman admitted with a broken femur Ht: 67 inches Wt: 140 lbs IBW: 119-158 lbs Laboratory values noted: K: 3.2 mEq/L Albumin: 3.2g/dL Prealbumin: 11mg/dL EEN: EER= 354 - 6.91 x 76 yrs + 1(sedentary) x [9.36 x 69.09 kg(desired wt.)] + [726 x 1.7018 m] = 354 - 525.16 + 1 x 646.6824 + 1235.5068 = 1711 calories Protein = 46 g/day Current diet is low protein, low intake, non-nutrient dense and low liquid intake Consult for education received

Nutrition Diagnosis Lack of caloric, protein and liquid intake due to depression, poor fitting dentures
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Low potassium and dehydration due to Furosemide intake and malnutrition

Nutrition Intervention Education: will provide pt with written and verbal instruction on nutrient-dense diet Goals: pt will be able to develop 1-day menu using nutrient-dense foods and liquids Pt will be able to identify good sources of protein, potassium and zinc from a list of nutrient-dense foods Pt will ask appropriate questions and verbalize understanding of dietary modifications

Monitoring and Evaluation Follow up with pt regarding questions about nutrient-dense diet. No further questions, good comprehension Evaluation: If counseling for depression is obtained, anticipate no problems following diet at home. Recommend a 1 month follow-up appointment to evaluate new labs and dietary intake. Gave business card/phone contact.

Calculations
FOOD CONSUMED Decaf. Tea half and half sugar white toast orange juice frozen pancake syrup (maple) Campbells microwave chicken noodle soup unsalted crackers peanut butter peaches in lt. syrup tea, sweet w/ 2 tbsp sugar chicken thigh w/ skin- stewed rice potato 1 tsp margarine spinach carrots tea, decaf. cream sugar total (pancake, rice & spinach) total (pancake, pot. & spinach) total (pancake, rice & carrots) total (pancake, pot. & carrots) total (toast, rice & spinach) total (toast, rice & carrots) total (toast, pot. & spinach total (toast, pot. & carrots) AMOUNT 8 fl. oz. 1 tbsp 1 tsp 1 slice 4 fl. Oz. 1 1 tbsp 8 fl. Oz. 4 2 tbsp 1/2 cup 8 fl. oz. 1 thigh (68 g) 1/2 cup 1 1 tsp 1/2 cup 1/2 cup 8 fl. oz. 1 tbsp 1 tsp CALORIES PROTEIN (g) WATER (g) Water (fl. Oz.) 2.00 0 236 7.9768 20.00 0 12.1 0.40898 15.00 0 0 0 132.00 4 13.7 67.00 0 107.5 3.6335 91.00 2 16.6 0.56108 52.00 0 6.4 0.21632 0 74.00 4 226 7.6388 52.00 188.00 68.00 230.00 158.00 121.00 278.00 33.30 20.50 27.00 2.00 29.00 15.00 1204.50 1394.80 1211.00 1401.30 1193.50 1200.00 1383.80 1390.30 0 8 0.5 0 16 2 7 0 2.5 1 0 0 0 35.00 40.00 33.50 38.50 37.00 35.50 42.00 40.50 0.4 0.6 106.5 236 42.9 64 224 0.77 82 70.3 236 11.1 0 1384.10 1544.87 1372.40 1533.17 1374.80 1363.10 1535.57 1523.87 0.01352 0.02028 3.5997 7.9768 0 1.45002 2.1632 7.5712 0.026026 2.7716 2.37614 7.9768 0.37518 0 46.78 52.22 46.39 51.82 46.01 45.61 51.44 51.04

REFERENCES
1

Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012.
2

Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology. 2nd ed. Belmont, CA: Brooks/Cole Cengage Learning; 2011.
3

USDA SuperTracker website. https://www.supertracker.usda.gov/myplan.aspx. Accessed September 14, 2013.

4

Pronsky ZM, Crowe JP. Food Medication Interactions. 17th ed. Birchrunville, PA. FoodMedication Interactions; 2012.
5

National Institutes of Health MedlinePlus Encyclopedia website. http://www.nlm.nih.gov/medlineplus/ency/article/003281.htm. Accessed September 15, 2013.

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