Jessica Salgado NCP: Case #3 Malnutrition associated with Chronic Disease

Nutrition Assessment Age, gender: 68, Male Dietary intake: PO intake, loss of appetite, decrease food intake Surgeries: glossectomy 5 yrs. ago Diagnosis: squamous cell carcinoma of tongue 5 yrs ago Lifestyle: Smokes 1ppd for 60+ yrs & drinks 1-3 cans of beer/day Takes ensure as supplement Pt. was treated with radiation therapy Medical History: Hypertension, hyperlipidemia, weight loss Anthropometric measurements o Ht/wt:63/ 1.905m and 156#/ 70.9kg o BMI= 19.5 kg/m (normal) o IBW= 196#/ 89.0kg, %IBW=156#/196#=79% o UBW=220# %UBW=156#/220#= 70% (severe malnutrition) Energy, Protein and Fluid Needs Total energy= 1773-2482 kcals/d Protein=70.9-106.3 g/day Fluid=1773-2482 ml/d o Based on BW of 70.9kg o For energy needs used 25-30kcals/kg/d o For protein used 1.0-1.5g/kg/d o For needs used 1ml/kcal/d Labs/tests o Sodium= 150mEq/L, High o Potassium= 3.4mEq/L, Low o Chloride= 118mEq/L, High o BUN=36mg/dL, High o Cratinine Serum: 1.27, High o Calcium=8.4mg/dL, Low o Total Protein=5.8, Low o Albumin= 1.8, Low o Prealbumin=9, Low o CRP= 2.4MG/dL, High o Cholesterol= 92mg/dL, Low o PT= 15.1, High o RBC= 2.4, LOW o Hemoglobin= 8.1, low o Hematocrit= 24.1, low o MCV=100.6, HIGH o MCH= 33.6, High o Lymphocyte= 11, low Nutrition Diagnosis Inadequate oral intake R/T decreased ability to consume sufficient energy AEB failure to maintain appropriate weight, weight loss, loss of appetite, low %IBW, low %UBW. Nutrition Intervention 1. Meals and Snacks Plan

a. Increase caloric intake through a mechanical soft diet containing nutrient dense foods or higher kcal for P/N nutrition b. Increase IV fluid requirements to 2500mL 2. Nutrition Education a. Teach pt to choose nutrient dense high in protein soft foods such as peanut butter, protein shakes, pureed meats soups, milk, cooked pumpkin, squash, and kale. 3. Nutrition related Medical Management a. Start taking multivitamin supplement immediately Goals 1. Increase weight, 1 to 2 lbs every 2 weeks until weight within IBW range 2. Consume nutrient dense food, to increase energy intake immediately Monitoring and Evaluation Follow up with pt progress within 1 to2 days. Nurse should keep progress of weight change chart Schedule appointment in 2 to 3 months to re-evaluate protein, albumin, prealbumin levels and determine if in normal range.