Meet Mr.

Dennis

Diet History
Had not been eating too well, has been losing weight and getting weaker and weaker. He has a loss of appetite.

Refuses to wear dentures, claims they are ill-fitting

Daughter-in-law prepares the food, but does not have time to make soft foods for Mr. Dennis. His refused to eat pureed foods.

His on multiple medications, but forgets to take them appropriately.

Diagnosis
Left Femur Fracture
Cachexia: Cachexia is wasting syndrome described as a loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite in an individual who is not trying to lose weight.

Dehydration
R/O malignancy

Medications

Metabolic Package

CBC

Liver Function

Labs after Rehydration

Labs after Rehydration

Labs after Rehydration

Labs Conclusion
Low Labs Calcium, Hemoglobin, Hemocrit, MCV
High Labs Liver function ALP, Glucose, TP Hydration status and lab results BUN, Calcium, Chloride, H/H, Total protein, Sodium and Ferritin are affected by hydration status. Albumin Serum albumin and H/H are not an accurate marker of visceral protein status.

RDs Note
Nutrition: S : Pts son states: My father has been depressed and is not eating well. He has lost weight gradually over the first year. Food preferences were obtained from the son. O: 73 YOM HT: 6 Wt: 133 UBW: 165 lb RBW: 178 lb +/- 10% Labs: Glucose 181 mg/dL (H) BUN: 40 mg/dL (H) CPK: 325 UL; H/H (L) Diet order: High protein, mechanical soft with nourishments TID Dx: Malnutrition, broken femur, dementia, dehydration A: 32 # wt loss in past year, 75% RBW/ 85% UBW. Pt dehydrated/under hydrated expect to see labs change and provide more indication in malnutrition. Agree with nutrition plan. P: Will send diet as ordered with high kcal and nourishments TID Will visit patient with diet tech during meal time to evaluate intake and will start calorie count 3x for 3 days to determine kcal and protein intake. Will re-evaluate protein 3 days of kcal count and when pt has been hydrated.

At the hospital
The RD was unable to interview Mr. Dennis because of his mental status. She was able to obtain information from his son. During the time of Mr. Dennis hospital stay, anthropometric measurements were not taken because it was established he was already at nutritional risk.
Mr. Dennis son was already planning to move his father into a nursing facility so his hospital stay was not long.

Anthropometrics
Current Body Weight 133 lb
Ideal Body Weight 178 lb 75% of IBW = Moderate Deficit

Body Mass Index 18.09 underweight, at risk for disease

Estimated Energy Needs

66.5 + 13. (w) + 5.0 (H) 6.8 (a) 66.5 + 13.8 (60.45) + 5.0 (182.88) 6.8 (73) 66.5 + 834.21 + 914.4 496.4 = 1,319 (1.3) = 1,714 1,700 kcals

Diagnosis
Malnutrition related to decreased appetite, difficulty eating as evidenced by BMI: 18, 75% of IBW, loose fitting dentures.

Intervention
Fortified foods/high protein Adding butter, powdered protein, increase calories with nutrient dense foods. Incorporate Ensure Complete BID Recommend social worker to assist Mr. Dennis and family with finding subsidized healthcare programs Educate son and daughter-in-law on the importance of family support while Mr. Dennis resides at the facility

Strategies to increase adequate intake

Offer favorite foods Schedule meals at certain times Avoid liquids during meals Enhance smell and flavors with herbs, sauces and dressings Work with healthcare team (Doctor) to prescribe appetite stimulate
Dronabinol, megestrol, oxandrolone

Monitor and Evaluation

Monitor patients PO intake Monitor patients weight, I/Os, GI function Follow up in 3 days to evaluate to calorie count.
Mr. Dennis should be monitored closely for weight gain and PO intake. Mr. Dennis food preferences should be honored, upsetting the patient and jeopardizing his willingness to eat is harmful. Resident appears to be adamant about remaining relatively independent and not babyed based on his refusing pureed or baby foods. Follow up with Mr. Dennis if he enjoys his meals at the nursing facility.

Conclusion
Enteral nutrition If PO intake is consistently < 50% Continue to honor Mr. Dennis food preferences to improve nutritional status and quality of life. Encourage son and daughter-inlaw to continue to be actively involved with Mr. Dennis life

References
Zaneta M Pronsky, MS, RD, LDN, FADA, Sr. Jeanne P. Crow, Pharm D, RPH. Food and Medication Interactions. 17th edition. 2012.

Nelms et al. Nutrition Therapy and Pathophysiology. 2nd edition, international edition. Wadsworth. Cengage Learning.