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FN 418/618: Medical Nutrition Therapy II Spring 2017

Malnutrition Associated with Chronic Disease

Dakota Cossairt

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Try oral intake first per discussion that we had in class

A Mr. Campbell is a 68 yo male who was admitted to acute care for

possible dehydration, weight loss, generalized weakness, and malnutrition.
Patient is on a mechanical soft diet. He has lost over 60# in past 1-2 years.
He states he gets full really easily and never feels hungry. Medical history
includes essential hypertension, hyperlipidemia, weight loss, peripheral
vascular disease, and primary squamous cell carcinoma five years previous.
Physical findings include temporal wasting, shallow respirations, dry mucous
membranes, decreased muscle tone, loss of lean mass on quadriceps and
gastrocnemius, and 1+ pedal edema. Medications include Lipitor and
Capoten. Family medical history includes mother who died of pneumonia and
father who died of lung cancer. Lab values indicate increased levels of
sodium, chloride creatine, BUN, CRP, PT, RBC distribution, mean cell volume
and mean cell Hgb. Decreased levels of potassium, calcium, total protein,
albumin, prealbumin, cholesterol, RBC, Hgb, Hct, and lymphocytes. Mr.
Campbells usual intake indicated that he was under in almost all nutrients,
vitamins, and minerals. Nutritional intake from 24-hr recall = 582 kcal

Ht. = 75 Wt. = 156# UBW= 216# %UBW= 72% BMI = 19.5

Recommended kcals = 1770-2,130 kcal/day

Recommended protein = 106-142 grams/day

Recommended fluid intake = 1770-2100 mL/day

D Malnutrition R/T chronic disease and inadequate energy intake AEB

depletion of lean body mass, loss of appetite, lab values and involuntary
weight loss.

I Will begin a 1.0 standard formula at 65cc/hour bolus feed. Goal is to

normalize protein markers and increase weight. Will educate and counsel on
ways he can reach his calorie needs through oral feeding.
ME Schedule f/u in 1-2 days. Assess whether or not patient can transition
to oral diet. Will monitor I/O, GI tolerance, and lab values.

1. Outline the metabolic changes that occur during starvation
that could result in weight loss.
a. Decrease in metabolic rate to ensure conservation of energy
i. Decreases 20-25 kcals/kg/day
b. Decreased need for glucose utilization
c. Utilization of lipid as main source of energy
d. Preservation of lean mass, minimizing protein loss
e. Overall energy needs decrease
f. Energy from fat storage >90% of kcal
g. Energy from protein <10% for gluconeogenesis
2. Identify current definitions of malnutrition in the United States
using the current ICD codes.
a. Inadequate intake of protein and/or energy over prolonged
periods of time resulting in loss of fat stores and/or muscle
wasting including starvation-related malnutrition, chronic
disease-related malnutrition, and acute disease or injury related
3. Current definitions of malnutrition use biochemical markers as
a component of the diagnostic criteria. Explain the effect of
inflammation on visceral proteins and how that may impact the
clinicians ability to diagnose malnutrition. What laboratory
values will confirm the presence of inflammation?
a. The synthesis of visceral proteins such as albumin, pre-albumin,
and transferring decreases in response to inflammation. The
synthesis of these proteins is decreased, favoring the synthesis
of acute phase proteins such as C-reactive protein, fibrogen,
procalcitonin, and serum amyloid. Reduced levels of visceral
proteins can be used as a marker of inflammation.
b. Increased levels of CRP can indicate acute inflammation.
c. Elevated or depressed WBC can also be used as a clinical
manifestation during inflammatory response. (Leukocytosis)
d. Hyperglycemia
e. Low albumin & pre-albumin
4. What does the AND evidence analysis indicate regarding the
correlation of albumin/pre-albumin with visceral protein status
and risk of malnutrition during periods of prolonged protein-
energy restriction?
a. Albumin and pre-albumin are reduced by inflammatory response
or disease.
b. There is a reduction and/or change with weight loss in prolonged
protein energy restriction anorexia nervosa, bariatric surgery,
energy restricted diets, starvation, and nitrogen balance.
c. Albumin and pre-albumin work best to reflect severity of
inflammation rather then nutritional status.
Read the article: Jensen et al. Adult starvation and disease-
related malnutrition: A proposal for etiology-based diagnosis in
the clinical practice setting from the International Consensus
Guideline Committee. Clinical Nutrition 29 (2010): 151-153.
5. Explain the differences between malnutrition associated with
chronic disease and malnutrition associated with acute illness
and inflammation.
a. Malnutrition Associated with Chronic Disease
i. When degree of inflammation is mild to moderate and is
also chronic
ii. Organ failure, pancreatic cancer, rheumatoid arthritis, and
sarcopenic obesity
b. Malnutrition Associated with Acute Illness & Inflammation
i. When degree of inflammation is severe and acute
ii. Major infections, burns, trauma, or closed head injury
6. Mr. Campbell was ordered a mechanical soft diet when he was admitted to the
hospital. Describe the modifications for this diet order.
a. Foods are altered by whipping, mashing, blending, or grinding.
This diet is designed for people who have chewing or swallowing
difficulties. Altering the foods helps them to be swallowed safely.
b. There are 3 levels to a mechanical soft diet
i. Pudding-like = pureed, consistent foods with smooth &
uniform textures
ii. Moist, soft-textured = finely cut
iii. Nearly normal = avoid hard, sticky and crunchy food
7. What is Ensure Plus? Determine additional options for Mr. Campbell that would be
appropriate for a high-calorie, high-protein beverage supplement.
a. Its a ready to drink oral nutritional supplement.
8. Assess Mr. Campbells height and weight. Calculate his BMI and % UBW.
Ht. = 75 190.5 cm 1.905m 3.63m2 d
Wt. = 156# 70.9 kg
UBW = 216# 98.2 kg
He has lost over 60#
70.9kg / 3.63m2 = 19.5
%UBW= 72%
(156# / 216#) * 100 = 72.2
9. After reading the physicians history and physical, identify any signs or symptoms
that support the diagnosis of malnutrition.
a. Weight loss
b. Feels weak
c. Decreased muscle tone
d. Doesnt have energy
e. Appears old for current age
f. Temporal wasting
g. Reduced neurologic strength
h. Lean mass loss in quadriceps and gastrocnemius
10. Evaluate Mr. Campbells initial nursing assessment. What important factors noted
in his nutrition assessment may support the diagnosis of malnutrition?
a. Weight loss >60# in past 1-2 years
b. Intake % of meals = <5% with sips of liquids
c. P.O. intake = 360 mL
d. Fluid requirements = 2000-2500 mL
11. What is a Braden score? Assess Mr. Campbells score. How does this relate to his
nutritional status?
a. A Braden scale is something used to assess a patients level of
risk for development of pressure ulcers.
b. The evaluation is based on six indicators: sensory perception,
moisture, activity, mobility, nutrition, and friction or shear.
c. Mr. Campbells score is a 17. This means that he is at low risk for
developing a pressure ulcer.
12. Identify any signs or symptoms for the physicians history and physical and from
the nursing assessment that are consistent with dehydration.
a. Skin is tenting
b. Increased sodium and chloride levels
c. Decreased potassium and calcium levels
d. Feels lethargic
e. Increased BUN & creatine levels
13. Determine Mr. Campbells energy and protein requirements. Explain the rationale
for the method you used to calculate these requirements.
Wt. = 156# 70.9 kg UBW = 216# 98.2 kg
Energy Requirements = 1770-2,130 kcal/day
70.9 kg * 25 kcal/kg = 1,772.5 kcal
70.9 kg * 30 kcal/kg = 2,127 kcal
Protein Requirements = 106-142 g/day
70.9 kg * 1.5 g/kg = 106.35 g
70.9 kg * 2.0 g/kg = 141.8 g
15. From the nutrition history, assess Mr. Campbells usual dietary intake. How does
this compare to the requirements that you calculated for him?
a. Mr. Campbells usual dietary intake provided him with 582 kcals.
This is 1,000+ kcals less than the requirements calculated for
b. His usual diet provided him with 35g protein. This is 71g less
than his estimated minimum requirement.
16. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses
and write at least two PES statements.
a. Malnutrition R/T chronic disease and inadequate energy intake
AEB depletion of lean body mass, loss of appetite, lab values
b. Inadequate energy intake R/T decreased ability to consume foods
AEB decreased appetite, mechanical soft diet, unintended weight
loss, and lab values
17. Determine the appropriate intervention for each nutrition diagnosis.
a. Achieve and maintain healthy lean body mass and body fat
b. Enteral nutrition bolus feed
18. Based on the criteria established in Jensen et al.s article as well as the consensus
statement from AND and ASPEN, what type of malnutrition is Mr. Campbell
experiencing? Provide the specific criteria that support your diagnosis.
a. Chronic-disease related malnutrition
i. Energy intake <75% of estimated/required
ii. 28% weight change in last 1-2 years
iii. Depletion of lean body mass
iv. Inflammation
1. Decreased albumin & pre-albumin
2. Increased CRP
19. Identify the steps you would take to monitor Mr. Campbells nutritional status while
he is hospitalized. How would this differ if you were providing follow-up care
through his physicians office?
a. Monitor I/O, weight, and lab values (albumin & pre-albumin).
b. Follow up care will monitor weight, lab values, rebuilding of
muscles and calorie intake.