Val PalamidyNutrition Therapy I Alireza Jahan-Mihan September 16, 2014 Clinical Case Studies for the Nutrition Care Process Case 1: General Nutrition Assessment Learning Objectives 1. Recognize anthropometric, biochemical, clinical, and dietary factors that impact on nutritional status. 2. Calculate and interpret weight change and body mass index. 3. Determine adequacy of dietary intake. 4. Apply the Nutrition Care Process to an elderly patient. Case Description Background Adequate nutrition can be viewed as a state of balance between intake, requirements, metabolism, and losses of nutrients. The term malnutrition usually refers to a state of undernutrition, and has been associated with increased morbidity and mortality in the clinical setting (1-4). The accurate identification and patients at risk for malnutrition and its associated complications is both an art and a science; subjective and objective data are interpreted along with clinical judgment to evaluate nutritional status. From the dietary standpoint, a full evaluation considers not only calorie and protein intake but also vitamin and mineral status. Surrogate markers of visceral protein stores such as serum albumin and prealbumin have traditionally been measured for nutritional assessment. These parameters are now known to be affected by many factors, including hydration, physiological stress, and inflammation. Particularly during metabolic stress, serum proteins more specifically reflect severity of illness than nutritional stores (1-7). While a low serum albumin is associated with an increased morbidity and mortality, it cannot be used alone to measure nutritional status or repletion. Conversely, a normal serum albumin cannot be used in isolation to rule out malnutrition. Serum protein levels by themselves do not form the basis for nutrition diagnosis or intervention. Individual assessment parameters should be considered as part of the biggest picture of nutritional equilibrium. The client is a 76-year old woman with a history of hypertension admitted to the hospital after tripping over her cat and falling at home. She is admitted for a femur fracture. She is currently confined to bed. Nutritional Assessment Data 1. Anthropometric Measurements. Height: 67’ Weight: 140lb Usual weight: 160lbs 6 months ago. She has been unmotivated to cook since the loss of her husband during the previous 6 months. 2. Biochemical Data, Medical Tests, and Procedures. a. Labs Parameter Value Sodium Potassium Chloride Carbon dioxide BUN Creatinine 140 mEq/L 3.2 mEq/L 103 mEq/L 29 mEq/L 19 mg/L 1.0 mg/L Normal Ranges* (may vary by age, sex, and lab) 135-147 mEq/L 3.5-5.0 mEq/L 98-106 mEq/L 21-30 mEq/L 8-23 mg/L 0.7-1.5 mg/L Glucose Hemoglobin Hematocrit Albumin Prealbumin 108 mg/L 12.0 g/L 38.1% 3.2 g/dL 11mg/dL 70-110 mg/L 12-16 g/L (female) 36-47% (female) 3.5-5.5 g/L 16-40 mg/L b. Test results, if pertinent X-ray indicates fracture of left femoral neck. 3. 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. 4. Client History Social Hx: No smoking or alcohol Husband diet 6 months ago and patient has lost weight since this time Family Hx: N/A 5. Food/Nutrition-Related History Usual Diet Breakfast: 1 cup (8oz) decaffeinated tea with 1 tbs half and half and 1 tsp sugar 1 slice white toast with 1 tsp margarine and 1tsp jelly or 1 frozen pancake with 1 tbs syrup ½ cup orange juice Lunch: Canned soup, usually chicken noodle, 1 cup 4 unsalted crackers with 2 tbs peanut butter ½ cup sliced peaches in light syrup Sweetened iced tea, 1 cup Dinner: Chicken thigh with skin, stewed ½ cup rice or potato with 1 tsp margarine ½ cup spinach or carrots 1 cup (8oz) 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 Questions: 1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW (1 point), % UBW (1 point), and BMI (1 point). Interpret her weight and weight change based on these parameters (2 points). Height=170.18 cm 1 Weight=63.50 kg 1 %IBW= 61.6 kg (under 3%) 2 %UBW= 12.5% 3 BMI=21.9 3 The patient’s height is 170.18 cm with a weight of 63.50 kg. Her IBW is 61.6 kg, however her current weight is 63.50 kg, so this would reflect her having a percent IBW of under 3 percent. Over a period of 6 months, the patient has suffered a severe weight loss of 12.5 % of her UBW, losing 20 lbs from her prior weight of 160 lbs. Her current BMI is at 21.9, within the normal range of 18.5 and 25, however, she should be closely monitored to prevent any more weight loss. 2. Calculate her nutritional requirements (calories, protein, and fluid) (3 points) and compare her current intake to her needs (2 points). According to myplate, her recommended caloric intake would be 1600 calories per day in order to sustain her current condition. Currently she is 500 calories short of the recommended caloric intake. The recommended amount of protein is 5 oz, however, she is consuming 1.5 oz more than the recommended. 4 She is currently consuming 826 mL of water per day, which is 1,079 mL short of her recommended amount of 1,905 ml when using the formula 30-mL/kg-body weight. 3 3. Are any major food groups and nutrients obviously missing from her diet? (2 points) Explain your answer. (3 points) Her lab results indicated that she had low levels of potassium (3.2 mEq/L when the normal range is from 3.5 mEq/L – 5.0 mEq/L). Since she is currently taking Furosemide, it is recommended that she increase her K, Mg, and Ca intake because of the increased excretion Furosemide causes. Due to her avoidance in dairy and eggs, I would be most concerned with her nutritional risks in Vitamin D and Ca. Being low in Ca could have also made her more vulnerable to sustaining the fracture. According to her food recall, she also has a low intake of fruits, vegetables and whole grains. Without her daily serving of fruits and vegetables, she is missing out on the vitamins, minerals, and phytochemicals. Although, she does consume grains with every meal, she can reap the benefits of receiving fiber, B vitamins, and minerals, simply by replacing them with whole grains. 3 4. Do you think she could be experiencing any drug–nutrient interactions? (2 points) If so, what dietary suggestions would you make? (3 points) Since furosemide is an antihypertensive loop diuretic, it is recommended that she increases her K, Mg, and Ca because of the loss of these nutrients that Furosemide causes due to increased excretion. Dietary suggestions would be to increase K, Mg, and Ca either through diet or supplementation. Foods such as bananas, leafy dark greens, beans, and dairy products should be incorporated into her diet to help improve intake of these nutrients. Nutritional risk from Furosemide include anorexia and increased thirst so I would ensure she receiving enough fluids as well monitoring any weight loss. 5 5. Interpret her serum albumin and prealbumin. (2 points) In addition to nutritional intake, what factors can cause these indices to drop? (2 points) What factors would cause them to be elevated? (1 point) Both albumin and prealbumin levels are below the normal range. The normal range for albumin is between 3.5 – 5.5 g/dL with her lab results showing albumin to be at 3.2 g/dL. Decreased levels of albumin are associated with aging, overhydration, poor diet, liver disease, rheumatoid arthritis, and acute and chronic inflammation. Dehydration would cause her albumin levels to be elevated. The normal range for prealbumin is between 16-40 mg/dL with her lab results showing prealbumin to be at 11 mg/dL. Factors that cause decrease prealbumin include liver disorders (i.e. hepatitis or cirrhosis), malabsorption, and hyperthyroidism while increased prealbumin levels are associated with renal disease and Hodgkin’s disease. 3 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) A 76-year old woman has been presented with a weight loss of 20 lbs within a 6 month period, a severe weight loss of 12.5% of her UBW. Although her BMI is within the normal range at 21.9, she is at risk for nutrient deficiencies based on other factors such as her food recall, medications, depression from the loss of her husband, injury, and age. Due to the patient’s history of having hypertension, she is currently prescribed Furosemide. Lab results indicated that her potassium levels are low which is an interaction from the medication. Her hemoglobin levels of 12.0 g/dL are within range, however they are close to the low end of the normal range of 12-16 g/dL. These levels should be monitored for risk of iron deficiency. Her albumin and prealbumin concentrations were below the normal range and could be a result from dietary changes and trauma. Signs show that her oral mucosa is dry and that her skin turgor has decreased which could be a sign of dehydration. Since Furosemide can lead to increase thirst, she would need to increase her fluid intake since she is not consuming enough fluids as is. 5 Having suffered a fracture in the femoral neck, the patient is at increased risk for calcium deficiency and osteoporosis due to her medication and her avoidance of dairy products. She will need to ensure she is receiving adequate calcium through her diet or by supplementation. Upper and lower dentures fit poorly and could be the reason why she is not meeting her caloric intake. Her caloric intake is 500 calories below the recommended amount of 1600 calories per day and she is lacking in food groups such as whole grains, fruits, and vegetables. Her weight will need to be closely monitored since Furosemide can lead to anorexia. 5 7. Write a PES statement based on the nutritional assessment data available. (5 points) Involuntary weight loss (P) related to inadequate energy intake (E) as evidenced by severe weight loss of 12.5% of her usual body weight over a 6-month period (S). 3 8. What dietary and social changes would you suggest to improve her nutritional intake? (5 points) Without overwhelming her, I would first recommend her to increase her caloric intake in order to achieve weight gain. Each week, I would have her increase her intake of 100 calories each day until we have succeeded in reaching 500-600 total calories towards her recommended amount of 1600 calories. While increasing calories, I would encourage her to consume more fruits and vegetables in her diet to ensure she replenishing the lost potassium levels as well as other nutrients not being met. If vitamins and minerals are still not being met through dietary changes, I would suggest further supplementation. Due to her age, medication, and food recall information, the need for calcium should also be considered. Foods such as leafy dark greens and beans would be advised through her meal planning. Encouraging her to switch over to a calcium enriched orange juice will boost her calcium levels while increasing her fluid intake. I would have her increase her fluid intake each week to reverse the signs of dehydration. Social changes I would make would be to encourage her to be closer to friends and family by having frequent meals together. Not only would this help her relieve some symptoms of depression, she could be exposed to different types of foods. Since she is currently on bed rest, I would strongly encourage any surrounding neighbors to help provide her with meals until she has regained her strength. 9. What are your nutritional goals for her (2 points), and how would you monitor the effectiveness of your interventions from question #8? (3 points) My nutritional goals for her would include ensuring that she has increased her caloric and fluid intake for each week. I would have her do another food recall to ensure she is also introducing more fruits, vegetables, and whole grains within her diet. If needed, I would develop a day-to-day meal plan for her, adjusted to the kind of foods that she likes, so that she could plan her meals in advance. New dentures would be recommended to improve her eating habits without any discomfort. With monitoring her social needs, I would ask if she has been receiving assistance from friends and family members. If not, I would provide information regarding the Meals on Wheel organization to ensure she is getting adequate nutrition. 3 10. Write a note documenting your assessment in SOAP or ADIME format. (5 points) Subjective data: severe weight loss of 12.5% of usual body weight caused by inadequate caloric and nutritional needs. Husband passed 6 months ago, lives alone and might be suffering from depression. Has a history of hypertension. Patient has dentures that are poorly fitted which may be cause of dietary changes. Objective data: 76-year old female patient currently on Furosemide. Has suffered fracture in femoral neck and is currently bed rest. She is 170.17 cm and her IBW is 61.6 kg with a UBW loss of 12.5% over the past 6 months. Patient is showing signs of dehydration from observation of dry oral mucosa and decreased skin turgor. Albumin and prealbumin levels are below normal range as well her potassium. Assessment: Involuntary weight loss due to inadequate energy intake as seen with severe weight loss of 12.5% of her usual body weight for the past 6 months. Inadequate fluid intake resulted from Furosemide causing decreased loss of nutrients and increasing thirst, evidence by dry oral mucosa and decreased skin turgor. Plan: Gradually increase caloric intake to achieve weight gain (recommendation of snacking in between meals) and modify diet to ensure food groups are being met. Ensure vitamins and minerals concentrations increase through diet or supplementation and would recheck on a biweekly basis. Provide assistance on how to obtain dentures that properly fit as well as providing sources on healing fracture. Encourage patient to be surrounded with family and friends for social support. References 1. Metric Conversions (2014) Available from http://www.metric-conversions.org 2. Mcauly, D. (2014) Globalrph. Available from http://www.globalrph.com/ibw_calc.htm 3. Lacey K, Nelms M, Roth S, Sucher K, Nutrition Therapy & Pathophysiology. Belmont : 2nd ed; CA; 2011. 4. Choosemyplate.gov. United States Department of Agriculture. Available from http://www.choosemyplate.gov 5. Pronsky Z, Crowe J. Food-Medication Interactions. Birchrunville, Pa: 2010.