Debbie McCall DIE 3213 Ms. J.

Dray 9/17/2013 Case Study #1

CASE Study 1 GENERAL NUTRITIONAL ASSESSMENT

1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW, % UBW, and BMI. Interpret her weight and weight change based on these parameters.

Height-67=170cm (67x2.54) Weight-140lb=63.6kg (140/2.2) %IBW- 104%; Using Hamwi Equation for IBW-100lbs for first 5 then 5lbs per inch over that (female): 100 + 5lbs (7) =135lbs; % IBW- actual wt (140lbs) / IBW (135lbs) x 100= 104% Appropriate weight range for BMI between 18.5 and 24.9 is 118lbs-158lbs 18.5 x 2.89=53.5kg or 118lbs 24.9 x 2.89=72.0kg or 158lbs %UBW-87.5 (current weight (140)/usual body weight (160) x 100=%UBW) BMI-22 (63.6kg / (1.70)2=22 (BMI) Her weight has dropped 20lbs in the last six months from 160lbs to 140lbs. This is a 12.5% weight change which puts her in the severe weight loss category (>10%UBW). However, her BMI of 22 is in the normal range with low health risk (18.5-24.9). She is just 5lbs over her ideal body weight of 135lbs and is at 104%IBW which is in the normal range. She is 87.5% of her usual body weight. Her usual body weight of 160lbs was heavier than what is considered ideal for her BMI range of 118lbs-158lbs. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012.
2. Calculate her nutritional requirements (calories, protein, and fluid) and compare her current intake to her needs.

Calories- using Harris Benedict Equation= 655.1+9.6(63.6kg) +1.9(170cm)-4.7(76 age) = 1231(BEE=basal energy expenditure) Add in activity factor and stress factors (this woman is bedridden): Using confined to bed AF= 1.2 x 1231(BEE) = 1478Kcal/day Protein-based on 1.3g protein x (63.6) kg/day = 83g/day (I used 1.3g protein as my calculation because of her low albumin and prealbumin levels)

Fluid range- 30mL/kg x 63.6kg= 1908mL/day or 35mL x 63.6kg=2226mL/day. I used 30mL35mL as my calculation range due to her blood pressure medication (Furosemide), which is a diuretic.
Current intake:

Her current caloric intake for the menu provided, according to Myplate.gov is 1083 calories. She should be consuming roughly 1500 calories a day and is under target in all her daily food groups of protein/whole grains/vegetables/fruits and dairy. Protein intake was at 39g/day compared to her needs of 83g/day. She is well below her estimated protein needs. Fluid intake was 828mL/day* compared to her needs range of 1908mL/day to 2226mL/day. She is well below her estimated fluid needs. *I calculated 28oz of fluid (3 8oz cups of tea and c of O.J.) and converted oz to mL 1oz=29.574mL Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology 2nd ed. Belmont, CA: Wadsworth; 2011. U.S. Department of Agriculture. Supertracker. Washington, DC. https://www.supertracker.usda.gov/foodtracker.aspx. Accessed September 14, 2013.
3. Are any major food groups and nutrients obviously missing from her diet? Explain your answer.

Dairy is missing entirely from her diet and she admits to avoiding milk because of her food preferences. Along with milk she avoids eggs also which could be why her intake of Vitamin D was 0ug and her calcium was only 300mg, nowhere near her target of 1200mg/day for calcium. She drinks no water at all during the day; coupled with the fact that she takes a diuretic in the form of her hypertension medication (Furosemide) can lead to dehydration because she is losing more water than she is taking in. She eats minimal grains and no whole grains at all, thus she is not getting enough fiber. Her Vitamin B levels were all under target. Her potassium intake was severely below target and copper, magnesium, phosphorus, selenium and zinc were all under where they should be. U.S. Department of Agriculture. Supertracker. Washington, DC. https://www.supertracker.usda.gov/foodtracker.aspx. Accessed September 14, 2013. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012.
4. Do you think she could be experiencing any drugnutrient interactions? If so, what dietary suggestions would you make?

Yes. She is taking Furosemide which is a loop diuretic which will cause her to urinate frequently. Potassium is eliminated mainly through the urine and thus is lost when she urinates. Hypokalemia (low serum potassium) can occur when levels drop below 3.5mEq/L. Her potassium level on her labs shows 3.2mEq/L. She needs to increase potassium foods in her diet or take a potassium supplement since she does not eat an adequately balanced diet. She may need to restrict sodium in her diet because an uptake of sodium can cause a decrease in potassium due to the Na+/K+ exchange in the kidneys. Although Furosemide can cause an increase in blood glucose and BUN, no indications of this have been seen in her lab values but should be monitored. Mayo Clinic. Potassium Supplement. Mayo Clinic Web site. http://www.mayoclinic.com/health/drug-information/DR602373. Published November 1, 2011. Accessed September 14, 2013. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology 2nd ed. Belmont, CA: Wadsworth; 2011. Pronsky ZM, Crowe JP. Food Medication Interactions. 17th ed. Birchrunville, PA: FoodMedication Interactions; 2012. U.S. Department of Agriculture. Supertracker. Washington, DC. https://www.supertracker.usda.gov/foodtracker.aspx. Accessed September 14, 2013.
5. Interpret her serum albumin and prealbumin. In addition to nutritional intake, what factors can cause these indices to drop? What factors would cause them to be elevated?

Her serum albumin is low at 3.2g/dL, the normal range is 3.5-5.5g/dL. Her prealbumin is even lower at 11mg/dL where the normal range is 16-40mg/dL. Trauma from her fall and subsequent fracture of the femur, the stress of losing her husband and her age could contribute to her low levels of both albumin and prealbumin. Trauma, surgery and metabolic stress can cause serum albumin to decrease. Decreases can be due to decreased rate of synthesis of albumin and increased rate due to degradation. Inflammation and acute stress can also cause albumin levels to drop as can burn injuries and cirrhosis of the liver. Levels naturally decrease with aging. Higher levels of albumin are attributed to dehydration and when persons are taking prescribed corticosteroids and anabolic hormones. Prealbumin levels decrease when there are diseases of the liver like hepatitis or cirrhosis. If there are issues with malabsorption or hyperthyroidism prealbumin levels will drop. Prealbumin levels also decrease in the presence of inflammation and stress and in zinc deficiencies. Increase in prealbumin levels can be seen in Hodgkins disease and renal disease. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012.

Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology 2nd ed. Belmont, CA: Wadsworth; 2011.
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.

Her anthropometric measurements are within normal range for all values. Her BMI is 22 which is in the appropriate weight range of normal. Her 20lb weight loss from 160lbs to 140lbs has put her near to her ideal body weight of 135lbs. She is currently 104% of her IBW and that puts her in the normal range. Her potassium levels are low, most likely due to her blood pressure medication, Furosemide, which is a loop diuretic and causes frequent urination where potassium in lost. Furosemide can also cause dehydration if not enough water is consumed daily as is the case with this woman. Her albumin and prealbumin levels are low which is likely in the event of a trauma, such as her femur fracture. The loss of her husband, and subsequent lower energy intake over the past six months because she is unmotivated to cook for herself, could lead to the lower albumin and prealbumin levels. These levels decrease with age and could also be an indicator of the lower levels. She has poor fitting dentures which could cause her to limit her intake of food because of how painful consuming certain foods would be. She is deficient in all food groups and takes in no dairy or eggs due to food preferences and consumes no whole grains. Her current energy intake is under 1100Kcal/day and she should be consuming approximately 1500Kcal/day. Her fluid intake of 828mL/day is well below what is normal for her which is in the range of approx 1900-2200ml/day. She has dry oral mucosa and her skin turgor is decreased, both signs of possible dehydration which can be exacerbated by her hypertension medication, Furosemide. She admits to rarely eating or drinking between meals. She is not physically active because she is currently confined to bed. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology 2nd ed. Belmont, CA: Wadsworth; 2011. Pronsky ZM, Crowe JP. Food Medication Interactions. 17th ed. Birchrunville, PA: FoodMedication Interactions; 2012. Emery EZ. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones & Bartlett Learning; 2012.
7. Write a PES statement based on the nutritional assessment data available. Problem: inadequate intake of food/fluid Etiology: lack of motivation to cook for herself Signs/Symptoms: has lost 20lbs since husband died 6 months ago

PES: Inadequate Oral Intake (N1-2.1) related to no motivation for cooking as evidenced by the 20 pound weight loss in the last six months.

Emery EZ. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones & Bartlett Learning; 2012. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013.
8. What dietary and social changes would you suggest to improve her nutritional intake?

Dietary changes: Because the patient has inadequate oral intake (N1-2.1), inadequate fluid intake (N1-3.1) due to lack of motivation to cook, poor dentition and dry mucosa: I would recommend Medical Food Supplements (ND-3.1) that would supplement energy, protein and fiber. I would recommend increased fluid intake (FH-1.2.2) I would recommend Vitamin and Mineral Supplements (ND-3.2) to compensate for her low level of potassium and her poor intake of nutrient dense foods. I would recommend texture modification due to poor dentition (NC-1.2). I would order a Vitamin D Profile (BD-1.13.3) to check for possible low Vitamin D levels due to her avoidance of milk/eggs

Social changes-I would counsel by using motivational interviewing strategies (C.2) to discuss her lack of motivation for cooking, perhaps discuss loss of husband and effect that has on her nutritional status (if this is within scope of practice) Offer Food/Nutrition program participation (FH-6.1) Give information about widow support groups in the area Find area senior centers with activities Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013.
9. What are your nutritional goals for her, and how would you monitor the effectiveness of your interventions from question #8? Nutritional goals: Increase energy intake (FH-1.1.1) to 1500kcal/day Increase food intake (FH-1.2.2) to 3-5 servings of fruits/vegetables a day Increase fluid/beverage intake (FH-1.2.1) to at least 68oz/day Food/Nutrition program participation (RC-1) use of Meals on Wheels due to bed confinement Increase her potassium (1.6.2) level to within normal range 3.5-5.0mEq/L If lab values show inadequate, increase her Vitamin D levels (FH-1.6.1)

Monitoring interventions:

Monitor weight to ensure there is not continued weight loss Assess progress of her intake of foods/fluids (FH-1.2.2/FH-1.2.1) Monitor lab values for potassium (BD-1.2.7), albumin (BD-1.11.1), prealbumin (BD-1.11.2) Monitor Vit D (BD-1.13.3) and calcium values (BD-1.2.9) Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013. U.S. Department of Agriculture. Supertracker. Washington, DC. https://www.supertracker.usda.gov/foodtracker.aspx. Accessed September 14, 2013.
10. Write a note documenting your assessment in SOAP format.

S-Patient lost husband six months ago and is unmotivated to cook. Does not smoke or drink alcohol, eats three meals a day but not enough from the different food groups; avoids milk and eggs, rarely eats or drinks between meals. No family history given. Activity: None, currently confined to bed. O-76 y.o. female s/p w/hx of htn, fractured femur. Ht: 5ft. 7in; current wt: 140lb; BMI-22; BP: 128/65 mm/Hg; Meds: 20mg Furosemide A-Inadequate Oral Intake (N1-2.1) related to no motivation to cook as evidenced by 20lb weight loss in past six months. Pt could benefit from increased oral intake of food and beverages and should start socializing when she has recovered. P- Need further blood work to monitor potassium, albumin and prealbumin levels. Order Vit.D and calcium labs to check levels Provide counseling strategies for lack of motivation to cook (C-2) Referral to local senior nutrition program (Meals on Wheels) in area to provide meals (RC-1) due to bed confinement Referral to dentist due to poor dentition (RC-1) Emery EZ. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones & Bartlett Learning; 2012. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013. The National Resource Center on Nutrition and Aging. Meals on Wheels Association of America Web site. http://www.mowaa.org/. Accessed September 14, 2013.

References Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology 2nd ed. Belmont, CA: Wadsworth; 2011. U.S. Department of Agriculture. Supertracker. Washington, DC. https://www.supertracker.usda.gov/foodtracker.aspx. Accessed September 14, 2013. Mayo Clinic. Potassium Supplement. Mayo Clinic Web site. http://www.mayoclinic.com/health/drug-information/DR602373. Published November 1, 2011. Accessed September 14, 2013. Pronsky ZM, Crowe JP. Food Medication Interactions. 17th ed. Birchrunville, PA: FoodMedication Interactions; 2012. Emery EZ. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones & Bartlett Learning; 2012. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013. The National Resource Center on Nutrition and Aging. Meals on Wheels Association of America Web site. http://www.mowaa.org/. Accessed September 14, 2013.