Updated 3/2016

Summary of the Disease Condition

(No more than 2 pages including the list of references)

Definition: There are several ways to define malnutrition with the simplest definition being a nutritional
imbalance. The Academy of Nutrition and Dietetics (AND) and the American Society of Parenteral and
Enteral Nutrition (ASPEN) collaborated to create etiology based definitions in 2009.

Epidemiology: Malnutrition or undernutrition is commonly seen in patients in hospitals. According to

ASPEN, one out of three admitted patients is malnourished. Critically ill patients, especially the elderly
are at a higher risk for developing malnutrition upon admission to hospitals (nutritioncare.org, 2017).

Etiology: When the nutritional risk is identified as compromised intake of food or a loss of body mass,
the patient is diagnosed with malnutrition. It is more accurately diagnosed upon inspection of the
presence of inflammation. With no inflammation present, it is possible that the patient is suffering from
starvation-related malnutrition (pure chronic starvation or anorexia nervosa). If the patient has minor to
moderate inflammation, this could be chronic-disease related. Possible chronic-diseases include but are
not limited to organ failure, pancreatic cancer, rheumatoid arthritis, and sarcopenic obesity. If the patient
has a marked inflammatory response, we know that the patient is suffering from acute disease or injury
related malnutrition. Examples of this include major infection, burns, trauma and closed-head injuries
(Jensen, 2014).

Pathophysiology: Malnutrition can result from a number or series of events. As mentioned in the
etiology of malnutrition, it can result from starvation and/or self-imposed non-inflammatory events or
injury or illness related conditions that result in a mild to severe inflammatory response.

Specific Examinations including Lab Indicators and Medical Diagnosis: There are six key
characteristics of which two out of the six must be identified in the patient for a diagnosis of malnutrition.
These characteristics for a medical diagnosis of malnutrition are: 1) Insufficient energy intake; 2) Weight
loss; 3) Loss of muscle mass; 4) Loss of subcutaneous fat; 5) Localized or generalized fluid accumulation
that may sometimes mask weight loss; 6) Diminished functional status as measured by hand grip strength.
(hcpro.com). Lab markers are used in conjunction with the six characteristics of malnutrition, so it is
important to note that we cannot use lab indicators alone to diagnose malnutrition. These lab markers
include changes in acute-phase proteins such as pre-albumin and albumin which will help indicate if the
patient has inflammation. (andeal.org)

Medical Treatment: Medical treatment is dependent on the patient’s severity and form of malnutrition.
If the patient is able to intake food orally, this method is preferred. If the patient is unable to consume
food orally, enteral or parenteral nutrition may be administered (Nelms 2010, p. 80).

Medical Nutrition Therapy: Malnutrition support can be provided through an oral diet designed to meet
the patient’s specific nutritional requirements and modified to meet his or her specific physical needs.
This might include modification of type or amount of food and nutrients within meals or at specified
times between meals, or the addition of medical food supplements and/or vitamin and mineral
supplements. For malnourished patients with unintended weight loss, the Registered Dietitian should
provide individualized nutrition care to increase protein, energy, and overall nutrient intake for improved
nutritional quality of life as well as nutritional status alongside weight gain. In situations where
modification of the oral diet is not enough, enteral nutrition (or tube feeding), and/or parenteral nutrition
can be administered (Nelms 2010, p. 80).
Updated 3/2016
References Cited in This Summary (Do not just cite the textbook. Please use EAL, guidelines and peer-
reviewed publications)

1. Feed Your Patient: ASPEN’s Malnutrition Solution Center. (2017). American Society for Parenteral
and Enteral Nutrition. Retrieved February 2017, from http://www.nutritioncare.org/malnutrition/
2. Malnutrition and Inflammation-- “Burning Down the House”: Inflammation as an Adaptive
Physiologic Response Versus Self-Destruction?. (2015). Jensen, G. L. Retrieved February 2017, from
American Society for Journal of Parenteral and Enteral Nutrition
3. Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2010). Nutrition Therapy and Pathophysiology.
Cengage Learning.
4. New Malnutrition Criteria Could Help Ensure Consistent Coding. (2012). JustCoding News:
Inpatient. Retrieved February 2017, from http://www.hcpro.com/HIM-282409-3288/New-
malnutrition-criteria-could-help-ensure-consistent-coding.html
5. Unintended Weight Loss in Older Adults. (2007). Evidence Analysis Library. Retrieved February 2017, from
http://www.andeal.org/topic.cfm?menu=5294&cat=5444

Updated 3/2016
 To Apply the Nutrition Care Process
Part One: Nutrition Assessment

Nutrition Assessment involves the following five subcategories of information being collected, analyzed
and interpreted.

Food/Nutrition Related Biochemical data, Anthropometric Nutrition-related Client History

History medical tests, and Measurements Physical Findings
procedures
Food and nutrient intake, Lab data (e.g., Height, weight, body Physical appearance, Personal history,
medication/herbal electrolytes, glucose) and mass index(BMI), growth muscle and fat wasting, medical/health/family
supplement intake, tests (e.g. gastric pattern indices/percentile swallow function, history, treatments and
knowledge, beliefs, food emptying time, resting tanks, and weight history appetite, and affect complementary/alternativ
and supplies availability, metabolic rate) e medicine use, and social
physical activity, history
nutrition quality of life

1. Food and Nutrition History

Consider: Patient’s/client’s food and nutrient intake, nutrition knowledge and beliefs; physical activity
habits; food availability; nutrient needs (measured, calculated, or estimated from a formula/equation)
● Food and Nutrient Intake: Pt reports eating very small amounts of food throughout the day;
portions are small and is reportedly eating less than 5% of meals and sips of liquid. Tries to drink
1 bottle of ensure daily, but sometimes only half. Pt has been admitted and put on mechanical soft
diet
● Food Intake Hx: Lost 60 lbs in the last two years because of cancer, gets full very easily and
never feels hungry.
● Physical Activity: Physical activity is little to none. Does not have much energy and lives a
sedentary lifestyle.
● Knowledge: Only 9 years of education; speaks English only; meat cutter for 26 years, but is now
retired.
● Beliefs: Baptist affiliation
● Nutrient Needs: Fluid requirement of 2000-2500 mL/day.
● Medications Taken: Lipitor 80 mg daily; Capoten 25 mg 2x daily. Started to take 100mg
thiamin injection daily; Metronidazole 500 mg in CaCl premix IVPB; Lopressor 5 mg every 6
hrs.
● Supplements: Drinks ½ -1 Bottle of ensure daily.
● Alcohol/ Drug Use: Has 1-3 cans of beer/day; Tobacco use of 1 ppd for 60 plus years.
● Appetite: Gets full quickly and never feels hungry.

Comparative Standards
ESTIMATED NUTRITIONAL NEEDS: include energy, protein, CHO, fat, fiber, vitamins, minerals,
H2O and reference or basis for this estimate

Energy:
RMR= (9.9 X 71kg) + (6.25 X 190.5cm) - (5 X 68y/o) -5
RMR= (702.9) + (1,190.6) - (340) - (5)
RMR= 1,548.5 Kcals/day
TEE= (RMR) X (AF of 1.3)
TEE= (1,548.5 Kcals) X 1.3

Updated 3/2016
 TEE= 2,013.05 kcals ~ 2,000 kcals/ day
EEN= 2,000 +500 = 2,500 kcals/day for a 1 lb increase in weight/ wk.
The MSJ equation has been chosen to calculate the nutritional needs for our patient because he is not
considered in critical condition. He currently has a normal BMI of 19.5, but according to an ideal body
weight of 200 lbs we feel that he should gain weight, especially considering his past steady weight of 220
lbs 5 years ago. An additional 500 calories have been added each day to help a slow and steady weight
gain. The activity factor of 1.3 was used because he does not seem to do much exercise, is retired and no
longer works.

Protein:
25% PRO-25% is on the high end of protein consumption, but we feel that it is necessary because his
muscle mass has been being depleted. Our pt has lost so much weight over the two years, he has become
malnourished and complains of being weak. With a higher protein intake, hopefully he will gain some
muscle back in his body and have more strength for everyday activities while also putting weight back on
as well. It is also stated that the highest amount of protein for external nutrition is set at 25% (Nelms
2010, p.91)

CHO, fiber (type, amount, distribution, if applicable):

55% CHO- 55% has been chosen because in his previous diet he does not seem to have many
carbohydrates, which give energy for someone to function throughout the day. Without carbohydrates,
someone can feel tired and sluggish, which he has said was a symptom that he had been having upon
admission. Upping his carbohydrate intake will boost his energy levels. It would also help for him to
consume more veggies and fruits containing fiber and complex carbs because he is missing a lot of vital
minerals, nutrients and vitamins found in these wholefoods. A high fiber diet may not be ideal due to Mr.
C’s condition of early satiety, so maybe juices that do not contain too much added sugar would be more
ideal. 5.5% of Total kcals will be from fiber, per the enteral nutrition equation (Nelms 2010, p.82) being
used for Mr. C. With a 2,500kcal diet, about 36 g will be fiber based, this is lower than the DRI, but this
is the only equation that uses fiber in the for enteral nutrition.

Fat (type and amount, if applicable):

25% FAT- 25% is a good amount for fat in our patient’s diet according to Abbott, the equation we are
using for enteral nutrition, the lowest amount of fat consists of 25%. Because he is not very active, we do
not want him getting too much fat because that may make him feel less actual energy, and have a negative
effect of what we are aiming for. It is on the lower end of macronutrient distribution range, but we feel
that because he has been malnourished for so long, having enough carbs and protein to rebuild muscle to
give strength and energy is more important.
** Macronutrients add up to 105% because of the enteral nutrition equation PROMOTE WITH
FIBER gives the following breakdown of 25% PRO, 25% FAT, and 55% CHO.

Water Consumption:
Fluid intake should be from 2,000- 2,500 mL. This is based on 1mL/kcals consumed daily. This is also
the required intake stated for our pt’s fluid recommendation for nutrition once he was admitted.

Please summarize the key dietary intake information (if available) in the table below

This pt/ client Expected, normal, or reference value

Fat: FAT: 69 g for weight gain
33.1 g (24 hr recall) 56g for TEE
20-35% AMDR (specific diet 25%)
**Saturated Fat: Saturated 7-10% calories from fat; but should
Updated 3/2016
 8.1% be as minimal as possible.
**Mono Fat: Mono Fat 10-15% calories from fat
9%
**Poly Fat: Poly Fat up to 10% calories from fat
7.1%
CHO: CHO: 344 g for weight gain
99.3 g (24 hr recall) 275 g for TEE
45-65% AMDR (specific diet 50%)

PRO: PRO: 156 g for weight gain

44.2 g (24 hr recall) 125 g for TEE
10-35% AMDR (specific diet 30%)
Fiber: 36 g (EN standard poly metric formula:
3.8 g (24 hr recall) PROMOTE with Fiber)
Total Energy Intake: 2,000 kcals/day = TEE
~880 kcals (24 hr recall) 2,500 kcals/day = EEN; for intended weight
gain
Vitamin D *ONLY 43% of recommended value
~ 6.5 mcg
Vitamin C * ONLY 41.5% of recommended value
~ 37.3 mg
Vitamin K *ONLY 22.7% of recommended value
~ 27.25 mcg
Zinc *ONLY 44.4% of recommended value
~ 4.9 mg
Potassium *ONLY 19.8% of recommended value
~ 935 mg

Interpretation and/or Comments:

Compared to the patient’s energy needs estimated to be around 2000 kcals per day, the patient has
inadequate energy intake (~880 kcal). Due to overall inadequate energy intake, patient is also not meeting
macronutrient needs for carbohydrates, proteins, or fats compared to his needs. Furthermore, his fiber
intake (~3.8 g) is not ideal compared with 36 g that is recommended. The patient’s food and nutrient
history illustrates a serious case of malnutrition as he is not meeting most of his nutrient, vitamin and
mineral needs, and it will be important for a registered dietitian to intervene and aid in restoring his
proper nutritional status.

2. Anthropometric Measurements

Consider: Weight, height, BMI, weight change, rate of weight change, growth percentiles (pediatric
pts), desirable or usual body weight, other anthropometric measures as appropriate (waist
circumference, skinfolds, body composition measures, etc.). Please remember to include appropriate
units of different measures.

This pt/client Expected or normal value

Ht: 6’3” Ht: N/A
CBW: 156# IBW: 200 (+/- 10% for frame size)
UBW (usual body weight): 220# → 5 years
BMI: 19.5 kg/m^2 (Normal Range) prior
Weight Change : 29.1% over 2 years
Updated 3/2016
 BMI: Normal Range: 18.5-24.9 kg/m^2
Weight Change: N/A

Interpretation and/or Comments:

Our patient is in a “safe”/normal zone as far as BMI standards, but he is much lower on the scale in
regards to ideal body weight. Additionally, the patient had a weight change of 29.1% over a span of 2
years and his current body weight is 156 lbs while his previous usual body weight was around 220
lbs. Due to signs of severe weight loss, we want to help him regain body weight closer to his ideal
body weight of 200 lbs.

2. Biochemical, Laboratory, and Diagnostic Tests

This pt/client Expected or normal value

Blood Pressure: 122/77 mmHg - Blood Pressure: <120/80 mmHg
Sodium = 150 mEq/L - Sodium: 136 -145 mEq/L
Potassium = 3.4 mEq/L - 3.5-5.5 mEq/L
Chloride = 118 mEq/L - 95-105 mEq/L
BUN = 36 mg/dL - 8-18 mg/dL
Creatinine serum = 1.27 mg/dL - Creatinine 0.6-1.2 mg/dL
Calcium = 8.4 mg/dL - 9-11 mg/dL
Protein, total = 5.8 g/dL - 6-8 g/dL
Albumin = 1.8 g/dL - 3.5-5 g/dL
Prealbumin = 9 mg/dL - 16-35 mg/dL
C-reactive protein = 2.4 mg/dL - <1.0 mg/dL
Cholesterol = 92 mg/dL - 120-199 mg/dL
PT = 15.1 (sec) - 12.4-14.4 sec
RBC = 2.4 x 106/mm3 - 4.5-6.2 x 106/mm for males
Hemoglobin (Hgb) = 8.1 g/dL - 14-17 g/dL for males
Hematocrit (Hct) = 24.1 % - 40-54 % for males
Mean cell volume = 100.6 μm3 - 80-96 μm3
Mean cell Hemoglobin = 33.6 pg - 26-32 pg
RBC distribution = 18% - 11.6-16.5%
Lymphocyte = 11% - 15-45 %
red = ABOVE normal range
orange = BELOW normal range

Interpretation and/or Comments:

● Systolic blood pressure of 122 is in the prehypertension range and while pt’s diastolic number is
within normal range being under 80, pt should be monitored as hypertension increases likelihood
for cardiovascular diseases.
● Hypernatremia, hypokalemia, and hypochloremia can be the result of dehydration and pt should
be monitored for presence of edema and hypertension. Pt’s current order is 0.9% sodium chloride
with potassium chloride 20mEq 125 mL/hr.
● Increased BUN can be seen with salt and water depletion and can be offset with fluid and
electrolyte regulation. Should monitor and evaluate post IV.
● Slightly increased creatinine levels can be the result of the dehydration and increased BUN levels.
Should monitor and evaluate post IV.
● Lower than normal albumin levels can be the result of acute or chronic inflammation, or any of

Updated 3/2016
 the following: starvation, malnutrition, malabsorption, anorexia; hypoalbuminemia is the most
common cause of decreased calcium levels as seen with pt; and low prealbumin indicates
moderate protein depletion. Should monitor and evaluate post IV and dietary intervention.
● CRP, as the most sensitive acute phase reactants, and most likely in pt’s case, indicates
inflammation. Should monitor and evaluate post IV and dietary intervention.
● Lowered cholesterol levels can be a result of malabsorption and malnutrition as seen with pt.
Should monitor and evaluate post IV and dietary intervention.
● Deficiency in vitamin K can cause an increase in PT - and may indicate pt special care to increase
vitamin K levels. Should monitor and evaluate post IV and dietary intervention.
● Decreased RBC count can be the result of dietary insufficiency of iron or other vitamins involved
in production of RBCs. Increased RBC distribution is also indicated with iron deficiency and/or
B12 or folate deficiency. Should monitor and evaluate post IV and dietary intervention.
● Decreased Hct and Hgb are commonly indicated in states of anemia, another outcome most likely
d/t insufficient dietary iron. The slightly increased mean cell volume and increased mean cell Hgb
indicates a slight macrocytic anemia may be present, which is the result of decreased ingestion of
animal products or impaired absorption. Should monitor and evaluate post IV and dietary
intervention.
● Low lymphocyte levels indicates pt is in an immunosuppressive state. Should monitor and
evaluate post IV and dietary intervention. Pt should receive proper nutrition education for food
safety.

In conclusion, pt’s labs should be monitored frequently along with fluid and dietary intake to ensure
treatment is improving pt’s state of dehydration, generalized weakness, and malnutrition. Special
considerations in feeding regime need to be taken with regards to sufficient protein and vitamin rich foods
to restore balance short and long term.

3. Nutrition-Focused Physical Findings

Consider: oral health, general physical appearance, skin integrity, muscle tone and/or subcutaneous
fat wasting, affect, swallowing function. WHAT WOULD YOU OBSERVE, FEEL, SMELL,
LISTEN FOR IF YOU WERE MEETING THIS PATIENT IN PERSON?

This pt/ client Expected or normal

General appearance: Cachetic, appears older than years No excessive body fat, no wasting
Heart: Regular rate and rhythm No clicks, murmurs, or gallops
HEENT: Sensitive to light
Head: Noted temporal wasting No wasting
Eyes: PERRLA PERRLA
Ears: Clear
Clear
Nose: Dry mucous membranes with petechiae
throat: Dry mucous membranes without exudates or No swelling, redness, smell
lesions
Skin: Warm and dry with ecchymoses Smooth, warm, dry
Presence of edema: +1 pedal edema No edema
Abdomen: Hypoactive bowel sounds x 4; nontender, Non-tender, no guarding, normal bowel
nondistended sounds
Extremities: Decreased muscle tone with normal ROM; Noncontributory
loss of lean mass noted quadriceps and gastrocnemius

Updated 3/2016
Neurologic: Alert and oriented; strength reduced Alert
Chest/lungs: Respirations are shallow- clear to Clear
auscultation and percussion
Peripheral vascular: Diminished pulses bilaterally Clear

Interpretation and/or Comments:

Pt’s physical examination indicates significant abnormal physical findings such as a cachectic state in
appearance. Additional notable abnormal findings indicate severe wasting in extremities with decreased
muscle mass and tone as well as presence of pedal edema which is in the feet and ankles.

4. Client history

Consider: Medications and supplements AND THEIR NUTRITION IMPLICATIONS, social

history, personal (age, occupation, family, education, etc.), medical/surgical/health history, substance
habits

Client History Implications on Nutrition Care

Caucasian, male
68 years old
Married, lives with wife
2 children, alive (42yo, 45yo)
9 years education
English speaking
Meat cutter (26 years); retired
Baptist
Tobacco: 1ppd for 60+ years
1-3 cans alcohol per day
Essential hypertension
Hyperlipidemia
Primary tongue squamous cell
carcinoma (5 yrs ago)
s/p partial glossectomy (5 yrs ago)
Radiation therapy (last treatment 3 yrs
ago)
Updated 3/2016
-Nutrient requirements modified for male pt
-Sense of taste diminishes with age
-Modified nutrient requirements (supplements, energy)
-Possible supportive partner; should include wife in
nutrition education and intervention
-Possible barrier to behavior change if unwilling to make
or assist in changes with pt
-Possible motivation for change, may be supportive
partners in making dietary changes
-Limited education implicates possible need for further
expansion on dietary knowledge and nutrition
information that is easy to comprehend
-Nutrition education, intervention, and materials should
be given in English
-Possible low activity level after retiring, mental health
should be evaluated and depression should be considered
-No dietary restrictions applicable
-May indicate altered taste (dysgeusia)
-Possible barrier to implementing strict dietary pattern
-Educate and counsel on a cardioprotective diet, and
methods to reduce sodium & increase K, Mg, Ca
- Educate and counsel on a cardioprotective diet
-Greater risk of poor nutrition quality of life
-continued professional nutritional counseling, education,
and psycho-social support
-May indicate dysphagia
-Coordination of care with SLP
-Possible Xerostomia as a result
-Can have lasting effect on taste, salivary gland function,

Peripheral vascular disease
Medications: Lipitor (80mg/d)
Medications: Capoten 25mg 2x/day
Father died of lung cancer
Mother died of pneumonia
Updated 3/2016
& cause chronic dry mouth
-May indicate long term diet modification necessary
-Increased risk of cardiovascular mortality
-Cardioprotective diet recommended
-Would not recommend peripheral parenteral nutrition
-Generic name atorvastatin; Statin - HMG- Reductase
inhibitor
-Taken w/o regard to food or time of day
-Works best with cardioprotective diet
-Generic name catopril; Angiotensin Converting Enzyme
(ACE) Inhibitor
-Advised to be taken on an empty stomach 1 hour before
meals, can decrease food absorbency by about 30-50%
-Insure adequate fluid intake/hydration
-Caution w/ IV Fe - severe systemic rxns reported
-Possible increased dysgeusia, although rare
-Fe and Mg supplements to be separated by at least 2hrs
-No nutritional impact at this time
-No nutritional impact at this time
 Part Two: Nutrition Diagnosis

Nutrition Diagnosis should be done using the approved NCP terminology.

Intake Clinical Behavioral-Environmental

Too much or too little of a food or Nutrition problems that relate to Knowledge, attitude, beliefs, physical
nutrient compared to actual or estimated medical or physical conditions environments, access to food, or food
needs safety
A. Analyze the assessment data collected in light of the patient’s admission medical diagnosis or
reason for referral. What was normal? What was not normal?

Normal: Pt’s physical examination indicates normal heart rate and rhythm, eyes PERRLA, clear ears,
neurologically alert and oriented, and his abdomen is nontender and nondistended. Anthropometric
measurements show BMI of 19.5 kg/m^2 being in the normal range (18.5-24.9 kg/m^2).

Abnormal: Pt’s general appearance is abnormal and cachectic, looking older than he is. Pt’s physical
examination indicates temporal wasting in the head, dry mucous membranes with petechiae in the nose,
dry mucous membranes without exudates or lesions in the throat, reduced strength in the neurological
level, decreased muscle tone and loss of lean mass in extremities with 1+ pedal edema , skin warm and
dry with ecchymoses. His respirations are shallow and peripheral vascular have diminished pulses
bilaterally. Biochemical lab results show almost all values as abnormal with high sodium (150 mEq/L),
low potassium (3.4 mEq/L), high chloride (118 mEq/L), high BUN (36 mg/dL), high creatinine serum
(1.27 mg/dL), low calcium (8.4 mg/dL), low total protein (5.8 g/dL), low albumin (1.8 g/dL), low
prealbumin (9 g/dL), high C-reactive protein (2.4 mg/dL), low cholesterol (92 mg/dL), high PT (15.1
sec), low RBC (2.4 x 106/mm3), low Hgb (8.1 g/dL), low Hct (24.1 %), high mean cell volume (100.6
μm3), high mean cell hemoglobin (33.6 pg), high RBC distribution (18%), and low lymphocyte (11%).

B. Is this a well-nourished patient? Why or why not?

No, this patient is in fact malnourished. All of the biochemical lab results show as higher or lower than
normal range values, which is highly concerning. In the past 1-2 years, he lost over 60 lbs and while he is
at a normal BMI range still with current BW, this indicates a very high weight change of 29.1% compared
to his usual body weight of 220 lbs.

C. Is the patient’s current oral nutrient intake or nutrition support meeting his/her nutritional
needs?

No, the patient is not meeting his nutritional needs according to the current oral nutrient intake as he is
currently experiencing severe wasting. The

D. Are there any other indications of nutrition problems?

This pt has been smoking 1ppd for over 60 years, which may indicate dysgeusia, or altered taste, which
also may affect appetite or oral food consumption. He consumes 1-3 cans of alcohol per day, which could
be a possible barrier to the patient being able to implement strict dietary patterns. Also, because he has
primary tongue squamous cell carcinoma and partial glossectomy, both 5 years ago, he has a greater risk
for a poor nutritional quality of life. This pt additionally has essential hypertension as well as
hyperlipidemia, and needs education on how to have a cardioprotective diet.

Updated 3/2016
Problem: Use the Nutrition Diagnostic Terminology (eNCPT) to make a list of possible nutrition
diagnosis terms that best match the abnormal nutrition assessment findings. Then check the definition of
each to make sure that the term fits the situation and assessment findings. List the nutrition diagnostic
terminology that best fits the pt’s/client’s situation.

Potential nutrition problems using NCP terminology:

● Malnutrition
● Inadequate energy intake
● Unintended Weight loss
● Loss of muscle mass
● Poor nutrition quality of life
● Inadequate protein energy intake

Etiology: What caused or contributed to these problems? Use the Nutrition Diagnostic Terminology
(eNCPT)

Potential causes using NCP terminology:

● Chronic disease or condition related malnutrition
● Inadequate energy intake
● Inadequate oral intake
● Unintended weight loss
● Inability to manage self-care
● Self-monitoring deficit

Signs and symptoms: What evidence shows that there is a problem? How do you know there is a
problem? These are also your monitoring and evaluation parameters. Use potential indicators to help you
decide on appropriate evidence, eg. results of diet analysis, lab tests, results of physical exam

From nutritional assessment we discovered:

● Food/Nutrition-Related
○ Patient self report of 24-hr recall
■ Inadequate energy intake (~880 kcal/day)
■ Inadequate protein intake (~ 44 g/day)
■ Inadequate fat intake (~33 g/day)
■ Inadequate Carbohydrate intake (~ 99 g/day)
● Anthropometrics
○ CBW: 156#
○ IBW: 200 (+/- 10% for frame size)
○ UBW (usual body weight): 220# (5 years ago)
○ Weight Change : 29.1% over 2 years

● Biochemical Data
○ Low Albumin 1.8 g/dL (RV 3.5-5 g/dL)
○ Low Prealbumin 9 mg/dL (RV 16-35 mg/dL)

● Client History
○ Medical Hx:

Updated 3/2016
 ■ Essential HTN; hyperlipidemia; weight loss; primary tongue squamous cell
carcinoma (5 years ago); peripheral vascular disease
○ Surgical Hx:
■ s/p partial glossectomy (5 years ago)
○ Tobacco usage 1 ppd for 60 + years
○ Alcohol usage 1-3 cans of beer per day

● Nutrition-Focused Physical Findings

○ Loss of muscle mass in quadriceps and gastrocnemius, temporal wasting
○ 1+ pedal edema

Please refer to the information in Nutrition Assessment- there are five subcategories of information
that could provide evidence for the Problems and Etiology.

USING APPROVED LANGUAGE, write the nutrition diagnosis as a PES statement.

Note: there may be many PES statements appropriate for one pt/client. Please write down two most
relevant and important PES statements below. These PES statements should drive your intervention later.

PES Statement 1
Problem Malnutrition R/T

Etiology Chronic disease or condition AEB

Sign and Symptoms Primary tongue squamous cell carcinoma and partial
glossectomy 5 years ago, pt’s physical examination
showing loss of muscle mass in quadriceps and
gastrocnemius, and loss of 60 lbs and weight change of
29.1% in the last 1-2 years.
PES Statement 2
Problem Unintended weight loss R/T

Etiology Inadequate oral intake AEB

Sign and Symptoms loss of 60 lbs and weight change of 29.1% in the last 2
years, pt’s self report on lack of appetite and insufficient
intake of 880 kcal/day as per 24 hr recall compared to
estimated needs of 2000 kcal/day.

Part Three: Nutrition Intervention

Please note: In Nutrition Intervention, you can and should address all potential problems you have
listed in Part Two. Please do not limit yourself to the two nutrition problems you have written PES
Updated 3/2016
statements for.

Nutrition Prescription (= The patient’s individualized recommended dietary intake of energy and/or
selected nutrients or foods based on current reference standards and dietary guidelines and the
pt’s/client’s health condition and nutrition diagnosis. Refer to eNCPT)

Nutrition Prescription (Nutrition Rx):

Specific diet (if applicable) Enteral Nutrition: Standard Polymeric

High(er) Protein Diet. Formula
PROMOTE® WITH FIBER (~1 Cal/mL, 83%
free water)
2500 mL/day
104 mL/hr
To increase lean muscle mass and gain weight
Energy goal (Kcal/day) ~2500 kcals/day from PROMOTE® WITH
+500 kcals/day for 1# increase in BW. FIBER
~2,500 kcals/day
Protein goal (g/day) ~156 g PRO/day from PROMOTE® WITH
25% of kcals/day FIBER
~156 g PRO/day
Carbohydrate goal (g/day) ~345 g CHO/day from PROMOTE® WITH
55% of kcals/day FIBER
~344 g CHO/day
Fiber ~36 g/ fiber/day PROMOTE® WITH FIBER
~30 g/day (DRI males aged 50-70)
Fat goal (g/day) ~71 g FAT/day from PROMOTE® WITH
25% of kcals/day FIBER
~69 g FAT/day
Fluid (ml/ day) 2500 mL formula x 83% free water = 2075
2500 ml/day mL
Extra Fluid: 425 mL water in addition to
formula.

If there is any specific goal or restrictions, please Goal rate: 104 mL/hour
list below

Strategic goals of nutrition intervention (What do you try to achieve all ANY patient with this
condition?):

Main goal: Restore nutritional balance by increasing caloric intake along with a high protein diet. Increase
weight and lean muscle mass.
STRATEGIES
Education:
● Explain rationale and goals for EN
● Describe and explain equipment, supplies, and location of tip of access device
● Discuss the signs and symptoms of intolerance and pot

Nutrient delivery: Enteral nutrition using PROMOTE® WITH FIBER (~1 Cal/mL, 83% free water)
Updated 3/2016
(Standard Polymeric Formula)
● X-ray to confirm initial placement
● Elevate head of bed to 30 degrees
● Continuous feeding: Full strength at 30 mL/hour and increase by 20 mL every six hours to goal
rate of 104 mL/hour.
● Assess patient status and tolerance
● Flush with water every 6 hours
● Measure gastric residuals every 4 hours
● Prior to discharge, switch patient to bolus regimen of 625 mL/hr feeding four times daily.
● Identify if EN will be necessary post discharge.
● If the patient has been clinically cleared to begin an oral diet and the required, safe consistency
has been determined, the diet may be advanced.
● When the patient is meeting 2/3rds to 3/4th of their nutrient needs through the oral route, EN may
be discontinued.

Please note: There are four categories of nutrition interventions (see table below). Food and/or
Nutrient Delivery is just one of them.

Food and/or nutrient Nutrition Education Nutrition Counseling Coordination of

delivery Nutrition Care
An individualized A formal process to A supportive process, Consultation with, referral
approach for food/nutrient instruct or train a pt/client characterized by a to, or coordination of
provision, including meals in a skill or to impart collaborative counselor- nutrition care with other
and snacks, enteral and knowledge to help patient relationship, to set health care providers,
parenteral nutrition, and pts/clients voluntarily priorities, establish goals, institutions, or agencies
supplements manage or modify food and create individualized that can assist in treating
choices and eating action plans that or managing nutrition-
behavior to maintain or acknowledge and foster related problems.
improve health responsibility for self-care
to treat an existing
condition and promote
health
Consult the Academy’s Nutrition Care Manual, Evidence Analysis Library, the AHRQ or Cochrane
databases to locate evidence-based recommendations or guidelines for nutrition care.

Please summarize the relevant evidence regarding nutrition therapy of the disease conditions.
Please indicate the source of the evidence.

Evidence gathered from A.S.P.E.N. 2009 Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient:

“Nutrition support therapy in the form of enteral nutrition (EN) should be initiated in the critically ill
patient who is unable to maintain volitional intake. (Grade: C)” (p.279)

“EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who
requires nutrition support therapy. (Grade: B)” (p.279)

“Enteral nutrition should be started early within the first 24–48 hours following admission. (Grade: C)”
(p. 280)

Evidence gathered from The A.S.P.E.N. Nutrition Support Core Curriculum : A Case-based Approach :
Updated 3/2016
The Adult Patient:

“Stable patients tolerate a fairly rapid progression of EN, generally reaching the established goal within
24-48 hours of initiation.” (p. 149)

Describe the nutrition intervention using approved NCP terminology (eNCPT). If you are
recommending dietary (diet order) changes, provide a one-day sample menu that meets your
recommendations, and a dietary analysis of the sample menu that proves that it meets your
recommendations (Use Food Processor software installed on computers in the FCS computer lab)

Food and/or Nutrient Delivery

● Energy-modified diet
○ Increased energy diet
● Protein-modified diet
○ Increased protein diet
● Enteral Nutrition
○ Modify rate of enteral nutrition

Updated 3/2016
 Part Four: Nutrition Monitoring and Evaluation

How will you know if your intervention is helping with the pt’s/client’s nutrition problem? Using
approved terminology, list indicators (signs and symptoms) you will re-evaluate. Monitoring and
Evaluation and Reference sheets are combined with Assessment Reference Sheets. (eNCPT).
Please feel free to add additional notes relevant to this case after each NCP term you deem appropriate
for this section.
Please delete any empty rows in each table.

Food/Nutrition-Related Biochemical Data, Anthropometric Nutrition-Focused

History Outcomes
Food and nutrient intake,
medication/herbal
supplement intake,
knowledge, beliefs, food
and supplies availability,
physical activity, nutrition
quality of life
Medical Tests, and
Procedure Outcomes
Lab data (e.g. electrolytes,
glucose) and tests (e.g.
gastric emptying time,
resting metabolic rate)
Measurement Outcomes Physical Assessment
Outcomes
Height, weight, body mass Physical appearance,
index (BMI), growth muscle and fat wasting,
pattern indices/percentile swallow function, appetite,
ranks, and weight history and affect

Please fill out the tables below and feel free to add more rows to accommodate more information, if
deemed appropriate.

Food/Nutrition-Related History Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Total energy intake - Recommended energy intake 2,500 kcal/day Commented [1]: TEE = 2000
2 Types of foods/meals - Monitor pt current intakes of types of foods, the 2500 was for weight gain?
24 hour recall, food frequency questionnaire Commented [2]: But it is recommended that he gain
3 Total fat intake - Recommended fat intake 69 g/day (20% of weight? So i thought that this would be 2,500 kcals,
total kcals) instead of just keeping his weight the same?
4 Total protein intake - Recommended protein intake 156 g/day (25%
of total kcals)
5 Total carbohydrate intake - Recommended carbohydrate intake 344 g/day
(55% of total kcals)
6 Total fiber intake - Recommended fiber intake 36g/day (5.5% of
total kcal intake)
7 Areas of knowledge/skill - Monitor improvement of knowledge/skill
related to diet

Biochemical Data, Medical Tests, and Procedure Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Sodium (mEq/L) - Sodium: 136 -145 mEq/L
2 Potassium (mEq/L) - 3.5-5.5 mEq/L
3 Chloride (mEq/L) - 95-105 mEq/L
4 BUN (mg/dL) - 8-18 mg/dL
Updated 3/2016
5 Creatinine serum 9mg/dL) - Creatinine 0.6-1.2 mg/dL
6 Calcium (mg/dL) - 9-11 mg/dL
7 Protein, total (g/dL) - 6-8 g/dL
8 Albumin (g/dL) - 3.5-5 g/dL
9 Prealbumin (g/dL) - 16-35 mg/dL
10 C-reactive protein (mg/dL) - <1.0 mg/dL
11 Cholesterol (mg/dL) - 120-199 mg/dL
12 PT (sec) - 12.4-14.4sec
13 RBC ( x106/mm3) - 4.5-6.2 x 106/mm for males
14 Hemoglobin (Hgb, g/dL) - 14-17 g/dL for males
15 Hematocrit (Hct, %) - 40-54% for males
16 Mean cell volume (μm3) - 80-96 μm3
17 Mean cell Hgb (pg) - 26-32 pg
18 RBC distribution (%) - 11.6-16.5%
19 Lymphocyte (%) - 15-45%

Anthropometric Measurement Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Body mass index - Recommended BMI range 18.5 -24.9 kg/m2
- Current BMI: 19.5 kg/m^2 (within normal
range)
2 Measured weight - CBW: 156#
3 Usual body weight percentage - 71% UBW
- (156#/220# x100)
5 Weight change - Monitor any additional wt loss
6 Estimated dry weight - if edema is found to be present

Nutrition-Focused Physical Assessment Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Subcutaneous fat - monitor additional loss
2 Early satiety - monitor pt satiety
3 Decrease in appetite - monitor pt appetite
4 Hypoactive bowel sounds - present, normal bowel sounds
5 Edema - monitor presence of edema
6 Muscle weakness - handgrip strength

Updated 3/2016
 Documentation ADIME Notes
A:
Chief Complaint: “I just feel weak all over and don’t have the energy to do anything.”
Gender: M Age: 68 y/o BMI:19.5 kg/m2 (Normal)
Ht:6’3” Wt:156# Ethnicity: Caucasian
Food Intake: Eats very small amounts of food throughout the day; reports are less than 5% of meals are
consumed. Drinks sips of liquid during meals. Tries to finish 1 bottle of ensure daily- but sometimes only
have, in order to increase protein needs. Never feels hunger and gets full easily. Admitted into the hospital
to consume a mechanical soft diet.
Physical Activity: No physical exercise is reported. Recently retired and reports feeling weak and having
no energy all the time.
Medical Hx: Essential hypertension; hyperlipidemia; weight loss; primary tongue squamous cell
carcinoma (5 years previous); peripheral vascular disease.
Family Hx: Mother- died of pneumonia; Father- died of lung cancer.
Biochemical Data: Protein, total = 5.8g/dL LOW (6-8g/dL); Albumin = 1.8 g/dL LOW (3.5-5g/dL);
Prealbumin = 9 mg/dL LOW (16-35 mg/dL); C-reactive protein = 2.4 mg/dL HIGH (<1.0 mg/dL);
Sodium = 150 mEq/L HIGH (136-145 mEq/L); Chloride = 118 mEq/L HIGH (95-105 mEq/L); BUN =
36 mg/dL HIGH (8-18 mg/dL) ; Creatinine serum = 1.27 mg/dL HIGH (.6-1.2 mg/dL)
Estimated Intake: 880 kcals/day Macronutrient intake:
FAT- 33.1 g; CHO- 99.7 g; PRO- 44.2 g
Comparative Standards:
Estimated Energy Needs:~ TEE = 2,000 kcals
Weight gain~ EEN= 2,500 kcals/day (+ 500 → for 1 lb weight gain/wk)
Estimated Protein Needs: 30% ~ 188 g/day (10-35% ADMR)
Estimated Carbohydrate Needs: 50% ~313 g/day (45-65% ADMR)
Estimated Fat Needs: 25 % ~ 69g/day (20-35% ADMR)
Estimated Fluid Needs: 2-2.5 L/ day (based on 1 mL/kcal consumed)
D:
1. Malnutrition RT chronic disease or condition AEB primary tongue squamous cell carcinoma and
partial glossectomy 5 years ago, pt’s physical examination showing loss of muscle mass in quadriceps
and gastrocnemius, and loss of 60 lbs and weight change of 29.1% in the last 1-2 years.
2. Unintended weight loss RT inadequate oral intake AEB loss of 60 lbs and weight change of
29.1% in the last 2 years, pt’s self report on lack of appetite and insufficient intake of 880 kcal/day as per
24 hr recall compared to estimated needs of 2,000 kcals/day.
I:
Nutrition Rx: Pt will be able to restore nutritional balance by increasing caloric intake along with a high
protein diet: increasing weight and lean muscle mass.
Intervention #1: Nutrition Education
Goal: Pt will be able to understand the roles of external nutrition, how it works, what equipment is used
the location of the where the device will be placed; will also be able to discuss the s/s of intolerance.
Intervention #2: Nutrient Delivery: Enteral Nutrition using PROMOTE with FIBER
Goal: Pt will go in for placement of enteral nutrition, and will assess pt’s status and tolerance. Gastric
residuals will be measured every 4 hours. If Pt meets 2/3rds to 3/4th of their nutrient needs through the
oral route, EN may be discontinued.
M/E: Monitor intake of kcals by 24 hr recall and equation for Enteral nutrition to see if pt is meeting
appropriate needs. Weight check-in at next appointment in 2 weeks.
Signatures: Angela Cho, Maya Cox, Kelsey Hughes, Alyssa Monis,Catherine Chann

Updated 3/2016
 References Cited in this Worksheet

Carrero, J.J., & Grimble, R.F. (2006). Does nutrition have a role in peripheral vascular disease? British Journal

of Nutrition, 95(2), 217-29

Fischbach, F., & Dunning III, M.B. (2015). A manual of laboratory and diagnostic tests (9th ed.).

Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.

Gellrich, N., Handschel, J., Holtmann, H., & Krüskemper, G. (2015). Oral cancer malnutrition impacts weight

and quality of life. Nutrients, 7(4), 2145-60. http://doi.org/10.3390/nu7042145

Gottschlich, M. M., DeLegge, M. H., Guenter, P., & American Society for Parenteral and Enteral Nutrition.

(2007). The A.S.P.E.N. nutrition support core curriculum: A case-based approach : the adult patient.

Silver Spring, MD: American Society for Parenteral and Enteral Nutrition.

McClave, S. A., Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., … Cresci, G. (2009).

Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient::

Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition

(A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 33(3), 277–316.

https://doi.org/10.1177/0148607109335234

Pronsky, Z.M., Elbe, D., & Ayoob, K. (2015). Food -Medication interactions (18th ed.). Birchrunville, PA:

Food Medication Interactions.

THANC Foundation. (2017). Glossectomy. Retreived from:

http://www.headandneckcancerguide.org/adults/cancer-diagnosis-treatments/surgery-and-

rehabilitation/cancer-removal-surgeries/glossectomy/

Nelms, M.N. (2015). Diseases of the Endocrine System. In Nelms, M.N., Sucher, K., and Lacey,
K. Nutrition Therapy and Pathophysiology (3rd ed). (pp.82 & 91). Boston, MA: Cengage
Learning

Appendices
Updated 3/2016
Appendix A. Intake analysis.
Please include the following components in order.

a. Spreadsheet
b. Bar graphs
c. Pie chart for macronutrient distribution

Appendix B. Nutrition Intervention: nutrition support prescription.

Please list all support therapies (oral, EN, or PN) including meal items, EN formulas, or PN
formulations with schedule.

Appendix C. Analysis of the nutrition support prescription.

Please include the following components in order.

d. Spreadsheet
e. Bar graphs
f. Pie chart for macronutrient distribution

Updated 3/2016
Appendix A. Intake Analysis

a. Spreadsheets

Updated 3/2016
Updated 3/2016
Updated 3/2016
Updated 3/2016
Updated 3/2016
Updated 3/2016
Updated 3/2016
b. Bar Graphs

Updated 3/2016
c. Pie chart for macronutrient distribution

Updated 3/2016
Appendix B. Nutrition Intervention: nutrition support prescription.

EN Prescription Continuous Feed:

NG TF of PROMOTE® WITH FIBER @ 104 ml/h x 24 hrs, full strength to provide 2500 Kcals, 156 g
protein (75:1 NCP:N), 2075 mL free water, with 106 mL water flushes q6h for a total of 2500 mL water

Updated 3/2016
Appendix C. Analysis of the nutrition support prescription.

a. Spreadsheet

Updated 3/2016
Updated 3/2016
b. Bar Graphs

Updated 3/2016
c. Pie chart for macronutrient distribution

Updated 3/2016