Running head: CLINICAL CASE STUDY 1

Clinical Case Study:

Chronic Obstructive Pulmonary Disease

Sara Foster

The University of Southern Mississippi

CLINICAL CASE STUDY 2

Abstract
Patient B.M. was admitted into an acute care facility on September 24, 2018, with

chronic obstructive pulmonary disease (COPD) exacerbation. His chief complaint was shortness

of breath and discomfort from a draining leg wound secondary to cellulitis. B.M. had a history of

COPD, bronchitis, hypertension, and congestive heart failure (CHF). He smoked a pack and a

half of cigarettes per day for 25 years and quit in 1978. The patient was treated with

supplemental oxygen to improve saturation, Duoneb to open airways, Solumedrol for wheezing,

Lasix for fluid overload, and Zosyn alongside Doxycycline for the respiratory infection.

Nutrition assessment was warranted due to his recent admission on August 31, 2018, for the

same symptoms and diagnosis. The initial assessment was completed on September 25th

prompting a nutrition intervention. B.M.'s appetite was good in the begining but quickly began to

decline, as did his p.o. intake. Diet modifications were made to meet patient needs, and nutrition

supplements were provided. Despite medical interventions, the patient developed atrial

fibrillation which progressed his decline further. Due to the patient’s age and worsening

condition he was placed with palliative care and all treatment was discontinued. Morphine was

administered as a means of comfort, allowing the patient to relax finally. B.M. passed away on

October 7, 2018, at the age of 83.

CLINICAL CASE STUDY 3

Clinical Case Study: Chronic Obstructive Pulmonary Disease

The contents of this report were constructed to present a detailed clinical case study. The

study follows a patient with an unfortunate disease throughout his treatment at an acute care

facility. Information provided in this case study includes disease progression, treatment, as well

as the patient’s outcome.

Primary Disease

Chronic Obstructive Pulmonary Disease (COPD) is a term used to describe a group of

prevalent-incurable lung diseases such as bronchitis and emphysema (Nahikian-Nelms, Sucher,

& Lacey, 2016). A diagnosis of COPD is characterized by severe breathing problems. Clinical

signs and symptoms for this disease include prolonged shortness of breath, fatigue, trouble

breathing, coughing, wheezing, and tightening of the chest (Nahikian-Nelms et al., 2016).

Etiology

Research shows that inflammation caused by smoking is the leading cause of COPD.

Inflammation continues to damage the lungs long after smoking cessation (Nahikian-Nelms et

al., 2016). Other risk factors for developing COPD include exposure to second-hand smoke,

multiple infections during lung development, as well as industrial and air pollutants (Nahikian-

Nelms et al., 2016). Once lungs are damaged from the inflammation, their ability to function

declines (MacNee & Drummond, 2016).

Pathophysiology

Bronchitis and emphysema are the primary disease classifications of COPD, both of

which result from smoking and develop gradually over time (Nahikian-Nelms et al., 2016).

However, each present with different pathological processes. Bronchitis arises from decreased

cilia function and bronchial edema due to inflammation (Nahikian-Nelms et al., 2016). Edema is
CLINICAL CASE STUDY 4

caused by excess mucus production when it goes uncorrected due to cilia damage (MacNee &

Drummond, 2016). The excess mucus also provides growth for bacteria, leading to infection

(Nahikian-Nelms et al., 2016). This condition results in difficulties inhaling . Conversely, people

with emphysema have trouble exhaling, rather than inhaling. Emphysema is characterized by

damaged lung tissue from inflammation, specifically the surfactant-producing alveoli. The

damaged cells result in a loss of surfactant causing the bronchioles to collapse. Air is then

trapped making exhalation difficult.

Prognosis

The World Health Organization reports over 200 million people currently living with

COPD and expects death rates to increase by 30% within the next decade (What, 2018).

According to Cavaillès et al. (2013), COPD is among the top three causes of death in the united

states. However, successfully managing COPD with proven-reliable treatments result in a

favorable prognosis, allowing for a longer life expectancy (Cavaillès et al., 2013).

The prognosis for COPD sufferers worsens as comorbidities such as cardiovascular

disease, hypertension, diabetes, malnutrition, and obesity develop. Mortality and quality of life

are significantly impacted by these additional disease states (MacNee & Drummond, 2016).

COPD directly causes malnutrition and artery disease, but it is not yet known why other

comorbidities are frequently experienced with COPD (MacNee & Drummond, 2016). However,

it is known that smoking causes both heart disease and COPD (Nahikian-Nelms et al., 2016).

Comorbid conditions influence patient prognoses related to effective treatment, disease

progression, and symptom severity, creating complications in COPD management (Cavaillès et

al., 2013). Patients often die from heart disease or pneumonia, rather than COPD itself (MacNee

& Drummond, 2016).

CLINICAL CASE STUDY 5

Treatment

Medical treatment for COPD is individually based on the severity of symptoms and

disease. Treatment first starts with smoking cessation. Additional treatments include

medications, pulmonary therapy, surgery, and nutrition therapy (Nahikian-Nelms et al., 2016).

Typical medications used to treat COPD symptoms: bronchodilators to relax airways,

anticholinergics to minimize mucus, steroids to relieve swelling, and mucolytic agents for mucus

secretions (Nahikian-Nelms et al., 2016). Surgical options include lung transplant and lung

volume reduction which removes compromised tissue (Nahikian-Nelms et al., 2016).

Additionally, antibiotics are used to treat infections, the leading cause of disease exacerbation

(Zeng & Jiang, 2012).

Secondary Disease

Chronic obstructive pulmonary disease and chronic heart failure (CHF) are two of the

world’s leading epidemics resulting in significant mortality rates (Zeng & Jiang, 2012). Similar

to COPD, risk factors for CHF include smoking and age. People with hypertension and diabetes

are at high risk for developing CHF (Nahikian-Nelms et al., 2016). Heart failure begins with

damage to the heart, causing the heart to work harder to regulate blood pressure. If the injury

goes untreated, the heart will eventually fail (Nahikian-Nelms et al., 2016). Because the heart is

forced to work harder, blood flow decreases, along with oxygen circulation leading to fatigue,

weakness, shortness of breath, early satiety, and edema (Nahikian-Nelms et al., 2016). According

to Zeng and Jiang (2012), COPD patients should be carefully assessed and monitored for CHF,

as it can often go undiagnosed due to symptom similarities. Patients suffering from COPD

alongside CHF typically die from cardiovascular issues rather than respiratory failure (Zeng &

Jiang, 2012).
CLINICAL CASE STUDY 6

Treatment for CHF focusses primarily on treating what initially caused damage to the

heart as well as the associated symptoms. Medications typically used for treatment include

diuretics for fluid retention, vasodilators to reduce blood pressure, inotropic agents for increased

muscle contraction, beta blockers to relax the heart, and digitalis to increase heart strength for

contractions (Nahikian-Nelms et al., 2016).

Evidence-Based Nutrition Recommendations

According to the Evidence-based Nutrition Practice Guidelines on COPD, published by

the Academy of Nutrition and Dietetics, primary nutrition therapy includes weight loss

prevention or treatment, with additional focus on comorbidity treatment (Chronic, 2008). Due to

exceeding benefits, nutrition therapy recommendations for COPD patients in an acute care

setting include the use of oral nutrition supplements in small amounts throughout the day (What

effect, 2014). The Evidence Analysis Library (EAL) reports an improvement in overall calories

consumed among patients with COPD when supplements are initiated (What effect, 2014). In a

systematic review by Collins, Elia, & Stratton (2013), it was found that the use of nutrition

supplementation significantly improved calorie and protein intake, preventing and treating

weight loss in patients with COPD.

Oral supplement selection should be based on patient tolerance and acceptance, as there

is insufficient research to provide recommendations based on supplement ingredients (Escott-

Stump, 2015). The EAL recommends using nutrition supplements in small amounts throughout

the day to prevent fatigue and labored breathing during consumption (Chronic, 2008).

Escott-Stump (2015) recommends a diet with increased protein (1.2-1.7 g/kg) and calories (30-

35 kcal/kg) due to hypermetabolism, to prevent muscle wasting, and weight loss. Protein and
CLINICAL CASE STUDY 7

calorie recommendations for CHF are the same as those for COPD, as wasting is common in

chronic diseases such as these (Saitoh, Rodrigues dos Santos, & von Haehling, 2016).

For patients suffering from both COPD and CHF consideration and clinical judgment

should be enforced concerning fluid needs. Dehydration is a risk for those with COPD, which

leads to mucus thickening, worsens the ability to breath (Escott-Stump, 2015). Fluid

recommendations for COPD are measured at 1mL/kcal and should be consumed between meals

to prevent early satiety (Escott-Stump, 2015). Patients with CHF typically have a strict fluid

restriction and should be limited to 2000 mL/day according to Nahikian-Nelms et al. (2016).

There is little evidence to support a specific macronutrient ratio for COPD or CHF (Nahikian-

Nelms et al., 2016). Therefore, carbohydrate and fat intake should follow the Dietary Reference

Intake (DRI). The DRI supports an intake of 45% to 50% carbohydrates and 20% to 30% total

fat per day with 2% of fat from Omega 3’s to aid in the reduction of inflammation (Escott-

Stump, 2015). Omega 3’s are equally beneficial and highly recommended for those with CHF.

Numerous studies show improvements in lipids levels, blood glucose, plaque buildup, and

calcification (Houston, 2018). Similar to COPD recommendations, patients with CHF should

consume at least 2% of their fat from Omega 3’s (Escott-Stump, 2015).

Escott-Stump (2015) encourage patients with COPD to consume antioxidants by meeting

the Recommended Dietary Allowance (RDA) for vitamins A and C per day: vitamin A, 900 mg

for men; vitamin C, 90 mg for men; and vitamin E, 15 mg. Additional micronutrient

recommendations include vitamin D, 800 IU/day and calcium, 1200mg/day due to the elevated

risk of osteoporosis from COPD (Long, Stracy, & Oliver, 2018). Fiber increased slowly over

time to meet the recommended Adequate Intake (AI) of 30 g/day. Salt should be limited to lower

the risk of retaining additional fluid for both COPD and CHF (Escott-Stump, 2015). According
 CLINICAL CASE STUDY 8

to Nahikian-Nelms et al. (2016), sodium intake should not exceed the Tolerable Upper Intake

Level (UL) of 2300 mg/day for those with COPD. However, When it comes to CHF, sodium

should be restricted to at least 2000 mg/day.

Nutrition Care Process

The Nutrition Care Process is used as a step by step process to navigate through this case

study, investigating all information relevant to the patient’s disease state. This process includes

patient assessment, nutrition diagnosis, and nutrition intervention. Patient assessment explores

nutrition-related history, anthropometric measurements, biochemical data, and nutrition-focused

physical findings.

Patient Information

This case study followed B.M., an 83-year-old, Caucasian male who lived with his sister,

who cared for him. B.M. is a former smoker, 1.5 packs per day for 25 years, with a quit date of

1978. On September 24, 2018, the patient presented to the emergency department with shortness

of breath lasting longer than three days and drainage from a leg wound. He was then admitted

with COPD exacerbation. Prior admission was noted for August 31, 2018, with the same

symptoms and diagnosis. B.M.'s chart reveals a history of COPD, bronchitis, hypertension, and

CHF. The patient's family history includes unspecified cancer for both parents in addition to

heart disease for the father.

Assessment

Food/Nutrition-Related History (FH)

Nutrition Specific
Describe the actual information gathered from the patient/patient’s
Assessment Nutrition
family/medical record
Terms Assessment Term
Energy Total energy According to documented intake, the patient consumed 15% of meal
Intake estimated intake trays during the first two days. However, the patient reported eating 75%
of meal trays. Documented intake for days three and four was 56%.
Documented intake for days five through ten was 25% of meal trays.
 CLINICAL CASE STUDY 9

The patient’s family reported bringing outside food in for the patient to
eat, which was not documented. Day eleven documentation states 0%
intake.
Fluid/Bever Liquid meal The patient was ordered Boost Pudding BID and Mighty Shake QD.
age Intake replacement or Pudding was not used, but Mighty Shake was.
supplement Mighty Shake was increased to BID upon patients request on day ten.
Diet Order General, The patient was given a regular diet without modification during the
healthful diet entire length of stay.
order
Medications Prescription Medication Condition Start End
medication use Date Date
Cardizem Ca channel blocker, 09/25 10/05
(Diltiazem) antihypertensive
(9-25-18)
30mg
10-3-18)
90mg
Daliresp Anti-inflammatory to reduce 10/05
(Roflumilast) COPD exacerbations in patients
500mcg with severe COPD.
Can cause decreased appetite.
Ipratropium- Bronchodilator combination of 10/05
Albuterol albuterol and ipratropium via
nebulizer is used to treat difficulty
breathing, chest tightness, and
coughing in people with COPD by
opening and relaxing bronchial
tubes.
May cause peculiar/metallic/bitter
taste.
Lovenox Anticoagulant to prevent blood 10/05
(Enoxaparin) clots.
40mg
Lasix 40mg Loop diuretic used to treat edema 09/24 10/05
associated with the patient’s
CHF/COPD fluid retention and
edema.
Decreases K, Mg, Cl, Increases
Glucose, BUN, and Creatinine
Doxycycline Antibiotic to treat a respiratory 09/24 10/05
100 mg infection.
Decreased Vit C absorption.
May cause anorexia.
Omnicef Antibiotic to treat a respiratory 09/24 10/05
300mg infection.
 CLINICAL CASE STUDY 10

Protonix A proton-pump inhibitor that aids 09/24 10/05

40mg in the treatment of
gastroesophageal reflux disease.
May decrease absorption of Fe.
Pulmicort Corticoid steroid used to treat 09/24 10/05
0.5 mg symptoms associated with asthma,
nebulizer wheezing and shortness of breath.
solution May decrease K, Ca, and Vit D.
Morphine Narcotic used for the pain to 10/5 10/7
Senokot- Laxative, a stool softener. 09/24 10/05
S/Peri- May increase blood glucose levels,
Colace 50mg decrease K, and Ca.
May cause electrolyte imbalance.
Solu-Medrol Corticoid steroid used to treat Given
60mg inflammation in bronchial tubes. in ED
injection May cause poor wound healing, on
altered fluid/electrolyte balance. 09/24
Singulair Anti-inflammatory used to treat 09/24 10/05
10mg asthma symptom, wheezing and
shortness of breath.
Spiriva Bronchodilator used to treat 09/24 10/05
18mcg symptoms of COPD.
Symbicort Bronchodilator used to treat 09/24 10/05
symptoms of COPD.
May caused decreased K levels.
Food and Nutrition Family members were always present with the patient and understood
nutrition knowledge of his food preferences and nutritional needs. They were aware of his gum
knowledge/s supportive sensitivity to cold and pain experienced with chewing certain foods.
kill individuals
Mealtime A limited number Due to oral problems and lack of appetite, the patient was not able to
behavior of accepted foods tolerate many foods. His teeth were in poor condition, causing pain when
eating certain meats. His sensitivity to cold foods prevented him from
drinking the Mighty Shakes regularly.
Anthropometric Measurements (AD)
Specific Describe the information gathered Provide calculations and
Nutrition
Nutrition from the patient/patient’s interpretation of
Assessment
Assessment family/medical record anthropometrics
Terms
Term
Body Stated height 5’6” 5’ x 12 in + (6 in) = 66 in
composition Measured 191 lbs on 9/24 191 lb/ 2.2 = 86.8 kg
/growth/wei weight
ght history Weight gain 197 lbs on 10/3 197 lb/ 2.2 = 89.5 kg
Body mass BMI of 30 Obese class I
index
Biochemical Data, Medical Tests, and Procedures (BD)
 CLINICAL CASE STUDY 11

Specific Describe the information Describe the cause of the abnormal lab
Nutrition
Nutrition gathered from the values, specifically as it relates to the
Assessment
Assessment patient/patient’s patient’s medical condition(s)
Terms
Term family/medical record
Electrolyte BUN (9-25-18) 21 mg/dL - H Elevated BUN indicates decreased renal
and renal (10-4-18) 35 mg/dL - H function (comorbidity of CHF) from
profile insufficient blood flow due to reduced
cardiac output.
Elevation can also be indicative to
dehydration.
Creatinine (9-25-18) 1.23 mg/dL - H Elevated creatinine levels indicate
(10-4-18) 0.96 mg/dL decreased renal function (comorbidity of
CHF) from insufficient blood flow due to
reduced cardia output.
Chloride (9-25-18) 97 mEq/L - L Kidneys are unable to excrete excess
(10-4-18) 102 mEq/L bicarbonate in the urine (Metabolic
alkalosis), related to low cardiac output
(heart failure) combined with a reduced
glomerular filtration rate.
Phosphorus (9-25-18) 4.9 mg/dL - H Kidneys are unable to filter out and
(10-4-18) 3.8 mg/dL expose of phosphorus, so it accumulates
in the blood.
Glomerular (9-25-18) 56 mL/min - L A low GFR indicates decreased renal
Filtration Rate (9-27-18) 58 mL/min - L function (comorbidity of CHF) from
insufficient blood flow due to reduced
cardiac output.
Osmolality (10-3-18) 298 mOsm/L - H Elevated levels indicate dehydration.
(10-4-18) 294 mOsm/L - H
Glucose/end Glucose, casual (10-3-18) 146 mg/dL Elevated blood glucose most likely due
ocrine (10-4-18) 151 mg/dL to steroid use to decrease inflammation.
profile
Protein Albumin (9-25-18) 2.9 g/dL - L Decreased kidney function
profile (10-3-18) 3.5 g/dL
(10-4-18) 3.2 g/dL - L
Nutrition-Focus Physical Findings (PD)
Specific Describe the information
Nutrition Provide a narrative that explains your
Nutrition gathered from the
Assessment findings from a NFPE that you
Assessment patient/patient’s
Terms conducted on your patient/client
Term family/medical record
Nutrition- Digestive Decreased appetite During exam patient reports decreased
focused system appetite due to fatigue.
physical Edema (9-25-18) +1 pitting edema The patient presented with severe edema
findings RUE & LUE, +4 pitting in his lower extremities which continued
edema RLE, LLE throughout his stay, despite the use of
(9-27-18) +4 pitting edema Lasix.
RLE & LLE on
 CLINICAL CASE STUDY 12

Muscles Muscle atrophy Physical exam revealed bilateral muscle

Deltoid muscle atrophy wasting in triceps, biceps, and deltoid
region, with pronounced clavicle and
scapula.
Skin Impaired wound healing Patient has a non-healing wound on the
right lower leg, infected upon admission.
Teeth Rampant dental caries Upon examination, multiple dark spots
were observed.
Patient-reported sensitive teeth.
Vital signs Blood pressure 118/62 Related to declining cardiac output.
(10/4)
Client History (CH)
Specific Describe the information gathered from the patient/patient’s
Nutrition
Nutrition family/medical record
Assessment
Assessment
Terms
Term
Personal Age 83 y.o.
data Gender Male
Race Caucasian
Language English
Tobacco use A former smoker, 1.5 packs/day 25 years, quit 02-15-78
Patient/clien Patient chief Loss of appetite, pain when chewing, oral sensitivity to cold, altered food
t OR family nutrition taste
nutrition- complaint
oriented Cardiovascular Congestive Heart Failure
medical Integumentary Wound/ infection RLE, nonhealing; Edema +4
history Gastrointestinal Constipation
Respiratory Chronic obstructive pulmonary disease
Social Living/housing Patient lives with his sister who cares for him, shopping and all the
history situation cooking.
Comparative Standards (CS)
Nutrition Indicate the Comparative Provide a referenced rationale for the
Calculate, as
Assessment Standard Used Comparative Standard Used
needed
Terms
Estimated Total energy 2170- 2604 kcal 25-30 kcal/kg body wt (COPD) according
energy needs estimated to Nelms et al. (2016).
needs in 24
hours 24 kcal/kg body wt + AF 1.2 (CHF)
2500 kcal according to Nelms et al.(2016).
Estimated Total protein 104-148g Pro 1.2 - 1.7 g/kg body wt (COPD) according
protein needs estimated to Nelms et al.(2016).
needs in 24
hours 95-121g Pro 1.1 – 1.4 g/kg body wt (CHF),
Individualized protein intake in Heart
Failure to prevent catabolism according to
 CLINICAL CASE STUDY 13

Academy of Nutrition and Dietetics

Evidence Analysis Library, (2017). Fair
Imperative,
Estimated fluid Fluid 2000 mL/ day For patients with CHF according to Nelms
needs et al.(2016).

Estimated Vitamin C 500 mg x 10 days Plays a role in all phases of wound healing
vitamin needs according to Moores, (2013).
Estimated Zinc Sulfate 220 mg x 10 days Wound healing
mineral needs

Malnutrition Identification. During the initial assessment, the patient reported having a

good appetite with sufficient energy intake per noted diet history. Two days later the patient was

reassessment with signs of malnutrition, which prompted a nutrition-focused physical exam.

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines were used to

classify malnutrition because the Academy of Nutrition and Dietetics (AND) deemed it a valid

tool (Hand, 2016). According to the A.S.P.E.N. guidelines, the patient presented with moderate

malnutrition in context of chronic illness, related to increased protein and energy needs with

COPD and CHF as evidenced by consuming less than 75% of estimated energy requirements for

eight days per diet history (see Table 4); fluid accumulation secondary to +4 edema in both lower

extremities which can mask weight loss; findings of muscle wasting: deltoid, biceps, triceps

(2013).

Medical Nutrition Therapy. Upon admission, the patient was given a regular diet with

no restrictions or modifications. The patient stayed on a regular diet for the duration of his stay.

During initial and subsequent assessments, the patient was offered dietary modifications to

accommodate issues with chewing that were reported. Modifications were refused due to patient

preference. Instead, menu selection was provided during patient assessment. This allowed the

patient to choose foods he preferred and could easily eat without limiting his options.
CLINICAL CASE STUDY 14

The patient’s energy needs were elevated due to the combination of chronic illnesses,

COPD and CHF (Collins, Elia, & Stratton, 2013). The patient’s energy needs were calculated to

include 2170- 2604 calories based on 25-30 kcal/kg of body weight for COPD; 104-148 grams of

protein based on 1.2 - 1.7 g/kg of body weight for COPD; 2170-2604 ml of fluid (Nelms et al.,

2016). Estimated energy intake was calculated during two reassessments to determine if the

patient was able to meet the recommended goals of at least 2,000 calories. Reassessments

showed that the patient was consuming an estimated 1,400 calories on September 25, 2018, and

an estimated 500 calories. Calorie intake declined despite modifying the patient’s menu selection

for the week, providing him with softer foods, easier to chew meats, and preferred vegetables

and deserts. Starting September 25, 2018, the patient was provided with a vanilla Mighty Shake

once a day on his lunch tray was providing 300 calories and 9 grams of protein and vanilla Boost

Pudding available upon request twice daily providing a total of 480 calories and 20 grams of

protein. On the October 4th visit the patient had denied eating any of the Boost Puddings but

states he likes the Might Shakes. The patient agreed to increase the Mighty Shakes to twice a day

and requested to change from vanilla to chocolate.

Anthropometric and Biochemical Trends. Initial labs were taken upon admission.

Albumin levels were below the normal range which indicated decreased kidney function for the

patient (see Table 1). Chart notes from admitting physician state the low levels are not related to

malnutrition. Elevated BUN indicates decreased renal function, comorbidity of CHF, secondary

to insufficient blood flow due to reduced cardiac output (see Table 2). Above average levels can

also be indicative to dehydration, which follows the patient's decline in p.o. intake. Similar to

BUN, abnormal serum creatinine levels indicate decreased renal function, comorbidity of CHF,

secondary to insufficient blood flow due to reduced cardiac output (see Table 3).
CLINICAL CASE STUDY 15

The patient experienced a weight gain of six pounds due to fluid overload between

September 24, 2018, and October 4, 2018. A sudden decrease in weight was observed shortly

before a new diagnosis of atrial fibrillation in sinus rhythm was given, on October 5, 2018 (see

Table 5).

Nutrition Diagnosis

Inadequate oral intake related to physiological causes increasing nutrient needs and

decreased ability to consume sufficient energy secondary to increased nutrient needs due to

prolonged catabolic illnesses, COPD and CHF as evident by reported change in appetite, change

in taste; estimates of insufficient intake of energy (~500 calories) diet when compared to

requirements (~2,500 calories).

Intervention
Describe the actual Discuss the Describe if this was
intervention that rationale/justification the most
Specific was completed for recommendations, appropriate
Nutrition
Nutrition including references intervention based
Intervention
Intervention on the literature. If
Terminology
Term(s) not, discuss what
should have been
done differently
Meals and Increased The patient was The patient’s energy The intervention
Snacks energy diet offered gravies and needs were elevated was appropriate for
sauces on meal due to the combination encouraging
trays, reminded of of chronic illnesses, adequate intake,
snacks available at COPD and CHF, giving the patient
nurses’ station, and putting him at higher multiple options,
provided nutrition risk for malnutrition and consulting the
supplements. (Collins, Elia, & nurse.
Family members Stratton, 2013). However, there
were encouraged to ASPEN guidelines for should have been a
continue bringing in nutrition support follow-up regarding
outside meals that suggest enteral the decision for the
the patient nutrition using a appetite stimulant.
preferred. polymeric formula On October 4th the
On the October 3rd when the intern noted
assessment a gastrointestinal tract is recommendations to
consult with the functioning, and consider nutrition
CLINICAL CASE STUDY 16

patient’s nurse was malnutrition is present support due to

warranted to discuss (Hand, 2016). increased nutrient
consistent Altered taste is needs, inadequate
inadequate intake common in COPD and oral intake,
and continued lack should be corrected inadequate
of appetite. The with acceptable protein/energy
intern flavoring (Escott- intake, malnutrition.
recommended an Stump, 2015). The intern should
appetite stimulant have consulted the
for the patient. The nurse or physician
nurse agreed to regarding this
consult the recommendation.
physician.
Upon chart review,
no stimulants were
given.
Texture The intern educated According to Nelms et The patient should
modified diet: the patient on eating al. (2016), patients have been educated
Easy to chew small frequent consume more on eating slowly
diet meals, avoiding calories when they are and taking small
liquids at mealtime, educated on ways to bites.
and offered texture reduce mealtime
modifications for fatigue.
the diet order Shortness of breath is
multiple times. The common in COPD,
patient requested making it difficult for
not to modify the patients to eat, while
diet order, so also increasing their
instead, the intern risk of aspiration.
worked with the Escott-Stump (2015)
patient and family recommends
members to educating patients on
customize meal eating slowly, taking
selection for the small bites, and
following few days. resting before and
The intern also after meals to decrease
spoke with a fatigue and early
nutrition technician satiety.
to request the
patient be contacted
daily for meal
selection.
Medical Commercial On September 25th Evidence-based Based on the
Food (prepackaged) the patient was Nutrition Practice literature this
Supplement beverage encouraged to try Guideline on COPD intervention was
Therapy oral nutrition published 2006 reports
CLINICAL CASE STUDY 17

supplements. Upon sufficient finding of appropriate for the

given options, he adequate calorie patient.
was provided with consumption and
Boost Pudding BID lowered risk of weight
(available upon loss when patients are
request) and Mighty provided nutrition
Shakes on lunch supplements while
trays. inpatient. There is
On October 3rd, insufficient evidence
upon patient for specific
request, he was macronutrients within
ordered and supplements to be
provided Mighty beneficial for COPD.
Shakes on lunch Therefore, supplement
and dinner trays. selection should be
The patient was based on patient
encouraged to preference (Chronic,
consume 2008).
supplements during
each follow-up
visit.
Vitamin and Vitamin On October 3rd the Escott-Stump (2015) The intern should
Mineral supplement intern encourage patients have recommended
Supplement therapy: recommended with COPD to a multivitamin to
Therapy Vitamin C vitamin c 500 mg x consume antioxidants supplement the
Mineral 10 days, zinc sulfate by meeting the RDA recommended
supplement 220mg x 10 days. for vitamin C (90 mg vitamins found to
therapy: Zinc The for men). be beneficial for
recommendation According to Moores COPD and CHF.
was provided in (2013), vitamin C The intern should
chart notes as well plays a role in all have spoken to the
as discussed with phases of wound nurse or physician
the patient’s nurse. healing. earlier in the
According to the Escott-Stump (2015) patients stay, after
chart review, encourage patients the initial
neither supplements with COPD to assessment on
were ordered. consume antioxidants September 25th.
by meeting the
Recommended
Dietary Allowance
(RDA) for vitamins A
and C per day: vitamin
A, 900 mg for men;
vitamin C, 90 mg for
men; and vitamin E,
15 mg. Additional
CLINICAL CASE STUDY 18

micronutrient
recommendations
include vitamin D,
800 IU/day and
calcium, 1200mg/day
due to the elevated
risk of osteoporosis
from COPD (Long,
Stracy, & Oliver,
2018).

Monitoring and Evaluation

The initial assessment on September 25th showed the patient to have a good appetite and

consuming 75% of his meals. During this visit the patient reported difficulty chewing certain

meats. The patient was offered diet modifications such as dental soft and minced, but the patient

declined and instead agreed to have a nutrition supplement on every lunch tray. Meal selection

for the patient was acquired for the following three days to allow the patient more options and

illuminate foods deemed challenging to chew. The goal was to improve nutritional status by

consuming 75% of his meals and supplements.

Reassessment on the 27th found that the patient consumed 50% of meals and supplements

and therefore was unable to meet the goal. The patient reported a lack of appetite secondary to

worsening condition.

A follow-up visit on October 3rd found the patient to be feeling better, with a slight

appetite but still unable to reach the intake goal. His reported intake was 30%, but he was able to

drink one nutrition supplement. The patient reported taste alterations and early satiety. A

nutrition-focused physical exam was warranted due to inadequate intake over the last six days

and increased fluid retention. The exam confirmed him to be malnourished. Meal selection was

completed for the following few days based on patient preference and acceptability. A new goal

was set to allow adequate time for meals and to consume two nutrition supplements per day.
CLINICAL CASE STUDY 19

Weight gain was noted at a six-pound increase in six days, likely due to fluid retention (see Table

5).

Reassessment on the 4th found the patient rapidly declining and refusing to eat for the last

24 hours. The patient was not able to talk, but the family members were able to discuss his

nutritional status. Family members reported the patient avoiding food due to altered taste, dental

pain from chewing certain foods, and sensitivity to cold foods. Labs were noted for increasing

osmolality levels indicative of dehydration. Chart note recommendations to consider alternate

means of delivering hydration and nutrition via tube feeds were made.

Conclusion

During the first two days after admission the patient initially improved but eventually

developed atrial fibrillation with a rapid ventricular response. Energy intake slowly declined

from September 25th (75%) to October 4th (25%). There is no documented p.o. intake after

October 4th as the intern was no longer at the facility. Nutrition-focused physical findings

provided evidence of moderate malnutrition in the context of chronic illness. Nutrition

supplementation was provided to the patient in two forms. The patient was encouraged to

achieve at least 66% of meals and supplements. The intern discussed recommendations for

achieving these goals with the patient and all family members present. A sudden weight

reduction was noticed around the time he was diagnosed with atrial fibrillation. During the last

few days his shortness of breath worsened with orthopnea and his edema severely progressed.

His heart rate continued to elevate despite treatment, resulting in left ventricular diastolic failure.

On day 11 the patient and family members requested a do-not-resuscitate order due to the

patient's age and worsening condition. The physician discontinued treatment, and the patient was

placed on palliative care. The patient passed away after 13 days of inpatient care. In cases such
CLINICAL CASE STUDY 20

as this, it is beneficial to have an interdisciplinary approach. The dietitian should discuss patient

goals and strategies with nurses, physicians, speech pathologist, and other relative disciplinaries

to coordinate the best possible care for the patient.

CLINICAL CASE STUDY 21

References

Cavaillès, A., Brinchault-Rabin, G., Dixmier, A., Goupil, F., Gut-Gobert, C., Marchand-Adam,

S., … Diot, P. (2013). Comorbidities of COPD. European Respiratory Review, 22(130),

454 LP-475. Retrieved from http://err.ersjournals.com/content/22/130/454

Chronic Obstructive Pulmonary Disease Evidence-Based Nutrition Practice Guidelines (2008).

Retrieved October 24, 2018, from the Academy of Nutrition and Dietetics Evidence

Analysis Library: https://www.andeal.org/topic.cfm?menu=5301&cat=3710

Collins, P. F., Elia, M., & Stratton, R. J. (2013). Nutritional support and functional capacity in

chronic obstructive pulmonary disease: A systematic review and meta-analysis.

Respirology, 18(4), 616–629. https://doi.org/10.1111/resp.12070

Escott-Stump, S. (2015). Nutrition and diagnosis-related care(8th ed.). Philadelphia, PA:

Wolters Kluwer.

Hand, R. K., Murphy, W. J., Field, L. B., Lee, J. A., Parrott, J. S., Ferguson, M., … Steiber, A. L.

(2016). Validation of the Academy/A.S.P.E.N. Malnutrition Clinical Characteristics.

Journal of the Academy of Nutrition and Dietetics, 116(5), 856–864.

https://doi.org/10.1016/j.jand.2016.01.018

Houston, M. (2018). The role of noninvasive cardiovascular testing applied clinical nutrition and

nutritional supplements in the prevention and treatment of coronary heart disease.

Therapeutic Advances in Cardiovascular Disease, 12(3), 85–108.

https://doi.org/10.1177/1753944717743920

Individualize Protein Intake in Heart Failure. (2017). Retrieved October 25, 2018, from the

Academy of Nutrition and Dietetics Evidence Analysis Library:

https://www.andeal.org/topic.cfm?menu=5289&cat=5570
CLINICAL CASE STUDY 22

Long, R., Stracy, C., & Oliver, M.-C. (2018). Nutritional care in Chronic Obstructive Pulmonary

Disease. British Journal of Community Nursing, 23(Sup7), S18–S26.

https://doi.org/10.12968/bjcn.2018.23.Sup7.S18

MacNee, W., & Drummond, M. B. (2016). Fast facts: chronic obstructive pulmonary disease

(Vol. 3rd edition). Oxford: Health Press.

Moores, J. (2013). Vitamin C: A wound healing perspective. British Journal of Community

Nursing, 8-11. https://doi.org/10.12968/bjcn.2013.18.Sup12.S6

Nahikian-Nelms, M., Sucher, K. P., & Lacey, K. (2016). Nutrition therapy and

pathophysiology (3rd ed.). Boston, MA: Cengage Learning.

Saitoh, M., Rodrigues dos Santos, M., & von Haehling, S. (2016). Muscle wasting in heart

failure: The role of nutrition. Wiener Klinische Wochenschrift, 128, 455–465.

https://doi.org/10.1007/s00508-016-1100-z

Seung, H.S. (2014). Medical nutrition therapy based on nutrition intervention for a patient with

chronic obstructive pulmonary disease. Clinical nutrition research, 3(2), 150-6.

What effect does nutritional supplementation have on patients with COPD? (2014). Retrieved

October 24, 2018, from the Academy of Nutrition and Dietetics Evidence Analysis

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COPD.aspx

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CLINICAL CASE STUDY 23

Tables
Table 1

Albumin
3.5-5.5 g/dL
Albumin

4
3.8
3.6
3.5
3.4 3.4
3.2 3.2
3
2.9 2.9
2.8
2.6
2.4
2.2
2

Note. Initial labs were taken upon admission. Albumin levels were below the normal range
which indicated decreased kidney function for the patient. Chart notes from admitting physician
state the low levels are not related to malnutrition.
CLINICAL CASE STUDY 24

Table 2

BUN
8-23 mg/dL

38
35 35
33
28
23
21 21 21
18
13
8

BUN

Note. Elevated BUN indicates decreased renal function, comorbidity of CHF, secondary to
insufficient blood flow due to reduced cardiac output. Above normal levels can also be indicative
to dehydration, which follows the patient's decline in p.o. intake.
CLINICAL CASE STUDY 25

Table 3

Creatinine
0.8-1.3 mg/dL
1.3
1.23 1.23 1.23
1.2
1.1
1 1
0.96
0.9
0.8
0.7
0.6

Creatinine

Note. Similar to BUN, declining creatinine indicates decreased renal function, comorbidity of

CHF, secondary to insufficient blood flow due to reduced cardiac output.

CLINICAL CASE STUDY 26

Table 4

PO Intake (%)
80
75
70

60
56
50 50

40

30
25
20

10

0 0
24-SEP 25-SEP 26-SEP 27-SEP 28-SEP 29-SEP 30-SEP 1-OCT 2-OCT 3-OCT 4-OCT

Note: Energy intake steadily declined as was observed from recorded diet intake as well as

patients self-reported intake.

CLINICAL CASE STUDY 27

Table 5

Weight
200

197
195

191
190

185
184

180

175
24-Sep 25-Sep 26-Sep 27-Sep 28-Sep 29-Sep 30-Sep 1-Oct 2-Oct 3-Oct 4-Oct 5-Oct

Weight in lb

Note: The patient experienced a weight gain of six pounds due to fluid overload. A sudden

decrease in weight was observed shortly before a new diagnosis of atrial fibrillation in sinus

rhythm was given.