Your name

Elizabeth OToole

Date September 17, 2013

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. (5 points). Height1 = 67 in x 2.54 cm/1 in = 170.18 cm %IBW1 = [63.42 / (100 + 5(7))] x 100 = 104% BMI1 = 63.42 kg / (1.70 m)2 = 21.94 kg/m2 The woman is only at 88% of her usual body weight and her percentage of weight loss over the past six months was > 10%, which is considered to be a severe weight loss and can lead to nutritional risks and health complications.2,3 However, she has a BMI that falls within the normal, healthy range (18.5 - 24.9) and her weight falls within 10% of her IBW.1 This and the fact that she has a mobility related injury that could be worsened in the case of a significant weight gain suggests that keeping weight gain minimal may present a safer course of action if nutrient status is brought up to sufficiency.2,3 2. Calculate her nutritional requirements (calories, protein, and fluid) and compare her current intake to her needs. (5 points) REE2 = 10(63.42 kg) + 6.25(170.18 cm) - 5 (76 y/o) - 161 = 1,156 kcal (unadjusted for injury status) REE(with injury factor adjustment)2 = 1,156(1.2) = ~1,390 kcal Nitrogen Balance1 = (127.58 g protein/6.25) - (0.019 g BUN + 4) = 24.159 Protein Requirement1 = 1.0 g/kg x 63.42 kg = 63.42 g protein x 4 = ~255 kcal Fluid Requirement2 = 30 mL/kg x 63.42 kg = 1,902.6 mL or 1.90 L Her average energy intake is estimated to be only a little more than 1,000 kcal/day, which is significantly lower than her estimated energy requirements of about 1,390 kcal/day. She is consuming approximately 4 ounces of protein per day, which converted to grams, equals about 127.58 g of protein or about 510 kcal.1,2,4 Considering that her protein requirement is only 63.42 Weight1 = 140 lb x 0.453 kg/1 lb = 63.42 kg %UBW1 = (140 / 160) x 100 = 88%

g or approximately 255 kcal, her intake appears to be sufficient.1 Lastly, her fluid intake is only about 828 mL/day, which is significantly lower than her recommended intake of 1,902.6 mL.2 3. Are any major food groups and nutrients obviously missing from her diet? Explain your answer. (5 points) Her lower than expected levels of albumin and prealbumin indicate that she is suffering from malnutrition, most likely due to inflammation caused by her injury combined with poor intake of nutrients.2 Despite her low levels of serum protein indicators, she appears to be eating a sufficient amount of protein and has a positive nitrogen balance.1,2 However, according to a MyPlate evaluation of her daily diet, she is underconsuming dairy foods, vegetables, fruit, and whole grains.3 Being that she is not consuming a significant amount of dairy products or other calcium-rich foods, her diet is severely deficient in calcium.4 Due to her minimal intake of vegetables, fruits, and whole grains, her diet also reflects a strong insufficiency in several vitamins and minerals, such as iron, magnesium, phosphorus, potassium, B vitamins, vitamin C, and vitamin D.4 4. Do you think she could be experiencing any drugnutrient interactions? If so, what dietary suggestions would you make? (5 points) The diuretic that she is taking, furosemide, may possibly lead to a loss in potassium due to increased urinary excretion.1,2 It can also lead to calcium loss in the body.3 In this case, I would recommend the patient to include in their diet more foods that are high in calcium and potassium.2 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? (5 points) Her serum albumin and prealbumin levels were lower than expected at a level of 3.2 g/dL compared to an expected 3.5-5.5 g/dL and 11 mg/dL compared to 16-40 mg/dL, respectively.1 Other than her poor nutrition status, the likely cause in this drop is due to the physiological stress and inflammatory response initiated by her injury.1,2 Her age may also be a contributing factor to having lower serum protein levels, as these naturally tend to decrease with aging.2 Factors such as dehydration could cause serum protein levels to become elevated.2

6. Describe how factors in her anthropometric, biochemical, clinical, and dietary nutritional assessment data all fit together to form a picture of her nutritional health. (5 points) Overall, her anthropometric data (BMI, IBW) reflects that she is at a healthy weight for her height, but is suffering from malnutrition due to inadequate intake and severe weight loss over six months.1,2,3 Her biochemical data shows that most of her serum values fall within the

normal range, but her potassium and serum protein levels fall below the normal range, indicating poor nutrition status, as well as a net response to the inflammation caused by her injury.2,3 Her blood pressure is close to the healthy range, but is controlled by the use of a diuretic, furosemide.1 The use of this diuretic, however, may cause potassium and thiamine losses, further exacerbating the problem of inadequate intake of these nutrients.2,4 Her dry oral mucosa and reduced skin turgor indicate that she is suffering from dehydration, a problem that is also apparent upon observation of her low daily fluid intake.1,2,3 She is deficient is most all macronutrient and micronutrient groups, with the exception of her protein intake.2,3,4 All of these factors considered, in combination with her inherent nutritional risks as an elderly person, suggests that she is at high nutritional risk.1,2,3 7. Write a PES statement based on the nutritional assessment data available. (5 points) -Inadequate energy intake related to a loss in motivation to cook as evidenced by a weight loss of 20 pounds in 6 months. -Inadequate fluid intake related to reduced oral intake as evidenced by signs of dehydration and low fluid intake recorded on fluid record. 8. What dietary and social changes would you suggest to improve her nutritional intake? (5 points) The first recommendation I would make is to generally increase the amount of calories being consumed each day, specifically an increase in fruit, vegetable, and whole grain foods. Due to her preference against consuming milk, an increase in other calcium-containing foods or taking a calcium supplement, is recommended.1,2,3 A formal educational process should be implemented to improve the patients knowledge of her nutritional needs.2 Her loss of motivation at the loss of her spouse may be improved by engaging in more social food-related activities, such as preparing and eating meals with a friend, if possible. If she has family, she may consider moving in with them or soliciting help at home from them.3 9. What are your nutritional goals for her, and how would you monitor the effectiveness of your interventions from question #8? (5 points) My nutritional goals for the client are to prevent further weight loss, increase fluid intake to 1,900 mL/day, increase fruit and vegetable consumption to 5 servings/day, and increase consumption of whole grain foods to 50% of grain intake.2 In order to monitor the effectiveness of these interventions, I will provide the patient with formal educational information and materials regarding her nutrient needs, address questions about food choices and dietary modifications, verify her adequate intake of these nutrients by performing routine 24-hour recalls and compare these levels to recommendations, record any further changes in weight/BMI.2,3 Other important health goals for the patient are to normalize blood parameters, including potassium, prealbumin, and albumin. If necessary, labs will be administered to monitor these parameters.1,2,3

10. Write a note documenting your assessment in SOAP format. (5 points) SUBJECTIVE - patient has experienced a decrease in motivation to cook due to husbands death; decreased dietary intake; low fluid intake; avoids eggs and milk due to food preferences; tripped over her cat and fractured femur OBJECTIVE - 76 years old; 67 in height; 140 lbs in weight; X -rays show a fractured femur; serum albumin and prealbumin are low; serum potassium is low; oral mucosa is dry and skin turgor is decreased; 88% UBW/ 12.8% loss in BW over six months; BMI falls within health range; blood pressure is 128/65 mm Hg ASSESSMENT - patient is experiencing an inadequate energy intake related to a loss in motivation to cook as evidenced by an energy intake approximately 600 calories lower than the estimated recommendation and a weight loss of 20 pounds in 6 months; patient is experiencing inadequate fluid intake related to reduced oral intake as evidenced by reduced oral intake and reflective lab values. PLAN - increase fruit and vegetable consumption to 5 servings/day, increase fluid intake to 1,900 mL/day, and to increase consumption of whole grain foods to 50% of grain intake; provide the patient with formal educational information and materials regarding her nutrient needs, address questions about food choices and dietary modifications, verify her adequate intake of these nutrients by performing routine 24-hour recalls and compare these levels to recommendations, record any further changes in weight/BMI; normalize blood parameters, including potassium, prealbumin, and albumin. If necessary, labs will be administered to monitor these parameters. Nutrition support will also be offered, if needed.

References 1. Emery, E.Z. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones & Bartlett Learning, LLC; 2011. 2. Nelms, M. Sucher, K. Lacey, K. Roth, S.L. Nutrition Therapy & Pathophysiology, 2nd ed. Cengage Learning; 2010. 3. Mahan, L.K. Escott-Stump, S. Raymond, J.L. Krauses Food and the Nutrition Care Process, 13th ed. St. Louis, MO: Elsevier Saunders; 2012. 4. SuperTracker. Accessed from https://www.supertracker.usda.gov/foodtracker.aspx on September 17, 2013.

Elizabeth OToole Nutrition Therapy I Alireza Jahan-Mihan September 17, 2013