Andrea Belloli

Mini Case Study

Nutrition Assessment: Medical Diagnosis Age: 51 y/o
Gender: Male, African American
Weight: 61 kg
Height: 182 cm
BMI: 18.42

PMH
Asthma, alcohol dependence, heroin abuse,
anxiety, COPD, HTN, intubation, delirium,
tremors, iron-deficiency anemia

Symptoms
SOB with cough and congestion x2 days
and vomiting x1.5 weeks

Diet History
Lives by himself in an apartment and
prepares own meals.

Labs:
Creatinine 0.62 (Low)
Calcium 8.1 (Low)
Sodium 135 (Low)
Albumin 3.3 (Low)
Phosphorus 3.0 (Low)
Medications:
Albuterol (asthma)
Amlodipine (HTN)
Azithromycin (anti-infective)
Budesonide-formoterol (asthma)
Budrenorphine-naloxone (opioiddependence)
Calcium-Vit D (Ca deficiency-prophylaxis)
Elonidine (HTN)
Folic Acid
Tiotropium (COPD)
Thiamin (prophylaxis)
Prednisone (respiratory disorders)
Heparin (venous thromboembolism)
Mntelukast (asthma)
PRN Medications
Acetaminophen (pain relief)
Albuterol-ipratropium (SOB-wheezing)
Haloperidol
Lorazepam
Prochlorperazine (n/v)
Tramadol (pain)
Trazodone (insomnia)
Current Diet
Regular
Receiving strawberry and vanilla Ensure
Complete TID

Nutrition Diagnosis utilize PES Statements

Increased nutrient needs R/T increased energy expenditure related to COPD AEB BMI of
18.4
Underweight R/T increased nutrient needs related to COPD AEB BMI of 18.4

Andrea Belloli
Mini Case Study

Nutrition Intervention Nutrition prescription, Interventions with goals

Nutrition Prescription
Intervention with goals
Regular Diet, 1946-2150 kcal/day (Mifflin Goal: Eat >75% of meals and/or
plus 250 kcal for wt gain), 61-73gm
supplements
protein/day (1-1.2 gm/kg), 1830-2135 mL
Goal: Prevent weight loss
fluid/day
Interventions:
Recommend diet modifications
(double portions)
Honor food preferences
Offer food, fluids, supplements as
desired/tolerated
Continue previously ordered
supplements

Nutrition Monitoring and Evaluation

Indicator
1. AD-1.1.2: Weight
2. FH-1.1.1.1: PO intake/tolerance

Criteria
1. Pt does not lose any more weight
2. Pt consumes at least 75% of meals
and monitor adequacy of PO intake.

Source
Facility standards

Kcal requirements
Mifflin St Jeor using
actual wt (1946-2150
kcal/day)

Protein requirements
61-73gm protein/day
(1-1.2 gm/kg)

EAL
Online nutrition care
manual

n/a-nothing found
Energy needs for
individuals with
COPD are highly
variable due to
differences in REE
and levels of PA.

n/a-nothing found
Same as kcal
requirements

Fluid requirements
1830-2135 mL
fluid/day (30-35
kcal/kg because pt is
77% of IBW)
n/a-nothing found
Not enough evidence
to support.

References:
Academy of Nutrition and Dietetics. Nutrition Care
Manual. http://www.nutritioncaremanual.org. Accessed February 4, 2015.

Andrea Belloli
Mini Case Study

Evidence Analysis Library. Academy of Nutrition and Dietetics Web site.

www.adaevidencelibrary.com. Accessed February 4, 2015.
http://www.andeal.org/topic.cfm?menu=1401&cat=1476