Clinical Case Report: Nutrition Management of Adult Failure to Thrive with other Comorbidities

Lily Leung ARAMARK Distance Dietetic Internship Bronx Lebanon Hospital Center March 2014

Abstract Geriatric patients seen during hospital admissions typically have multiple disease diagnoses. Adult Failure to Thrive (FTT) is a clinical diagnosis used to categorize patients who are not seeing improvements in health outcomes despite appropriate nutritional and medical interventions. These patients are also highly susceptible to health-care acquired infections such as pneumonia and Clostridium difficile (C. diff) during hospital stays. Unfortunately, these patients are frequently admitted to the hospital due to compromised immune systems. The rational course of action would be to maximize nutrient needs however many factors need to be considered when administering nutrition. For example, a high carbohydrate nutrition regimen can exacerbate intubated patients with higher CO2 production. Increasing tube feed volume is often unadvised for someone suffering from chronic diarrhea with active GI bleeding. The following clinical case study will analyze appropriate plan of care for a patient with a multitude of adverse factors affecting health status using the American Dietetic Associations Nutrition Care Process: assessment, nutrition diagnoses, interventions, monitoring and evaluation.

Disease Description Adult FTT is prevalent among geriatric populations and is generally categorized by a multifactorial state of decline caused by chronic diseases. Manifestations of adult FTT include (but are not limited to) weight loss, decreased appetite, poor nutrition, and

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inactivity.!$"% Clinical diagnosis of adult FTT is comprised of three components: (i) Physical frailty, (ii) Disability and (iii) Impaired neuropsychiatric function. (2) Frailty as defined by the Cardiovascular Health Study (CHS) involves patients meeting three of out the following five criteria: (a) Weight loss (!5 percent of body weight in last year), (b) Exhaustion (positive response to questions regarding effort required for activity), (c) Weakness (decreased grip strength), (d) Slow walking speed (>6 to 7 seconds to walk 15 feet) and (e) Decreased physical activity (Kcals spent per week: males expending <383 Kcals and females <270 Kcal). Disability is defined as difficulty or dependence of others for completing activities of daily living (ADLs) for the foreseeable period of stay. Impaired neuropsychiatric function most commonly refers to delirium, depression and dementia among older adults. Other Co-morbidities C. diff is a bacterial infection than can cause chronic diarrhea and when left untreated can lead to life-threatening malnutrition and dehydration. C. diff infections are most commonly facility-acquired and associated with nursing homes and hospitals where there are a higher percentage of patients carrying the bacteria. (3) Congestive Heart Failure (CHF) occurs when the heart cannot keep up with normal demands placed on it to pump blood to the rest of the body. Cardiac muscles may weaken and increased ventricle dilation reduces pump efficacy. CHF comes from blood backing up and congesting organs and lower extremities. Some risk factors for CHF include hypertension, coronary artery disease, diabetes, heart attack, congenital heart conditions, viruses and alcohol abuse. (4)
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Chronic Respiratory Failure is a condition in which not enough oxygen from the lungs passes into the blood. Complications can also occur when carbon dioxide is not adequately removed from the body. Patients with respiratory failure often require ongoing breathing support such as home oxygen therapy or mechanical ventilation. (5) Hypertension or high blood pressure is a common condition in older adults whereby high arterial pressure may eventually cause damage to major organs, such as heart disease. Normal blood pressure should be below 120/80 mm Hg. Prehypertension is a systolic pressure ranging from 120 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. Stage 1 hypertension is a systolic pressure ranging from 140 to 159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg. Stage 2 hypertension is a systolic pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher. (6) Alcohol abuse is characterized by impaired control over drinking, a preoccupation with alcohol consumption, alcohol use despite adverse consequences and a distortion of thinking such as habit denial. A clinical diagnosis is made based on meeting two of more defined criteria as outlined by the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Alcohol abuse and dependence are often associated with higher rates of morbidity and mortality. (7) Hepatitis C is a viral infection that attacks the liver and leads to inflammation. Most people with the virus do not display symptoms however the infection may lead to liver damage often decades after diagnosis. The disease is transmitted through contaminated blood. (8)
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Evidence-Based Nutrition Recommendations The patient is in need of critically-ill enteral nutrition due to multiple comorbidities. According to the AND Evidence Analysis Library the specific threshold for enteral nutrition during hospitalization and how it affects mechanical ventilation in critically ill adult patients is unknown and the evidence is inconsistent. One randomized control trial found no clinical significance in mechanical ventilation improvement between a control group and a permissive underfeeding variable group. (9) The patients age and liver damage also places him at greater risk for PEG tube placement complications. Complications post PEG placement are factors when optimizing the feeding methods for critically-ill hospital patients. In a retrospective, single-institution crosssectional study, Hossein et al (2011) found PEG tube placement to have a relatively low mortality rate six months post-surgery. (10) One hundred patients averaging 59 years in age underwent PEG tube placement between October 2007 and June 2009. Results showed 27% of patients resuming oral PO intake and subsequent tube removal after 36 months while 42 patients died due to primary diseases. Researchers concluded that PEG placement is a minimally invasive method with low morbidity and mortality rates. Limitations from the findings include no discussion of actual enteral regimen patients were placed on, no limitations on disease inclusions and scope and a relatively short observation period (6-months). Liver disease and subsequent PEG tube placement complications were observed in a case series conducted by Baltz et al (2010). (11) The retrospective, single-

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institution case series used data gathered from University of Virginia Health System over a 10-year period from 1995 to 2005 on mortality rates after PEG in patients with cirrhosis. There were 26 clinical cases identified that fit the description for the study. The mortality rate was 38.5% for the first 30-days after PEG placement and 42.3% for the 90-day period. A major finding was that nine out of the ten patients who died within the first 30 days also had ascites at the time of PEG surgery. Two patients died as a direct consequence of PEG surgery complications. Researchers cautiously concluded that the overall mortality of patient with cirrhosis who had PEG tube placement was high, and the risk is even higher for patients who had existing ascites. While enteral nutrition is important, it should be weighed against the risks of PEG tube placement among patients with cirrhosis. The limitations of the case series are that the patients had varying degrees of illness and nutritional needs and reasons for PEG surgery. The tube feeding administration rate was also reduced due to C. diff related GI distress. While optimizing DRIs are important for normal ADLs, in this case permissive underfeeding was an appropriate plan of care until his diarrhea resolved. There are numerous studies completed over the years that support permissive underfeeding in critically ill patients. The latest study published in January 2014 was conducted at Scarborough General Hospital in the UK by Owais et al (2014). (12) This was a singleblinded randomized clinical trial following 50 patients under parenteral nutrition support. Participants were randomized to receive either normocaloric (100% of estimated calories) or hypocaloric (60% of estimated calories) feeding. After five days of the clinical trial, patients assigned to the hypocaloric group saw fewer septic complications, fewer feed related complications, and a lower incidence of systemic inflammatory
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response syndrome. Some limitations of the study include the relative short study period and the use of Schofield's equations for estimated caloric needs which typically overestimate daily caloric requirements. Furthermore, this was a short-term TPN study while our invention is related to long-term PEG feedings. While permissive underfeeding have been shown to be effective in multiple studies, it is important to accurately estimated protein requirements for the critically ill. Rugeles et al (2013) conducted a double-blinded randomized clinical trial following 80 patients randomly assigned to hyperproteic hypocaloric (15 kcal/kg with 1.7 g/kg protein) or isocaloric enteral nutrition (25 kcal/kg and 20% of calories from protein) groups. (13) Using the Sequential Organ Failure Assessment (SOFA) score with no difference in standard deviation at baseline, the hyperproteic hypocaloric patients saw an improvement in SOFA score after 48 hours and less hyperglycemic episodes per day. Furthermore, the underfed and high protein patients experienced decreased mechanical ventilation days and ICU length of stay. Limitations of the study include the small sample size, relatively short intervention period, use of soy protein and the exclusion of patients with renal failure. Soy protein can cause allergic reactions and high protein feedings may be inappropriate for some patients with renal failure not currently on dialysis.

Case Presentation Patient is a 67 year old African-American male sent from Concourse Nursing Home (NH) due to low hemoglobin (Hgb) and hematocrit (Hct) levels on January 29,
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2014. The patient has had multiple admissions in the past few months due to adult failure to thrive, positive C. diff cultures and chronic respiratory failure. Patient also has a long history of ETOH abuse and liver damage (ascites and Hepatitis C). Admission BMI was 17.8 kg/m2. He underwent a tracheostomy in November 2013 and was subsequently placed on a tube feeding regimen through a percutaneous endoscopic gastrostomy (PEG) tube. The patient past medical history includes CHF (Ejection Fraction 48%) and hypertension. The first course of action in Intensive Care Unit was transfusing two pints packed red blood cells (PRBCs) to correct CBC counts. Patient also seen with hyponatremia and started on IV fluids normal saline at 75 mL/hr with sodium tabs 2 gm TID. Patient also developed diarrhea from C. Diff infection and was given antibiotics (see Appendix 1 for complete medication list). Patient also developed pyogenic granuloma at the PEG tube site and silver nitrate stick was used to cauterize the granuloma. An esophagogastroduodenoscopy (EGD) and colonoscopy were performed on February 14, 2014 to rule out GI bleed from positive blood occult and showed one TI diverticulum, small and medium diverticulum from sigmoid to ascending colon and a 3 mm polyp in sigmoid colon which was biopsied. Patient was discharged on February 15, 2014.

Nutrition Care Process: Assessment Patient History Past patient history is limited to nursing home transfer notes that include medication list, recent lab values and past hospital admissions. Patient had a long
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hospital stay in November 2013 with chief complaint of altered mental status. He develop respiratory failure and was intubated. After multiple failed weaning attempts, patient underwent tracheostomy on November 13, 2013. Shortly afterwards, a PEG tube was placed on November 15, 2013. Patient also had C. diff and E. Coli infections at the time and was transferred back to NH after infections were resolved. Past medical history includes alcohol abuse however there is no information on duration and consumption levels. Food/Nutrition-Related History At the NH, patient was receiving Jevity 1.5Cal TF formula, 1000 mL daily at 70 mL/hr with 143 mL free H2O every two hours through pump flush. Patient also received medication through PEG with up to 300 mL fluid flushes daily. Patient was given folic acid 1 mg tablet via PEG daily. The initial diet order at BLHC is Standard Isotonic TF Formula 1.2kcal at 20 mL/hr x 18 hrs + 50 mL bolus flushes TID. The reduced feed is due to C. diff related GI distress and granulomatous bleed at PEG site. Nutrition-Focused Physical Findings Patient is completely bedbound and relies on continuous mechanical ventilation through trach. He requires complete assistance for ADLs. Patient also has poor dentition but does not require oral PO intake. Patient has documented ascites from chronic liver damage. Patient has multiple skin lesions and healed scars on his arms and legs. One left heel deep tissue injury documented in charts but is not a decubitus ulcer. Patient has limited speech abilities due to permanent trach however most
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assessments documented alert and oriented x 3 and that he followed verbal commands, nodding his head to answer questions. Anthropometric Measurements Patient is 59 or 175.3 cm tall. Admission weight was 119 lbs or 54 kg. BMI was 17.6 kg/m2 placing him just below normal and in the underweight category. Weight history was documented from previous admissions. Patient was 59 kg on November 7, 2013 indicating a 9.3% weight loss in three months. Biochemical Data, Medical Tests and Procedures Appendix 2 displays laboratory values relevant to the patients nutrition care process. The patient had multiple urine analyses for bacterial infections as well as a blood occult sample that tested positive. An exploratory EGD and colonoscopy were performed to identify the source of the GI bleed. Nutrition Needs Nutrition needs were based on patients BMI of 17.6 kg/m2 and ranged from 3035 kcal/kg per BLHCs nutrition care guidelines for someone who is underweight. The patient had normal albumin at 3.3 g/dL (BLHC defines normal range 3.2 4.6 g/dL) and hydration status was sufficient because of continued IV fluid NS drip. Protein needs were estimated at 1.4 gm/kg and fluid needs were the standard 25 cc/kg. Based on current body weight of 54 kg, energy needs were 1635 kcal/day, protein needs were 75 gm/day and fluid needs were 1362 mL/day. Nutrition Status Classification
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Using ARAMARKs Nutrition Status Classification, the patient was classified as severely compromised (Status 4) based on the following priority points: patient has diarrhea (3 points), initial TF was providing less than 1000 kcal (3 points), 9.3% unintentional weight loss in 3 months (3 points), 74% of IBW 160 lbs (3 points), albumin 3.3 g/dL (2 points) and adult FTT (4 points). The patient accumulated approximately 18 priority points. Malnutrition Identification Using the Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identication and Documentation of Adult Malnutrition (Undernutrition), the patient suffered from severe chronic disease-related malnutrition. (14) TF was held on separate occasions due to GI bleed and active C.diff-related diarrhea so he was receiving less than 75% of estimated energy needs for over two weeks. The patient had also experienced a 9.3% unintentional weight loss in the past three months. Patient has a history of ascites and his pro BNP level of 41879 pg/mL indicating some fluid retention (CHF). We were unable to determine body fat, muscle mass or grip strength. The patient definitely met two out of the six criteria for severe malnutrition of chronic illness.

Nutrition Care Process: Nutrition Diagnoses PES Statement 1: Altered GI Function (NC 1.4) due to C. diff infection related to chronic diarrhea as evidenced by need for reduced PEG tube feeding. (15)
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PES Statement 2: Increased nutrition needs (NI 5.1) related to adult FTT as evidenced by 9.3% unintentional weight loss in past three months. (15) PES Statement 3: Inability to manage self-care (NB 2.3) related to chronic respiratory failure as evidenced by need for mechanical ventilation and PEG tube feeding. (15)

Nutrition Care Process: Interventions Medical Interventions Hospital Course of Action: 1/29/2014 Admitted to ED from NH for low Hgb/HCT 6.5/19, isovolemic hyponatremia (Na 112 mEq/L), GI bleed from PEG site 1/29/2014 Received 2 PRBCs and Hgb/HCT is 8.5/24.7. Start IVF NS 75 mL/hr and add Na tabs 2gm TID 1/31/2014 - Sodium tabs were d/c once sodium became 130. Laparoscopic gastrostomy found pyogenic granuloma at PEG site, silver nitrate stick used to cauterize the granuloma 2/1/2014 Patient was transferred to 7th floor and developed diarrhea, stool sent for C. diff came back positive so started on flagyl and vancomycin. Patient developed atrial fibrillation with rapid ventricular response (A.Fib with RVR). He was given metoprolol 5mg IV push x2 along with PO metoprolol 25 mg through PEG but heart rate continued to be in 140's so MD spoke to cardiology fellow again and patient accepted to CCU for A. Fib with RVR 2/5/2014 Electrolytes are low due to chronic diarrhea, magnesium and potassium replaced. 2/6/2014 Transferred back to 7th floor, hemodynamically stable and following commands 2/10/2014 - No diarrhea currently. BAL growing Pseudomonas secondary to HCAP; will continue Zosyn for total of 14 days. No growth on repeated stool culture. Not febrile. Hemodynamically stable.
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2/11/2014 - Complains of chronic knee pain. Diarrhea improving. No abdominal pain. No fevers. In good spirits on ventilator. Foley removed and no retention, draining clear urine via condom catheter. BAL growing Pseudomonas. And Urine shows growth of ESBL Klebsiella. Started on Imipenem for same. 2/12/2014 - No pain anywhere today. Diarrhea has resolved. No abdominal pain or fevers. Remains hyponatremic. 2/13/2014 - No diarrhea, feels well and does not offer new complaints. No pain anywhere. Patient and his son agreed for EGD and Colonoscopy tomorrow. NPO for same. No fever and patient is hemodynamically stable. 2/14/2014 - Kept NPO for EGD/colonoscopy today. No diarrhea or abdominal pain. Patient and family consented to the procedure. Colonoscopy: - one TI diverticulum - small and medium diverticulum from sigmoid to Ascending colon - 3 mm polyp in sigmoid status post biopsy - rectal erosion status post biopsy EGD findings: Esophagus - z-line at 38 cm Stomach - Normal Duodenum - Pseudo-diverticula in the duodenum Recommendation: - follow pathology report of the colon polyp biopsy 2/15/2014 Patient discharged to Concourse Rehabilitation & Nursing Center Nutrition Interventions The patient was seen three times during this admission. The patient was first seen in ICU when he was NPO due to GI bleed at PEG site. After the granuloma was treated by GI, Standard Isotonic tube feeding was initiated at 20 mL/hr x 18 hrs. On February 4, 2014, a follow-up visit was completed and the tube feed was changed to Calorie Dense (Isosource 1.5Cal) at the same rate. The patient was still experiencing C. diff related diarrhea. The recommended goal rate was 60 mL/hr x 18 hours based on

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the energy and protein needs outlined above. The goal rate provides 1080 mL total volume, 1620 total kcal, 73 gm protein, 184 gm CHO, and 842 mL free H2O. Additional free H2O was not recommended because the patient was on continuous normal saline IV drip. The recommendations were communicated to the medical resident in charge however the TF was placed as Standard Isotonic at 45 mL/hr x 18 hrs. The patient was seen again on February 10, 2014 tolerating the tube feed. Serum Na levels were still below normal however they were trending upwards. Electrolytes were low and magnesium and potassium was replenished. He was still experiencing C. diff related diarrhea. The recommendation was to once again change the formula to Calorie Dense but at the same rate of 45 mL/hr x 18 hrs. There were no observed weight changes since admission and his serum albumin level was normal. The patient was discharged back to the nursing home on February 15, 2014 after the diarrhea resolved.

Nutrition Intervention Terminology Enteral Nutrition (ND 2.1) Composition (ND 2.1.1) Recommend change in TF formula from Standard Isotonic to Calorie Dense which is more in line with what the patient is used to at the nursing home. (15) Rate (ND 2.1.3) and Volume (ND 2.1.4) Recommend increasing TF rate from 20 mL/hr to 45 mL/hr x 18 hrs. As tolerated, advance to goal rate of 60 mL/hr x 18 hrs. (15) Site care (ND 2.1.8) Monitor PEG tube site granuloma progress. (15)

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Short-term goals: 1) Meet at least 50% of estimated nutrient requirements from enteral nutrition. 2) Albumin levels will be within daily limits. 3) Serum Na levels to normalize. 4) No more diarrhea. Long-term goals: 1) Meets 100% of estimated nutrient requirements from enteral nutrition. 2) BMI within normal range 18.5 24.9 kg/m2. 3) Eventual transition to oral PO intake.

Nutrition Care Process: Monitoring and Evaluation As a risk level 4 admission, the patient was seen at admission and every 5 days thereafter. Nutrition recommendations were communicated to the medical resident each time since RDs cannot place diet orders. Tube feed tolerance was evaluated each time but with chronic diarrhea, the volume was not maximized. The patient was cleared for discharge on February 14, 2014 after the diarrhea had resolved and Hgb/HCT and serum Na levels trended upwards. The following domains were assessed:

Enteral nutrition intake (FH 1.3.1) Initiate at 20 mL/hr x 18 hrs and advanced to 45 mL/hr x 18 hrs which meets at least 50% of estimated energy needs. (15)

Previously prescribed diets (FH 2.1.2.1) Nursing home records were consulted for existing TF regimen. (15)

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Enteral nutrition order (FH 2.1.1.3) Recommendations were documented and left to physician discretion. (15)

Sodium (BD 1.2.5) Monitor serum sodium levels and confirm enteral nutrition is not the source of hyponatremia. (15)

Albumin (BD 1.11.1) Monitor serum albumin levels for signs of protein deficiency. (15)

Conclusion For an adult FTT diagnosis, there is not much nutrition intervention if the patient is already receiving appropriate nutrition management. In this instant, permissive underfeeding was used to reduce diarrhea output. The patient has many comorbidities affecting health outcomes. In a hospital setting, his treatment was all short-term until he returns to his nursing home. Long-term goals are difficult to monitor and left to the clinical judgment of the nursing home nutrition staff. Nutrition recommendations are typically not included in discharge instructions for someone returning to a nursing home with no changes in feed regimen. This clinical case was a good example of a typical geriatric patient seen at BLHC with proper application of ARAMARK policies and procedures.

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Appendix 1: Medications Medication

Heparin Pantoprazole NaCl 0.9% IV Drip NaCl 1gm Tablet Albuterol Atorvastatin (Lipitor) Folic Acid Lisinopril Multivitamin Morphine Thiamine D50 drip Oxycodone Silver Nitrate Topical Metronidazole IV Acetaminophen (Tylenol) Vitamin A&D Topical Magnesium Sulfate Metoprolol (Lopressor)

Rationale
anticoagulant (blood thinner) that prevents the formation of blood clots Acid reflux To replenish Na To replenish Na bronchodilator Lowers serum cholesterol vitamin Treats hypertension vitamin Pain relief vitamin Provides dextrose when NPO Pain relief Anti-infection Antibiotic Pain relief and anti-inflammatory Skin-healing To replenish Mg Betablocker that treats hypertension To replenish K Antibiotic Sedative Antibiotic

Food-Drug Interaction

Avoid high K diet

Do not ingest, topical use only Avoid alcohol, 14 mEq Na per each 500 mg dose of metronidazole

Using metoprolol together with multivitamin with minerals may decrease the effects of metoprolol

KCl IV drip Vancomycin Midazolam Piperacillin + Tazobactam (Zosyn)

Avoid grapefruit 108 mg Na (4.7 mEq) per 2.25 gram of total drug

Source: All medication descriptions taken from Drugs.com

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Appendix 2: Laboratory Values At Admission January 29, 2014

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At Discharge February 14, 2014

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Citations 1. Robertson RG MM. Geriatric Failure to Thrive. Am Fam Physician. 2004;70(2):343350. 2. Agarwal K. Failure to thrive in elderly adults: Evaluation. UpToDate. Nov 27, 2012:March 3, 2014. 3. C. difficile infection. Mayo Clinic Web site. http://www.mayoclinic.org/diseasesconditions/c-difficile/basics/definition/con-20029664. Published July 16, 2013. Updated 2013. Accessed March 3, 2014. 4. Heart Failure. Mayo Clinic Web site. http://www.mayoclinic.org/diseasesconditions/heart-failure/basics/definition/con-20029801. Published August 16, 2013. Updated 2013. Accessed March 3, 2014. 5. What is Respiratory Failure? National Heart, Lung and Blood Institute Web site. https://www.nhlbi.nih.gov/health/health-topics/topics/rf/. Published December 19, 2011. Updated 2011. Accessed March 3, 2014. 6. High Blood Pressure (or Hypertension). Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/high-bloodpressure/basics/definition/con-20019580. Published August 3, 2012. Updated 2012. Accessed March 3, 2014. 7. Gold MS et al. Alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, adverse consequences, and diagnosis. UpToDate. 2013:March 3, 2014. 8. Hepatitis C. Mayo Clinic Web site. http://www.mayoclinic.org/diseasesconditions/hepatitis-c/basics/definition/con-20030618. Published August 13, 2013. Updated 2013. Accessed March 3, 2014. 9. Arabi Y, Tamim H, Dhar G, Al Dawood A, Al Sultan M, Sakkijha M, Kahoul S, Brits R. Permissive underfeeding and intensive insulin therapy in critically ill patients: a randomized controlled trial. Am J Clin Nutr. 2011; 93(3):569-577. 10. Hossein S, Leili M, Hossein A. Acceptability and outcomes of percutaneous endoscopic gastrostomy (PEG) tube placement and patient quality of life. The Turkish journal of gastroenterology. 2011;22(2):128-133. 11. Baltz J, Argo C, Al-Osaimi A, Northup P. Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series. Gastrointest Endosc. 2010;72(5):1072-1075. 12. Owais A, Kabir S, McNaught C, Gatt M, Macfie J. A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition. Clinical nutrition. 2014.
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13. Rugeles SJ, Rueda JD, Diaz CE, Roselli D. Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial. Indian Journal of Critical Care Medicine. 2013;17(6):343-349. 14. White J, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN, Journal of Parenteral and Enteral Nutrition. 2012;36(3):275-283. 15. Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013.

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