NCP Step 1: Nutrition Assessment

Patient Profile
Practice setting in which you are Adult Surgical Heart Unit (ASHU)
assessing this patient/client
Age 70
Gender Male
Race/Ethnicity Caucasian
Relevant personal data (i.e. language, English speaking
marital status, lives in a nursing home, Married
socioeconomic status, occupation etc.) Lives at home
Retired car salesman
No tobacco or illicit drug use
Beer on occasion per wife
Admitting diagnosis, chief complaint Abdominal pain
Symptoms on presentation Epigastric pain and dyspnea
Small full thickness wound on coccyx
CURRENT Medical Coronary artery disease (CAD), NSTEMI,
Conditions/Diagnoses sepsis, and acute kidney injury (AKI)
PAST Medical Conditions/Diagnoses Diabetes (DM), CAD, bladder cancer, and
anemia
Medical Test(s) conducted CT, EEG
Medical procedure(s) conducted EGD/Colonoscopy 2/13 at OSH
Cardiac cath 2/15 (balloon pump placed) at
OSH
CABG (3/19)

Anthropometric Data:

Indicator Value for the patient/client Assessment of

patient/client value
Height 198 cm (78 in)
Weight 101.5 kg (223 lbs)
Weight change/% change 7% in 2 years Not severe
UBW/%UBW 109 kg (240 lbs) 93% Normal
IBW/%IBW 97.3 kg (214 lbs) 104% Normal
BMI 25.3 Overweight
Adjusted Body Weight (if N/A
appropriate)
Patient’s Goal Weight (if N/A
appropriate)

Food/Nutrition Related History

Food Allergies N/A

Chewing and/or Dental Problems Dentures

Swallowing Problems N/A
Bowel Habits/Problems N/A
Recent Changes in Eating Habits Fair intake/appetite (lower than normal) x
1 week PTA
Current Appetite Poor
Food Preferences Soft foods
Nutrient Malabsorption Problems? N/A
N/V/D/C Nausea
Past Diet Prescriptions Cardiac, DM
Past Diet Instructions N/A

24 – Hour Recall - **Patient not appropriate due to medical status**

Meal Type of Food Cooking Method Portion
First Meal of Day
Snack
Second Meal of Day
Snack
Third Meal of Day
Snack

Calorie Count Results

2/25: 1 breakfast ticket saved, 0% eaten
2/26: 1 breakfast ticket saved, 0% eaten
2/27: no tickets saved

Total kcal/protein from calorie count: 0 kcal and 0gm protein

Total EN: 2665 kcals (100%) and 140 gm protein (92%)

Nutrition Focused Physical Assessment

Physical Appearance Nourished
Muscle and fat wasting Mild muscle loss, no fat loss
Swallowing function Good
Appetite Fair prior to admission
Affect (e.g. lethargic, sleeping, coma, Lethargic, confusion, altered mental status
energetic, in pain, etc.) (AMS)

LABORATORY DATA:

Date: 2/19 Date: 2/22 Date: 2/25 Date: 2/27

Laboratory Test: Normal Values: Values: Values: Values: Values:
Diet Order NPO Soft Dys 1, Nepro
(chopped), noc & bolus
ensure & MC
Height 198 cm
Weight 101.5 kg 98.2 kg
Albumin > 3.5 mg/dL 2.3 2.3 2.1 2.1
Glucose 70-99 163 173 117 221
Creatinine .67-1.17 1.55 3.04 4.74 3.42
BUN 7-21 mg/dL 22 51 55 38
Phosphorus 2.5-4.9 mg/dL 6.2 2.1
A1C 5.7-6.4% 7.2%
Hematocrit 39-51 23 25.2 25.7 24.9
Hemoglobin 7.2 8.4 8.0 8.1
Discussion of Laboratory Data
Although albumin is not a great indicator for nutritional status as it has been taught to
other medical fields over the years, it is still an important indicator of how sick a
patient is. As time went on, albumin did decrease just a little which coincides with his
medical course getting slightly worse as time went on.
This patient does have past history of diabetes which is likely why they are overall
elevated. However, his medical course added extra stress on the body which caused
them to increase even more as the days went on. To control this, he was on insulin
while in the hospital.
BUN and Creatinine were monitored, because this patient ended up on hemodialysis.
He became fluid overloaded at the beginning of his admission, but did not respond to
the Lasix drip that was started and they needed to get the fluid off. BUN and
especially Creatinine are used to assess kidney function; the higher they are, the
worse shape the kidneys are in. However, while a patient is on dialysis, they tend to
be elevated so while it’s important to bring them down, in this case it was just
important to monitor them to make sure they didn’t jump up suddenly. While you
would want to limit protein when Creatinine is elevated, protein is being used more
frequently while a patient is on dialysis, so his needs were assessed higher to try and
make up for those losses.
An A1C was measured at admission to assess average levels of blood glucose over
the last 3 months. This patient’s was at a 7.2%, which is elevated from the normal
range and indicates type 2 diabetes which the patient does have a history of.
Hematocrit and hemoglobin were included due to his past history of anemia. They
were low as expected and the patient was on an iron supplement during his admission
to help.

MEDICATIONS:

Date: Medication &Amount: Purpose or Function: Significant Nutritional Implications:

2/19 Lipitor (Atorvastatin) -Statin NO grapefruit, increase omega 3
40 mg daily -Inhibitor of HMG-CoA
reductase
Aspirin (Acetaminophen) Analgesic Nausea, dark stools
650 mg PRN
Pepcid (Famotidine) -Antacid Constipation, diarrhea
20 mg daily -GERD, excessive stomach
acid
Iron (FeSo4) Iron supplement Constipation, nausea (try not to take on an empty
325 mg daily stomach)
Lopressor (Metoprolol) Beta blocker N/V/D/C
25 mg Q8
Zofran (Ondansetron) Anti-nausea Dry mouth, abdominal pain, nausea, diarrhea,
4 mg PRN constipation
Insulin: Anti-diabetic Lispro: Cramps, weight gain
Lispro (Humalog), 2-12 Hypoglycemic Glargine: SOB, weight gain
units QID
Glargine (Lantus), 10 units Subcutaneous
daily
2/26 Haldol (Haloperidol) Anti-psychotic Weight gain
0.5 mg PRN
Discussion of Medications
A drug-nutrient interaction is a reaction between a medicine and one or more nutrients
(1). Different medications can cause different side effects in different people; it will not
be the same for everyone. The most common side effects of these medications are
nausea and constipation. The only side effect this patient really dealt with was nausea
and he was put on Zofran (anti-nausea) to help resolve these symptoms. In dealing with
his main reason for admit, the patient was on atorvastatin and lopressor which are also
likely home medications. With that, he was also placed on insulin to keep his diabetes
under control, especially since his body is under stress with everything going on
medically. None of these medications negatively interact nor did the patient experience
any severe side effects due to any of these medications.

NCP Step 2: Nutrition Diagnosis

PATHOPHYSIOLOGY
NSTEMI: A non-ST-Elevation Myocardial Infarction is caused by a severely narrowed
artery but the artery is usually not completely blocked. It is a type of heart attack, but
causes less damage. After a MI occurs, an EKG will be ordered to look at the heart
tracing. If there is a an ST-elevation pattern observed, it was just a STEMI, but if there is
an elevation of blood markers but no ST-elevation, then it is referred to as an NSTEMI
(2). From this point, a cardiologist will perform an angioplasty, also known as a cardiac
catheterization, which involved injecting dye into the arteries to check for blockages.
However, if a cardiac cath isn’t applicable or there are numerous blockages, a Coronary
Artery Bypass Graft may be done instead. CABG is a type of surgery that improves
blood flow to the heart and is used before or during a heart attack to treat blocked
arteries. (3) Life after a NSTEMI and/or CABG has a good outlook, however lifestyle
changes should be made and medications will need to be utilized to stay on the right track
and prevent something like this from occurring again. Secondary prevention is especially
important in this case. This involves making changes after an event such as a heart attack
and/or surgery has occurred to prevent any future recurrence. Outpatient hospital based
cardiac rehab programs have proven to be beneficial in overcoming barriers that come up
when making lifestyle changes (4). They involve physical activity programs, group
activities, food journaling, and educations on numerous topics.
Coronary Artery Disease*: Coronary artery disease (5) is damage or disease in the
heart’s major blood vessels. It is under the umbrella of cardiovascular disease and is the
leading cause of death in the United States (5). Due to the damage the blood vessels
suffer in CAD, the arteries cannot deliver enough oxygen rich blood to the heart. Plaque
(a waxy substance) is what builds up in the arteries to partially or totally block blood
flow. The interesting thing about CAD is that most people have no physical symptoms
until something serious occurs such as a heart attack or cardiac arrest (5). Of course, if
someone is following up with a primary care provider and regularly getting blood work
evaluated, CAD and/or a heart attack can be prevented. One thing that would push people
to continually check in with their doctor and watch blood work would be risk factors.
Major risk factors such as age, gender, family history, and race are uncontrollable but
may place you at higher risk for acquiring CAD. Other modifiable risk factors place you
at risk and can increase your risk if you also have one of the major risk factors.
Modifiable risk factors include high triglycerides, high cholesterol, high LDL, low HDL,
obesity, physical inactivity, diabetes, smoking, and diet (1). These are called modifiable,
because they can be altered to decrease your risk of developing any type of CVD
including CAD. However, once diagnosed, it’s not the end of the world. Heart-healthy
lifestyle changes (diet, exercise, and smoking cessation) are encouraged along with
medicines and surgery (if needed) to prevent complications.
AKI: Acute Kidney Injury is a sudden episode of kidney failure or damage that can
occur over a few hours or a few days. (6) Due to AKI, a build up of waste products
occurs in a person’s blood and it is hard for the kidneys to maintain the right balance.
AKI can also potentially affect the brain, heart, and/or lungs so it’s important to treat it
right away. AKI can have many different causes but main ones are hypotension, heart
attack, organ failure, burns, injury, major surgery, bladder cancer, sepsis, scleroderma,
and multiple myeloma among many others (1, 6). The main goal of treating AKI is to
treat the original issue that is causing the kidney injury to occur. However, in more
serious cases, dialysis may be needed until your kidneys can recover and function on
their own again. Outlook for AKI is good as long as your doctor is carefully monitoring
your kidney function.
Sepsis: Sepsis is a potentially life-threatening condition caused by the body's response to
an infection (7). A chain reaction throughout your body is triggered by an infection
(bacterial, viral, or fungal) that is already present and isn’t stopped causing sepsis.
Anyone can get an infection that can lead to sepsis, however some people are at higher
risk such as adults 65 and older, those with chronic medical conditions such as DM, lung
disease, cancer, and/or kidney disease, and those with weakened immune systems.
Similar to AKI, it is important to treat it right away, but sepsis presents with more serious
consequences if untreated in a timely manner. Treatment includes antibiotics and large
amounts of IV fluids (7). If left untreated and sepsis worsens, blood flow to vital organs
such as the brain, heart, and kidneys, can be impaired. Recovery rate is high, but again,
time is of the essence and depending on the severity, aggressive care may also be
warranted to prevent more damage.

PAST Medical Conditions/Diagnoses

Diabetes Mellitus: In simple terms, diabetes mellitus (DM) is a disease in which your
blood sugar (glucose) levels are too high. Glucose plays a major role in your body,
because it is used as a source of energy for cells that make up your muscles and tissues
and is also your brain’s main source of fuel (8). DM refers to a group of diseases that
affect how your body uses glucose and they lead to excess sugar in a person’s blood. The
2 main types of DM are type 1 and type 2. Type 1 is generally diagnosed at a younger
age and occurs when the immune system attacks insulin producing cells in the pancreas
which leaves little or no insulin and it builds up in the bloodstream (1). Type 2 is more
common, can occur at any age, and can be as a result of other risk factors. In type 2, cells
become resistant to insulin and the pancreas can’t make enough to overcome the
resistance so it builds up in your bloodstream instead of going into cells (1). Some risk
factors are weight, inactivity, high blood pressure, family history, race, and age. Some of
those risk factors are modifiable and type 2 diabetes can be prevented if those factors are
changed through lifestyle adjustments. If blood sugars aren’t properly controlled by
medications or lifestyle changes, they can produce lifelong complications such as
cardiovascular disease, nerve damage, kidney damage, eye damage, and foot damage to
name a few (9). As stated previously, type 2 diabetes can be prevented, however, once
diagnosed, it can also be maintained properly. It is important to follow up with a PCP to
keep diabetes under control to prevent any lifelong issues that come along with DM.
Coronary Artery Disease: *See above.
Bladder Cancer: Cancer itself is a group of diseases that involve abnormal cell growth.
Like any other major disease state, there are risk factors for developing cancer that are
modifiable and non-modifiable. Some include physical inactivity, family history, age,
gender, smoking, overweight or obese, etc. Symptoms, treatment, and prognosis of
cancer vary widely by type. When it comes to bladder cancer specifically, it is one of the
most common cancers and it occurs when cells that make up the urinary bladder grow out
of control and form a tumor (10, 11). The most common type is urothelial carcinoma and
it starts in the urothelial cells that line the inside of the bladder (1). Symptoms include
hematuria, painful urination, and pelvic pain. These symptoms can occur because of
something other than bladder cancer so either way it is important to visit with your
doctor. Most of the time, it is diagnosed early and highly treatable. However, recurrence
is likely so follow up is extremely important to monitor.
Anemia: Anemia is a condition in which your body’s tissues do no get enough oxygen
rich blood delivered to them (1). Hemoglobin (HgB) is responsible for carrying oxygen
from the lungs to the rest of the body so when it is negatively affected, your body does
not get the proper oxygenated blood that it needs (1). HgB may be affected when your
body destroys red blood cells, your body doesn’t make enough red blood cells, or
bleeding causes you to lose red blood cells more quickly than they can be replaced. Some
symptoms include lethargy, shortness of breath, dizziness, headaches, or an irregular
heartbeat (12). There are some people that are at higher risk for developing anemia, such
as women, older adults, and those with a family history, but regardless, it is highly
treatable by simply incorporating more iron into the diet by means of food or
supplementing with iron. However, if left untreated, it can cause complications such as
severe fatigue, heart problems, or even death (in severe cases of anemia) (12).

Medical Conditions/Diagnoses Inter-Relationships

Risk factors for Cardiovascular

disease (CVD), Diabetes (DM), and Cancer are all related to each other and similar. They
can be broken down into 2 main categories: Modifiable and non-modifiable risk factors
(1). Modifiable risk factors are those that you have the power to change while non-
modifiable you do not. Non-modifiable are risk factors such as age, gender, or race. You
are born with these risk factors and tend to be at higher risk for developing chronic
diseases if you are male or female, age 65+, or african american, for example (1). Non-
modifiable risk factors do place you at an automatic higher risk, but if you have
modifiable risk factors under control you can decrease your risk. Modifiable risk factors
consist of physical activity, smoking, and diet to name a few (1). As stated earlier, these
are risk factors people have control over and can help decrease your risk for developing
these chronic disease. These are also related, because not only risk factors similar, but
once you develop one of these chronic diseases, it can also increase your risk for
developing one of these other chronic diseases. For example, developing diabetes
increases your risk for developing cardiovascular disease down the line (1). This is why
prevention is so important in the first place, but if you do develop diabetes, keeping
blood sugars and symptoms under control and changing lifestyle factors can decrease the
risk of developing CVD.

Assessment of Nutrition Needs

Calories
Show your work:
25-30 kcal/kg

25x101.5 = 2,530 kcals/day

30x101.5 = 3,045 kcals/day

Rationale for calorie level:

25-30 was chosen based on his borderline normal/overweight BMI and increased needs
for healing

Protein:
Show your work:
1.5 kcal/kg

1.5x101.5 = 152 gm pro/day

Rationale for protein level:

1.5 was chosen for wound healing and overall increased needs for healing

Other pertinent macronutrient levels:

N/A

Other pertinent micronutrient levels:

N/A

Fluid
Show your work:
25 mL/kg*

25x101.5 = 2,350 mL/kg/day*

Rationale for calorie level:

*Normally, 25 mL/kg would be chosen based on his age (70) since that’s recommended
for age 65+, however fluids were recommended per medical team due to his issues with
AKI, being on hemodialysis, and then eventual tube feeding.

Which of the following domains is the patient/client presenting with :

DOMAIN Check (✓) if patient If checked, explain
presents with this evidence to support this
characteristic decision
INTAKE
Energy Balance
Oral or Nutrition Support ✓
Intake
Fluid Intake
Bioactive Substance Intake
Nutrient Intake
CLINICAL
Functional
Biochemical
Weight
BEHAVIORAL-ENVIRONMENTAL
Knowledge and Beliefs
Physical Activity &
Function
Food Safety and Access

What is the Nutrition Diagnosis for this client/patient?

Diagnosis or Etiology Signs and/or
Problem Symptoms
Inadequate Oral Related to Abdominal Related to Need for NPO
Intake pain status, reported
fair intake PTA
Inadequate Oral Related to Confusion Related to Documented/re
Intake and/or mental ported poor/fair
status changes oral intake
Inadequate Oral Related to Confusion Related to Documented/re
Intake and/or mental ported poor
status changes, oral intake,
decreased need for
intake, swallow eval
difficulty
chewing

NCP Step 3: Nutrition Intervention:

Nutrition Prescription (Diet Order)

Indicate the diet changes and progression since patient’s admission to present
Date Diet Prescription/Order
2/17 NPO (for possible CABG)
2/18 Soft for Dentition (chopped) with cardiac restrictions
Glucerna (chocolate) BID
Magic up (chocolate) BID
2/27 Oral: Dysphagia Level 1 Pureed
 Glucerna (chocolate) BID
Magic Cup (chocolate) BID
EN: Nocturnal TF of Nepro @ 60 mL x 12 hours (6p-6a) w/ 1 HS
Bolus feeds at meal times of 240 mL Nepro if <50% of meals
eaten
2/28 EN: Continuous Nepro @ 65 mL/hr w/ 1 Healthy Shot (HS)

Discussion of Diet Order(s)

After the NPO was lifted since it was confirmed he wouldn’t be having surgery until his
status improved, soft for dentition (chopped) was appropriate, because the patient has
dentures (that he doesn’t like to wear) and can only eat soft foods. Supplements were also
ordered to aid with PO intake. Over the next couple days, his PO intake remained poor.
The decision was made to trial puree foods to see if he would tolerate those foods better
with his dentition along with nocturnal feeds to ensure he’s getting enough nutrition.
Nocturnal feeds for 12 hours were ordered along with bolus feeds during the day if he
didn’t eat at least 50% of meals. Nepro was the chosen formula, because he is on dialysis
for ongoing AKI and had elevated phosphorus and needed a more concentrated formula
since he was fluid overloaded. Along with this, a swallow evaluation was ordered with a
SLP to evaluate whether he is even appropriate for oral feeds. The SLP found he was not,
so the decision was made to place him on continuous tube feedings, which I agree with.
He was not alert enough to eat orally and with his poor dentition on top of it, tube
feedings were appropriate.

Nutrition Intervention Plan

Nutrition Intervention(s) Intervention #1: Soft for dentition diet
1. Food and/or Nutrient Delivery (chopped) + Oral nutrition supplements
2. Referral to a Speech Pathologist (ONS)

Goal(s): Tolerate oral diet

Problem Intervention #2: SLP evaluation;

Inadequate oral intake Dysphagia Level 1 pureed diet + ONS
along with nocturnal and bolus feeds

Goal(s): Tolerate oral diet, increase PO

intake to at least 50% of meals and
supplements, tolerate enteral feeding goal
Etiology Intervention #3: SLP F/U; Enteral
Confusion and/or mental status changes nutrition

Goal(s): Meet >75% of estimated needs

Signs/Symptoms
Documented/reported poor oral intake,
Need for SLP eval
Which goal is the priority at this time?
Meet > 75% of estimated needs, because
whether he is on oral feeds or tube feeds,
meeting his needs is the priority. To
achieve that, proper recommendations were
made for both diet orders
Why was a referral to speech made?
Does the patient have any barriers to
compliance to the interventions?
The patient has poor dentition which may
be interfering with his intake and may need
an altered consistency. Also, he is
confused/not alert and may not even be
appropriate for oral feeds
Altered mental status, poor dentition, and
lack of compliance with dentures

NCP Step 4: Monitoring and Evaluation

Health Care Outcomes

Intervention Health & Disease Patient Outcomes
Outcomes
Recommend Soft for Adequate PO intake Patient to increase oral intake to at
dentition (chopped) diet and least 50% of meals and supplements
Glucerna and Magic Cup
supplements BID
Recommend Dysphagia Adequate PO intake Patient to tolerate oral diet
Level 1 Puree, keep same
supplements
Recommend nocturnal Prevention of malnutrition Patient to tolerate oral diet and
feeds of Nepro and bolus transition to enteral feeding
feeds at meal times if <50%
of meals consumed
Recommend continuous Prevention of malnutrition Patient to tolerate enteral nutrition
feeds of Nepro @ 65 mL/hr goal and meet >75% of estimated
needs

Monitoring and Evaluation

Question to Consider
What indices are you using to determine
success of your intervention?
Did the intervention work? Explain.
If the intervention is not working, indicate
what follow up action you took.
What are the causes of initial interventions
Answer/Reflection
Quality of PO intake, discussion with RN
and documentation, tolerance of tube
feedings.
At first, no. Oral feeds weren’t working
and patient was not meeting needs due to
his altered mental status. Utilizing tube
feedings, even if just for a few days,
worked to ensure the patient would meet
his estimated nutritional needs and helped
get him support him and back to his prior
status.
Patient’s altered mental status, poor PO
 that did not work?
How will you monitor success of your
follow up interventions?
intake, and refusal to wear dentures.
Whether he is on an oral diet or on tube
feeding, I will evaluate whether patient is
meeting 100% of needs enterally and
tolerating EN regimen or oral diet by
visiting patient and family, talking with the
nurse(s), reviewing documentation, and
discussing with speech to monitor
appropriateness of PO and diet
consistency.

Conclusion:
1) Brief concluding remarks. How did the case end in terms of your involvement?
I followed this patient for about half his hospital stay. After I stopped following him, his
diet was eventually advanced from Dysphagia 2 to Soft for dentition and his tube
feedings were discontinued. His altered mental status improved, so along with that, so did
his PO intake and he was transferred to the rehab floor. In terms of my involvement, I
ensured that he was still meeting his nutritional needs even if it meant through alternate
routes (via NG). I believe that my nutrition interventions helped him to build back up his
strength and recover while his other issues improved/subsided. He needed to do this in
order to improve his status so he could have surgery (CABG) to fix his initial cardiac
issues he was having. It was an interesting bumpy road, but he stuck it out and stayed
strong and was able to get just about back to his normal functioning status. He finally
ended up completing rehab and resuming enough functional status to have surgery.

2) What did you learn from this case that you feel you can use for future practice?
This case pushed me to look further into history and connect the dots as to why things are
the way they are. It also helped to kick in my clinical judgement. For example, the patient
isn’t alert and has poor PO intake, so what do you do? He didn’t need to be on tube
feeding forever, so I had to come up with a temporary plan that would meet his estimated
needs. It also taught me how important prevention really is, even if it’s secondary. After
this crazy road, it’s important for this patient to really look at his lifestyle and make
adjustments to improve his cardiac and overall health. It pushes me to want to educate
people about nutrition and the importance of taking care of themselves through food and
wellness. I also am more comfortable with choose an enteral formula and calculating out
rates for continuous, nocturnal, and bolus. I put myself through the ringer calculating tube
feeds for him and selecting a formula so when I finally arrived at the goal prescription, it
was very satisfying. It was good to make errors along the way, because it helped me use
critical thinking skills of why this formula, why not this one, how to do you achieve his
higher protein goals, etc. It turned out to be a bit more of a difficult patient due to the
other medical issues he had come up along the way, but it also helped me to focus on the
end goal of improving his nutritional status so he could then improve his overall status.

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