Kelly Davis
KNH 413
Case Study: 3
March 18, 2014
1. What is depression?
Depression is a clinical disorder that results in someone to feel sad, at loss,
angry, or frustrated. Doctors do not know the exact cause of this disorder but it
is believe that chemical changes in the brain are responsible. Symptoms may
include fatigue, feelings of worthlessness, being isolate, thoughts of suicide, and
distorted views of oneself. These symptoms affect the person’s daily life for an
extended period of time.
Zieve, & Merrill. (2012). Major Depression. Retrieved from PubMed website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/
2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake
inhibitor (SSRI). Are there any pertinent nutritional considerations when using
this medication?
When using this medication it is important to avoid alcohol. Zoloft should
not be taken in combination with certain herbs. One of the herbs includes St.
John’s Wort, but it may be taken under the care of a physician. To help lessen the
side effects of depression, extra vitamin D is advised.
Zoloft. (2007). Retrieved from Applied Health website:
http://www.naturalnews.com/DrugWatch_Zoloft.html
3. How do selective serotonin reuptake inhibitors (SSRIs) work?
Selective Serotonin Reuptake Inhibitors are the most commonly prescribed
antidepressants. They work by helping to ease depression by changing the
neurotransmitters that communicate between brain cells. SSRIs block the
reabsorption of serotonin. Changing the balance of serotonin seems to help
brain cells send and receive chemical messages, which in turn boosts mood.
Selective serotonin reuptake inhibitors . (2010). Retrieved from MayoClinic
website: http://www.mayoclinic.com/health/ssris/MH00066
4. During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals,
or herbal supplements. She tells you her mother suggested she try Hypericum
perforatum (St. John’s wort) because in Germany it is prescribed to treat
depression. Ms. Geitle did as her mother suggested, as it is available without
prescription in the U.S. What is St. John’s wort?
St. John’s wort is a plant with yellow flowers whose medical uses were first
recorded in Greece. It interacts with many medications, making the medications
less effective. Because of this physicians need to ensure that it will be safe for
the patient to use. This medication is usually used to treat depression, anxiety,
and/or sleep disorders.
St. John's wort. (2011). Retrieved from National Institute of Health website:
http://nccam.nih.gov/health/stjohnswort
5. How is St. John’s wort used in the US?
The flowering tops of St. John’s wort are used to prepare teas, tablets, and
capsules for medicinal use. In the US there this medicine is used to treat
depression. However, the US Food and Drug Administration does not approve
St. John’s wort in the function of treating depression.
St. John's wort. (2011). Retrieved from National Institute of Health website:
http://nccam.nih.gov/health/stjohnswort
6. How does St. John’s wort work as an antidepressant?
The exact cause of how St. John’s wort works as an antidepressant isn’t fully
known yet. Many studies have shown that this medication works on seritonina
nd dopamine. Other studies suggest that St. John’s wort might prevent nerve
cells in the brain from reabsorbing the chemical messenger serotonin. And some
studies say that it works by reducing the levels of protein involved in the
functioning of the bodies immune system.
St. John's wort. (2011). Retrieved from National Institute of Health website:
http://nccam.nih.gov/health/stjohnswort
7. Does St. John’s wort have any side effects?
Side Effects include:
 Anxiety
 Dry mouth
 Dizziness
 Gastrointestinal symptoms
 Fatigue
 Headache
 Sexual dysfunction
St. John's wort. (2011). Retrieved from National Institute of Health website:
http://nccam.nih.gov/health/stjohnswort
8. How is St. John’s wort regulated in the U.S?
St. John’s wart is currently unregulated in the US. It is classified as a dietary
supplement, which is considered unregulated.
St. John's wort. (2000). Retrieved from U.S. Food and Drug Administration
website:http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlerts
forHumanMedicalProducts/ ucm173258.htm
9. How is St. John’s wort used in Europe?
St. John’s wort is widely used in Europe to treat depression, anxiety, and sleep
disorders. It is only available by prescription in parts of Eurpoe. In Germany,
doctors often prescribe it more often than prozac, a popular anti-depressant. It
is also used to treat bronchial inflammation, bed-wetting, stomach problems,
insomnia, migraines, and kidney disorders.
(http://www.cancer.org/Treatment/TreatmentsandSideEffects/Complementar
yandAlternativeMe dicine/HerbsVitaminsandMinerals/st-johns-wort).
10. Why do you think people are interested in alternative medicine and herbal
treatments?
People are interested in alternative medicines because different drugs effect
patients differently depending on their condition, the situation, and the person.
Herbal treatments are usually labeled as “natural” products and many believe
they are safer and better for you. Herbs have been used for a long time and have
been seen to produce health benefits, making it a more attractive product for
consumers.
Herbal Medicine. (2012). Retrieved from MedlinePlus website:
http://www.nlm.nih.gov/medlineplus/herbalmedicine.html
11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight.
She is 5’11” tall and weighs 160 pounds. You also determine that she is of
medium frame. Because Ms. Geitl is from Germany, she is used to reporting her
weight in kilograms and her height in centimeters. Convert her height and
weight to metric numbers.
Weight: 160 lb./ 2.2 = 72.72 kg
Height: 60 in. + 11 in. = 71 inches x 2.54 = 180.34 cm
12. Is Ms. Geitl’s recent weight loss anything to be worried about?
The patients recent weight loss of 5 lbs. is not something to be severely
worried about at the moment. The weight loss is related to her poor appetite,
which is stemming from her depression. If she continues to lose weight due to
her poor appetite, then it will become an issue and nutritional problems are
likely to occur.
13. Because Ms. Geitl is alert and cooperative, you ask her to complete a PatientGenerated Subjective Global Assessment of Nutritional Status. What is her score?
(See Appendix I).
Sections
Box 1
Box 2
Box 3
Box 4
Weight Loss section (Table 1)
Disease section (Table 2)
Metabolic section (Table 3)
Physical section (Table 4)
Total
Score
1
1
1
3
0
0
1
0
7
14. Using Appendix 1, how would you triage nutritional intervention?
Based on Ms. Geitl’s PS-SGA point score her triage point score would be 2-3.
This score means that Ms. Geital needs patient and family education by a
dietitian, nurse, or clinician with pharmacologic intervention as indicated by
symptom survey and lab values as appropriate. If she continues to lose weight
her triage score by change to 4-8. This means that an intervention with a
dietitian is needed in conjunction with nurse or physician as indicated by
symptoms.
15. What methods are available to estimate Ms. Geitl’s energy needs?
The methods available to estimate Ms. Geitl’s energy needs are the HarrisBenedict equation, Mifflin-St Jeor Formula, World Health Organization
Equation, and the Quick Estimate Equation.
16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed
above.
Mifflin- St. Jeor:
10 x wt + 6.25 x ht – 5 x age – 161
10 x (72.72 kg) + 6.25 x (180.34 cm) – 5 x (20) – 161
727.2 kg + 1127.125 – 100 -161
= 1,593.33 kcal  1500-1600 kcals/day
17. What is Ms. Geitl’s estimated energy expenditure?
Estimated energy expenditure:
 354–6.91 x age + PA x (9.36 x weight + 726 x height)
 354–6.91 x (20) + (1.12) x (9.36x (72.73)+ 726 x (1.8034)) = 2, 287.5 kcal
 Protein needs:
o 2,287.5 x (.15) = 343.125/ 4 = 85.78 grams
 Fat needs:
o 2,287.5 x (.07) = 160.125/ 9 = 17.79 grams
 Carbohydrate needs:
o 2,287.5 x (.60) = 1372.5/ 4 = 343.13 grams
18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy
needs?
Ms. Geitl is not meeting her energy needs. To determine the amount of
calories she is consuming on a daily basis, fitday.com was used. Her diet history
shows that she is consuming about 495-calories/ day and her 24-hour recall
shows that she is consuming about 470 calories/day. The amount of calories the
patient actually needs per day is about 1,600 kcals, so she is significantly lower.
The patients diet history shows she consumed about 19 grams of fat, 7 grams of
carbohydrate, and 19 grams of protein. Her 24- hour recall shows she consumed
about 9 grams of fat, 54 grams of carbohydrates, and 42 grams of protein. Ms.
Geit needs about 18 grams of fat, needs 86 grams of protein, and needs 344
grams of carbohydrate. In conclusion, this patient needs to increase her calorie,
fat, protein, and carbohydrate intake in order to gain her weight back.
19. What would you advise?
The patient is lacking many nutrients due to her insufficient intake of food. I
would suggest that she eat small, more frequent meals that are nutrient dense.
She should also receive more vitamin D because of the Zoloft she is taking and it
can help with depressive symptoms. Finally, I would explain the importance of
nutrition with nutrition materials in order for the patient to better understand
its significance.
20. List each factor from your nutritional assessment and then determine an
expected outcome from each.
Assessment Factor:
More Vitamin D
Inadequate Calorie Intake
Expected Outcome:
Less depressive symptoms
Increase calorie consumption by
increasing food consumption (for
breakfast, lunch or dinner). Increasing
calorie would stop weight loss
Inadequate Protein Intake
Inadequate Fat Intake
Inadequate Carbohydrate Intake
Increase protein consumption, by
consuming more sources of protein
(such as meat or beans). Increasing
protein would happen as a result of
increasing calories
Slightly increase fat intake. Focus on lean
meats sources like chicken, or turkey.
Increasing fat would happen as a result
of increasing calorie consumption.
Increase carbohydrate consumption by
following the daily-recommended intake
of grains (examples, pasta and bread)
Increasing carbohydrates would happen
as a result of increasing calories
21. What is your immediate concern regarding this use of St. John’s wort?
The SSRI medication and St. John’s wort should not be taken simultaneously,
this is an immediate concern. And, as said earlier, it can also reduce levels of
protein in the body, which can affect the immune system’s function.
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
After reviewing the initial nutrition note for this patient it was determined
that the note was set up appropriately but contained some errors and was
somewhat incomplete. The subjective portion of the SOAP note should have
included calorie and protein data from the patients diet history and 24-hour
recall in the objective data portion. The RD omitted important information
about the patient’s alcohol consumption, religious, or ethnic background. The
objective data portion of the nutrition note has omitted information about
converting the patents height and weight to metric units, patient’s gender,
temperature, pulse, blood pressure, respiration rate, medical diagnosis, and
current medical care. The assessment is lacking the nutrition problems followed
by the supporting PES statement.