Anastasia Maczko
Admitted: Sept 10, 2014 - 12:54 EDT via ER
Patient presents with bilateral knee pain x 1 week ago, difficulty walking, left leg and right foot
numbness. BP 216/91 upon arrival, finger stick = 412 and hypokalemic.
Allergies: penicillin
Patient lives alone and uses cane.
Patient received information on pressure ulcer prevention and type two diabetes control.
Patient cannot remember medication names or doses – compliance factor.
Notes:









Pt admitted to ER via stretch with son for medical treatment/observation
Patient’s daughter manages home medication
Patient had decreased appetite for two weeks and lost 15 lbs – trying to
Patients appetite increased at hospital
Patient was very receptive to DM education and willing to make change
o Did not what a CHO was pta
Patient requires partial assistance and has had reported falls in the past year
o Legs giving out
Former smoker, stopped 15 years ago
Religion: Jehovah’s witness
CT performed to check for head injury d/t recent fall
Discharge Plan
- Pt appt with Cigna Health Spring office 9/12/14
- Bring all medication speak with internist, social worker and pharmacist to adjust insulin and
blood pressure medications
- Final diagnosis: diabetic neuropathy, uncontrolled DM, uncontrolled HTN, osteparthritis of
bilateral kneeds, hypokalemia – resolved
Anastasia Maczko
Nutrition Assessment: Medical Diagnosis – Bilateral leg pain, RN consult for wgt loss >15 lbs
Age: 74 y/o
Labs:
Gender: Female
9/09/14
09/11/14
Weight: 63.4 kg, 140 lbs, 138% IBW
Na
139
140
UBW: 79 kg, 174 lbs
K
3.3 L
3.0 L
Height:153 cm, 5’0”
Cl
l 98
103
BMI: 27 (overweight), UBW BMI 33
CO2
30
26
BUN
15
10
PMH
Creat
0.83
0.74
Uncontrolled HTN
Gluc
456 H
218 H
Uuncontrolled DM
Ca
10.1
8.8
Hypokalemia
GFR
82
Microycytosis
Mag
1.3 L
DVT
Phos
3.5
Increased urine output
Total Pro
6.2 L
Fall 3 weeks ago
Album
3.0 L
Fall last year
A1C
12.2 H
Hysterectomy
Lower back pain
Lower leg joint pain
Arthritis
Asthma
Hypercholesteromia
Denies current alcohol, tobacco, drug abuse
Hx of tobacco and alcohol use
Symptoms
Increased urine output
Acute knee pain
Numbness
Diet History
Per pt, appetite has decreased over past two weeks,
stating she has lost 15 lbs over the past “month or
so” intentionally. Pt appetite has improved since
arrival at hospital and pain has decreased. Pts idea
of following diabetic diet is to “tries to eat low
sugar foods.” Pt did not know what a carbohydrate
was PTA. Pts daughter prepares meals at home
making chicken often, fried, baked or broiled. Pts
daughter also distributes and manages pt
medication. Pt states “does not check BS as often
as I should.”
Medications:
Hospital Medications:
Enoxaprin (DVT) – 40 mg q24h
Gabapentin (pain management) – 300 mg
q24h (nightly)
Insulin glargine (insulin) – 30 units q24h
(nightly)
Lisinopril (hypertension) – 40 mg q24h
Magnesium oxide (hypomagnesia) – 400
mg q24h
Insulin lispro correction scale (insulin)
150-199 = 1 unit
200-249 = 3 units
250-299 = 5 units
300-349 = 7 units
>349 = 8 units
Metaprolol (hypertension and acute MI)
5 mg SBP>170 mmHg
Home Medications:
Insulin glargine – 100 units/mL
Metformin
Ranitidine – 150 mg oral
Sertraline – 25 mg oral
Current Diet
Hospital: Cardiac, Med Carb
Anastasia Maczko
Home: low-sugar
Nutrition Diagnosis – utilize PES Statements
NB-1.1: Food nutrition knowledge deficit related to lack of prior exposure to accurate nutrition
information; poor food choice aeb fs: 213, 337, 209 and A1C 12.2.
NI-2.1: Inadequate oral intake r/t decreased appetite aeb pt report of decreased PO intake PTA and
15-lb weight loss.
Nutrition Intervention – Nutrition prescription, Interventions with goals
Nutrition Prescription
Intervention with goals
Cardiac, med carbohydrate diet (1800
Goal: Increase PO intake >75% of meals.
kcals, 87 g pro)
E-1.1 – Nutrition Education
- Importance of diabetic diet
Mifflin St Jeor (1.2 AF): 1,207-1,335 kcal
- What a carbohydrate was
Protein Needs (based on IBW): 63-79 g pro
- What foods to eat/avoid
Fluid Needs: 20-25 mL/kg, 1,268-1,585
- Provided list of carbohydrate foods and
mL
serving sizes, taught comparison of food
size to hand
RC-1.4 – Collaboration with other providers
- MD referral to Cigna Health Spring office
- Pt had ride and time pick up to meeting
- Pt told to bring all medications to have
reviewed
Maintain blood glucose of <160 mg/dL as
medically feasible.
Achieve normal electrolyte balance.
Eat >75% meals and/or supplements.
Understand diet education prior to discharge.
Nutrition Monitoring and Evaluation
Indicator
FH-1.1.1.1 – Total energy intake
HF-4.2.7 – Readiness to change nutritionrelated behaviors
BD-1.5.1, 1.5.3 – Glucose fasting and A1C
Criteria
Pt receives appropriate diet order and carbohydrates
per day.
Pt consumes 75%+ of meals.
Pt eager to learn information, asked nutrition-related
questions related to her diet and received verbal and
documented education.
Monitor pt glucose and A1C levels.
*Med CHO diet provides 1800 kcal, 87 g protein, no fluid restriction
Source
Kcal requirements
Protein requirements
Facility standards
1,207-1,335 kcal (1.2 63-79 g protein
activity factor)
Fluid requirements
20-25 mL/kg (IBW
90-120%), 1,268-
Anastasia Maczko
1,585 mL
EAL
Online nutrition care
manual
When possible use
indirect calorimetry, if
unavailable use
Mifflin st jeor
Use Mifflin st jeor
Pts over 65+ 1.0-1.25
with 1.3 sedentary
g/kg/day
activity factor *Note
UMH uses 1.2 AF for
sedentary, 1,3081,446 kcal/day
1 mL/kcal
References:
Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT)
Reference Manual. Chicago, IL: American Dietetic Association; 2013.
Academy of Nutrition and Dietetics. Nutrition Care
Manual®. http://www.nutritioncaremanual.org. Accessed September 13, 2014.
Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's
Food & the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier/Saunders, 2012. Print.