Miska Upton
Medical Nutrition Therapy 1
Case Study #1
Dr. Alireza Jahan-mihan
September 8, 2014
Clinical Case Studies for the Nutrition Care Process
Case 1: General Nutrition Assessment
Learning Objectives
1. Recognize anthropometric, biochemical, clinical, and dietary factors that impact on
nutritional status.
2. Calculate and interpret weight change and body mass index.
3. Determine adequacy of dietary intake.
4. Apply the Nutrition Care Process to an elderly patient.
Case Description Background
Adequate nutrition can be viewed as a state of balance between intake, requirements, metabolism, and losses of
nutrients. The term malnutrition usually refers to a state of undernutrition, and has been associated with increased
morbidity and mortality in the clinical setting (1-4). The accurate identification and patients at risk for malnutrition
and its associated complications is both an art and a science; subjective and objective data are interpreted along with
clinical judgment to evaluate nutritional status. From the dietary standpoint, a full evaluation considers not only
calorie and protein intake but also vitamin and mineral status. Surrogate markers of visceral protein stores such as
serum albumin and prealbumin have traditionally been measured for nutritional assessment. These parameters are
now known to be affected by many factors, including hydration, physiological stress, and inflammation. Particularly
during metabolic stress, serum proteins more specifically reflect severity of illness than nutritional stores (1-7).
While a low serum albumin is associated with an increased morbidity and mortality, it cannot be used alone to
measure nutritional status or repletion. Conversely, a normal serum albumin cannot be used in isolation to rule out
malnutrition. Serum protein levels by themselves do not form the basis for nutrition diagnosis or intervention.
Individual assessment parameters should be considered as part of the biggest picture of nutritional equilibrium. The
client is a 76-year old woman with a history of hypertension admitted to the hospital after tripping over her cat and
falling at home. She is admitted for a femur fracture. She is currently confined to bed.
Nutritional Assessment Data
1. Anthropometric Measurements.
Height: 67’
Weight: 140lb
Usual weight: 160lbs 6 months ago. She has been unmotivated to cook since the loss of
her husband during the previous 6 months.
2. Biochemical Data, Medical Tests, and Procedures.
a. Labs
Parameter
Value
Sodium
140 mEq/L
Normal Ranges*
(may vary by age, sex, and lab)
135-147 mEq/L
Potassium
3.2 mEq/L
3.5-5.0 mEq/L
Chloride
103 mEq/L
98-106 mEq/L
Carbon dioxide
29 mEq/L
21-30 mEq/L
BUN
19 mg/L
8-23 mg/L
Creatinine
1.0 mg/L
0.7-1.5 mg/L
Glucose
108 mg/L
70-110 mg/L
Hemoglobin
12.0 g/L
12-16 g/L (female)
Hematocrit
38.1%
36-47% (female)
Albumin
3.2 g/dL
3.5-5.5 g/L
Prealbumin
11mg/dL
16-40 mg/L
b. Test results, if pertinent
X-ray indicates fracture of left femoral neck.
3. Nutrition-Focused Physical Findings
Blood pressure: 128/65 mm Hg
Oral mucosa dry. Has upper and lower dentures which are poorly fitting.
Skin turgor decreased.
4. Client History
Social Hx:
No smoking or alcohol
Husband diet 6 months ago and patient has lost weight since this time
Family Hx:
N/A
5. Food/Nutrition-Related History
Usual Diet
Breakfast:
1 cup (8oz) decaffeinated tea with 1 tbs half and half and 1 tsp sugar
1 slice white toast with 1 tsp margarine and 1tsp jelly or 1 frozen pancake with 1 tbs syrup
½ cup orange juice
Lunch:
Canned soup, usually chicken noodle, 1 cup
4 unsalted crackers with 2 tbs peanut butter
½ cup sliced peaches in light syrup
Sweetened iced tea, 1 cup
Dinner:
Chicken thigh with skin, stewed
½ cup rice or potato with 1 tsp margarine
½ cup spinach or carrots
1 cup (8oz) decaffeinated tea with 1 tbs cream and 1 tsp sugar
Notes:
Rarely eats or drinks between meals.
Avoids eggs and milk due to food preferences.
Medications
Furosemide 20 mg daily
Supplements
None
Questions:
1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW (1
point), % UBW (1 point), and BMI (1 point). Interpret her weight and weight change
based on these parameters (2 points).
2. Height: 170.18cm 1
3. Weight: 140lb/2.2kg/lb= 63.63 kg 1
4. IBW: (63.64 kg/ 60.09 kg) x 100 = 104 % 1
5. The patient has lost 20lbs in six months, resulting in a 12% wt loss.
6. BMI: 21.9 1
7. UBW= (63.64 kg/72.73 kg) x 100 = 87.5%. 1
8. Calculate her nutritional requirements (calories, protein, and fluid) (3 points) and
compare her current intake to her needs (2 points).
9. Mifflin St Jeor:
10. 10 x 63 (630) + 6.25kg x 170cm (1062.5)-5 x 76(380)-161=1151.5
11. Harris-Benedict Equation:
12. 447.593+ (9.247 x 63kg) + (3.098 x 170)- (4.330 x 76)=1227.7 cal
13. Total Carbohydrate: 130.0g 2
14. Dietary Fiber: 21.0g 2
15. Protein: 1g/kg BW= 64 g/d 1
16. Fluid intake: 30ml/kg BW= 1910 ml/d 1,2
17. The pt fluid intake is very low. She is only taking in, on average around 1000 ml/d of fluid,
none of which is water.
18. Based off the patients food history, an example day of eating provides her with an estimated
1000 kcal, which is only around 65% what her caloric intake should be.
19. The protein requirements for the patient is 64g/d, though she is roughly only taking in about
40g/d.1,2
20. Are any major food groups and nutrients obviously missing from her diet? Explain
your answer.
21. Even though the patient is not fond of milk, there is a need for dairy products (yogurts or
cheese) in order to increase her calcium intake. Her protein intake is low due to only a small
amount of proteins in the diet. And the patients fruit and vegetables are not in the amounts
that they should be.3
22. Do you think she could be experiencing any drug–nutrient interactions? (2 points) If so,
what dietary suggestions would you make? (3 points)
23. The patient is taking 20 mg of Furosemide daily, which is an antihypertensive loop diuretic.
This calls for an increase in potassium as well as magnesium and calcium. Furosemide
interacts with many minerals, which leads to loss of minerals in the urine. I would
recommend that the patient eat foods like sweet potatoes, beans, bananas, yogurt, or green
leafy vegetables. Furosemide also can increase the risk of anorexia. This will need to be
particularly monitored for risk of inadequate nutrient intake. 4
24. Interpret her serum albumin and prealbumin. (2 points) In addition to nutritional
intake, what factors can cause these indices to drop? (2 points) What factors would
cause them to be elevated? (1 point)
The normal ranges for albumin are between 3/5-5.5 g/dL and for prealbumin 16-40mg/dL. 1,5
The patients albumin levels are at 3.2 g/dL and her prealbumin level is 11 mg/dL. Her low levels
or albumin and prealbumin levels indicate that her protein intake is too low. Decreased albumin
levels can also indicate low levels of iron, vitamin A and zinc deficiencies. 1 It could also
decrease from malnutrition, kidney disease, liver disease and gastrointestinal malabsorption
syndromes. 5 Elevated levels of albumin can occur when the patient is dehydrated. 1 Low levels
of prealbumin levels can occur if the patient is deficient in zinc, has acute stress reactions, liver
disease or hemodilution. 5 Elevated levels of prealbumin can be due to renal failure. 1
25. Describe how factors in her anthropometric, biochemical, clinical, and dietary
nutritional assessment data all fit together to form a “picture” of her nutritional health.
(5 points)
26. Anthropometric Ax: The patient is an elderly, 76 year old woman who’s BMI is in the
normal range. However, she has lost nearly twenty pounds in the last 6 months, causing
concern.1
Biochemical Ax: The woman’s albumin and prealbumin levels are both very low, which
could indicate a number of deficiencies or risk factors. 1,2 The patients low levels most likely are
related due to inadequate amounts of protein in her diet. 2
Because the patient is taking furosemide, she needs to increase her amounts of potassium. Currently
the patients potassium levels are around 3.2 mEq/L, which is below the normal ranges of 3.5-5.0
mEq/ L.
Clincal Ax: Though the patient has no family history of hypertension, the patient’s blood pressure is 128/65 which
is pre-hypertensive. 3 Some causes of hypertension might be high levels of sodium intake, insufficient
calcium, potassium and magnesium consumption, kidney disease, or stress.
Dietary Ax: The patient clearly is not taking in enough calories to sustain a healthy diet. Her protein
requirements are also not being met, which is leading to low levels of albumin and prealbumin.
The patients lack of calcium, due to the patients preference to not have milk, is low. There is a need
for the patients to increase her protein, dairy, and whole grains in her diet. Her fluid intake is also
low and should be increased. 1,3
27. Write a PES statement based on the nutritional assessment data available. (5 points)
Inadequate amounts of protein related to low intake as evidence by low albumin and
prealbumin levels.
Inadequate amounts of potassium in the diet related to inadequate intake of fruits, vegetables
and whole grains and supplementation of furosemide as evidence by patients diet recall and
biochemical test.
28. What dietary and social changes would you suggest to improve her nutritional intake?
(5 points)
29. For dietary changes, I would suggest that the patient increase her calorie intake by 200-300
calories. I would stress the importance of adding protein sources like beans, lean meats and
fish into her diet as well as the importance of adding whole grains, fruits, and dairy. Because
of her medications, I would explain the need for potassium and how she could easily raise her
levels by incorporating fresh produce into the diet. Because of her fracture and lack of milk
consumption, I would encourage the client to look for other sources of calcium like leafy
greens, broccoli, nuts, and beans. 1,3
30.
For social changes, I would ask the client if she had any family near by that could
help prepare and enjoy meals with. According to the patients assessment, the client has lost
twenty pounds since the death of her husband, indicating decreased amounts of food as well
as a possible sign of depression. 1
31. What are your nutritional goals for her (2 points), and how would you monitor the
effectiveness of your interventions from question #8? (3 points)
32. My nutritional goals for the client would be an increase in protein, calcium and potassium
within 3 days. I would also like to see her increase her fluid and caloric intake by 25% within
the next 42 hours.
33. I would monitor the effectiveness of my intervention by asking how the patient is feeling in
regards to cooking and preparing meals with family members or friends and follow up on this
to see if she initiated any meal time fellowships within the last week.
34.
35. Write a note documenting your assessment in SOAP or ADIME format. (5 points)
S: Inadequate diet, inadequate fluid intake, inadequate protein intake. Lives and eats alone since
husbands passing. PMH-HTN. 1
O: Patient is 5’7. Admitted into hospital for femur fracture. PMH-HTN. BMI= 21.9. IBW=60. Low
K. ALB: 3.2 g/dL. Taking furosemide for HTN. 1-5
A: Pt is a at normal BMI. severe wt loss since husband passing in 6 months. Needs to increase fluid
intake, calories, protein. Drug-nutrient interactions with furosemide could possibly be leading to
anorexia, need for K, Ca, and Mg. 1-5
P: Counseling on ways increase fluid and calories needed. Recommending social meal times to enjoy
eating meals more. Schedule snacks throughout the day and set goals to achieve fluid intake. Follow
up with pt in 2 weeks to check levels of Ca, K, and Mg as well as albumin and prealbumin to check
for adequate dietary changes. 1-6
References:
1.
Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care
Process. St. Louis, Mo: Elsevier Saunders; 2012.
2.
SuperTracker Web site. http://supertracker.usda.gov. Accessed September 10, 2014.
3.
Nelms M, Sucher K, Long S. Thomson/Wadsworth, Nutrition Therapy and Pathophysiology
Australia, Third Edition, 2010- 2011.
4.
Pronsky ZM, Crowe JP. Food-Medication Interactions. Birchrunville, Pa: FoodMedication Interactions; 2010: 110.
5.
WebMD Website. http://www.webmd.com/a-to-z-guides/total-serum-protein?page=2.
Accessed September 10, 2014.
6.
Emery EZ. Clinical Case Studies for the Nutrition Care Process. Burlington, Ma: Jones &
Bartlett Learning; 2012: 3-7.