Nutrition Care Conference
Joanna Murawski
December 4, 2014
Evergreen Health Care Center
Stafford Springs CT
Patient Background
HR
92 years old
Female
Caucasian
Admission date: 8/2/14 initial admission after discharge from
MMH with BLE edema and blistering
• Dates seen: 10/16/14, 11/6/14
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Physical Signs
• Swollen, bruised, blistered legs
• Other skin areas: intact, healthy
▫ No dryness
• Appeared overweight
▫ edematous
Psychosocial data
• Previously lived alone at home
• In the process of applying for long
term care Medicaid
• Currently in the subacute unit and
will be transitioning to long term
care
• Non-ambulatory
• Roommate
Anthropometric data
• Ht: 61” (1.55m)
• Wt: 261 lb (118.6 kg)
• BMI: 49 (class 3 obese Morbid)
Clinical data:
• BP:110/62
• Temperature: 98.3°F
• UBW - admission: 182 lb (82.7 kg)
• BMI 34 (class 1 obese)
• IBW: 105 lb (47.7 kg)
• % IBW: 248.6%
• Adjusted: 144 lb (65.5 kg)
• % IBW (using UBW): 173%
• Adjusted: 124.5 lb (56.4 kg)
Primary Diagnosis
• Anasarca: massive edema.
▫ Edema occurs when fluid accumulates in body
cavities or extracellular tissue spaces.
 fluid buildup in the tissue around the body.
▫ May be d/t kidney disease, acute
glomerulonephritis (related to acute renal
failure), thyroid disease, some medications, and
other diagnoses.
▫ MNT: sodium and fluid restriction, diuretics.
▫ Input and output should be monitored to note any
decrease in fluid retention.
Secondary Diagnoses
• Lower extremity cellulitis and lymphedema:
• Lower extremity cellulitis:
▫ Inflammatory response, often d/t S. aureus or S. pyogenes infection
▫ Typically occurs on lower limbs. Painful swelling, blisters / ulcers
▫ Risk factors: obesity, skin trauma / wounds, leg ulcers, foot fungal infections
▫ Tx: elevate the leg, keep the area clean, pain relievers, antibiotics
• Lymphedema:
▫ Poor lymph drainage (from leg)
▫ Secondary d/t an existing infection
▫ Symmetrical lymphedema: typically d/t low albumin, kidney disease
▫ Tx: compression, leg elevation, manual drainage
Additional History
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Hypothyroidism
COPD
GERD
Osteoporosis
Pressure ulcer
Hypokalemia
UTI
• Hx blunt head trauma
• ARF
• Asthma: acute
exacerbation
• Anxiety
• Spinal stenosis
• Eczema
• Legally blind
• Intractable L. ankle
Significant Medications
• Protein powder: 1 scoop BID
• Lasix: Antihypertensive loop diuretic.
▫ Depletes potassium, can increase blood glucose
• Synthroid: Thyroid hormone
▫ May increase glucose levels, grapefruit interaction, do not take with calcium
supplements
• Actonel: Osteoporosis treatment
▫ Calcium intake should be 1500 mg, Vitamin D intake 800 IU
• Vitamin D3: Calcium regulator
▫ Can cause increased thirst, dry mouth
▫ Use caution with decreased renal or cardiac function
• Serevent: Asthma, COPD treatment
▫ Can cause hypokalemia, stomach ache, N/V, throat irritation, decreased salivation
• Lactulos, Miralax, Colace : Stool softeners/ laxatives
Biochemical Data
Pt
Lab
Normal Range result:
10/14
BUN
7-18 mg/dL
34
Creatinine .6-1 mg/dL
0.6
136-145
Sodium
135
mmol/L
21-32 mmol/L
29.3
CO2
Pt
result:
10/28
25
0.6
Pt
result:
11/9
Pt
result:
11/10
23
0.7
Result
Significance
High
Normal
Renal failure, infections
136
136
Normal
34.4
34.4
High
7.4
Calcium 8.5-10.5 mg/dL
7.9
7.4
Albumin
3.4-5 gm/dL
1.7
1.9
Protein
6.4-8.2 gm/dL
4.2
N/A
N/A
4
WNL
3.7
WNL
3.4
N/A
Potassium 3.5-5.1 mmol/L
Prealbumin
18-35.7
1.8
16.2
N/A
May be d/t COPD
Low intake, vitamin D,
Low
osteomalacia
Low
Edema, stress on the body
Edema, renal failure, protein
Low
deficiency
Low, borderline
Hypokalemia, diuretic
Low
Stress, infection, low protein
I & O, Weights
Date
29-Oct
1-Nov
4-Nov
7-Nov
10-Nov
11-Nov
12-Nov
I
O
1360
1500
1400
2400
1580
2400
1200
1400
1380
1450
1500
950
1500
1400
Amounts are in cc
Difference
-140
-1000
-820
-200
-70
550
100
Dietary Data
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Appetite: eats 75-100% of meals
No snacks
No allergies
Current diet order: NAS, 1500 cc fluid
▫ 1 scoop protein powder BID
Nutrition Diagnosis
PES: Increased protein needs related to leg cellulitis and
lymphedema as evidenced by albumin (1.9 gm/dL).
Dietary intervention adjustments:
• Increased protein needs (1.5 g/kg adjusted body wt)
• Monitor sodium 2000 mg/day or less
• Monitor calcium to meet 1200 mg/day
Intervention
• Follow up:
▫ Patient knowledgeable about need for protein
 Asks for double portions of meat for some meals
 Eats an egg daily
 Protein powder with applesauce BID
▫ Fluid restriction – Avoiding Xerostomia:
 Eats oranges slowly morning and night
 Mints, gum
 Sips water slowly
• Re-educate staff on supplement preparation
Nutritional Needs
• Harris Benedict:
• Adjusted BW, USUAL, AF = 1.2, IF = 1.1
= 1369 kcal
• Carbohydrate: 45% 154 g
• Protein: 25%: 86 g
• 1.5 g/kg ABW (usual) = 84.6 g
• 1.1 g/kg UBW = 91 g
• Fat: 30% 46 g
• 1500 cc fluids
• 2g Na+
Vitamins & Minerals
• Sodium: 2g Na+ / day
• Calcium: strive to meet 1200 - 1500 mg/day
• Vitamin D: continue supplementation of 1000 IU QD
Sample Meal Plan
Lunch:
Breakfast:
▫ 1 hardboiled egg
▫ ½ cup cream of
wheat
▫ 1 small orange
▫ 4 oz lowfat milk
▫ 8 oz water
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5 oz baked salmon
1/3 cup brown rice
½ cup cooked spinach
½ cup light ice cream
4 oz lowfat milk
8 oz water
Snacks:
• 4 oz applesauce with 1 scoop protein powder
BID, 7 oz water
• 4 oz applesauce with 1 scoop protein powder
BID, 7 oz water
Dinner:
• Grilled cheese sandwich:
• 2 slices low sodium
cheese with 2 slices
low salt wheat bread
and 2 tsp butter
• ½ cup cooked zucchini
• 2 oz grapes
• 4 oz lowfat milk
• 8 oz water
Evaluation
• Monitor weight and Intake / Output
• Monitor leg wound healing
• Lab results:
▫ Steady decrease in BUN to 18 gm/dL
▫ Albumin increase to 3.4 gm/dL
▫ Monitor calcium
Questions?
References
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Al-Niaimi F, Cox N. Cellulitis and lymphoedema: a vicious cycle. Journal of Lymphoedema 2009;4(2):38-42. Retrieved from:
http://www.woundsinternational.com/pdf/content_11173.pdf
American Dietetic Association. (2008). Choose Your Foods: Exchange Lists for
Diabetes. Alexandrea, VA: American Diabetes Association.
Anasarca.org. (2007-2014). Anasarca. Retrieved from: http://www.anasarca.org
Lab Tests Online. (2012) Bicarbonate. Retrieved from: http://labtestsonline.org/understanding/analytes/co2/tab/test/
Conde Nast. (2014) SelfNutritionData: Know what you eat. Retrieved from:
http://nutritiondata.self.com/
Mahan, K.L., Escott-Stump, S., Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th ed.). St. Louis, MO: Elsevier Saunders.
MedLine Plus: Trusted Health Information for You. (2014, October 09). Swelling.
Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm
Medline Plus: Trusted Health Information for You. (3 January 2014). Drugs,
Supplements, and Herbal Information. Retrieved from:
http://www.nlm.nih.gov/medlineplus/druginformation.html
The Merck Manual: Professional Edition. (2010-2014). Hypokalemia. Retrieved from:
http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/electrolyte_disorders/hypokalemia.html
NCM: Nutrition Care Manual Pressure Ulcers and Other Skin Conditions (2014): Academy of Nutrition and Dietetics. Retrieved from
Pronsky, Z.M., Crowe, J.P. (2012). Food-Medication Interactions (17th ed.).
Birchrunville, PA: Food-Medication Interactions.
Images:
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http://www.algen.com/images/Detecto495_small.jpg
http://openi.nlm.nih.gov/imgs/512/278/1852096/1852096_1471-2369-8-6-2.png
http://g-ecx.images-amazon.com/images/G/01/aplus/detail-page/B001W6RHRK_043900284101_L11_3D.jpg
Eggs: Free Images. (2009) HAAP Media. Retrieved from: http://www.freeimages.com/ http://www.freeimages.com/assets/35/349234/4-eggs-731131-m.jpg