Your Name and/or Name of Partner (if working with one):
Sydney Boehnlein
Kaela Pittman
University of Minnesota - Department of Food Science & Nutrition
FScN 4665 - Medical Nutrition Therapy I
Fall 2014
Case 1
100 Points
Due Date: THURSDAY, OCTOBER 9th
Please be sure to do the following:
 Show all calculations, and explain your rationale. Calculations do not have to be typed.
 Answer all questions directly on this form. Type all answers (except calculations).
Submit in hard copy in class on the due date. You will be deducted one point per day
after the due date until the hard copy is turned in.
 You may work ALONE or with ONE other person. Do not share your work with other
individuals beyond your group. If you work with a partner, you should hand in only
ONE case with your name and your partner’s name clearly listed at the top of the first
page.
Some resources needed for solving the Case:
1. Lecture notes on Nutrition Assessment I-History and Physical Examination
2. Lecture notes on Nutrition Assessment II- Anthropometry
3. Lecture notes on Nutrition Assessment III-Biochemical/Laboratory
4. Lecture notes on Assessment of Acid-Base Balance
5. Module I: Nutrition Care Process, Nutrition Diagnosis and Medical Record
Documentation
6. Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting
7. Module III: An Introduction to the Exchange Lists for Meal Planning
8. Module IX: Pulmonary Disorders
9. Academy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines
(Chronic Obstructive Pulmonary Disease). Link to the EAL website is posted in Moodle
10. IDNT Reference Manual nutrition diagnoses pages
11. Krause’s Food and the Nutrition Care Process, 13th edition.
a. Chapter 35: Medical Nutrition Therapy for Pulmonary Disease.
b. Appendix 34 (1110-1121)
From the admitting physician’s note:
Chief complaint: “I am always short of breath, especially when I am doing any kind of physical
activity and my husband thinks I am confused in the morning.”
Patient Hx: Stella Bernhardt is a 62-year-old Caucasian retired office manager who is married
and has 4 grown children. Mrs. Bernhardt was initially diagnosed with type I COPD
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(emphysema) five years ago. She has a 46-year history of smoking, but quit 1 year ago. She
states: “I’m hardly able to do anything for myself right now. Even taking a bath or getting
dressed makes me short of breath. I feel that I am gasping for air. I am coughing up a lot of
stuff that is dark brownish-green.” Mrs. Bernhardt is wondering if her symptoms are related to
her COPD.
Type of treatment:
PMH: COPD type I (emphysema), bronchitis and upper respiratory tract infections (mostly
during winter months), four live births, and two miscarriages
Meds: Combivent inhaler
Allergies: None
Smoker: 1 ppd
Family Hx: Father deceased at age 52 from pneumonia, mother still living
Physical Examination:
General appearance: Very thin, middle aged woman, evident temporal and interosseous wasting,
in no acute distress
Vitals: Temp 99.1° F, BP 135/70, HR 77 BPM, RR 21
Skin: Warm, skin pallor
Nail bed: mild koilonychias
Eyes: pale conjunctiva
Height: 5’3”
Weight: 92 lbs
Mid arm muscle circumference (MAMC): < 5th percentile,
Exhibits generalized loss of muscle in shoulders and thighs. Subcutaneous fat loss is evident in
triceps.
Clinical Examination:
The nervous system is intact. Chest/lung examination reveals decreased breath sounds,
percussion hyperresonant, prolonged expiration with wheezing, rhonchi throughout. Pt has
poorly fitting dentures.
From the initial nutrition screen documented by dietetic technician:
Nutrition Hx:
General: Mrs. Bernhardt states that her appetite is poor. She says “I fill up so quickly – after just
a few bites.” She also relates that meal preparation is difficult: “By the time I fix a meal, I am too
tired to eat. And things just don’t seem to taste as good either.” In the previous two days, she
states that she has eaten very little. Increased coughing has made it very hard to eat. Her
“normal” adult weight was 145-150 lbs (~3 years ago). She estimates that she weighed ~120 lbs
about 6 months ago. She states that her family constantly tells her how thin she has gotten. She
states that she hasn’t weighed herself for a while, but that she knows her clothes feel baggy.
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Typical dietary intake:
Breakfast:
1 poached egg, 1 tsp butter, 1 slice whole wheat toast, 16 oz. coffee, 1 T.
half and half, ½ cup orange juice
Lunch:
3 chicken nuggets (fast food), ½ cup mashed potatoes, 1 T. reduced fat
margarine, 1 biscuit (plain), 16 oz. coffee, 1 T. half and half
Dinner:
1 cup cream of mushroom soup made with water, 1 slice whole wheat
toast, ½ large (8 oz.) banana, 36 oz. Diet Pepsi
HS Snack:
3 saltine crackers, 1 oz. American cheese
Food allergies/intolerances/aversions: None
Previous MNT? Mrs. Bernhardt has never met with a Registered Dietitian in the past, but her
primary physician has told her she needs to increase calorie consumption.
Food purchase/preparation: Mrs. Bernhardt purchases and prepares her own food or she eats at
restaurants/fast food outlets. She avoids milk because she has heard it can increase mucous
production.
Vit/Min or other supplements: None
Activity: None
Treatment Plan:
O2 1 L/min via nasal cannula with humidity – keep oxygen saturation (SaO2) 90 – 91%
IVF: D5 ½ NS with 20 mEq KCl @75 ml/hr
Labs/Tests: ABGs q 6 hours, CXR – EPA/LAT, sputum cultures and gram stain
Diet order: Regular
Meds:
Solumedrol 10 mg/kgq 6 hr
Ancef 500 mg q 6 hr
Ipratropium bromide via nebulizer 2.5 mg q 30 minutes X 3 treatments then q 2 hr
Albuterol sulfate via nebulizer 4 mg q 30 minutes X 3 doses then 2.5 mg q 4 hr
Hospital course:
Mrs. Bernhardt was diagnosed with acute exacerbation of COPD secondary to bacterial
pneumonia. This was confirmed by CXR (chest X-ray) and sputum culture. She responded well
to aggressive medical treatment for her emphysema. She will be discharged on home oxygen
therapy for the first time, and referred to outpatient pulmonary rehabilitation. Her discharge
medications will be the same (Combivent), but she will complete an oral course of
corticosteroids and an additional 10-day course of Keflex. A nutrition consultation is ordered,
with recommendations for nutrition follow-up through the outpatient pulmonary rehabilitation
program.
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Laboratory data:
Lab Test
Day 1
Day 2
Day 3
Normal Range
Units
Glucose
92
103
88
70 - 110
mg/dL
Na+
139
137
140
136 - 145
mEq/L
-
Cl
101
100
99
95 - 107
mEq/L
K+
3.7
3.6
3.6
3.5 - 5.0
mEq/L
9
8
8
8 - 25
mg/dL
Cr
0.9
0.9
0.8
0.6 - 1.5
mg/dL
Phosphorus
2.3
2.5
3.0
2.6 - 4.5
mEq/L
Mg++
1.5
1.7
1.5 - 2.2
mEq/L
Calcium
8.2
8.1
3.0 – 7.0
mg/dL
Albumin
8.0
8.5 – 10.5
mg/dL
4.5
6 – 8.5
g/dL
BUN
Prealbumin
Alkaline Phosphatase
Lab Test
8.0
4
220
219
217
200 - 400
mg/dL
Day 1
Day 2
Day 3
Normal Range
Units
White Blood Cells (WBC)
115
25 - 160
U/L
Hemoglobin (Hgb)
10.5
12.5 – 17.0
g/dL
Hematocrit (Hct)
33
36.0 – 50.0%
%
Mean corpuscular volume (MCV)
65
80.0 – 98.0
fL
pH
7.29
7.35 – 7.45
PCO2
50.9
35 - 45
mmHg
77
80 - 100
mmHg
24.7
22 - 26
mEq/L
Arterial Blood Gases:
PO2
HCO3
Laboratory information prior to admission:
Annual CBC and lipid profile- WNL
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NUTRITION ASSESSMENT
Dietary Intake Data
1. From Mrs. Bernhardt’s typical dietary intake, calculate the total number of calories she
consumed. Also calculate the energy distribution of calories for protein, carbohydrate, and fat.
For this question, you must use the Exchange Lists for Meal Planning (Use Appendix 34 in the
back of the Krause text: See pp. 1110-1121 (13th ed.) and Module III, “An Introduction to the
Exchange Lists for Meal Planning”), and complete each of the steps outlined below, showing
your calculations.
Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate
that is designated as such under “Other Carbohydrate” or “Combination” lists as simply
“Carbohydrate” rather than “Starch”, and then count these separately under “Other
Carbohydrates” in the table for Step 2. Complete the table below. (10 points)
Breakfast
1 slice whole wheat toast
1 tsp butter
1 poached egg
16 oz. coffee
1 Tbsp half and half
½ cup orange juice
Lunch
3 chicken nuggets (fast food)
½ cup mashed potatoes
1 Tbsp reduced fat margarine
1 biscuit (plain)
16 oz. coffee
1 Tbsp non-dairy creamer
Dinner
1 cup cream of mushroom soup made
with water
1 slice whole wheat toast
1/2 large (8 oz) banana
36 oz. Diet Pepsi
Evening (HS) Snack
3 saltine crackers
1 oz. American cheese
Counts As (Specify Exchanges)
1 starch
1 fat
1 medium fat meat
Free food
½ saturated fat
1 fruit
½ carbohydrate, 1 medium fat meat, ½ fat
1 starch
1 fat
1 starch
Free food
Free food
1 carbohydrate & 1 fat
1 starch
1 fruit
Free food
½ starch
1 high fat meat
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Step 2: Add the totals from the table in step 1. Count all items that were listed anywhere
besides the “STARCH” list, that counted as carbohydrate exchanges, under the “Other
carbohydrate” section in the table below. Count as starches ONLY those foods listed
specifically on the STARCH list. (10 points)
Total
servings/
day
Exchange Group
CHO
(g)
Protein
(g)
15
4.5
Starch
Fat
(g)
3
Use 0
5
2
0
15
0
0
15
0
0
12
8
0
12
8
0
12
8
5
12
8
8
0
7
3
0
7
5
67.5
13.5
0
Non-Starchy Vegetables
2
Fruit
1.5
Other Carbohydrates
Fat-Free Milk
0
Low-Fat Milk (1/2 - 1%)
0
Reduced-Fat Milk (2%)
0
Whole Milk
0
Lean Meats/Substitutes
0
Medium Fat Meats/Substitutes
2
30
22.5
14
0
High Fat Meats/Substitutes
1
7
0
8
8
0
4
Fats
10
7
5
20
TOTAL grams
120
34.5
38
Determine kcals by multiplying TOTAL grams
X4=
X4=
X9=
TOTAL KCALS
480
138
342
GRAND TOTAL KCALS (CHO + protein + fat)
960
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Step 3: Determine the % kcals provided by CHO. (2 points)
480 kcals CHO/960 kcals = 0.5 *100 = 50% kcals provided by CHO
Step 4: Determine the % kcals provided by protein. (2 points)
138 kcals Pro/960 kcals= .14*100 = 14% kcals provided by protein
Step 5: Determine the % kcals provided by fat. (2 points)
342/960 = .36 *100 = 36% kcals provided by fat
Anthropometric Data
2. A. Calculate Mrs. Bernhardt’s “ideal” weight using the Hamwi equation. (2 points)
IBW = 100 + (5*3) = 115 pounds
B. Calculate the % “ideal” weight and % usual body weight she is at her current weight. (4
points)
% IBW = (92 lbs/115 lbs) *100= 80%
%UBW = (92 lbs/145 lbs) * 100 = 63%
Note: 145lbs was determined as pts’ usual body weight because the evaluation of changes
of body weight over time is the most useful (See Nutrition Assessment II:
Anthropometry, slide 9)
C. Calculate Mrs. Bernhardt’s BMI. Into which category does she fall, based upon the
National Institutes of Health, National Heart, Lung, and Blood Institute’s Clinical
Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults, which was provided in the “Nutrition Assessment II: Anthropometry” notes? (2
points)
5.25ft/3.28 ft per meter = 1.6 m
92 lbs /2.2 lbs per kg = 41.8 kg
BMI = 41.8/1.6^2 = 16
BMI Classification: Underweight
D. Evaluate Mrs. Bernhardt’s current weight in terms of change from usual body weight
over time (be specific). If she has lost weight, is it clinically significant? Explain. (4
points)
In 3 years: [(145 lbs – 92 lbs) /145 lbs]*100=36.6% weight loss.
In 6 months: [120 – 92)/120] *100 = 23% weight loss.
According to Nutrition Assessment II: Anthropometrics, Slide 9, pts’ weight loss is
considered clinically severe weight loss because she has lost over 10% of her usual body
weight in the last 6 months.
3. Evaluate Mrs. Bernhardt’s dietary intake, anthropometric, PE/clinical, and biochemical data
pertinent to her pulmonary status. When appropriate, compare her data to standard/normal
values. Be as thorough and SPECIFIC as possible, and then clearly identify at least ONE
piece of data that is of concern from a nutritional standpoint within each data category
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as you begin to prioritize the most prominent nutrition issues that need to be addressed.
EXPLAIN your rationale for each issue that you mention.
A.
Dietary intake data (Refer back to what you found in question #1 and evaluate Mrs.
Bernhardt’s intake in terms of major nutrients or food groups that appear to be
lacking, and any obvious problems you think she is having with intake) (2 points):
Mrs. Bernhardt is lacking in her vegetable (3-4 serving less than the suggested
number of vegetables serving per day), fruit (1 serving less than the suggested
number of fruit serving per day) and dairy (2 servings less than the suggested number
of dairy servings per day) intake, according to the Academy of Nutrition Dietetics
MyPlate’s suggestions. At the same time, the patient has excessive fat intake.
Based on her dietary intake data, one primary concern from a nutritional standpoint is
the thought that she is not getting enough of the vitamins and minerals that come
from produce as she should. There is no claim that she has been taking a multivitamin
either.
B. Anthropometric data (refer back to your answers in question #2) (2 points):
Mrs. Bernhardt is 23 pounds underweight, her BMI is 16 (which classifies her as
underweight), she is only 80% of her ideal body weight and 63% of her usual body
weight. In the last 3 years she has lost 36.6% of her body weight and in the last 6 months
she has lost 23 % of her body weight. Both weight loss percentages are considered severe
weight loss when evaluated over time. Her mid arm muscle circumference percentile is
under the 5th percentile, determining that patient is in muscle and fat deficit. Based on
anthropometric data, one primary nutrition concern from a nutritional standpoint is her
severe weight loss based on her current weight.
C.
PE/clinical findings (2 points):
From Mrs. Benhardt’s physical examination the following the following conclusions
can be made: based on general appearance , including her evident temporal and
interosseous wasting, her thin body type, extremely low mid arm muscle
circumference, noticeable general loss muscle in shoulders and thighs as well as
subcutaneous fat loss in triceps all lead to the conclusion that the patient suffering
from subcutaneous fat and muscle loss. Her body temperature is slightly higher than
the normal value (normal being 98.6 degrees F). Her nail bed appetence
(kolilonychia) and eye discharge (pale conjunctivia) both lead to the conclusion that
patient is iron deficient.
Based on clinical examination from a nutritional standpoint, one main concern would
be the patient’s ill-fitting dentures because this may hinder her ability to eat and
therefore consume the nutrients she needs.
D.
Biochemical data (2 points):
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Based on the patient’s laboratory data, while all other tests were measured in the
normal range, Mrs. Bernhardt’s prealbumin and albumin levels were low days 1-3
which both indicate metabolic stress, inflammation, inadequate protein intake and the
possibility of liver disease. Her phosphorous levels were low day 1 and 2 and her
blood calcium was elevated day 1-3. One hypothesis for the patient’s high calcium
would be that it is a result of her low prealbumin which is responsible for the
transport of major blood constituents, including minerals like calcium. This low
prealbumin could also be responsible for her elevated body temperature because this
protein is no longer transporting enough thyroxine (which regulated body
temperature).
Because Phosphorous, Magnesium and Potassium were all measured to be low or at
the low end of their normal range, it is important for these minerals to be watched and
maintained to avoid the refeeding syndrome since the patient is currently receiving
nutrition support.
The patient exhibits elevated calcium levels, hypercalcemia, which would account for
some of her muscle weakened and her anorexia.
Mrs. Bernhardt also exhibited a low Hemoglobin, Hematocrit and Mean Corpuscular
Volume indicating she has iron deficiency anemia.
The patients low pH and pO2 and high pCO2, as well as her normal HCO3 lead to the
conclusion that the patient has respiratory acidosis and high lung CO2 retention.
4. Calculate Mrs. Bernhardt’s serum osmolality from her admission labs, as one indicator of her
hydration status upon admission. What does this value you calculated suggest about her
hydration status at admission? Mention any relevant clinical/PE data to support your
evaluation. (6 points)
Serum Osmolality, using the Day 1 admission measurements = (139 mEq/L*2) +(9
mg/dL/2.8)+(92mg/dL/18)= 286.3 mOsm/kg. The measurement indicated that she is
euhydrated and within a normal hydration status. Physical examination and clinical data that
support this evaluation include her within normal range blood pressure and heart rate and
warm skin pallor.
5. Review all four of Mrs. Bernhardt’s current medications, and describe any relevant foodmedication interactions. If there are no relevant food-medication interactions for a particular
medication, be sure to state that. (4 points)
- Solumedrol: this anti-inflammatory/corticosteroid may cause hyperglycemia, negative
nitrogen balance, and sodium & fluid retention and decreased absorption of calcium &
potassium. The patient exhibits none of the side effects listed above.
- Ancef: this antibiotic may cause a decreased intestinal flora and decreased vitamin K
synthesis. Patient should maintain probiotic and vitamin K intake and watch for diarrhea
caused by C. difficile. This should be tested before any anti-motility agent is prescribed.
- Albuterol sulfate: a bronchodilator which does not exhibit any food-medication interactions.
- Ipratropium bromide: an anticholinergic drug that does not exhibit any food-medication
interactions.
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6. Look at Mrs. Bernhardt’s arterial blood gas report when she was admitted.
Using your “Assessment of Acid-Base Balance” notes, assess Mrs. Bernhardt’s acid-base
status at admission. She could be in one of 4 conditions (see the summary chart at the end of
the note set): Specify whether she is in respiratory or metabolic (one or the other, depending
upon the origin of the disorder) acidosis or alkalosis. Use specific values to support your
answer. (4 points)
Because the patient’s pH is low (at 7.29, when a normal range is 7.35-7.45), pCO2 is high
(at 50.9, when a normal range is 35-45), p02 is low (at 77, when normal range is 80- 100)
and HCO3 is normal (at 24.7, within the normal range of 22-26) the patient is considered to
be exhibiting uncompensated respiratory acidosis with high lung CO2 retention (kidneys are
not yet doing anything to compensate for acidosis.
Calculation of Nutrient Needs
7.
Refer to the guidelines given in “Module II: Energy, Protein, and Fluid Requirements in
the Clinical Setting” and “Module IX: Pulmonary Disorders” to complete the following.
Show your work and specify the source for your answers, and explain your reasoning for
making the choices you made.
A.
B.
Using an appropriate prediction equation (with or without activity/stress or injury
factor, as you deem appropriate), estimate Mrs. Bernhardt’s total energy
requirement. As always, explain your thinking and show your work. (4 points)
Because the patient is not critically ill (and dependent on a ventilator) we chose to use
the Mifflin-St. Jeor Equation v. the Penn State Equation when estimating her resting
energy expenditure.
REE = 655.1 + (9.56 *41.8kg) +(1.85*63 in) – (4.68*62yrs)= 1461.41
TEE= 146* 1.4= 2119 kcals/day
We used 1.45 as an adjustment factor for the Mifflin-St. Joer Equation as suggested
by Module IX: Pulmonary Disorders, Slide 23.
Cross-check your answer found in 7A by calculating what your assessed total
energy requirement is on a kcal/kg basis. You do this by taking the total energy
requirement estimated by your prediction equation method and dividing it by Mrs.
Bernhardt’s weight to get kcal/kg. How does the number you calculate compare to
the consensus numbers provided in Module II (i.e. is it within the range of what RDs
tend to use, even though this practice is not evidence-based per se)? Show your
calculations. (2 points)
2119kcal /41.8kg = 50.69 kcal/kg = total energy requirements based on kcal/kg basis
The consensus numbers provided in Module II would is 35 kcals/kg; this provide a
TEE of 1463 kcals based on the patient’s weight. This is almost exactly what we
calculated for the patient’s REE. However, the consensus numbers are not evidence
based and do not account for the adjustment needed because of the patient’s
pulmonary disorder.
10
C.
Estimate Mrs. Bernhardt’s protein requirement. Explain your thinking and show
your work. (2 points)
When managing COPD, it is important to have 1.2-1.7 g protein/kg body weight, as
stated by Module IX: Pulmonary Disorders, Slide 27.
1.2g protein/kg * 41.8 kg = 50.16 g protein
1.7 g protein/kg * 41.8 kg = 71.06 g protein
The range of protein requirements for the patient is 50.16-71.06 g protein per day. It
is important, when refeeding, to start out on the low end of protein requirement to
avoid respiratory muscle fatigue. Our goal would be to gradually increase the
patient’s protein intake within the necessary range to promote positive nitrogen
balance for repletion. Amino acids have been shown improve the side effects of
COPD. As protein administration advances, it is important to closely monitor its
effect on pCO2 and RQ.
D.
Using guidelines given in Module II, estimate Mrs. Bernhardt’s fluid needs. Show
your work. (2 points)
Using the ‘Rule of Thumb’ method for assessing fluid needs, on Module II: slide 50,
1 mL/ kcal energy required is required.
1mL*2119kcal = 2119 mL (21.19 L) of fluid is needed by Mrs. Bernhardt.
E.
Now go back to what you calculated as Mrs. Bernhardt’s typical total energy and
protein intake from Question #1, and compare it to your estimated total daily energy
requirement from part A. of this question (7A) and to your estimated total daily
protein requirement calculated in part C. of this question (7C). In other words, how
does her typical energy and protein intake compare to what you think are her actual
needs? You should express any differences in whole numbers and also as a
percentage of estimated needs (i.e. actual intake/estimated needs X 100). (2 points)
Typical total energy intake = 960 kcals
Typical protein intake = 34.5 g protein
TEE = 2119 kcals
Total protein requirement = starting at 50.16, advancing to 71.06 g.
(960 kcals/2219 kcals)*100 =45.3% TEE consumed
(34.5g/71.06g)*100 = 48.6% --- (34.5g/50.16g)*100 = 68.8 %
54.9-77.8% protein requirement consumed
Patient is consuming 1259 calories less than require (only 45.3% of her total energy
expenditure). She is consuming 15.7-36.6g less than requires (only 48.6-68.8% of her
total protein requirement).
NUTRITION DIAGNOSIS
8. Based on your assessment in question # 3, refer to the four required supplemental articles on
malnutrition listed under September 4th in the course schedule of the syllabus to determine if
Mrs. Bernhardt meets the definition of a specific category of malnutrition. Explain your
11
rationale with specific data relevant to the malnutrition characteristics. (2 points)
According to the supplemental readings, the patient is reported to meet 4 out of the 6
characteristics for the diagnosis of malnutrition including inadequate energy intake (45.3 % of
her caloric needs), severe weight loss (23% weight loss in months), loss of muscle mass (as
evidenced by temporal and interosseous wasting, and MAMC < 5th percentile during physical
exam) and subcutaneous fat loss (as evidenced by MAMC < 5th percentile and evident fat loss in
triceps during physical examination). No lab results indicated inflammation; because of this, it is
deduced that, based on the chart in the Krauss Text (Figure 34.4) & Welcome to Medical
Nutrition Therapy I, Slide 11, the patient suffers from Starvation –Related Malnutrition.
9. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record
Documentation and your nutrition diagnoses pages from the IDNT Reference Manual. Based
on what you discovered in earlier questions, identify TWO of Mrs. Bernhardt’s most
prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL
and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS) using the standard Nutrition
Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each
nutrition diagnosis you write. Even if you determined in the preceding question that she is
malnourished, choose two nutritional diagnoses OTHER than malnutrition that you can
address as the RD. In other words, think about the reasons why she is malnourished as you
identify her most important nutrition diagnoses.
A.
Nutrition Diagnosis #1: (2 points)
NI-1.2: Inadequate Energy Intake
B.
Nutrition Diagnosis #2: (2 points)
NB-2.4: Impaired ability to prepare food/meals
*Both Nutrition diagnosis #1 and #2 are focused on what would have caused the
patient’s malnutrition. Certain nutritional diagnoses were considered, such as iron
deficiency anemia, but were ruled out because the directions for question 9 call for
“reasons why she is malnourished” and they such problems would have stemmed
from the malnutrition itself.
NUTRITION INTERVENTION, MONITORING AND EVALUATION
10. Now go back to your two nutrition diagnoses. For each one, write a complete nutrition
diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling
each section (P, E, and S) appropriately. Identify your short- and long-term goals, an
appropriate intervention strategy to address the problem, and measurable outcomes you will
monitor to evaluate the effectiveness of your intervention. You may want to use Module II
and the “What is ADIME” document on the course web site under “Reference Materials and
Resources for Clinical Cases” to help you with this question.
10.1
A.
PES #1: (3 points)
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Patient presents with inadequate energy intake (NI-1.2) related to anorexia, ill-fitting
dentures as evidenced by severe weight loss, insufficient calorie intake, muscle &
subcutaneous fat wasting and pulmonary disorder.
B.
Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE short- and long-term goal that you will establish collaboratively
with Mrs. Bernhardt. Remember that the goals should be clear, measureable,
achievable, and time-defined. (4 points)
Short-term goal (i.e. between now and the next visit):
Within the next 3 weeks (before the next visit), patient should increase daily
caloric intake starting with 750 more calories, advancing to 1100 more calories
per day.
Long-term goal (i.e. over the next several visits, or longer):
Patient will increase bodyweight by 10% in the next 6 months (weight gain of 9.2
pounds)
C.
Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of
care with the patient)
State what nutrition-related action(s) you as the RD will take to address the
problem identified in part A’s PES statement. Be sure that the
INTERVENTION will specifically address the nutrition-related diagnosis
and/or its underlying etiology described in your PES statement. This
information will be documented in the “Intervention” section of your ADIME
chart note. (2 points)
As the RD, nutrition related actions we will take include increasing nutrient intake
of the patient by providing supplemental/enriched shakes and meals, deliver
nutrition education and counseling to improve patients knowledge about personal
nutrition requirements, conduct nutrition related cooking classes at hospital to
increase patients desire to prepare and eat meals. We will also refer patient to a
dentist to improve fit of dentures.
D.
Measurable Outcome: State what nutrition care indicator you will MONITOR in
order to EVALUATE the progress of the patient resulting from your
INTERVENTION described in part C. Nutrition care indicators are clearly defined
markers that can be observed and measured and are used to quantify the changes that
are the result of nutrition care. For example, food and nutrient intake data, laboratory
values, etc. Keep in mind that you may also identify clinical/laboratory parameters
that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is
the intervention you identified for your PES. Be sure that the nutrition care indicator
can be used specifically to evaluate the success of your nutrition intervention. This
information will be documented in the “Monitoring/Evaluation” section of your
ADIME chart note. (2 points)
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To ensure positive nutrition care we will monitor the following: patient’s weight and
skin fold thickness measurements; conduct a follow up 3-day food record to evaluate
caloric and protein intake.
10.2
A. PES #2: (3 points)
Patient presents with impaired ability to prepare foods/meals (NB-2.4) related to
anorexia, fatigue food aversion and time constraint as evidenced by patient’s nutrition
screening statement, inadequate energy intake.
B. Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE short- and long-term goal that you will establish collaboratively
with Mrs. Bernhardt. Remember that the goals should be clear, measureable,
achievable, and time-defined. (4 points)
Short-term goal (i.e. between now and the next visit):
Within the next 3 weeks (before the next visit), patient should prepare at least 3
quick and easy recipe at home per week, as supplied by dietitian, to increase
ability and desire to prepare own meals.
Long-term goal (i.e. over the next several visits, or longer):
Within the next 6 months, patient will be able to create her own meal plan with
recipes she is able to prepare, for 7 days a week, while enjoying consumption.
C.
Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of
care with the patient)
State what nutrition-related action(s) you as the RD will take to address the problem
identified in part A’s PES statement. Be sure that the INTERVENTION will
specifically address the nutrition-related diagnosis and/or its underlying etiology
described in your PES statement. This information will be documented in the
“Intervention” section of your ADIME chart note. (2 points)
As the RD, nutrition related actions we will take will similarly include delivering
nutrition education and counseling to improve patient’s knowledge about personal
nutrition requirements, conduct nutrition related cooking classes at hospital to increase
patients desire to prepare and eat meals. In addition, we will refer patient to a
psychologist to improve patient’s relationship with food.
D.
Measurable Outcome: State what nutrition care indicator you will MONITOR in
order to EVALUATE the progress of the patient resulting from your
INTERVENTION described in part C. Nutrition care indicators are clearly defined
markers that can be observed and measured and are used to quantify the changes that
are the result of nutrition care. For example, food and nutrient intake data, laboratory
values, etc. Keep in mind that you may also identify clinical/laboratory parameters
that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is
the intervention you identified for your PES. Be sure that the nutrition care indicator
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can be used specifically to evaluate the success of your nutrition intervention. This
information will be documented in the “Monitoring/Evaluation” section of your
ADIME chart note. (2 points)
E. To ensure positive nutrition care we will monitor the following: patient’s weight,
conduct a follow up 3-day food record to evaluate caloric and protein intake,
macronutrient diet proportional distribution, food group serving counts.
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