Nutrition Care Conference

Manchester ManorBy: Cassondra Hunter

Overview of Patient

Initials: A.C.

Gender: Male

Age: 87

Admitted on 7/11/13

Seen on 10/23/13 and 11/6/13

Psychosocial

Lives with his wife at home; reported he does most of the cooking and grocery shopping

Never received Meals on Wheels or SNAP

White, non-Hispanic

Opted for DNR/DNI in an emergency

Was an investigator at Pratt & Whitney

Has a good attitude overall; was impatient toward the end

Physical Signs

In a wheelchair

Glasses

Partial dentures

Skin, eyes, mouth, and hair were all in good condition

Anthropometric Data

Height: 5 feet 7 inches

Weight (10/23/13): 126.5 lbs

BMI: 19.85 (normal, but on the low end & has had significant weight loss)

IBW: 148 lbs ± 10%

%IBW: 85.5% (mild malnutrition)

Clinical Data (taken 10/14/13): BP- 110/58 Temperature- 92.6°F

Nutrition History

Likes: Lobster, steak, shrimp, chocolate cake (eats it every

night)

Dislikes: Ensure, fortified pudding (provided by MM), and

chicken

Meal Pattern: Breakfast, Lunch, Dinner, Snack

Appetite: Currently taking Megace, so his appetite is very

good. Now eats 100% of his meals. Prior to medication, he only consumed 60-85% of his meals.

Medical History

Stage 3 Pressure Ulcer (sacral wound)

GI Bleeding

Pneumonia, SOB worsening

COPD

Unspecified Essential HTN

Clostridium difficile infection colitis

UTI, site not specified

Pulmonary Embolism

Depression

2 Chief Diagnoses 1st = Severe Weight loss

Date: Weight (lbs):

Weight Lost (lbs):

% Change:

Classification:

6/28/13 158 - - Normal (BMI=24.8)

8/1/13 145 13-8.2%

(lost in 1 month)

Severe wt loss

9/8/13 130.75 14.25-9.2%

(lost in 1 month)

Severe wt los

9/18/13 127.5 3.25-2% (lost

in 1 week)

Significant wt lost

10/16/13 129.7 2.2+1.4%

(gain in 1 month)

Not significant

10/23/13 126.5 3.2-2% (lost

in 1 week)

Significant wt lost

Summary of Weight Loss

020406080

100120140160180

Weight Trend (lbs)

Weight Trend (lbs)

A.C. had a 19.9% loss of weight in 4 months severe wt loss

Chief Diagnosis (cont.)

2nd = Stage 3 Pressure Ulcer

Stage: Description:

Stage IA reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop.

Stage II The skin blisters or forms an open sore. The area around the sore may be red and irritated.

*Stage IIIThe skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin.

Stage IVThe pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

Stage 3 Pressure Ulcer

Medications

FeSO4- hematinic, antianemic mineral supplement A.C. lost iron from blood loss with GI bleed &

has protein malnutrition

Megace- appetite stimulant Symptoms: nausea, dyspepsia

Coumadin- anticoagulant Symptoms: taste changes, N/V, cramps, diarrhea

Metoprolol- antihypertensive Symptoms: dry mouth, N/V, diarrhea, dyspepsia,

constipation, flatulence

Medications (cont.)

Remeron- antidepressant Symptoms: dry mouth, N/V, abdominal pain,

constipation

Pantoprazole- anti-GERD, antisecretory Symptoms: abdominal pain, nausea, diarrhea

Sertraline- antidepressant Symptoms: dry mouth, N/V, dyspepsia,

diarrhea, constipation

Protein Supplements

Mighty Shakes

Magic Cup

Super Cereal

Prosource

Biochemical Data

Chloride Maintains body water & acid/base balance Normal Range: 98-106 mmol/L Patient’s Results: 110 mmol/LHigh value can indicate renal failure, use of

potassium-sparing diuretics, acidosis, cell damage, dehydration, diabetes out of control, addison’s disease, SIADH, hypoaldosteronism,

sepsis, shock, or pneumonia

Biochemical Data (cont.)

BUN (Blood Urea Nitrogen) Detoxified product of protein metabolism &

indicates recent protein intake Normal Range: 10-20 mg/dL Patient’s Results: 36 mg/dLHigh value can indicate dehydration,

increased protein intake, renal failure/insufficiency, increased catabolism of protein D/T infection, tumors, starvation, stress, trauma, MI, DM, increased age,

bleeding ulcers, GI hemorrhage, pneumonia, multiple myeloma, pancreatitis, CHF, and renal vein thrombosis.

Biochemical Data (cont.)

Na+ 138 mmol/L

K+ 4.8 mol/L

HCO3- 22

mmol/L

Creatinine 0.8 mg/dL

Glucose 73 mg/dL*All of these lab values fell within normal ranges, therefore, were not concerning

Medical Nutrition Therapy

Increase calorie, protein, and fluid intake Calorie: 35-40 kcals/kg

40 kcal x 57.5 kg= 2,300 Protein: 1.5 g/kg

1.5 g x 57.5 kg= 86 g Fluid: 1 mL/kcal

1 mL x 2,300 kcal= 2,300 mL (~10c)

Zinc, Vitamin C, & protein supplements for wound healing Protein supplements: magic cup, super cereal, &

prosource

Multivitamin supplement to increase mineral levels

Diet Order

Cardiac Diet, Regular Consistency

A regular consistency diet allows the pt to consume all foods in their naturally prepared state, with no mechanical modifications made to them

The cardiac diet includes limiting sodium, saturated, trans, and total fats in the diet as well as cholesterol. Additionally, the cardiac diet encourages eating more omega-3 fats, fiber, and plant based meals

Nutritional Needs

Calories: 2,300 kcal 40 kcal/kg

Carbohydrates: 316 g/day 55% CHO

Protein: 1.5 g/kg 86 g/day 15% Protein

Fat: 77 g/day 30% Fat

Fluid: 2,300 mL (~10c) 1 mL/kcal

Pertinent Vitamins & Minerals

Zinc 200 mg/day Protein structure, immune function, & wound

healing

Vitamin C 1000 mg/day Wound healing, immune function, & collagen

synthesis

Multivitamin supplement Iron, B Vitamins, Vitamin A ,and Vitamin E Increase mineral levels & increase healing

Sample MenuBreakfast

1c super cereal w/ 1c skim milk

1/2c cranberry juice 1 apple 16 fl oz coffee w/ 2tbsp

half and half + 1tbsp sugar

Mid-morning Snack

1/2c canned peaches 1/4c low sodium

cottage cheese

Lunch Salad- 1c lettuce,

2hardboiled eggs, 2tbsp reduced fat Italian dressing, 1/4c tomatoes, 1/4c cucumbers

1 banana 2/3c whole wheat pasta 1/2c tomato sauce

Afternoon Snack 12 saltines 1c grapes 1 Magic Cup (provided by

MM)

Sample Menu (cont.)

Dinner

3oz shrimp, stir fry with 1/2c broccoli, 1/2c carrots, 1/2c green beans

2/3c brown rice

Evening Snack

2" chocolate cake 1 Mighty Shake

(provided by MM)

Total calories: 2,275 kcalTotal Protein: 117 g

Nutrition Care Process

Diagnosis: Unintended weight loss Inadequate protein intake

PES statements: Unintended weight loss related to decreased

appetite/intake not meeting needs, as evidenced by 19.9% weight loss over four months (severe), 158 lbs to 126.5 lbs.

Inadequate protein intake related to increased protein needs as evidenced by stage 3 pressure ulcer on sacrum.

Nutrition Care Process

Intervention Increase weight

Patient will consume 85-100% of each meal (nurse to monitor) Patient will continue to take Megace medication to stimulate

appetite Increase protein intake

Patient will consume protein supplements including mighty shakes, super cereal, and magic cup

Promote wound healing Patient will supplement with Vitamin C, Zinc, and multivitamin

daily

Monitoring & Evaluation Follow up with tolerance of supplements Continue to monitor weight closely by taking weekly

weights RD to request albumin, BUN, Hgb &Hct labs

Works Cited: Mahan, L. Kathleen., and Sylvia Escott-Stump. Krause's Food, Nutrition, & Diet Therapy.

Philadelphia: Saunders, 2004. Print.

Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: Food-Medication Interactions, 2012. Print.

"Zinc." — QuickFacts. N.p., n.d. Web. 25 Nov. 2013. <http://ods.od.nih.gov/factsheets/Zinc-QuickFacts/>.

"MedlinePlus - Health Information from the National Library of Medicine." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 24 Nov. 2013. <http://www.nlm.nih.gov/medlineplus/>.

Mayo Clinic. Mayo Foundation for Medical Education and Research, n.d. Web. 24 Nov. 2013. <http://www.mayoclinic.com/>.

"NCM Nutrition Care Manual Eat Right." Public Home Page. N.p., n.d. Web. 25 Nov. 2013. http://nutritioncaremanual.org/

“Stages of Pressure Ulcers.” [Image] https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1008&bih=491&q=stage+3+pressure+ulcer&oq=stage+3+pressure+ulcer&gs_l=img.3..0l4j0i5j0i24l5.997.5062.0.5178.22.17.0.5.5.0.129.1498.13j4.17.0....0...1ac.1.32.img..0.22.1520.MjZtSNemdEI#facrc=_&imgdii=_&imgrc=DXivIyM8JbWl0M%3A%3B8iDyEs45F-7Y5M%3Bhttp%253A%252F%252Fimg.webmd.com%252Fdtmcms%252Flive%252Fwebmd%252Fconsumer_assets%252Fsite_images%252Fmedia%252Fmedical%252Fhw%252Fh9991533_002.jpg%3Bhttp%253A%252F%252Fwww.webmd.com%252Fskin-problems-and-treatments%252Ffour-stages-of-pressure-sores%3B460%3B300