Professional Documents
Culture Documents
Sydney Boehnlein
Kaela Pittman
(emphysema) five years ago. She has a 46-year history of smoking, but quit 1 year ago. She
states: Im 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: 53
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 dont 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 hasnt weighed herself for a while, but that she knows her clothes feel baggy.
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
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
115
25 - 160
U/L
Hemoglobin (Hgb)
10.5
12.5 17.0
g/dL
Hematocrit (Hct)
33
36.0 50.0%
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
PO2
HCO3
NUTRITION ASSESSMENT
Dietary Intake Data
1. From Mrs. Bernhardts 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
cup orange juice
Lunch
3 chicken nuggets (fast food)
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
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)
Use 0
15
15
12
12
12
12
67.5
13.5
Non-Starchy Vegetables
Fruit
1.5
Other Carbohydrates
30
22.5
Fat-Free Milk
Low-Fat Milk (1/2 - 1%)
Whole Milk
Lean Meats/Substitutes
14
0
7
0
8
0
Fats
10
7
20
TOTAL grams
120
34.5
38
X4=
X4=
X9=
TOTAL KCALS
480
138
342
960
C. Calculate Mrs. Bernhardts BMI. Into which category does she fall, based upon the
National Institutes of Health, National Heart, Lung, and Blood Institutes 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. Bernhardts 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. Bernhardts 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.
Bernhardts 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
MyPlates 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.
D.
Based on the patients laboratory data, while all other tests were measured in the
normal range, Mrs. Bernhardts 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 patients 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. Bernhardts 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. Bernhardts 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.
6. Look at Mrs. Bernhardts arterial blood gas report when she was admitted.
Using your Assessment of Acid-Base Balance notes, assess Mrs. Bernhardts 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 patients 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.
C.
Estimate Mrs. Bernhardts 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
patients 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. Bernhardts 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. Bernhardts 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
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Documentation and your nutrition diagnoses pages from the IDNT Reference Manual. Based
on what you discovered in earlier questions, identify TWO of Mrs. Bernhardts 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.
B.
*Both Nutrition diagnosis #1 and #2 are focused on what would have caused the
patients 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.
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 As 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: patients 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 patients 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 As 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 patients 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 patients 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
14
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: patients 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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