You are on page 1of 20

1

Comprehensive Clinical Case Study


Anna Ipsen
April 2014
The Sage Colleges




















TABLE OF CONTENTS

2

Introduction of Patient Case....................................................................................................pg 3

Etiology and Pathophysiology of Conditions..........................................................................pg 4

Medical List of Concerns..........................................................................................................pg 6
Hip Fracture...............................................................................................................................pg 6
Body Inclusion Myositis..............................................................................................................pg 6
Deep Vein Thrombosis................................................................................................................pg 7
Dyphagia/Zenker's Diverticulum................................................................................................pg 7
Pressure Ulcer............................................................................................................................pg 9
Malnutrition..............................................................................................................................pg 10

Nutrition Practice Guidelines................................................................................................pg 10
Dysphagia.................................................................................................................................pg 10
Pressure Ulcers.........................................................................................................................pg 12
Malnutrition and Long-Term Tube Feeding.............................................................................pg 13

Discussion................................................................................................................................pg 14

Conclusion/Recommendations...............................................................................................pg 16

References................................................................................................................................pg 17

Nutrition Care Process...........................................................................................................pg 19




















I ntroduction of Patient Case
3

An 81 year old female was admitted to the hospital after visiting the emergency room on
January 28th. The patient presented with right leg and knee pain from a mechanical fall at home,
due to a history of inclusion-body myositis (IBM). The x-rays that were completed confirmed a
displaced supracondylar fracture of the right distal femur. Orthopedics was consulted and the
patient underwent a successful open reduction internal fixation (ORIF) surgery on January 29th.
Upon nutrition assessment, the patient was flagged for being underweight for age, with a BMI of
22.59 and also reported having a history of difficulty swallowing and weight loss. Due to this
condition, the patient was ordered a National Dysphagia Diet mechanical soft (NND2) and
honey thick liquids diet. To prevent further weight loss and promote hip fracture healing, the
patient was also started on an oral liquid supplement two times per day, a honey thickened
carnation instant breakfast. The supplement, however, was not tolerated well and the patient
agreed to try nectar thick milkshakes with the addition of a scoop of Beneprotein. Additionally,
speech pathology held a barium swallow test on January 30th to determine the safest oral intake
consistency. The patient was assessed on the ability to ingest pureed foods, thin liquids, nectar
thick liquids, and honey thick liquids. Results of the evaluation were moderate oropharyngeal
dysphagia and the discovery of a small to medium sized Zenker's Diverticulum (ZD). Based on
results, the diet was downgraded to NDD1 (pureed) and liquids were upgraded to thin. Due to
the small size of the ZD and advanced age of the patient, the medical doctor (MD) did not
believe the patient was a candidate for surgery. The patient continued to have poor oral intake,
continually complaining about not being able to eat favorite or familiar foods. On February 4th,
speech pathology upgraded the patient's diet to NDD3 (advanced/soft foods) and thin liquids. At
this time, dietary also changed the oral liquid supplementation to Ensure two times a day.
Despite these changes, nursing reports continued to state that the patient was not consuming
4

sufficient oral intake so the MD ordered a three day calorie count from February 5th-7th. During
the second day of the calorie count, the patient confessed to sneaking snacks outside the
parameters of the NDD3 diet. Dietary made all members of the interdisciplinary team aware and
requested that the snacks be accounted for in the calorie count. With additional snacks, the
patient's calorie count increased, and by day three was able to achieve 90% of caloric needs and
76% of protein needs. However, because the patient was receiving most of their nutrition
through oral liquid supplements, the MD ordered a second three day calorie count from February
8th-10th. During the second calorie count, the patient's intake declined, meeting less than 50%
of daily caloric and protein needs. Simultaneously, the patient developed swelling in the right
lower extremity. A venous Doppler study confirmed deep venous thrombosis (DVT) in the right
superficial femoral and poplitheal veins, secondary to prolonged immobilization of legs. A stage
two pressure ulcer developed on the patient's right buttocks, which was also caused by being
immobile and bedridden since admission. Additionally, a three pound weight loss occurred over
a two week period from lack of adequate oral intake. The combination of the above factors, led
to a diagnosis of malnutrition from the MD. On February 13th, the MD decided a long-term
PEG tube placement was necessary to keep the patient adequately nourished. Dietary was
consulted for enteral tube feed calculations. Initial NG-tube placement failed due to the patient's
ZD, indicating the need to instead surgically place a G-tube. On February 16th the patient was
declared medically stable and was discharged to rehab.
Etiology and Pathophysiology of Conditions
The patient exhibited a number of conditions that ultimately led to a malnutrition
diagnosis. Malnutrition is a broad term, that can be defined as calorie and protein deprivation
resulting from inadequate intake, which can result in muscle wasting
1
. The advanced age of this
5

patient is important to the overall case. Advanced age is accompanied by changes that can
negatively impact nutritional status, such as decreased appetite, loss in sensory functions, oral
problems, gastrointestinal alterations, muscle loss, decreased physical ability, side effects from
chronic diseases and medications, reduced social contact, and limited food access
1,2
. Studies
have shown that 26-32% of independent elderly and up to 83% of the home-bound elderly are at
moderate to high risk for malnutrition
1
. Due to a nutrition assessment in which the patient
reported already following a soft foods diet for known difficulty with swallowing, a common
symptom of IBM, a progressive inflammatory disease that results in body muscle weakness
3
,
and underweight BMI, it is likely that the patient arrived already malnourished. Further
evaluation of the patient's swallowing function led to the discovery of a small to medium sized
ZD, an abnormal pouch in the throat where ingested food may get stuck, causing aspiration and
regurgitation. The combination of the patient's IBM, ZD and ultimately dysphagia made it
impossible to meet adequate nutrition needs. Failure to provide the body with essential daily
nutrients allowed for a dermal disruption and the development of a pressure ulcer on the buttocks
two weeks into the patient's stay, as well as a three pound weight loss. Despite treating the
patient's dysphagia by altering the diet order and providing the patient with oral liquid
supplementation, the patient was still unable to meet their estimated daily needs. The placement
of a long-term tube feed became necessary for this patient to prevent further malnutrition and
wasting.



Medical List of Concerns
6

The patient was originally admitted for a hip fracture. However, as indicated above, this
patient's case presented several medical concerns such as IBM, right leg DVT, dysphagia/ZD, a
pressure ulcer, and malnutrition.
Hip Fracture
A hip fracture is a break in the upper quarter of the femur and usually occurs from a fall
or direct blow to the side of the body
4
. Elderly persons, who often have inadequate nutrition and
thus weaker bones are at a high risk for hip fractures
5
. The diagnosis of a hip fracture can be
confirmed by an x-ray. Treatment may be surgical or non-surgical, depending on the severity of
the break. If surgery is performed, a patient will work with a physical therapist to strengthen the
bone and restore their ability to walk
4
. Another common medical intervention may be to take
blood thinner medications to reduce the chance of developing blood clots while the fracture
heals
4
. Additionally, it is also suggested that increasing protein intake may aid in the recovery
process. In the hospital setting, this is often accomplished with the use of an oral liquid
supplementation that is higher in calories and protein, as well as enriched with vitamins and
minerals. A recent study examined the impact of using oral liquid supplements in elderly hip
fracture hospitalized patients with positive results
5
. The patients who were supplemented when
compared to the control group had a reduced length of hospital stay and fewer complications
such as weight loss and pressure ulcers
5
.
Inclusion Body Myositis
IBM is the gradual loss of muscle strength, usually occurring in those over the age of 50
6
.
Weakness is first noticeable in the wrists and fingers, followed by the forearms and leg muscles
6
.
The cause of IBM is unknown, but the suggestion of viruses or certain medications triggering an
autoimmune response, as well as genetics has been made
6
. About one-third of people with IBM
7

have difficulty swallowing due to the weakening of throat muscles
6
. Often this symptom goes
unnoticed and can lead to unintended weight loss and malnutrition
3
. For example, one study
examined 57 patients with the clinical diagnosis of IBM and found that dysphagia was present in
37 (65%) of these patients, but only 17 of these patients (46%) had complained about swallowing
to their physician
3
. IBM has not been found to decrease life expectancy, but managing
symptoms is critical
6
. In those with dysphagia from IBM modified consistency diets, esophageal
dilation, or crycopharyngeal myotomy surgery may be necessary to keep a patient nourished
7
. In
extreme cases, a PEG tube or G-tube may be necessary
7
. Medical management may also include
medications and physical therapy
6
.
Deep Vein Thrombosis
DVT occurs when a blood clot forms in one or more of the deep veins in the body,
typically the legs, resulting in swelling, pain, and skin color changes
8
. DVT can be caused by
multiple factors, but most commonly in the hospital setting it is caused by prolonged bed rest
8
.
Either a Doppler ultrasound of the legs or D-dimer test can be performed to confirm the
diagnosis. Most patients will be placed on anticoagulant therapy and symptoms will disappear
quickly
9
. After discharge, prevention of DVT consists of maintaining a healthy lifestyle by
staying physically active, promoting blood flow, maintaining a normal weight, and improving
dietary habits by limiting fat and increasing fiber
10
.
Dysphagia/Zenker's Diverticulum
Dysphagia, also known as swallowing difficulty, currently affects 300,000-600,000
people annually
11
. Dysphagia is common in the elderly, due to reduction in muscle mass and
connective tissue elasticity in the esophagus muscles
11
. Reports have shown that dysphagia
occurs in 68% of elderly nursing home residents, 30% of elderly admitted to the hospital, 64% of
8

patients after stroke, and 13-38% of elderly who live independently
11
. As previously mentioned,
dysphagia is a common symptom in the presence of a ZD due to undigested food debris getting
trapped in the diverticulum
12
. A ZD is a sac-like out-pouching of the muscosa and submucosa
layers in the throat
12
. The etiology of a ZD is unknown, but most theories conclude a structural
or physiological abnormality of the cricopharyngeus muscle of the throat
13
. Some studies have
investigated the possibility of a genetic predisposition without much success. A study done in
Finland used a questionnaire of 77 patients with ZDs to find a familial linkage. However, only
three in 77 of the patients were discovered to have a relative with a ZD
14
. The annual estimated
incidence of ZDs is two per 100,000, with prevalence 0.01 and 0.11%
15
. Studies have shown
that ZDs occur mainly in the elderly, around the age of 70 and are more common in males than
females
12
. The gold standard for diagnosing ZD is the barium swallow which is a test held by a
speech language pathologist that allows the speech pathologist to classify the size of the
diverticulum and thus determine the best treatment
15
. A ZD can be categorized as small (up to
two centimeters), intermediate/moderate (two to four centimeters) or large (four to six
centimeters)
16
. Treatment for a ZD is usually surgery, which can be done in three different
forms: complete open, rigid endoscopy, or flexible endoscopy
12
. A retrospective study on 22
patients who underwent surgery in one of the three forms for their ZD were followed over ten
years and showed that 95% of the patients showed improvement in their ability to swallow
15
.
Professionals may disagree on the best form of surgical treatment, but the current trend is
flexible endoscopic surgery because it is considered less invasive and has a lower complication
rate
16
. However, a literature review study of multiple published studies that used each surgery
method found an approximate 90% success rate in all surgery methods, thus concluding no one
technique more superior to another
16
. Surgical treatment for a ZD may not be appropriate for
9

some patients because the risks may outweigh the benefits. If this is the case, treatment for a
patient with ZD may be through dysphagia management techniques such as altering food and
liquid consistencies, adjusting posture, and/or swallowing maneuvers
11
. If dysphagia
management strategies still do not allow a patient to their daily estimated needs, long-term
nutrition support may be necessary
11
.
Pressure Ulcers
The Mayo Clinic defines a pressure ulcer as an injury to skin and underlying tissue
resulting from prolonged pressure to the area
17
. The National Ulcer Advisory Panel has created a
staging system from one to four to grade the severity of pressure ulcers
17
. Many patients in the
hospital are bedridden and are more susceptible to sustained pressure on areas of the body
17
. In
U.S. acute care facilities, an estimated 2.5 million pressure ulcers are treated a year
18
. In
particular, the elderly are at an increased risk of developing pressure ulcers due to fragile skin
and poor nutrition
19
. In the acute clinical setting, prevention is key in stopping the development
of pressure ulcers. Nursing staff must reposition patients and clean/wrap pressure ulcers per MD
orders
17
. Additionally, adequate nutrition, particularly in the form of protein is necessary to
promote healing. In a study of 108 patients with pressure ulcers, individuals with low serum
protein or serum albumin were found to have significantly less healing capability than those with
normal protein values
18
. A common intervention in the clinical setting is to increase calories,
protein, and essential vitamins and minerals to promote healing through the use of oral liquid
supplements. In a double-blind, randomized trial of 50 elderly patients referred for pressure
ulcer management, the use of oral liquid supplementation showed significant reduction in
pressure ulcer size and exudates when compared against the control group, as well as additional
benefits of weight loss prevention and an increase in cognitive function
19
.
10

Malnutrition
The International Dietetics and Nutrition Terminology defines malnutrition as inadequate
intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores
and/or muscle wasting including starvation-related malnutrition, chronic disease-related
malnutrition and acute disease or injury-related malnutrition
21
. The Academy of Nutrition and
Dietetics and A.S.P.E.N. have developed a table of six clinical characteristics to diagnose
malnutrition
21
. This chart is beneficial to clinicians because so many assume that a patient must
be underweight to be considered malnourished. For example, in a survey of U.S. primary care
physicians, it was found that only 10% assessed overweight patients who could be classified as
malnourished
1
. In particular, the elderly are at an increased risk of malnutrition due to multiple
physiological changes such as body composition changes, sedentary lifestyles, sensory losses,
oral health, gastrointestinal disorders, chronic diseases, loss of functionality, and depression
20
.
Among hospitalized elderly patients, 40-60% are malnourished or at risk for malnutrition, 40-
85% of nursing home residents have malnutrition, and 20-60% of home-care patients are
malnourished
20
. In a clinical setting, oral liquid supplements are commonly used to increase a
malnourished patient's intake
1
. In severe cases, nutrition support may need to be used, especially
if malnutrition has developed as a result of the patient's inability to voluntarily consume enough
food and/or beverages to meet their estimated needs
20,21
.
Nutrition Practice Guidelines
When developing a nutrition care plan for this patient, the Dietitian must identify the
conditions of the patient that can be alleviated nutritionally. The specific complications of this
patient that can be addressed nutritionally are dysphagia, a pressure ulcer, and malnutrition.
11

Decisions on how to treat the selected conditions must be made after carefully investigating the
most current recommendations and published guidelines.
Dysphagia
The intent of dysphagia intervention is to provide adequate oral and fluid intake to
maintain a healthy weight, prevent nutrition deficiencies, and support independent eating
behaviors
22
. A nutrition care plan can be developed based on finding the safest food and liquid
consistencies, determining the patient's needs, food preferences, and addressing underlying
medical, psychological, or social factors
22
. Often the NDD is used when modified consistency
food and fluids is needed. The three levels of solid foods on the NDD are pureed, mechanically
altered, and advanced. The four levels of fluids are thin, nectar, honey, and spoon-thick
22
.
However, it is important to note that some studies contradict the use of a modified consistency
diet in dysphagia patients. One study compared intake in dysphagia patients on a regular diet to
those on a modified consistency diet and showed that patients eating a regular diet had greater
oral intake than those on the modified consistency diet
23
. Additionally, another study conducted
over a 12 week period, compared dysphagia patients on a modified consistency diet and found
that patients who were offered a modified diet with the addition of some regular foods ate greater
amounts and gained weight when compared to those patients who were on the standard modified
consistency diet
24
. Other general recommendations for dysphagia patients are to avoid alcohol,
hot foods and beverages, spicy foods, and caffeine as well as avoiding easily aspirated foods
such as popcorn, bran cereal, nuts, cottage cheese, skins of fruit, hully vegetables, and dry,
crumbly, or sticky foods
22
.

Pressure Ulcers
12

According to the Academy of Nutrition and Dietetics, the goals of the nutrition
intervention in pressure ulcer management are to maintain adequate nutritional status by
providing optimum dietary and fluid intake, identifying and treating causes of poor nutritional
intake, and monitoring weight status routinely
25
. When determining calorie needs for a patient
with a pressure ulcer, The Agency for Health Care recommends increasing energy needs to 30-
35 calories per kilogram of body weight per day
25
. The European Pressure Ulcer Advisory Panel
recommends an even higher energy intake per day for those who are underweight or losing
weight, at 35-40 calories per kilogram per day
25
. Providing extra protein is also suggested as
being beneficial in treating pressure ulcers. Normal protein recommendations per the Institute of
Medicine for an adult are 0.8-1.0 grams per kilogram per day

and 1.0-1.2 grams per kilogram per
day for elderly patients
26,27
. However, when a patient has a pressure ulcer, protein needs can be
anywhere from 1.0-1.5 grams per kilogram per the European Pressure Ulcer Advisory Panel
25
. If
vitamin and mineral deficiencies are present, providing a multivitamin to meet the recommended
daily intakes for micronutrients is suggested, but no clear data exists to indicate further
supplementation will decrease risk or aid in pressure ulcer healing
28
. However, there is some
support for the supplementation of the amino acids arginine and glutamine in pressure ulcer
healing. In one study, a group of 30 volunteers were provided either a mixed amino acid
supplement containing both arginine and glutamine or a placebo supplement. This study found
those receiving the amino acids had significantly higher collagen deposition
29
. In a hospital
setting, providing a patient with an oral liquid supplement is an easy method to increase calories
and protein, as well as vitamins and minerals. Pressure ulcer patients may also benefit from
general education on the relationship between adequate calories, protein, and vitamins and
minerals in pressure ulcer healing
25
.
13

Malnutrition and Long-Term Tube Feeding
According to the Academy of Nutrition and Dietetics and A.S.P.E.N., malnutrition has
three typical etiologies: acute illness or injury (severe acute inflammation), chronic illness (mild
to moderate chronic inflammation), or social or environmental circumstances (without
inflammation)
21
. Standardized characteristics of malnutrition are weight loss, insufficient energy
intake, loss of subcutaneous fat, loss of muscle mass, localized or generalized fluid
accumulation, and/or diminished functional status (measured by hand-grip strength)
21
. A
minimum of two of the above characteristics must be met for a patient to be coded as
malnourished
21
. In a patient who has permanent swallowing problems or damage to the
esophagus, which prevents them from meeting their daily estimated needs, a long-term enteral
tube feed may be necessary and/or useful
30
. According to A.S.P.E.N., when an enteral tube feed
must continue for more than four weeks, a nasogastric tube or gastrostomy tube placement is
recommended
30
. The Dietitian caring for the patient is responsible for calculating the patients
nutritional needs, choosing the proper formula, determining the initiation and goal rate of the
tube feeding, and monitoring and evaluating tolerance. Nutrition requirements can be calculated
using several methods such as Mifflin St. Jeor or the Harris-Benedict equations, with
adjustments based on the confounding medical conditions of the patient and the Dietician's
clinical judgement
30
. As previously stated, normal protein recommendations per the Institute of
Medicine for an adult are 0.8-1.0 grams per kilogram per day

and 1.0-1.2 grams per kilogram per
day for elderly patients
26,27
. Fluid requirements can be determined using a variety of methods,
but the most commonly used is assuming 30 milliliters per kilogram is needed, with a minimum
of 1500 milliliters
31
. In long-term tube-fed patients, polymeric standard formulas have proven to
be the most beneficial, with the potential for the addition of fiber to enhance benefits
30
. A
14

randomized, double-blinded, crossover trial tested the addition of fiber in standardized formulas
in long-term enterally fed patients with overall positive results on gut micobitoa health
33
. Tube
feedings can be administered continuously, intermittently, or in bolus feeds. Often patients on
long-term tube feeds will be fed using an intermittent drip because feedings mimic a typical meal
and snack pattern and allow for more freedom and mobility
30
. A bolus tube feed at night to
make up for leftover needs may be appropriate in those patients who can orally consume only
500-700 calories on their own during the day
30
. Current guidelines for enteral feeding initiation
are not available, but can begin as high 50 milliliters per hour, if desired
32
. However, clinical
judgment should be used based on the patient's conditions, meaning a slower initiation may be
warranted
32
. After an initial rate is tolerated and advanced to the goal rate, a long-term stable
enterally fed patients still need to be monitored. Intake and output as well as bowel movements
should be recorded daily, weekly weights recorded, with laboratory values taken monthly, and
tube feeding placement and gastric residual volumes checked only if signs/symptoms indicate
that the patient's tube may have migrated
32
.
Discussion
The nutrition care plan developed for this patient utilized all of the guidelines discussed
above. The original reason for the patient's admission was a hip fracture, which does not usually
call for nutrition intervention. However, because the patient was underweight for age with a
BMI of 22.59, the patient was considered at nutritional risk and was placed on an oral liquid
supplement. After a nutrition assessment, the patient admitted to having difficulty swallowing,
further increasing nutritional concerns, and a swallow evaluation was ordered. The result of the
evaluation was a small to moderate ZD, the primary contributor to the patient's dysphagia . The
patient was not considered a candidate for surgery, and was placed on NDD1 (pureed) and thin
15

liquids to prevent aspiration and regurgitation. The change in diet order did not satisfy the
patient in terms of quality of life and continuous complaints were made. The patient was re-
evaluated by the speech pathologist and advanced to NDD3 (advanced/soft). Two separate
calorie counts over three days each were utilized to determine if the patient was able to meet
their daily estimated nutritional needs. Even after modified consistency diets and the use of oral
liquid supplementation, the patient did not reach the required levels. Additionally, a pressure
ulcer developed on the patient's buttocks and a three pound weight loss occurred over a two
week period. The combination of the characteristics of weight loss and insufficient energy
intake, under the etiology of an acute injury, allowed for the medical diagnosis of malnutrition,
thus indicating to the MD that a long-term NG- tube placement was necessary. After this
placement failed due to the patient's ZD, a G-tube was surgically placed instead of the NG-tube
on the following day. Tube feeding recommendations were made by the Dietician using
A.S.P.E.N. guidelines. The patient's needs were determined using Mifflin St. Jeor with an
activity factor of 1.3, 1.0-1.2 grams of protein per kilogram, and 25-30 milliliters per kilogram of
fluids per day. Jevity 1.2, a high-protein, fiber-fortified formula was ordered in the form of bolus
tube feeds five times per day, in hopes that the patient could lead a more normal lifestyle and
potentially still consume food orally if desired using pleasure feeds. After the patient was
declared medically and nutritionally stable, the patient was discharged to a rehab facility where
the patient could begin to work on the mobility of her healing hip fracture.


Conclusion/Recommendations
16

The primary concern for this patient became preventing further progression of
malnutrition. The care plan for this patient was multi-faceted and required several team
members to achieve a stable outcome. Even though the patient was discharged on a long-term
tube feed, it is evident that extraordinary efforts were made to keep the patient's quality of life as
high, and as normal as possible throughout the hospital stay. Tube feeding became necessary to
sustain the life of the patient because the use of an oral liquid supplement and modifications in
the consistency of the patient's foods and fluids were not enough to allow the patient to achieve
their daily estimated needs. However, the goal of nutrition support should not only be to provide
sufficient means of nutrition, but to also improve quality of life
1
. While not immediately
apparent, a bolus tube feed was ordered specifically for this reason. The bolus feeds would be a
way for the patient to fulfill their physiological need of nutrition, while the option of pleasure
feeds would fulfill the psychological need of smell, taste, fullness, and satisfaction with the
overall result of enhancing quality of life
1
.


















References

17

1. Johnsen C, East JM, Glassman P. Management of malnutrition in the elderly and the
appropriate use of commercially manufactured oral nutrition supplements. The Journal
of Nutrition & Aging. 2000; 4(1):42-46.
2. Causes of malnutrition. Nestle Nutrition Institute Website. http://www.mna-
elderly.com/causes_of_malnutrition.html. Updated 2014. Accessed March 2014.
3. Cox FM, Verschuuren JJ, Verbist BM, Niks EH, Wintzen AR, Badrising UA. Detecting
dysphagia in inclusion body myositis. Journal of Neurology. 2009; 256: 2009-2013.
4. Hip fractures. American Academy of Orthopaedic Surgeons Website.
http://orthoinfo.aaos.org/topic.cfm?topic=A00392. Reviewed April 2009. Accessed
March 2014.
5. Myint MWW, Wu J, Wong E, Chan SP, To TSJ, Chau MWR, Ting KH, Fung PM, Au,
KSD. Clinical benefits of oral nutritional supplementation for elderly hip fracture
patients: A single blind randomized controlled trial. Age and Ageing. 2013: 42: 39-45.
6. Inclusion-body myositis. Muscular Dystrophy Association Website.
http://mda.org/disease/inclusion-body-myositis. 2014. Accessed March 2014.
7. Inclusion-body myositis. The Myositis Association Website.
http://www.myositis.org/learn-about-myositis/types-of-myositis/inclusion-body-myositis.
Updated March 2012. Accessed March 2014.
8. Deep vein thrombosis. MayoClinic Website. http://www.mayoclinic.org/diseases-
conditions/deep-vein-thrombosis/basics/definition/con-20031922. January 2013.
Accessed March 2014.
9. Dugdale DC, Zieve D, Black B, Wang N. Deep venous thrombosis. MedlinePlus
website. http://www.nlm.nih.gov/medlineplus/ency/article/000156.htm. Updated
January 2013. Accessed March 2014.
10. DVT prevention and management. The Coalition to Prevent Deep-Vein Thrombosis
Website. http://www.preventdvt.org/management/dvt-diet-nutrition.aspx. Updated
February 2013. Accessed March 2014.
11. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: Management and
nutritional considerations. Clinical Interventions in Ageing. 2012; 7: 287-298.
12. Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: Exploring
different treatment options. Acta Otorhinolaryngologica Italica. 2013; 33: 219-229.
13. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (zenker's diverticulum). Postgrad
Medical Journal. 2001; 77: 506-511.
14. Klockars T, Sihvo E, Makitie A. Familial zenker's diverticiulum. Acta Oto-
Laryngologica. 2008; 128: 1034-1036.
15. Egea AH, Delgago LP, Galve GT, Larpa MG, Aldea CO, Garcia AO. Treatment of
zenker's diverticulum: Comparison of techniques. Acta Otorrinolaringol Espanola.
2013; 64(1): 1-5.
16. Vogelsand A, Schumacher B, Neuhaus H. Therpay of zenker's diverticulum. Deutsches
Arzteblat International. 2008; 105(7): 120-126.
17. Bedsores (pressure ulcers). MayoClinic Website. http://www.mayoclinic.org/diseases-
conditions/bedsores/basics/causes/con-20030848. March 2014. Accessed March 2014
18. Gruen D. Wound healing and nutrition: Going beyond dressings with a balanced care
plan. Journal of the American College of Certified Wound Specialists. 2010; 2: 46-49.
19. Collins CE, Kershaw J, Brockington S. Effect of nutritional supplement on wound
healing in home-nursed elderly: A randomized trial. Nutrition. 2005; 21: 147-155.
18

20. Wellman NS, Kamp BJ. Nutrition in aging. In: Mahan LK, Escott-Stump S, ed. 12.
Krause's Food & Nutrition Therapy. St. Louis, Missouri: Saunders Elsevier; 2008: 286-
305.
21. Malnutrition. American Academy of Nutrition and Dietetics Nutrition Care Manual
Website.
http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=109585&highlight=m
alnutrition. 2014. Accessed March 2014.
22. Dysphagia. American Academy of Nutrition and Dietetics Nutrition Care Manual Web
Site.
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=22679&lv2=25
5550&ncm_toc_id=255550&ncm_heading=Nutrition%20Care. 2014. Accessed March
2014.
23. Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of
older people consuming a texture modified diet with a normal hospital diet. Journal of
Human Nutrition Dietetics. 2005; 18: 213-219.
24. Germain I, Dufresne T, Gray-Donald K. A novel dysphahia diet improveds the nutrient
intake of institutionalized elders. Journal of American Dietetic Association. 2006; 106:
1614-1623.
25. Pressure ulcers. American Academy of Nutrition and Dietetics Nutrition Care Manual
Web Site.
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5546&lv2=166
68&ncm_toc_id=16668&ncm_heading=Nutrition%20Care. 2014. Accessed March
2014.
26. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat,
Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC:
National Academies Press; 2005.
27. Campbell WW, Crim MC, Young VR, Joseph LG, Evans WJ. Effects of resistance
training and dietary protein intake on protein metabolism in older adults. American
Journal of Physiology. 1995; 268: E1143-E1153.
28. Reddy M, Sudeep SG, Kalkar SR, et al. Treatement of pressure ulcers: A systematic
review. JAMA. 2008; 300(22): 2647-2662.
29. Williams JZ, Barbul A. Nutrition and wound healing. Surg Clin North Am. 2003; 83:
571-596.
30. Dorner B, Posthauer ME, Friedrich EK, Robinson GE. Enteral nutrition for older adults
in nursing facilities. Nutrition in Clinical Practice. 2011; 26(3): 261-272.
31. American Dietetic Association Evidence Analysis Library. Available to members at:
www.adaevidencelibrary.com. Accessed March 2014.
32. Enteral nutrition. American Academy of Nutrition and Dietetics Nutrition Care Manual
Website. http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255292. 2014.
Accessed March 2014.
33. Schneider SM, Girard-Pipau F, Anty R, et. al. Effects of total enteral nutrition
supplemented with muli-fibre mix on fecal short-chain fatty acids and microbiota.
Clinical Nutrition. 2005; 28:2267-2279.

Nutrition Care Process
19

Sage Dietetic Internship - NCP Form
Patient: MT Referred for: Enteral Tube Feed
NUTRITION ASSESSMENT
Food and Nutrition Related History:
Admin 1/28: NPO for ORIF surgery
Assessment: Patient lives at home w/ husband and has health aide who comes to house Mon-Fri to help w/ care. At home pt
usually eats soft foods prepared by aide. Pt states not being a big eater and has small snacks throughout the day. Examples
provided by patient include eggs, flaxseed toast, chocolate shakes, mashed sweet potatoes, pudding. shaved ham. Pt reports
avoiding hard or rough food due to prolonged difficulty swallowing. Pt agreeable to carnation instant breakfast BID (300kcal,
26g pro).
1/30/14: Mech. Altered (NND2), Honey Thick Liquids, Chocolate Milkshake w/ Beneprotein BID (710kcal, 38g pro)
2/1/14: Puree (NND1), Thin Liquids, Chocolate Ensure BID (700kcal, 26g pro)
2/4/14: Advanced (NND3), Thin Liquids, Chocolate Ensure BID (700kcal, 26g pro)
2/5/14: 3-day calorie count
*2/5= 870kcal (54% total kcal needs), 34g pro (49% total pro needs)-majority of kcals from ensure
*2/6= 760kcal (48% total kcal needs), 21g pro (30% total pro needs)-majority of kcals from ensure, pt found to be sneaking
cheese snack crackers and dry honey nut cheerio cereal in between meals
*2/7 =1440 (90% total kcal needs), 53g pro (76% total pro needs)-majority of kcals from ensure
2/8: Second 3-day calorie count
*2/8=1200kcal (75% total kcal needs), 40g pro (59% total pro needs)-majority of kcals from ensure
*2/9=640kcal (40% total kcal needs), 19g pro (27% total pro needs)-majority of kcals from ensure
*2/10=720kcal (45% total kcal needs), 24g pro (34% total pro needs)-majority of kcals from ensure, possible 3lb wt loss
2/13: NPO for PEG placement per MD order; placement failed due to Zenker's
2/14: NPO for G-tube placement
Anthropometric Measurements
Age: 81 Gender:
Female
Ht: 66" Wt: 140lb (bed
scale)
Wt Hx: 165lb 2
years ago
% Wt change:
19%
BMI: 22.59-underweight for age
Biomedical Data, Medical Tests & Procedures
Labs/Date Albumin Glucose HbA1C BUN Creat Na+ K+ Hgb Hct MCV Other
2/20 2.0 90 N/A 11 0.5 144 4.4 9.2 28.8 93.5 Ca 8.3
Phos
2.4
AST 14
Mg 1.7
Medical Diagnosis: Malnutrition
Relevant Conditions: R femoral fracture (ORIF), R L deep vein thrombosis, Zenkers Diverticulum
PMH: inclusion body myositis x20 years, vertigo, hemorrhoid surgery, cholescystectomy
Fam Hx: noncontributory
Pertinent Medications: Bactrim 200/40 mg 5ml 2x/day until Feb 22, Lovenox 60mg subcutaneous q 12hrs until therapeutic,
Coumadin 5mg daily based on INR levels, Tylenol 650mg every 4 hrs, Dulcolax 10mg daily, Miralax 17g via tube feed daily,
Senokot 1 tablet daily, Prevacid 30mg daily, Vitamin B 1 tablet daily, Chewable Multivitamin 1 tablet daily, Vitamin D3 1 tablet
daily, TUMS, aspirin, tropical betamethasone, royal jelly powder.
Skin status: Intact X Pressure Ulcer/Non-healing wound
Comments: Stage 2 to R buttock 4cm in length; 3cm in width; dressings per MD orders BID
Physical Assessment: neurological WNL, mental: WNL, cardiovascular WNL, respiratory: WNL, gastrointestinal: soft abdomen,
non-distented, non tender; active bowel sounds, genitourinary: WNL
Estimated Nutritional Needs Based on Comparative Standards:
Calories: Mifflin St. Jeor x 1.3 activity factor
1417-1717kcal/day
Protein: 1.0-1.2g/kg/day
64-77g/day
Fluid: 25-30ml/kg/day
1600-1900ml/day
Diet Order:
NPO

Feeding Ability
Independent
Limited Assistance
Oral Problems
Chewing Problem
X Swallowing Problem
Intake
Good (> 75%)
Fair (approx. 50%)
20


Extensive/Total
Assistance
X N/A

Mouth Pain
None of the Above
Poor (<50%)
Minimal (<25%)
X NPO
No Nutritional Diagnosis at this time X Proceed to Nutrition Diagnosis Below
NUTRITION DIAGNOSIS
P (problem) Inadequate oral intake related to:

E (Etiology) decreased ability
to consume sufficient energy
secondary to Zenker's
Diverticulum as evidenced by:
S (Signs & Symptoms): 2 sets of 3-day
kcal counts of pt not meeting est. needs
and possible 3lb wt loss in 2 wks.
INTERVENTION
Nutrition Prescription: Recommend enteral nutrition: Jevity 1.2 bolus feedings; initiate 140ml/hr for first 2 feedings, if
tolerated, advance to goal rate of 280ml/hr 5x/day to provide 1680kcal, 78g pro, 1128ml free fluid. Recommend 50ml flushes
before and after each bolus to meet est fluid needs 1700ml/day
Food or Nutrient Delivery:
Enteral Nutrition: Jevity 1.2 bolus feed @280l/hr 5x/day with 50ml
before and after each bolus

Nutrition education:
Content: purpose of tube-feed, risks/benefits, formula
selection, how tube feed will be provided, water flushes,
administration of medications, care of tube placement
site, advancement goals/discontinuation
Nutrition Counseling: n/a Coordination of Care (refer to):
During Nutrition Care: daily interdisciplinary meeting
Discharge and Transfer of Care to New Setting or
Provider: rehab per case manager report
Goal(s): Initiate enteral nutrition within 48 hours
MONITORING & EVALUATION
Indicators:
1. Tube-feed goal rate met
2. Tube-feed toleration
Criteria:
1. Jevity 1.2 bolus tube feed @280ml/hr 5x/day
2. Residuals <500 (ASPEN guidelines), normal abdominal
distention, no signs/symptoms of edema, adequate I&Os,
all electrolytes, BUN, creatinine, phosphorus, magnesium,
calcium and glucose lab values within normal limits,
normal stool output/consistency, minimal weight
fluctuation

You might also like