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To Apply the Nutrition Care Process

Step One: Nutrition Assessment

Nutrition Assessment involves the following five subcategories of information being collected, analyzed
and interpreted.

Food/Nutrition- Anthropometric Biochemical Nutrition-related Client


Related History Measurements data, medical Physical Findings History
tests, and
procedures

Food and nutrient Height, weight, Laboratory Findings from a Current and
intake, food and body mass index data, (e.g., nutrition-focused past
nutrient (BMI), growth electrolytes, physical exam, information
administration, pattern glucose, and interview, or the related to
medication and indices/percentil lipid panel) medical record personal,
complementary/altern e ranks, and and tests (e.g., including muscle medical,
ative medicine use, weight history. gastric and subcutaneous family, and
knowledge/beliefs/attit emptying time, fat, oral health, social history.
udes, behavior, food resting suck/swallow/breat
and supply metabolic he ability, appetite,
availability, physical rate). and affect.
activity and function,
nutrition-related
patient/client-centered
measures.

1. Food/Nutrition-Related History

Consider: Patient’s/client’s appetite, food and nutrient intake, nutrition knowledge and beliefs; physical
activity habits; food availability; nutrient needs (measured, calculated, or estimated from a
formula/equation)
❖ Pt has lost over 60 lbs in the past 1-2 years
❖ His intake is less than 5% of the meals
❖ Has lost some weight when diagnosed with cancer 5 years ago
❖ Has held steady 220 lbs even after radiation therapy
❖ States that he gets full very easily and never feels hungry
❖ His usual intake includes
➢ Eggs, coffee, toast (few bites)
➢ Half sandwich, milk
➢ Soft meat (few bites), potatoes and rice
➢ At least one can of Ensure Plus
❖ Lives with his wife
❖ Has two children aged 42 and 45
❖ Has been a meat cutter for 26 years and is currently retired
❖ Feels weak all the time
❖ Claims to lack energy to do anything
❖ Appears cachetic and older than years
❖ Uses 1 ppd for more than 60 years
❖ Drinks 1-3 cans of beer per day
❖ Uses Lipitor 80 mg daily and Capoten 25mg twice daily
❖ Has been diagnosed with squamous cell carcinoma of tongue 5 years ago
❖ Has been treated with radiation therapy and has had no treatment for 3 years
❖ Has had partial glossectomy five years ago
❖ His mother died of pneumonia
❖ His father died of lung cancer

Comparative Standards
ESTIMATED NUTRITIONAL NEEDS: include energy, protein, CHO, fat, fiber, vitamins, minerals,
H2O and reference or basis for this estimate

Energy:
BMR = (10 x weight in kg) + (6.25 x height in cm) - (5 x age in years) + 5 (measured in Kcal/day) =
(10*70) + (6.25*190) - (5*68) + 5= 1561.5
1561.5 * 1.1= 1717.65~1800 Kcal
Also: 25-30 Kcal/day
1773kcal-2127 Kcal
The value chosen is 1800 Kcal

Protein:
1.5-2 Pro/Kg
105-140 g protein
Chosen: 112g, 25% from Diet

Carbohydrate:
55% from diet 247.5 grams

Fat:
22% from diet 40 grams
Less than 7% from total Kcal from Saturated fat and trans fat

Vitamins and minerals (if applicable):


1300 mg sodium, 1240 mg calcium, 500 mg magnesium, 4700 mg potassium
Please summarize the key dietary intake information (if available) in the table below. Please be selective.

This pt/ client Expected, normal, or


reference value

Total kcal: 868.66 kcal 1800 kcal

Protein (g) 46.21 g 112 g

Fat (g) 30.46 g 40 g

CHO (g) 99.02 g 247 g

Sodium (mg) 1756.63 mg 1300 mg

Calcium (mg) 565.74 mg 1000 mg

Magnesium (mg) 153.58 mg 420 mg

Potassium (mg) 1011.69 mg 4700 mg

Interpretation and/or Comments on impacts of nutrition care (Note: Do not just paraphrase the
information)
Total Calories:
The 24-hr. recall, the patient is consuming approximately 868.66 Kcal which is lower than his estimated
1800 Kcal needs calculated based on MSJ. The number of calories taken is helpful in determining the
patient’s current status and the reason for his weight loss to a great extent.

Protein:
Since the patient is under metabolic stress and starvation the protein consumption of 46.21 g compared to
recommended 112 g per day shows that the patient needs more protein from diet. Also, the protein is
important in determining the gluconeogenesis that the patient undergoes in response to metabolic stress.

Carbohydrates:
The patient is not getting enough carbohydrates and they are the most important source of energy in the
body. It is important to provide the patient with a carbohydrate dense to provide for his REE.

Fat:
Since patient is suffering from hyperlipidemia it is very important to provide him with no more than 20%
fat from his total Kcal also less than 7% of his Kcal from saturated fatty acids and trans-fat.

Sodium:
The patient suffers from hypertension and the sodium level for the patient with hypertension plays a key
role. His current sodium level both in 24 hr recall intake and lab results is well above recommendations
thus the patient needs to be given the appropriate sodium amount within the range.

Cholesterol:
Cholesterol this value is especially important for this patient since he suffers from hyperlipidemia, the
intake must be optimized so that he receives no more than 200 mg cholesterol per day.

Alcohol:
According to the dietary recommendation for hypertensive patients, it is recommended
patient doesn’t drink more than 1 drink per day. The patient has to be provided with proper resources and
support to decrease his alcohol intake.

Smoking:
The patient currently consumes 1 pack per day. According to his history his parents have both had
conditions related to their lungs so genetically he is at great risk for lung respiratory problems. Proper
education classes can be provided to manage his smoking and reduce the following nutritional
complications accompanying this habit.

2. Biochemical data, Medical Tests and Procedures

This pt/client Expected or normal value

Sodium: 150 mEq/L 136-145 mEq/L

Potassium: 3.4 mEq/L 3.5-5.5 mEq/L

Chloride: 118 mEq/L 95-105 mEq/L

Carbon dioxide (CO2): 29 mEq/L 23-30 mEq/L

BUN: 36 mg/dL 8-18 mg/dL

Creatine serum: 1.27 mg/dL 0.6-1.2 mg/dL


BUN/ CREA ratio: 28 --

Glucose: 71 mg/dL 70-110 mg/dL

Phosphate: 2.8 mg/dL 2.3-4.7mg/dL

Magnesium: 2.0 mg/dL 1.8-3 mg/dL

Calcium: 8.4 mg/dL 9-11 mg/dL

Bilirubin total: 0.6 mg/dL <1.5 mg/dL

Bilirubin, direct: 0.1 mg/dL <0.2 mg/dL

Protein: 5.8 g/dL 6-8 mg/dL

Albumin: 1.8 mg/dL 3.5-5 mg/dL

Prealbumin: 9 mg/dL 16-35 mg/dL

Ammonia: 11 umol/ L 9-33 umol/ L

Alkaline phosphatase: 75 U/L 30-120 U/L

C-Reactive protein: 2.4 mg/dL <1.0 mg/dL

Cholesterol: 92 mg/dL 120-199 mg/dL

Triglycerides: 72 mg/dL 40-160 mg/dL

RBC: 2.4 x10^6/mm3 4.5-6.2 x10^6/mm3

Hemoglobin: 8.1 g/dL 14-17 g/dL


Hemacrit: 24.1% 40-54%

Urinalysis

Color ----

pH: 7 5-7

Protein: 100 mg/dL Neg

Glucose: Neg Neg

Ketones: + Neg

Blood: small Neg

Bact: + 0

Interpretation and/or Comments on impacts of nutrition care (Note: Do not just paraphrase the
information).
 Potassium: Mr. Campbell’s potassium level is 0.1 under the expected range. This could be a
result of dehydration. Potassium is an electrolyte that has multiple functions throughout the body.
Potassium helps regulate blood pressure by reducing the amount of sodium in the blood to be
excreted through the urine. Thus, we must ensure that the patient is receiving the fluids he needs
to ensure that potassium is replenished.

 Chloride: Mr. Campbell’s chloride level exceeds the normal range. Hyperchloremia is usually a
result of dehydration. When water loss exceeds sodium and chloride loss then the body’s capacity
to handle excessive amounts of chloride is overwhelmed.

 BUN/Creatinine serum: Mr. Campbell’s BUN level is twice the upper range value and can be
due to dehydration as well. Dehydration causes BUN levels to rise higher than creatinine levels
which results in a high BUN-to-creatinine ratio. Severe dehydration results in high BUN levels
due to low amount of fluid available to excrete waste. High BUN levels also indicate kidney
failure. Since the patient suffers from hypertension it is important to closely monitor BUN levels
to ensure the patient’s kidneys are properly functioning
 Albumin: Patients albumin levels are also elevated. EAL determined that albumin levels cannot
be used to determine malnutrition. However, high albumin levels could be a result of dehydration,
an acute infection or stress. Also, calcium binds to prealbumin and since calcium levels are low,
this could lead to a decrease in albumin levels as well.

 Prealbumin: Similar to albumin, pre-albumin should not be used to determine nutritional status.
However, increased levels of prealbumin can signify inflammation or alcoholism. Patient does
not appear to intake excessive amounts of alcohol, but his body could be under stress which can
initiate an inflammatory response. Similarly, to albumin, calcium binds to prealbumin and since
calcium levels are low, this could lead to a decrease in pre-albumin levels as well.

 Protein: Mr. Campbell’s protein levels are slightly low. This is important because we want to
avoid muscle wasting and ensure protein is available for the body to use.

 Calcium: Patient is slightly under calcium range. This can possibly mean kidney failure. We will
need to continually assess calcium levels since calcium binds to pre-albumin and albumin. Pre-
albumin and albumin serve as inflammation markers and are important considering the patient’s
condition.

 C-reactive Protein: Mr. Campbell’s C-reactive protein is elevated. C-reactive is sent through the
bloodstream in response to inflammation. High C-reactive levels indicate inflammation response.
We would need to determine the source of the inflammatory response and ensure the patient is
meeting his nutritional needs so his body can properly function during the inflammatory response.

 Cholesterol: Patient has hyperlipidemia, but his lab results show a cholesterol level lower than
the expected range. This could mean that the cholesterol medications he is taking are helping
regulate his cholesterol levels.

 RBC: Decreased red blood cells can be a result of iron deficiency anemia. Iron deficiency anemia
occurs when there is a low amount of iron in the body thus, there is a decrease in red blood cells.
Since the patient’s intake is limited, he may not be eating iron rich foods

 Urinalysis:
o Ketones: Ketones present in the body indicate that the body is undergoing lipolysis to
obtain the energy requirements it needs. Lipolysis is the conversion of fatty acids,
triglycerides, into energy and ketones are a product of this conversion. This means that
Mr. Campbell is not consuming enough carbohydrates for his body to utilize glucose as a
main fuel source and has to rely on fatty acids.
o Protein: There is protein present in Mr. Campbell’s. This could be a result of his
dehydrated status.
o Bact: Bacteria tested positive in Mr. Campbell’s urine analysis. This could be a possible
result of a kidney infection and/or infection.
o Blood: Mr. Campbell’s urine analysis tested positive for blood. This indicates possible
kidney disease, kidney injury and/or a kidney infection. We should provide sufficient
liquids to ensure patient is hydrated, monitor lab values.

3. Anthropometric Measurements

Consider: Weight, height, BMI, weight change, rate of weight change, growth percentiles (pediatric
pts), desirable or usual body weight, other anthropometric measures as appropriate (waist
circumference, skinfolds, body composition measures, etc.). Please remember to include appropriate
units of different measures.

This pt/client Expected or normal value

Current Body Weight: 156lbs IBW= 196 lbs


● Around 220 lbs 5 years ago even IBW%= 79.6%
after radiation therapy
● Lost over 60 lbs in past 1-2 years

Height: 6’3” N/A

BMI: 19.5 18.5-24.9

Interpretation and/or Comments on impacts of nutrition care (Note: Do not just paraphrase the
information).
 Weight: It is concerning that there was an unintended weight loss of 60 lbs over the last two
years. The weight of the fluid from the edema could be masking even more weight loss. He is
only 79.6% IBW which could point to malnutrition.
 BMI: A 19.5 BMI is within normal range however this number is most likely an overestimate of
his true BMI due to the weight of fluid from his edema. An underweight BMI could be used as
evidence for long-term energy intake deficit.
 Height: His height will be used to calculate his BMI. There are no complications with his height.
4. Nutrition-Focused Physical Findings

Consider: oral health, general physical appearance, skin integrity, muscle tone and/or subcutaneous
fat wasting, affect, swallowing function. WHAT WOULD YOU OBSERVE, FEEL, SMELL,
LISTEN FOR IF YOU WERE MEETING THIS PATIENT IN PERSON?

This pt/ client Expected or normal

Skin: Warm and dry ecchymoses Warm and dry (for pt’s age) with no
ecchymoses

Skin color: Pale Skin color should have more color

Cachetic: Appears older Should look his age

Skin Turgor: Tent Good

Temporal wasting in head No wasting

Extremities: Decreased muscle tone, normal Normal muscle tone and ROM with
ROM; loss of lean mass in quadriceps and no edema present
gastrocnemius; 1+ pedal edema

Neurologic: Alert and oriented; strength Alert with strength at normal


reduced capability

Interpretation and/or Comments on impacts of nutrition care (Note: Do not just paraphrase the
information).

 Skin: Warm and dry skin is normal for an aging individual. However, there is present
ecchymoses but this can also be from aging since the blood capillaries are thin or from injury.
With the patient being cachetic, it is a physical indication of his wasting and weakness. With his
extremities showing decreased muscle tone, slight fluid retention in his feet, and wasting in his
temporal region. Temporal wasting can be from the natural cause of aging but can also be from
nutritional deficiencies.
 Turgor: Tenting is present in patient indicating that he is dehydrated. RD must be aware of
patient’s fluid intake in order to increase his body functioning at a normal level.
 Skin color: His pale skin color and his complaint of being weak can be a sign of his chronic
fatigue.
 Neurological: He is alert but is weak. This may be due to his malnutrition and dehydration that
causes this fatigue.

5. Client history

Consider: Medications and supplements AND THEIR NUTRITION IMPLICATIONS, social


history, personal (age, occupation, family, education, etc.), medical/surgical/health history, substance
habits.

Please feel free to add rows to the table as needed.

Client History Implications on Nutrition Care

Medication for hyperlipidemia which may indicate


Lipitor 80mg-daily the patient is taking care of his high blood lipid levels.

This medication controls his blood pressure. We have


Capotean 25 mg- 2x daily to take into consideration the nutritional interaction
this medicine has when determining intervention
methods.

Patient may still have loss of sensitivity in tongue or


Pt was diagnosed with squamous perhaps present symptoms for dysgeusia and
cell carcinoma of tongue five years dysphagia
ago.

Hypertension may present more risk at the time of


Hypertension intervene the patient, also when recommending
formula medications for this condition should be
considered

Hyperlipidemia Medication for the condition should be considered


when prescribing formula of tube feeding
Patient who lose weight especially lean body mass
Weight loss present higher risk for malnutrition and death

Peripheral vascular disease May explain his pedal edema and the Capotean
medication something to take in consideration when
calculating weight and analyzing fluid retention

Partial glossectomy five years Patient may experience dysgeusia, difficulty or


ago inability for PO intake and have difficulty talking

Smoking may contribute to weight loss and worsen


Smoking 1 ppd for 60+ years his hypertension status and put him at risk for lung
cancer

Alcohol consumption is over the daily


1-3 cans of beer per day recommendation for men. Alcohol may interact with
current medications.

Family history of pneumonia can increase his chances


Mother died of pneumonia of getting lung problems adding to the fact that he
smokes.

Father died of lung cancer Direct family history of lung cancer may increase his
risk of getting it as well.

Married and lives with wife Wife can be a supportive caregiver for the patient and
take care of him or at least help him

2 children alive May serve as motivation for the patient to recover

9 years of education Limited education which tells the patient may have
difficulty comprehending complicated language so
take into consideration when talking and advising the
patient
Language English Patient can fully understand oral directions provided

Retired-meat cutter for 26 yrs Patient was on his feet for long periods during his
prior to retirement work years which may have led to peripheral
complications, moderate -high active job that required
some physical activity

Caucasian Higher risk for skin cancer


May follow typical American diet prior to disease

Baptist Normal diet. No specific preferences so there are no


limitations of certain food groups.

Cachetic and older appearance May be due to loss of lean body mass, weight loss
malnutrition, muscle wasting

Respiratory rate: 20 Normal for an adult to have 20 breaths per min

Weight 156 lbs Patient seems to have low weight for his height
Though his BMI comes out to 19.5 we need to take in
account his pedal edema that skews his weight

BP 122/77 Patient presents slightly elevated systolic pressure

Pulse of 101 Slightly elevated pulse may indicate heart is working


harder than it should

Noted temporal wasting This indicated patient is losing lean body mass which
can be very detrimental to his health status, indicated
patient is breaking up muscle mass.
Dry mucous membranes in nose This may indicate signs that patient is dehydrated
and throat

Strength reduced Patient may feel tired, fatigued due to his state of
catabolism losing muscle mass and undergoing
malnutrition. Take into consideration when
suggesting exercise.

Decreased muscle tone and lean This may be due to his malnutrition and may be
mass in quadriceps and leading to unintended weight loss. This can
gastrocnemius exacerbate his health status and increase his mortality
risk.

Pedal edema Patient is retaining fluids, and this may skew his
weight. Consideration for DASH diet/low sodium diet

Warm and dry skin with This may be due to his dehydration status as well
ecchymoses malnutrition status, RD should look at micronutrient
deficiencies. However, this dryness can be part of the
aging process.

Hypoactive bowel sounds Intestinal activity has slowed down, but GI tract is
still functioning, so we can use nasogastric route for
tube feeding if needed

Catheter Patient may encounter some discomfort from the use


of a catheter to urinate

Pale skin color Sign that something is wrong. Reduced blood flow
and oxygen?

Tent skin turgor Sign that patient is dehydrated, consider fluids during
nutrition intervention

0.9 % sodium chloride with May help patient recover fluid and electrolytes losses
potassium
Vancomycin in dextrose Patient is getting antibiotics to kill bacteria, RD
should look for med interactions and side effects.
Patient may have been fighting infection.

Thiamin injection 100mg daily Patient is already receiving B1 supplementation


perhaps there as a deficiency before

Multivitamin capsule daily Patient is receiving some micronutrients, check for


medication interactions and proper use.

Metronidazole in NaCl Patient may be fighting infection which increases his


energy needs and risk for inflammation

Docusate 2x daily Used to make stools softer. Patient may be


experiencing constipation. Consider increase of fiber
in nutrition intervention

Lipitor 80 mg daily Medication interaction and side effects. Patient


present may have high LDL cholesterol

Lopressor 5mg every 6hrs Patient is treating his high blood pressure, RD should
look at food interaction and side effects that may
place a barrier for nutrition intervention.

Step Two: Nutrition Diagnosis

Intake Clinical Behavioral-


Environmental
Actual problems related Nutritional Nutritional
to intake of energy, findings/problems findings/problems identified
nutrients, fluids, identified that relate to that relate to knowledge,
bioactive substances medical or physical attitudes/beliefs, physical
through oral diet or conditions environment, access to
nutrition support food, or food safety

1. Fill out the table below following the instructions. Please feel free to add lines to the table as
needed.

a. Identify potential nutrition issues


Based on Nutrition Assessment, please come up with a laundry list of ALL potential nutrition issues.
You can use your own words for now. What makes you think each of the potential nutrition issues
may exist (you can get the information from Nutrition Assessment)
b. Identify Nutrition Problems
Use standard language in the latest eNCPT, create a list of Nutrition Problems that corresponds to the
list of nutrition issues. Just a reminder, nutrition problems are classified into three domains (see table
above)
c. Determine Causes of Nutrition Problems
What do you think are the causes of each nutrition problem? You should be able to use information
from Nutrition Assessment to determine this. The Etiology Matrix is very helpful in this step.

Please feel free to add rows to each domain in the table as needed.

Potential Nutrition What data from Nutrition Etiology


Issues Nutrition Assessment Problems (Use the Matrix as
(can use your own word) make you thnk this (Use eNCPT) necessary, can use
issue may exist? free text or standard
(get information from language)
Nutrition Assessment)

Intake Domain

eg. too much calorie 24hr recall: 2600 Kcal Excessive energy Overconsumption of
intake vs needs of 2000 Kcal intake high fat foods (you
would know this from
Nutrition
Assessment)
Intake of less than 5% of 868.66 kcal intake vs Inadequate oral Difficulty eating
meals 1800 kcal needed intake NI-1.2;
Predicted
inadequate energy
intake NI-1.4

Patient is not drinking Takes sips of liquids Inadequate fluid Inability to eat/drink
enough liquids and needs 2000-2500 intake NI-3.1 and low energy
ml of fluid
Turgor present a sign
for dehydration

Patient doesn’t consume Current consumption of Inadequate energy Decreased ability to


enough energy to support 868.66 Kcal/ day intake NI 1.2 consume sufficient
his body needs compared to 1800 Kcal energy, nutrients
needed

Not enough CHO Intake Current intake: Inadequate Difficulty eating


99.02g CHO carbohydrate
Estimated needs: CHO: intake NI-5.8.1
55% from diet 277.51
grams

Not enough Fat Intake Current intake: Inadequate fat Difficulty eating
30.46g FAT intake NI-5.5.1
Estimated needs: Fat
20% from diet 44.85
grams

Not enough PRO Intake Current intake: Inadequate Difficulty eating


46.21g PRO protein intake NI-
Estimated needs: 5.6.1
Protein
25% from diet 126.14
grams

Clinical Domain

Difficulty Chewing Intake of meals <5% Biting/ Chewing Due to squamous cell
and on a mechanical (masticatory) carcinoma on tongue
soft diet difficulty NC-1.2 and had radiation
therapy 3 years ago
Possible alcohol- Alcohol intake of 1-3 Predicted food– Food and Drug
medication interaction of beer per day medication interaction
interaction NC-
2.4

Chronic disease or Very little appetite and Chronic disease Squamous cell
condition related never feels hungry or condition carcinoma of tongue
malnutrition NC-4.1.2 Pt is losing lean body related (radiation therapy and
mass, temporal malnutrition NC- partial glossectomy)
wasting. 4.1.2

Behavioral-
Environmental Domain

Patient is unable to self- Pt states lack of energy, Inability to Lack of prior


care predicted EN feeding manage self-care exposure or exposure
and older age NB-2.3 to inaccurate
nutrition-related
information

Patient smokes a lot and Long term Smoking Limited Food and nutrition
for a long time which can behavior:1 ppd for 60+ adherence to knowledge deficit
exacerbate his current years nutrition-related concerning: How to
health status and quality of recommendations make nutrition-
life NB-1.6 related changes

Patient may not know Patient has a limited 9- Food-and Patient lacks
much about nutrition year total education nutrition-related education about the
background knowledge deficit correct diets to treat
NB-1.1 his hypertension

2. USING APPROVED LANGUAGE, write the nutrition diagnosis as a PES statement.


Note: there may be many PES statements appropriate for one pt/client. Please write down two most
relevant and important PES statements below. These PES statements should drive your intervention later.
By default, nutrition problem in the first PES statement will receive the highest priority in Nutrition
Intervention.

PES Statement 1
Problem Chronic disease or condition related malnutrition R/T
NC 4.1.2

Etiology Difficulty eating and decreased ability to consume AEB


sufficient energy, nutrients

Sign and Symptoms Predicted insufficient energy intake of 868.66 kcal


vs. estimated needs of 1800 kcal and 60 lbs weight
loss in the past 1-2 years.

PES Statement 2

Problem Inadequate fluid intake NI-3.1 R/T

Etiology Inability to eat/drink and low energy AEB

Sign and Symptoms The admission for dehydration and


Oral fluid intake of a few sips, dry mouth and tenting
of skin.
Step Three: Nutrition Intervention

Food and/or Nutrition Nutrition Coordination of


nutrient Education (E) Counseling (C) Nutrition Care
delivery (ND) (RC)

Individualized Formal process to A supportive Consultation with,


approach for instruct or train process, referral to, or
food /nutrient patients/clients in characterized by a coordination of
provision. a skill or to impart collaborative nutrition care with
knowledge to help counselor– other providers,
patients/clients patient/client institutions, or
voluntarily relationship to agencies that can
manage or modify establish food, assist in treating
food, nutrition and nutrition and or managing
physical activity physical activity nutrition-related
choices and priorities, goals, problems.
behavior to and individualized
maintain or action plans that
improve health. acknowledge and
foster responsibility
for self-care to treat
an existing
condition and
promote health.

Please note:
1. In Nutrition Intervention, Please do not limit yourself to the two nutrition problems you have
written PES statements for. You can and should address more nutrition problems you have listed in
Nutrition Diagnosis.
2. There are four strategies of nutrition interventions (see table above). Food and/or Nutrient
Delivery is just one of them.

1. Nutrition Prescription (Nutrition Rx):

Nutrition Prescription: The patient/client’s individual recommended dietary intake of energy


and/or selected foods or nutrients based on current reference standards and dietary guidelines
and the patient/client’s health and nutrition diagnosis (specify).

Specific diet (if applicable) EN Nasogastric Jevity 1.2 Continuous


feeding
Energy goal (Kcal/day) 1800 Kcal

Protein goal (g/day) 112 g/day

Total Fluid needs (ml/day) 2122 ml/day

If there is any specific goal or restrictions, please


list below

Meet the fluid needs, bring the patient back to


normal anabolic state, reduce lean body mass
wasting

Have patient tolerate a low saturated fat diet once


switched to PO to help with the hyperlipidemia

Once pt is switch to bolus feeding, monitor


patient’s bolus feeding and if he can meet more than
60% of his Kcal intake from oral intake adjust the
intake to start conversion to oral intake

Nutrition prescription:
NG tube feed Jevity 1.2 @ 20 ml/hr, advance 20ml Q4 until goal rate of 60ml/hr (continuous) reached
with 1 serving of beneprotein Q4 for a total of 5 servings/day to provide 30g protein, flush water 160ml
Q4 to provide 960ml fluid. In total to provide 1440 ml formula/day, 1853 kcal/day, 110g protein/day, and
2122ml total fluid/day.

2. Please summarize the relevant evidence regarding nutrition therapy of the disease conditions.
Please indicate the source of the evidence (eg. the Nutrition Care Manual, Evidence Analysis Library, the
AHRQ or Cochrane databases, etc).
 Metabolic stress: Since the patient is consuming only 5% of his meals and less than 75% of his
EER, he is suffering from metabolic stress. His body will respond to starvation by decreasing in
overall energy needs and his metabolic rate decreases to 20-25 kcal/kg/d. 90% of his energy comes
from fat storage and less than 10% protein is used for gluconeogenesis which will help protect the
protein stores and provides the glucose for brain and other tissues that require glucose as their source
of energy. Lean mass will undergo minimal catabolism for meeting glucose needs and will provide
amino acid alanine for liver to provide glucose through the process of gluconeogenesis as discussed
above. Since the body is going through starvation and cannot meet the needs by the current intake, the
patient’s body will lower BMR and begin lipolysis as an effort to save the lean mass and protein
reserves.
 Chronic Inflammatory Response: The patient’s lab results show an increased C-reactive protein of
2.4 mg/dl compared to the normal value of less than 1.0 mg/dl. In addition, his albumin is 1.8 mg/dl
(normal range 3.5-5 mg/dl) and his prealbumin is 9 mg/dl (normal range 16-35 mg/dl). These values
indicate inflammation. However, patient’s present edema may have affected the albumin and
prealbumin laboratory measurements. The patient has also indicated fatigue and his WBC lies at 10.6
* 103 /mm3 which is at the upper level of normal range (4.8* 103 /mm3 -11.8* 103 /mm3).
 Hypertension: Patient suffers from hypertension and his BP is 122/77, which according to American
Heart Association and American College of Cardiology, is indicative of elevated blood pressure. As
indicated on patient’s medical history, he suffers from essential hypertension, currently smokes,
consumes alcohol, physical inactive and age are all risk factors for HTN. His lab results show sodium
consumption of 150 mEq/L which is above the reference range of 136-145 mEq/L and his potassium
is 3.4 mEq/L which is below the reference range of 3.5-5.5 mEq/L. Depending on patient’s NG EN
feeing tolerance and oral diet intake, the DASH diet can be recommended to him.
 According to National Heart, Lung, and Blood Institute (NHLBI) DASH diet which will provide him
with optimal calorie levels, 2400 mg of Sodium and 4700 mg of potassium. This will result in a more
nutritious diet for him once he can be taken off the tube feeding.
 Hyperlipidemia: According to the Evidence Analysis Library, HTN along with hyperlipidemia will
put patient in the risk for cardiac problems. As a result, he will need to have a cardioprotective diet
that provides 20-25% of total calories from fat and less than 7% of Kcal from trans-fat and saturated
fatty acids. Moreover, the patient’s cholesterol intake must not exceed 200 mg/day.

3. Please fill out the table below regarding Nutrition Intervention. If you are recommending dietary
(diet order) changes, provide a one-day sample menu that meets your recommendations, and a
dietary analysis of the sample menu that proves that it meets your recommendations (Use Food
Processor software installed on computers in the FCS computer lab)

Please note: the same nutrition problem can be tackled by different intervention tactics.

Nutrition Problems Describe the specific Standard Language Intervention Strategy


(see table in intervention tactics that corresponds to (ND, E, C, or RC)
Nutrition Diagnosis) you plan to the intervention
implement (use your tactics
own words for now) (per eNCPT)

Inadequate oral intake Work with a speech Mechanically altered Referral of Nutrition
NI-1.2; Biting/ pathologist and OT to diet ND-1.2.1.2 Care and Nutrient
Chewing improve his eating Delivery
(masticatory) with partial tongue
difficulty NC-1.2

Inadequate energy Educate the patient General/healthful diet Nutrient Delivery


intake NI 1.2; about healthier softer ND-1.1
Predicted inadequate food options making
energy intake NI-1.4 each bite count with
more nutrient-dense
foods.

Chronic disease or Encourage healthier Modify concentration Nutrient Delivery


condition related food options that are of enteral nutrition
malnutrition NC-4.1.2 more nutrient-dense ND-2.1.2
and find an enteral Modify composition
formula that meets the of meals/snacks ND-
nutrient deficiencies of 1.2
the patient. Monitor
risk for refeeding
syndrome!

Inadequate fluid Find food items that Increased fluid diet Nutrient Delivery
intake NI-3.1 retain higher amounts ND-1.2.8.1
of water in order to get
water into his diet
besides drinking
water.

Limited adherence to Suggest patient to sign Stimulus control C- Nutrition education


nutrition-related up for a quit smoking 2.7 and counseling
recommendations program or support Recommended
NB-1.6 group and explain the modifications E-1.5
risks that come with
his family hx and how
smoking can
exacerbate his health
status.

Inadequate Select a formula that Modify composition Nutrient Delivery


carbohydrate intake meet the patient of enteral nutrition
NI-5.8.1; Inadequate carbohydrate, fat and ND-2.1.1; Medium
protein intake NI-5.6.; protein needs to chain triglyceride
Inadequate fat intake increase muscle mass, modified diet ND-
NI-5.5.1 energy, and reduce 1.2.5.8
inflammation. With fat Increased omega 3
intake, increase fatty acid diet ND-
Omega-3’s, preferably 1.2.5.7.1
with an oil for EN and
food for PO intake, to
help with
inflammation with EN
feeding and gradual
PO intake.

Food-and nutrition- Educate the patient on Nutrition relationship Nutrition Education


related knowledge the importance of to health/disease E-1.4
deficit NB-1.1 maintaining a balance
diet low in sodium to
aid his hypertension
such as DASH diet
after he is able to eat
normally.

Inability to manage Suggest patient and Referral to other Referral of Nutrition


self-care NB-2.3 caregiver (wife) to providers RC-1.5 Care
look for long term Referral to community
assistance such as agencies/programs
hiring a caregiver or RC-1.6
assisted living that
helps with the oral
feedings and
medication delivery
after discharge from
the hospital. Also refer
them to a social
worker for assistance.

Biting/ Chewing After discharge and Referral to other Referral of Nutrition


(masticatory) modification of PO providers RC-1.5 Care
difficulty NC-1.2 diet, patient should be
referred to an OT to
help him recover and
improve chewing
abilities

Predicted food– Educate patient on the Priority modifications Nutrition Education


medication interaction danger of alcohol and E-1.2
NC-2.4 medication interaction
since he is taking a lot
of medications.

Food-and nutrition- Educate the patient on Nutrition relationship Nutrition Education


related knowledge why he should be to health
deficit NB-1.1 consuming healthy
food options E-
1.4

Food-and nutrition- Introduce patient to Nutrition Education-


related knowledge healthy food options Skill development Application
deficit NB-1.1 and provide brochures E-2.2
on easy-to-make
snacks/ foods that are
soft or easy to chew.

Step Four: Nutrition Monitoring and Evaluation

How will you know if your intervention is helping with the pt’s/client’s nutrition problem? Using
approved terminology, list indicators (signs and symptoms) you will re-evaluate. Monitoring and
Evaluation and Reference sheets are combined with Assessment Reference Sheets. (eNCPT).
Please feel free to add additional notes relevant to this case after each NCP term you deem appropriate
for this section.
Please delete any empty rows in each table.

Food/Nutrition- Biochemical Data, Anthropometric Nutrition-Focused


Related History Medical Tests, and Measurement Physical Assessment
Outcomes Procedure Outcomes Outcomes
Outcomes

Food and nutrient Lab data (e.g. Height, weight, body Physical appearance,
intake, electrolytes, glucose) mass index (BMI), muscle and fat
medication/herbal and tests (e.g. gastric growth pattern wasting, swallow
supplement intake, emptying time, indices/percentile function, appetite,
knowledge, beliefs, resting metabolic ranks, and weight and affect
food and supplies rate) history
availability, physical
activity, nutrition
quality of life

Please fill out the tables below and feel free to add more rows to accommodate more information, if
deemed appropriate.

Food/Nutrition-Related History Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Oral fluids FH-1.2.1.1 Make sure the patient is meeting his adequate fluid
needs

2 Enteral nutrition formula/solution Making sure the formula meets the patient needs
FH-1.3.1.1 and monitor tolerance

3 Feeding tube flush FH-1.3.1.2 Make sure patient is meeting fluid needs that are
not met through formula

4 Total energy intake FH-1.1.1.1 Make sure patient is meeting energy needs to

5 Enteral nutrition order FH-2.1.1.3 Change formula as needed or if any intolerance


present

6 Enteral access FH-2.1.4.1 Monitor to make sure the NG tube was placed
correctly and continues to be appropriate during
his recovery, minimize patient discomfort

7 Receives assistance with intake FH- To ensure that once discharge the patient has
7.2.4 assistance to prepare and feed the patient such as
providing the bolus as indicated or mechanical soft
food if ready for PO.

8 Readiness to change nutrition- Check patient readiness to quit smoking and


related behaviors FH-4.2.7 alcohol consumption or at least reduce the amount
9 Liquid meal replacement or Monitor if patient need a meal replacement after
supplement FH-1.2.1.3 EN has been moved to PO

10 Pattern of alcohol consumption FH- To check if patient started to try


1.4.1.3 to reduce alcohol consumption since it is
detrimental to his health status

Anthropometric Measurement Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Weight change AD-1.1.4 Monitor weight changes to see long term effect
of therapy

2 Blood pressure PD-1.1.21.1 Continue to monitor BP to maintain to see if his


hypertension is being controlled

3 Respiratory rate PD-1.1.21.6 Monitor his respiration rate to assess whether


patient will be able to be moved to PO and self-
feed after he meets > 66% intake

4 Pulse rate PD-1.1.21.5 Monitor pulse to make sure we are not


overworking his heart

5 Body mass index (BMI) AD-1.1.5.1 Monitor BMI to check patient is within normal
range after his pedal edema has gone away

Biochemical Data, Medical Tests, and Procedure Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Urine volume BD-1.12.4 To monitor I/O of fluids to see if we are meeting


patient’s fluid needs
2 Urine specific gravity BD-1.12.3 To monitor hydration status

3 BUN:creatinine ratio BD-1.2.3 To measure dehydration status

4 Creatinine BD-1.2.2 To measure muscle mass and possible catabolism

5 BUN BD-1.2.1 To monitor protein intake

6 Potassium BD-1.2.7 To monitor for signs of refeeding syndrome since


patient has malnutrition

7 Calcium, serum BD-1.2.9 Make sure patient has normal levels of this
mineral

8 Magnesium BD-1.2.8 10262 To monitor for refeeding syndrome

9 Triglycerides, serum BD-1.7.7 To monitor his lipids levels since he has


hyperlipidemia

10 Glucose, casual BD-1.5.2 To monitor glucose intolerance and check for


hyperglycemia

11 Sodium BD-1.2.5 To check sodium intake since patient has


hypertension and edema

Nutrition-Focused Physical Assessment Outcomes

M/E NCP Terminology Additional Notes if Applicable

1 Body position, EN FH-2.1.4.3 Monitor patient’s bed is elevated at least to >30


degrees to prevent aspiration

2 Constipation PD-1.1.5.9 Check patient is not experiencing bowel problems

3 Normal bowel sounds PD-1.1.5.25 To check for functional GI tract


4 Edema of foot PD-1.1.6.9 To monitor pedal edema

5 Excessive thirst PD-1.1.13.16 To monitor hydration status and hypernatremia

6 Gastric emptying time BD-1.4.29 To monitor residue amount and see formula
tolerance and timing

7 Handgrip strength FH-7.3.7.1 To monitor if patient is recovering his strength

8 Muscle atrophy PD-1.1.14.1 To monitor muscle wasting

9 Fat wasting Monitor if pt is still looking cachectic, check


temporal wasting

10 Abdominal distension PD-1.1.5.3 Monitor abdominal girth after feedings


Documentation ADIME Notes

Nutrition Assessment
Chief Complaint:Pt feels very weak and have no energy to do anything.
Personal/Social History: Patient is married and retired. Currently lives with his wife. Pt was a meat cutter for 26
years, mother died of pneumonia and father of lung cancer.
Age: 68 Gender: M Ht: 6’3” Wt:156 lbs or 71 kg IBW: lbs BMI: 196 kg/ m^2 Goal Weight:196 lbs
Rx/ Supplements: Vancomycin, NaCl with KCl, Thiamin injection multivitamin, Metronidazole in NaCl premix
IVPB, docusate, Lipitor, Lopressor. Allergies: N/A
Medical Hx: Pt admitted to acute care for possible dehydration, malnutrition and weight loss. Essential Hypertension,
hyperlipidemia, 1ry tongue squamous cell carcinoma 5 yrs ago, peripheral vascular disease.
Wt history: Pt has lost 60lbs over the past 1-2 yrs. He lost some weight when diagnosed with cancer, but held steady
at 220lbs, looks cachectic, noted loss of lean mass in quadriceps, temporal and gastrocnemius
Diet history: Pt is in a mechanical soft diet and consumes <5% of meals and a few sips of liquid. Pt gets full easily
and never feels hungry. Pt also drinks 1-3 cans of beer per day, and smokes 1 ppd for 60 yrs.
Physical activity history: none stated
Food intake: Egg, coffee, few bites of toast , ½ can of Ensure plus at 10 am, lunch: soup or ½ sandwich, milk and of
dinner: a few bites of soft meat, potatoes or rice and tries to drink the other ½ of Ensure Plus.
Estimated intake: 868.66 kcal PRO 46.21g FAT 30.46g CHO 99g
Comparative Standards: 1800 Kcal, PRO 112g, FAT 40g, CHO 247g
Nutrition Diagnosis
PES Statements
1. Chronic disease or condition related malnutrition R/T difficulty eating and decrease ability to consume
sufficient energy, nutrients AEB predicted insufficient energy intake of 868.66 kcal vs. estimated needs of
1800 kcal and 60 lbs unintended weight loss in the past 1-2 years.
2. Inadequate fluid intake R/T inability to eat/drink and low energy AEB the admission for dehydration and
oral fluid intake of a few sips, dry mouth and tenting of skin.
Nutrition Rx
NG tube feed Jevity 1.2 @ 20 ml/hr, advance 20ml Q4 until goal rate of 60ml/hr (continuous) reached with 1
serving of beneprotein Q4 for a total of 5 servings/day to provide 30g protein, flush water 160ml Q4 to provide
960ml fluid. In total to provide 1440 ml formula/day, 1853 kcal/day, 110g protein/day, and 2122ml total fluid/day.
Nutrition Intervention
Intervention #1: EN Feeding Needs
Goal: Assess patient lab values three times per week to ensure formula is provided the nutrients his body needs and
reduced inflammation and combat malnutrition specifically, CRPs, albumin, and prealbumin.
Intervention #2: Introduce patient to nutritional soft food options
Goal: Patient will know how to prepare healthy soft food options and will incorporate at least 5 to his diet for 4
weeks after being discharged and to be consuming foods to meet 66% of his nutrition needs in two weeks or by the
time he is discharged.
Nutrition Monitoring and Evaluation
1. Monitor patient’s feeding tolerance Q6 while continually monitoring for Refeeding Syndrome.
2. Monitor and evaluate patient’s hydration status through laboratory tests every 3 days.
3. Monitor residuals every 4 hours and if the residual is more than 250 mL take measures to reduce aspiration
risks and if the residuals are more than 500 mL stop the feeding and assess tolerance.
4. Monitor patient’s P.O intake until 66% of nutritional needs are met.
References

American Association for Clinical Chemistry. (2016, May 25). Urinalysis - Understand the Test & Your
Results. Retrieved from https://labtestsonline.org/tests/urinalysis

Beck, F. K., & Rosenthal, T. C. (n.d.). Prealbumin: A Marker for Nutritional Evaluation. Retrieved
October 04, 2018, from https://www.aafp.org/afp/2002/0415/p1575.html

Blood in urine (hematuria). (2017, August 17). Retrieved from https://www.mayoclinic.org/diseases-


conditions/blood-in-urine/symptoms-causes/syc-20353432

C-Reactive Protein (CRP) Test: MedlinePlus Lab Test Information. (2018, July 30). Retrieved from
https://medlineplus.gov/labtests/creactiveproteincrptest.html

Hand, Murphy, Field, Lee, Parrott, Ferguson, . . . Steiber. (2016). Validation of the Academy/A.S.P.E.N.
Malnutrition Clinical Characteristics. Journal of the Academy of Nutrition and Dietetics, 116(5),
856-864.

Michigan Medicine, University of Michigan. (2018, March 15). Blood Urea Nitrogen. Retrieved October
05, 2018, from https://www.uofmhealth.org/health-library/aa36271#aa36277

Nagami, G. T. (2016, June 3). Hyperchloremia - Why and how. Retrieved October 8, 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/27267918

Nahikian-Nelms, M., & Sucher, K. (2015). Nutrition therapy and pathophysiology (Third ed.).

U.S National Library of Medicine. (2018, July 30). Albumin Blood Test: MedlinePlus Lab Test
Information. Retrieved October 04, 2018, from
https://medlineplus.gov/labtests/albuminbloodtest.html

White, J., Guenter, P., Jensen, G., Malone, A., & Schofield, M. (2012). Consensus Statement: Academy
of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation of Adult Malnutrition
(Undernutrition). Journal of Parenteral and Enteral Nutrition, 36(3), 275-283
Appendices

Appendix A. Intake analysis using Food Processor software (installed in FCS computer labs). Please
include the following components in order.

a. Spreadsheet
b. Bar graphs
c. Pie chart for macronutrient distribution
d. MyPlate recommendation

Appendix B. Nutrition Intervention: sample menu for one-day. Please list all items in each
eating/feeding event with quantity.

Appendix C. Analysis of the sample menu using Food Processor software (installed computers in the FCS
computer lab). Please include the following components in order.

e. Spreadsheet
f. Bar graphs
g. Pie chart for macronutrient distribution
h. MyPlate recommendation