ElizabethFerrer

N00936977
DIE321381263
MedicalNutritionTherapy1
Dr.AlirezaJahanmihan
September15,2015

CaseStudy#1Questions
1. Convertherheightandweighttocentimetersandkilograms.Calculateher%IBW(1point),
%UBW(1point),andBMI(1point).Interpretherweightandweightchangebasedonthese
parameters(3points).
Height:67in=170.2cm1
Weight:140lb=63.6kg(2.2lb=1kg)1
IBW:135lb=61.4kg(HamwiEquation)1
103.7%IBW
UBW:160lb=72.7kg1
87.5%UBW
12.5%weightchange1
BMI:21.9(Queteletindex)1
Accordingtotheunintentionalweightchangedatatablethatindicatesthedegreeof
weightlossbasedonthepercentageofUBW,theclienthashadsevereweightloss.After
atimeframeof6monthsshehasunintentionallylost12.5%ofherUBW.Foraclientto
considertohaveunintentionalsevereweightlosshe/shemusthavelostmorethan10%of
theirUBWwithina6monthtimeframe.1
ThisclienthasaBMIof21.9,whichisinthenormalrangeof18.524.9considered
healthyandlowriskforthegeneralpopulation.However,sincesheis76yearsoldthe
regularBMIstandardsarenotaccurate.Fortheelderlypopulation,menandwomen65
yearsorolder,ahealthyBMIishigherfrom2527.HavingahigherBMIfortheelderly
populationisimportantbecausethismayprotectthemformthinningofthebones,
osteoporosis,laterinlife.Withthatbeingsaid,thisclientcanbeconsideredunderweight
forherageataBMIof21.9.1
2. Calculatehernutritionalrequirements(calories,protein,andfluid)(3points)andcompare
hercurrentintaketoherneeds(2points).
Calories:REE=1,232kcal/day(HarrisBenedictEquation)1
Protein(EPR):63g/day(1g/kgbodyweightfortrauma)1
Fluid:1,590mL/dayor1.6liters/day(Method2basedonBW)1
Theclientscurrentintakeisveryminimalandpicky.Itseamsthatshelikestoaddsugar
toeachofhermealsintheformofjelly,syrupandsweetenedtea.Hercurrentsourcesof
proteinareinthechickennoddlesoup,peanutbutter,andchickenthigh.Hercurrent
carbohydratesourcesarecomingfromwhitetoast,crackers,rice,noodlesformthesoup,
fruitjuice,andfruit.Theonlyfruitsandvegetablessheisconsumingisaglassoforange
juice,peaches,potato(sometimes),andspinach/carrots.Hercurrentintakedoesnot
includeanysnacks,whichshouldbeusedtoreplenishhernutritionalneedsthatsheisnot
attaininginherbasic3meals/day.Theclientscurrentintakedoesnotaccountforeggsor
milkproductsduetofoodpreferences.Therefore,protein,calciumandvitaminDare
someofthenutrientsthatsheismissingfromherdiet.
Theclientscurrentusualdietincludes:
Breakfast:

 1cup(8oz)decaffeinatedteawith1tbshalfandhalfand1tspsugar
1slicewhitetoastwith1tspmargarineand1tspjellyor1frozenpancakewith1tbs
syrup
cuporangejuice
Lunch:
Cannedsoup,usuallychickennoodle,1cup
4unsaltedcrackerswith2tbspeanutbutter
cupslicedpeachesinlightsyrup
Sweetenedicedtea,1cup
Dinner:
Chickenthighwithskin,stewed
cupriceorpotatowith1tspmargarine
cupspinachorcarrots
1cup(8oz)decaffeinatedteawith1tbscreamand1tspsugar
3. Areanymajorfoodgroupsandnutrientsobviouslymissingfromherdiet?(2points)Explain
youranswer.(3points)
Thefoodgroupthatismissingfromherdietisdairybecauseshedoesnotconsumemilk
productsduetopersonalpreference.Thedairyfoodgroupincludesmilk,yogurt,cottage
cheese,andcheese,whicharenotincorporatedintoherdiet.2
Thenutrientsobviouslymissingfromherdietareprotein,complexcarbohydrates,
vitaminB12,Ca,vitaminD,vitaminA,Zinc,protein,K,P,Mg,mostofthesenutrients
arethosethatareincludedinthedietwhendairyproductsareconsumed.3,4
4. Doyouthinkshecouldbeexperiencinganydrugnutrientinteractions?(2points)Ifso,what
dietarysuggestionswouldyoumake?(3points)
TheclientisonthemedicationFurosemide(20mg/day),whichmayalsobecalledLaxis,
isadiureticandantihypertensivedrugusedtoreduceextrafluidinthebody,edema.This
drugisalsousedtotreatand/orlowerhighbloodpressure.Furosemideisalsousedto
helppreventstrokes,heartattacksandkidneyproblems.Furosemideshouldbetakenon
anemptystomachbecausethefoodcanreducethedrugsbioavailabilityinthebody,but
maybetakenwithfoodormilkifGIdistressoccurs.5,6
Thedrugnutrientinteractionthatidpresentisthatsincethismedicationisadiureticit
increasesthelikelihoodofhavingincreaseminerallossintheurine.Theclienttendsto
drinkmorethanoneglassofsweetenedteadailyandteacanbeseenasadiuretic,which
alongwithhermedicationthatisadiureticmaybetoomuchexcretionandnotasmuch
absorptionofkeynutrientsinherbody.5,6
Effectsofmedicationonnutritionalstatusmaybeseeninherbiochemicaldatafor
potassium,whichwaslowerthanthenormalrange.Withthemedicationsheistaking,
Furosemide,herdietshouldaccountforhigheramountsofpotassiumandmagnesium.A
lowerconsumptionofcalciumandsodiummayberecommended.5,6
ThedietarysuggestionIwouldmakewouldbetotakethemedicationasdirectedandto
increaseherKandMginherdiet.ShecanincreaseherintakeofKbyconsumingfoods
suchas;potatoes,beans,fruit(bananas,dates,orplums),vegetables,andmilkproducts.

ToincreaseherconsumptionofMgshecaneatgreenleafyvegetables,wholegrain
breads,beansandnuts.Overallthisclientshouldfocusonincreasingfreshfruitsand
vegetablesinherdiet.Alsomakesuretokeepcaloriesnottoolowbecausethis
medicationmayleadtoanorexia.35
5. Interpretherserumalbuminandprealbumin.(2points)Inadditiontonutritionalintake,what
factorscancausetheseindicestodrop?(2points)Whatfactorswouldcausethemtobe
elevated?(1point)
Theclientsserumalbuminis3.2g/dL(Normalrange3.55.5g/dL),whichis.2g/dLlower
thanthelowerendofthenormalrange.Albuminisanegativeacutephaseprotein,which
declineswiththeinflammatoryprocess.
Factorsthatcancausealbumintodropmaybebecauseofliverdiseaseoracute
inflammatorydisease.Whenserumalbuminlevelsdecrease,thewaterintheplasma
movestotheinterstitialcompartmentandpromotesedema.Thelossofplasmafluid
resultsinhypovolemia,whichtriggersrealretentionofwaterandNa.Theclientalso
hasdecreasedskinturgor,whichindicatesalatesignofdehydrationandmaybe
causingherbodytokeepallthefluidssheisconsumingcausingedemaandalower
serumalbumin.1
Factorsthatcancausealbumintobeelevatedareahighproteindiet,butalbuminmay
notbetheperfectmeasureofthisbecausealbuminhasahalflifeof1821days,
whichistoolongtoreflectcurrentproteinintake.1
Theclientsprealbuminis11mg/dL(Normalrange1640mg/dL),whichis5mg/dL,
significantlylowerthanthelowerendofthenormalrange.PABisanegativeacutephase
reactant.
BecausePABhasashorthalflife,2days,itisagoodindicatorofproteinstatus.
Controversially,wellnourishedindividualswhohaveundergonerecentstressor
traumamayhavedecreasedPABlevels.FactorsthatcancausePABtodropare
inflammatorystress,malignancy,andproteinwastingdiseasesoftheintestinesor
kidneys.SerumPABlevelsalsodecreaseduetoazincdeficiencybecausezincis
requiredforhepatic(liver)synthesisandthesecretionofPAB.1
FactorsthatcancausePABtobeelevatedduetoirondeficiency,kidneyfailure,
proteinuriaandhyperproteinemiabecausePABisrapidlysynthesized.1
6. Describehowfactorsinheranthropometric,biochemical,clinical,anddietarynutritional
assessmentdataallfittogethertoformapictureofhernutritionalhealth.(5points)
Thisclientsanthropometricdatashowsthatshehasunintentionalsevereweightlossof
12.5%ofherUBWafteratimeframeof6months.HerBMI21.9,sincesheis76years
oldtheregularBMIstandardsarenotaccurate.Fortheelderlypopulation,menand
women65yearsorolder,ahealthyBMIishigherfrom2527.HavingahigherBMIfor
theelderlypopulationisimportantbecausethismayprotectthemformthinningofthe
bones,osteoporosis,laterinlife.1,2
Herbiochemicalandlaboratorydatashowsthattheelectrolytepotassiumislowerthan
thenormalrangeandthisisaconcernbecausethemedicationsheison,Furosemide,she
needstoincorporatepotassiumintoherdietmore.Hervisceralproteins,albuminand

PABarealsolowerthanthenormalranges,whichcanberelatedtoproteindeficiency.
ShehasalsohadanXrayindicatingthatshehasafracturedleftfemoralneckinjury
fromherfall,whichsignifiesthatherbodyhasbeenthroughsometraumarecently.The
clientsclinicaldatashowsthatshehasnosignificantmedicalfamilyhistory,butshehas
hadahistoryofhypertension.Herbloodpressureis128/65mmHg,whichisconsidered
prehypertensionforthesystolicBPof128mmHg.Theclientalsohasadryoralmucosa,
hasupperandlowerpoorlyfittingdenturesandhasadecreaseskinturgor,whichisalate
signofdehydration.2,5
Theoverallpictureofthisclientsnutritionalhealthshowsthatsheisnotgettingenough
fluidsandisdehydrated,sheisnotconsumingenoughcalories,sheisnotreachingher
proteinrequirements,shehasalackofCainherdietduetothefactthatshedoesnot
consumedairyproducts,andshedoesconsumewholegrainsandfreshfruits,whichmay
beareaswhereshecangetkeepnutrientstohelpheroverallhealth.

7. WriteaPESstatementbasedonthenutritionalassessmentdataavailable.(5points)
Involuntaryweightlossrelatedtoinadequateenergyrequirementsasevidencedbya
twentypoundsweightlosswithinsixmonths.2
Inadequateintakeofproteininthedietrelatedtolowerintakeofproteinrichfoodsas
evidencebylowalbuminandprealbuminlevels.2
Inadequateamountofpotassiuminthedietrelatedtoinsufficientintakeofwholegrains,
fruitsandvegetablesalongwith20mg/dayofFurosemidemedicationasevidencebythe
patientsdietrecallandlowpotassiumlevelsinbiochemicaltest.2
8. Whatdietaryandsocialchangeswouldyousuggesttoimprovehernutritionalintake?(5
points
ThedietarychangesIwouldsuggesttoimprovenutritionalintakewouldbetofocuson
eatingfromallthefoodgroups,especiallyproteins,dairy,wholegrains,fruitsand
vegetables.Sinceitmaybeharderforhertochewbecauseofherpoorlyfittingdentures,
shemayneedtohaveherfoodmashed,pureed,orblendedsoitisnotadifficulttask.I
wouldalsotrytoslowlyincreasehercaloriescomparedtowhatsheiscurrentlyeatingby
incorporatingsnacksthatwillhelpherreachhernutritionalneeds.Somesnackideas
wouldbetohaveacupof100%naturaljuice,amashedbanana,oryogurtwithfruit.I
wouldalsotrytoincreaseherproteinrequirementbyaddingbeans,leanmeats,andfish
intoherdiet.AlongwiththoseproteinrecommendationsIwouldinsistshetryto
incorporateeggsanddairyproductsintoherdietsuchas;cottagecheese,milk,oryogurt.
Lastly,Iwouldremindhertostayhydratedwithplentyofliquidsmainlywater,100%
fruitjuice,andminimalsweetenedteathroughoutthedaynotonlyatmealtimes.1,2
AsocialchangethatIwouldsuggestwouldbetoeatwithotherssuchasoldfriendsor
familymemberssoshedoesnotfeellonelyfromthedeathofherhusband.1,2
9. Whatareyournutritionalgoalsforher(2points),andhowwouldyoumonitorthe
effectivenessofyourinterventionsfromquestion#8?(3points)
NutritionalgoalswouldbetoslowlyincreasefluidintakeandincreaseherK,protein,and
Caintakeinhernormalmealsandbyincorporatesnackswithinthenext5days,which

willalsobeincreasingherdailycaloricneeds.2
Iwouldmonitortheeffectivenessoftheinterventionsbyhavinganurserecordhow
muchfoodsheatefromherplatealongwithhowmuchliquidshedrank.Iwouldalso
wanttofollowupwiththepatientherselfandjusttalkabouthowsheisfeeling,howher
cookinghasbeenplanningout,andifshehasbeensharinghermealswithanyfriendsor
familymembers.

10. WriteanotedocumentingyourassessmentinSOAPorADIMEformat.(5points)
Subjectivedata:Inadequatefluidintake,calorieintake,andproteinintake.Sheasa
historyofhypertension.Shedoesnoteateggsormilkduetofoodpreferences.Her
husbanddiedsixmonthsago.Shedoesnotsmokeordrinkalcohol.2
Objectivedata:Shehasadryoralmucosa,hasupperandlowerdentureswitharepoorly
fittingandhasadecreasedskinturgor.Sheiscurrentlyconfinedtobedduetoher
admittancetothehospitalforafractureofherleftfemoralneck,xrayresults.Herblood
pressureis128/65mmHg,sheisa76yearoldfemale.Sheistakingthemedication
Furosemide(20mg/day).HerBMIis21.9,heightis170.2cm,herweightis63.6kg,and
shehassevereunintentionalweightlosswithinthelastsixmonths.REE=1,232kcal/day
andEPR=63g/day.2
Assessment:Thepatienthashadsevereweightlosssinceherhusbanddiedsixmonths
ago.HerBMIof21.9indicatesthatsheisunderweight;thenormalhealthyrangeforthe
elderlypopulationisaBMIform2527.Sheneedstoincreaseproteinintake,fluid
intake,Kintake,andcalorieintake.Furosemidedrugnutrientinteractionscouldbelead
toanorexiaandneedstoincreaseK,Mg,andCaconsumptioninthedietor
supplementation.24
Plan:2
1) Modifydiettoaccommodatesoft,easilychewablefoodsandliquids.
2) Increasenutrientandfluidintake.
3) Initiatecaloriecounttomonitoradequatepatientintakes.
4) Monitordailywhileatthehospitalforpatientvisitation,caloriecounts,daily
weights,andvitalstoassessadequacyofthecurrentinterventions.

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