Christina Kalafsky

University of Maryland College Park Dietetic Internship

2013-2014 MINI CASE STUDY
Nutrition Assessment: Medical Diagnosis Kidney Stones; Consulted for unintentional weight loss >10# in one month Age: 52 Labs: Gender: Female Na: 137 trending down Weight: 395 lbs (179.171 kg) K+: 3.8 Height: 59 (175.3 cm) Cl: 109 (H) trending up BMI: 58.5 (morbidly obese) BUN: <5 (L) trending down IBW: 66.2 kg Cr: 0.99 trending down Glucose: 231 (H) PMH: FS: 173-304 T2DM Ca: 8.5 Hypothyroidism GFR 59 (L) Nephrolithiasis Obesity Medications: HTN IV NS @ 100 ml/hr Hyperlipidemia Ofirmev (IV acetaminophen) Tachycardia Tenormin (antihypertensive) Positive TB test Colace (stool softener) Genitourinary system disorder (kidney stones) Prozac (antidepressant) GI problem (hiatal) Lopid (lipid regulation) Depression Garamycin (antibiotic) Transient ischemic attack Heparin (anticoagulant) Anemia Humalog (SSI) Partial thyroidectomy Synthroid (hypothyroidism) Cholecystectomy Pravachol (statins) Percutaneous Nephro Lithotripsy Flomax (increase passage of ureteral stones) Vancocin (antibiotic) Symptoms PRN: Constipation, Early satiety, Morphine sulfate (opioid, pain management) Decreased appetite/anorexia (pt may be at risk for Zofran (antiemetic) sarcopenic obesity if intake has truly been poor), Roxicodone (opioid, pain management) Unintentional weight loss- Pt reports 50-pound Noted 10/21 given Decadron (hyperglycemia) unintentional wt loss over the past 2-3 months. Per chart: Current Diet 10/21 CHO controlled standard 12/5/12: 190.51 kg 10/22 Regular diet 8/15/13: 181.44 kg 10/22 CHO controlled standard 8/28/13: 181.4 kg No intakes documented per RN flowsheets; pt Based on wt from 12/5/12, pt with 11 kg does not like diabetic diet, would prefer regular (24.2 lb) wt change (-5.8% wt change in diet. Agreeable to try Glucerna. ~10.5 months)

Diet History Per pt, no appetite over past several months. Reported some days she does not eat at all and other days eats only a couple bites. She has tried to eat full meals but gets full after only a few bites. Pt does not follow any special diet at home and does not monitor CHO or sugar intake. Pt does not regularly check BS, but when she does readings usually around 150-220 (usually checked around mid-day). Pt reports being compliant with her DM medications ~20% of the time. Nutrition Diagnosis utilize PES Statements NI-2.1: Inadequate oral intake related to decreased appetite as evidenced by pt report of poor po intake PTA x several months and report of weight loss. NC-3.2: Unintended weight loss related to inadequate oral intake as evidenced by 11 kg (24.2 lb) wt change (-5.8% wt change in ~10.5 months). Nutrition Intervention Nutrition prescription, Interventions with goals Nutrition Prescription Intervention with goals 2,600 3,200 kcal CHO controlled dietGoal: PO intake > 25% of meals High 1. Food &/or Nutrient Delivery ND-1.2: Will change diet to CHO controlled(Kcal Mifflin St. Jeor with factors 1.05High diet to allow for more options and 1.3 for obesity) encourage PO intake. Pt did not desire any snacks at this time. ND-3.2.1: Will order MVI given report of poor intake to ensure adequate vitamins/minerals for wound healing. ND-3.1.1: Will add Glucerna BID (440 kcal, 20 gm protein). 2. Nutrition Education- Diabetes E-1.3: Discussed importance of adequate protein kcal intake and glucose control for wound healing. Also discussed importance of diabetic diet (briefly discussed watching sugar intake) and medication compliance at home (discussed risk of hypoglycemia if pt does not eat). Recommended pt consumes small frequent meals at home. 3. Coordination of Care- Collaboration with Other Providers- RC-1.4: Nursing to monitor intake of food and fluid at meals. Recommend optimal glucose control for wound healing. May need to add oral hypoglycemia agent and/or insulin. Recommend checking A1c level given noncompliance with medications at home.

Nutrition Monitoring and Evaluation Indicator 1. AD-1.1.2: Weight

2. FH-1.1.1.1: PO intake/tolerance 3. BD-1.2, 1.5: Nutrition-related labs 4. PD-1.1.5: GI function

Criteria 1. Pt does not gain anymore wt; unintentional wt loss minimized- however, once anorexia is resolved, intentional wt loss would benefit glucose control 2. Pt consumes at least 25% of meals 3. Monitor electrolyte and renal profile, as well as glucose levels, A1c 4. No reports of N/V/D/C; bowel sounds return to normal

Source Facility standards

Kcal requirements 2,600-3,200 kcal/day (Kcal Mifflin St. Jeor with factors 1.05-1.3 for obesity = 2589.65 3206.23 kcal)

Protein requirements 80-100 gm protein/day (Using IBW for obesity and factors 1.2-1.5 for pressure ulcer)

Fluid requirements 2600-3200 ml fluids/day (Using 1 ml/kcal)

EAL

Online nutrition care manual

2469 kcal (w/o factor) N/A (Estimated energy needs should be based on RMR, if possible (e.g., indirect calorimetry). If RMR cannot be measured, then the Mifflin-St. Jeor equation using actual weight is the most accurate for estimating RMR for overweight and obese individuals.) 2,600-3,200 kcal/day 109 218 gm protein/day (Overweight/Obesity: (15-30% of energy as Use Mifflin-St. Jeor to protein. Minimum of estimate RMR 65-70 g protein/day (kcal/day) and multiply (this recommendation is by an activity factor of for a balanced deficit 1.3 for sedentary meal plan for wt loss in individuals.) those who are overweight/obese)) 2,900 100 132 gm pro/day 435 kcal 870 (The general recommendation for protein intake for pts with pressure ulcers is 1.5g-2.0 g/kg/day)

N/A

2,600-3,200 ml fluids/day (1 ml/kcal pressure ulcers) Overweight/obesityremain well-hydrated

References: Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago, IL: American Dietetic Association; 2013; Academy of Nutrition and Dietetics. Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed October 29, 2013. http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5545&lv2=16997&ncm_toc_i d=16997&ncm_heading=Nutrition%20Care http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5546&lv2=16668&ncm_toc_i d=16668ncm_heading=& Evidence Analysis Library. Academy of Nutrition and Dietetics Web site. www.adaevidencelibrary.com. Accessed October 29, 2013. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=621