Marcy Robertson

DIE 3213
Case Study 1
Instructor: Janine R. Dray, MSH, RD, LD/N
October 1, 2014

LABS
PARAMETER

VALUE

REGULAR RANGES1

Sodium

140

135-145

Potassium

3.2

3.5-5

Chloride

103

100-110

Carbon Dioxide

29

21-31

BUN

19

5-20

Creatine

1.0

0.6-1.2

Glucose

108

70-99

Hemoglobin

12.0

12-16

Hematocrit

38.1

35-47

Albumin

3.2

3.5-5

Prealbumin

11

15-36

QUESTIONS
1. Convert her height and weight to centimeters and kilograms. Calculate her %
IBW, % UBW, and BMI. Interpret her weight and weight change based on these
parameters. (5 points)
Height1: 62 x 2.54 = 157.5 cm
Weight1: 145 lbs. / 2.2 = 65.9 kg
% IBW1: 100 + (6 x 2) = 112 lbs. 112/2.2= 50.9kg

65.9 x 100 = 129.5%

50.9
1
% UBW : 155 145 x 100 = 6.5% = severe weight loss
155
1
BMI : 145 x 703 = 26.5
622
2. Calculate her nutritional requirements (calories, protein, and fluid) and compare
her current intake to her needs. (5 points)
Calories1 = 10 (65.9) + 6.25 (157.5) 5 (79) 161 = 1087.4 x 1 = 1087.4 calories
Protein1 = 65.9 kg
Fluid2 = 1mL per kcal 1087.4 calories= 1087.4 mL
3. Are any major food groups and nutrients obviously missing from her diet?
Explain your answer. (5 points)

She is currently consuming 1526 calories a day and 65.5 grams of protein.
According to the United States Department of Agricultures Super Tracker, Marian has
many areas of concern. She is not eating the recommended daily values for vegetables,
fruits or dairy, and the grains she is consuming are all refined. She is under in many
important vitamins and minerals as well including calcium, potassium, magnesium, zinc,
vitamins A, C, D, E, K, and choline. She is also under in fiber and consuming too much
saturated fat. Her failing to consume these key nutrients can be adding to her
osteoarthritis pain and management. Considering her risk of stroke she also needs to be
concerned with her saturated fat intake. She is consuming 1230 calories according to the
site, above the recommended 1087.4 based off her weight, height and activity level, so
this is another issue of concern.1,3
4. Do you think she could be experiencing any drugnutrient interactions? If so,
what dietary suggestions would you make? (5 points)
She can definitely be experiencing drug-nutrient interactions. The Bumex she is
prescribed is a diuretic and increases blood glucose levels; according to her labs her
glucose level is 9 mg/dL above what is should be. This drug also decreases potassium
levels, which happens to be low in her blood work. Older patients on low sodium diets
can experience sodium depletion when using this drug and Marian happens to be on a
low sodium diet, so this will have to be taken into consideration.1, 4
Kaopectate the antidiarrheal the physician prescribed her also decreases
potassium levels. The self-prescribed mineral oil is known to decrease weight and cause
diarrhea. It also can decrease absorption of fat-soluble vitamins, so this could also be
contributing to her decreased potassium levels. The drug Trilisate she was prescribed for
her osteoarthritis should not be used if you have had a stroke, have high blood pressure,
or diabetes. She has had a stroke, she has high blood pressure and is prediabetic so
another drug to help with her osteoarthritis should be considered.1, 4, 5, 6
Dietary suggestions I would make is to eliminate the self-prescribed mineral oil
from her diet, this will probably help with the diarrhea, unexpected weight loss and could
even get her potassium levels a little higher. I would also recommend a potassium
supplement to help get her levels higher and would redo blood work to make sure we get
her at her target level. I would also recommend her to see a doctor to look at all the
medications shes taking together, their possible interactions, and a replacement for the
Trilisate because it is not suitable for her considering her history.1, 4, 6
5. Interpret her serum albumin and prealbumin. In addition to nutritional intake,
what factors can cause these indices to drop? What factors would cause them to be
elevated? (5 points)
Her Albumin is 3.2, normal range is 3.5-5, and so her albumin is low and she is
showing a mild depletion in stores. Albumin levels are lowered during inflammatory

stress, injury, stress, and illness. Dehydration and high protein diets can cause increased
blood albumin levels. Her osteoarthritis in her wrists and ankles could be a contributing
factor to the lowered level as well as her diarrhea and the passing of her husband. Overall
an albumin level is not a reliable indicator of early protein depletion due to its long half
life and stressors that cause its reading to be false. 1, 7
Her prealbumin is 11, normal range is 15-36, and so her prealbumin is also low
and she is showing a mild depletion in stores. Prealbumin levels fall steeply when
inflammatory stress is present and often do not improve even with aggressive nutrition
support. Serum levels also decrease with malignancy, with protein wasting disease of the
intestines or kidneys and with zinc deficiency. During pregnancy or nephrotic syndrome
levels may be increased. As stated with albumin her osteoarthritis, diarrhea and stress
from the passing of her husband could be contributing factors for her prealbumin levels
being low. However, overall prealbumin is a sensitive indicator of visceral protein status,
so her lower levels are reason to be concerned and could possibly be indicating
malnutrition.1
6. Describe how factors in her anthropometric, biochemical, clinical, and dietary
nutritional assessment data all fit together to form a picture of her nutritional
health. (5 points)
Anthropometrically she is 62 inches, 145lbs, and overweight with a BMI of 26.5.
She has had a severe weight loss of 6.5% in the past month. Biochemically she has high
glucose levels and is considered prediabetic. She is low in potassium, albumin and
prealbumin, prealbumin levels being low can be an indicator of malnutrition. Clinically
she has stage 2 hypertension with a reading of 170/100 mmHg, osteoarthritis in her wrists
and ankles, and a history of stroke. According to her dietary nutritional assessment she
has been placed on a low sodium diet of 2,000 mg. She is not eating enough fruit,
vegetables, and dairy items and is consuming all refined grains instead of whole grain
options. She has self-prescribed herself mineral oil that can be contributing to her issues.
She is also taking multiple prescribed drugs that have nutrient-drug interactions that
could be the culprit for her lab results. Collectively this information shows a picture of a
woman who is in poor physical and nutritional health. 1, 3, 4, 5
7. Write a PES statement based on the nutritional assessment data available.
(5 points)
Problem (P): Unintended weight loss
Related to
Etiology (E): chronic diarrhea
As evidenced by
Signs and Symptoms (S): weight loss of 6.5% within 1 month

Unintended weight loss related to chronic diarrhea as evidenced by weight loss of 6.5%
within 1 month.8 NC-3.2

8. What dietary and social changes would you suggest to improve her nutritional
intake? (5 points)
The first dietary change I would suggest to Marian is to stop taking the selfprescribed mineral oil. I would also explain to her how her blood sugar levels are in the
range that she is considered prediabetic. She would benefit from adding more whole
foods to her diet, for example reducing canned foods and opting for fresh fruits and
produce as well as eating more whole grains. Nutrition management I would recommend
for her osteoarthritis is having a balanced diet with appropriate calories for weight loss or
maintenance of appropriate weight, consuming an anti-inflammatory diet, taking omega3 fat supplementation, obtaining adequate calcium and vitamin D, and consideration of
glucosamine and chondroitin. 1, 3, 4
Due to the fact she has osteoarthritis in her wrists and ankles I would recommend
social changes such as low impact activities like swimming, range of motion work outs,
and weight bearing exercises to help reduce her symptoms as well as manage blood
glucose levels. Her teeth are in poor condition and could be the reason why she stays
away from other forms of protein, so I would encourage her to see a dentist. Other social
changes she would benefit from is having her son join her for meals regularly and maybe
getting out more in the community by joining a senior center for companionship.1

9. What are your nutritional goals for her, and how would you monitor the
effectiveness of your interventions from question #8? (5 points)
Goal: Maintain current weight.
Indicator: Monitor her weight daily
Criteria: Weight must not fluctuate within +/- 3 lbs.1
Goal: Increase oral intake
Indicator: Monitor how much she is eating
Criteria: Make sure she is eating 50-75% of her meals1

10. Write a note documenting your assessment in SOAP format. (5 points)

S- Subject

O- Objective

79 Yr/ Old white woman, husband passed 7 years ago, and son visits
daily. Chief complaint chronic diarrhea, son mentioned her feeling more
sad than usual.
Special diet: Low Sodium 2,000 mg Diet
Anthropometric data:
Height: 62
Weight: 145 lbs

% IBW:129.5%1
% UBW: 6.5% (severe weight loss)1
BMI 26.5 (Overweight)1
BP 170/100 (stage 2 hypertension)1
Lab Results1:
PARAMETER
VALUE

A- Action

P- Plan

Sodium

140

REGULAR
RANGES1
135-145

Potassium

3.2

3.5-5

Chloride

103

100-110

Carbon Dioxide

29

21-31

BUN

19

5-20

Creatine

1.0

0.6-1.2

Glucose

108

70-99

Hemoglobin

12.0

12-16

Hematocrit

38.1

35-47

Albumin

3.2

3.5-5

Prealbumin

11

15-36

Clinical observations: CVA 5 years ago, poor teeth condition, and

osteoarthritis in wrists and ankles.
Diet: Not eating well, does not eat pork, chicken or beef, but will
occasionally eat fish.
Medications: Bumex, Trilisate, Kaopectate, self-prescribed mineral oil.
Caloric needs for maintaining weight 1087.4 calories.1
Weight history: Severe weight loss 6.5% in 1 month.1
Nutrition inadequacies: fruit, dairy, whole grains, protein.3
Patient is not eating well seems depressed, only eats fish as protein
source.
Expected to maintain weight.1
Goals:
1. PT will maintain weight +/- 3 lbs.1
2. PT will eat 50-75% of plate.1
Will monitor food intake 50-75%1
Will monitor weight +/- 3lbs every other day.1
Recommend more whole foods: fruits, vegetables, grains, dairy and
protein.3
Recommend potassium supplement.1
Return visit 1 day to monitor patient oral intake.

References:
1. Mahan K, Escott-Stump S, Raymond J, et al. Krause's Food and the Nutrition Care
Process. Elsevier Saunders; 2012. 24, 166, 167, 194, 198, 215, 216, 218, 452, 470, 759,
906-909, 1052, 1082-1099, 1142
2. American Dietetic Association. Manual of Clinical Dietetics, 6th Ed: Nutrition
Assessment of Adults. American Dietetic Association. 2000: 33.
3. Super Tracker: Food Tracker. United States Department of Agriculture.
https://www.supertracker.usda.gov/foodtracker.aspx. Accessed September 20, 2014.
4. Pronsky Z, Crowe J. Food Medication Interactions. Birchrunville, PA: FoodMedication Interactions; 2012. 58, 114, 218.
5. Diagnosing Diabetes and Learning About Prediabetes. American Diabetes Association.
http://www.diabetes.org/diabetes-basics/diagnosis/. Last Edited: September 22, 2014.
Accessed September 20, 2014.
6. Trilisate. WebMD. http://www.webmd.com/drugs/2/drug-6173/trilisate-oral/details.
2005-2014. Accessed September 20, 2014.
7. Albumin-blood (serum). Medline Plus.
http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm. Updated September 8,
2014. Accessed September 20, 2014.
8. AND. International Dietetics and Nutrition Terminology (IDNT) Reference Manual,
Standardized Language for the Nutrition Care Process. Chicago, IL: Academy of
Nutrition and Dietetics; 2013: 322.