Amar Burgic

Medical Nutrition Therapy (1:40-2:55 T/R)

Professor Alireza Jahan-Mihan
September 16,2014

Clinical Case Studies for the Nutrition Care Process

Case 1: General Nutrition Assessment
Learning Objectives
1. Recognize anthropometric, biochemical, clinical, and dietary factors that impact on
nutritional status.
2. Calculate and interpret weight change and body mass index.
3. Determine adequacy of dietary intake.
4. Apply the Nutrition Care Process to an elderly patient.
Case Description Background
Adequate nutrition can be viewed as a state of balance between intake, requirements,
metabolism, and losses of nutrients. The term malnutrition usually refers to a state of
undernutrition, and has been associated with increased morbidity and mortality in the clinical
setting (1-4). The accurate identification and patients at risk for malnutrition and its associated
complications is both an art and a science; subjective and objective data are interpreted along
with clinical judgment to evaluate nutritional status. From the dietary standpoint, a full
evaluation considers not only calorie and protein intake but also vitamin and mineral status.
Surrogate markers of visceral protein stores such as serum albumin and prealbumin have
traditionally been measured for nutritional assessment. These parameters are now known to be
affected by many factors, including hydration, physiological stress, and inflammation.
Particularly during metabolic stress, serum proteins more specifically reflect severity of illness
than nutritional stores (1-7). While a low serum albumin is associated with an increased
morbidity and mortality, it cannot be used alone to measure nutritional status or repletion.
Conversely, a normal serum albumin cannot be used in isolation to rule out malnutrition. Serum
protein levels by themselves do not form the basis for nutrition diagnosis or intervention.
Individual assessment parameters should be considered as part of the biggest picture of
nutritional equilibrium. The client is a 76-year old woman with a history of hypertension
admitted to the hospital after tripping over her cat and falling at home. She is admitted for a
femur fracture. She is currently confined to bed.
Nutritional Assessment Data
1. Anthropometric Measurements.
Height: 67
Weight: 140lb
Usual weight: 160lbs 6 months ago. She has been unmotivated to cook since the loss of
her husband during the previous 6 months.
2. Biochemical Data, Medical Tests, and Procedures.
a. Labs
Parameter
Value

Sodium
Potassium
Chloride

140 mEq/L
3.2 mEq/L
103 mEq/L

Normal Ranges*
(may vary by age, sex, and
lab)
135-147 mEq/L
3.5-5.0 mEq/L
98-106 mEq/L

Carbon dioxide
BUN
Creatinine
Glucose
Hemoglobin
Hematocrit
Albumin
Prealbumin

29 mEq/L
19 mg/L
1.0 mg/L
108 mg/L
12.0 g/L
38.1%
3.2 g/dL
11mg/dL

21-30 mEq/L
8-23 mg/L
0.7-1.5 mg/L
70-110 mg/L
12-16 g/L (female)
36-47% (female)
3.5-5.5 g/L
16-40 mg/L

b. Test results, if pertinent

X-ray indicates fracture of left femoral neck.
3. Nutrition-Focused Physical Findings
Blood pressure: 128/65 mm Hg
Oral mucosa dry.Has upper and lower dentures which are poorly fitting.
Skin turgor decreased.
4. Client History
Social Hx:
No smoking or alcohol
Husband diet 6 months ago and patient has lost weight since this time
Family Hx:
N/A
5. Food/Nutrition-Related History
Usual Diet
Breakfast:
1 cup (8oz) decaffeinated tea with 1 tbs half and half and 1 tsp sugar
1 slice white toast with 1 tsp margarine and 1tsp jelly or 1 frozen pancake with 1 tbs
syrup
cup orange juice
Lunch:
Canned soup, usually chicken noodle, 1 cup
4 unsalted crackers with 2 tbs peanut butter
cup sliced peaches in light syrup
Sweetened iced tea, 1 cup
Dinner:
Chicken thigh with skin, stewed
cup rice or potato with 1 tsp margarine
cup spinach or carrots
1 cup (8oz) decaffeinated tea with 1 tbs cream and 1 tsp sugar
Notes:
Rarely eats or drinks between meals.
Avoids eggs and milk due to food preferences.

Medications
Furosemide 20 mg daily
Supplements
None
Questions:
1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW (1
point), % UBW (1 point), and BMI (1 point). Interpret her weight and weight change
based on these parameters (2 points).
Height: 170.18 cm
Weight: 63.5 kg
IBW: 127.27%
UBW: 88%
BMI: 21.9
Her usual weight was 160lbs and she lost 20lbs in the last 6 months since the loss of her
husband. Her current weight is 88% of her usual weight.
2. Calculate her nutritional requirements (calories, protein, and fluid) (3 points) and
compare her current intake to her needs (2 points).
Calories: 1450
Protein: 46 g
Fluid: 70 ounces (8 cups)
Her current intake of calories, protein, and fluid is very low. She is only getting 3 and a
half cups of fluid daily when she should get at least 8 cups. Protein intake is around 30g
when she should get around 50g.
3. Are any major food groups and nutrients obviously missing from her diet? (2 points)
Explain your answer. (3 points)
According to the food diary that we were provided she only consumed 3 and a half cups
of fluid during the day. This amount is way less than the recommended intake of 8 cups a
day. She is also taking Furosemide which is diuretic, she can become dehydrated this way
because the diuretic is causing her to excrete more liquid and nutrients. Her potassium
levels are lower than normal as well. She does not drink any water in her diet, she has
very little fat, nuts, grains, and vegetables. It is stated that her dentures fit poorly in her
mouth, this could be causing difficulties with chewing certain foods. Her protein intake
may be a bit low, which can be seen from her low albumin levels. She also stated that she
avoids milk and eggs which explains her low dairy diet.
4. Do you think she could be experiencing any drugnutrient interactions? (2 points) If so,
what dietary suggestions would you make? (3 points)

She could be experiencing a drug-nutrient interaction with Furosemide. Furosemide is an

antihypertensive diuretic and diuretics can deplete the body of potassium, magnesium,
and other minerals. I would suggest that she increases fluid intake, potassium and
magnesium intake. In the physical findings it states that she has been experiencing dry
oral mucosa and a decrease in skin turgor, which indicates dehydration.

5. Interpret her serum albumin and prealbumin. (2 points) In addition to nutritional intake,
what factors can cause these indices to drop? (2 points) What factors would cause them to
be elevated? (1 point)
Albumin and prealbumin levels in the patient are lower than normal. Decreased albumin
levels may occur when the body does not get or absorb enough nutrients. Elevated levels
of albumin may be the result of dehydration, high protein diet, or having a tourniquet on
for a long time when giving a blood sample. A low prealbumin level could mean
malnutrition, severe or chronic illness, liver disease, or hyperthyroidism. Prealbumin
levels can also be high in Hodgkins disease, kidney failure, iron deficiency, pregnancy,
and with hyperactive adrenal glands.
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)
The results from her anthropometric, biochemical, clinical, and dietary nutritional
assessment data fit together to show that she may be dehydrated and lacking proper
nutrition in her diet. In the anthropometric portion of the assessment it shows that she has
lost 20lbs in the last 6 months, this is due to a lack of calories. However she also stated in
the assessment that her dentures are poorly fitting so this may be a result of her low
calorie diet. The biochemical test shows low potassium, albumin, and prealbumin levels
for her. The dietary nutritional assessment shows that she is only consuming 3 and a half
cups of fluid a day. It also shows that she has a dry mucosa and decreased skin turgor
which are signs of dehydration.

7. Write a PES statement based on the nutritional assessment data available. (5 points)

Type of Consult

Nutrition Diagnosis
Problem (P)

Related to Etiology
(E)

Weight Loss

Inadequate energy
intake
Inadequate protein
intake
Disordered eating

Calorie intake not

meeting caloric
needs
Protein intake not
meeting needs

As Evidenced by
Signs and
Symptoms
Poor dentures
causing difficulty
chewing
Lost 20lbs in 6
months after

Abnormal
laboratory values
Dehydration

Low albumin

pattern
Involuntary weight
loss
Impaired nutrient
use
Inadequate fluid
intake

Inadequate food

husband passed
away
Excrete specific
nutrients
Fluid intake <
calculated bodily
needs
Intake not meeting
needs

Low albumin levels

Dry oral mucosa
Decreased skin
turgor
Low fluid intake.
Low albumin levels
Stress

8. What dietary and social changes would you suggest to improve her nutritional intake? (5
points)
I would suggest that she starts off by drinking more water. Since water is vital for life and
she isn't drinking any water just tea. She is only getting 3 and a half cups of fluid a day
which is water too little. Secondly I would suggest that she gets more protein in her diet.
Increasing her intake of fruits and vegetables should also help with getting more
micronutrients in her diet so she doesn't have low levels of potassium or other
micronutrients anymore. The last thing I would suggest about her nutritional intake is to
start consuming more dairy products. She stated she doesn't consume eggs or milk, but an
alternative would be good. Social changes that I would suggest is that she starts to cook
again. This will help with consuming more nutrient dense and healthier foods.

9. What are your nutritional goals for her (2 points), and how would you monitor the
effectiveness of your interventions from question #8? (3 points)
My goals for her would be very specific. Drink more fluid throughout the day. Try to
consume more protein, and calories. Monitor your intake of sodium while using the
diuretic Furosemide and increase your intake of fruits and vegetables. The way that I
would monitor this is through regular checkups to see how her albumin and prealbumin
levels are. On top of that seeing if her sodium levels change at all.
10. Write a note documenting your assessment in SOAP or ADIME format. (5 points)

Nutrition Assessment
76 Year old woman admitted to a hospital after tripping over her cat and falling at home.
Ht: 170.18cm; Wt: 63.5kg; IBW: 72kg
Laboratory values noted: Low potassium, low albumin, and low prealbumin levels.
Dry oral mucosa, decreased skin turgor, and taking Furoesmide.

Nutrition Diagnosis
Lack of motivation to cook due to the loss of her husband 6 months ago. Refuses to eat
milk and eggs due to preference.

Nutrition Intervention
Education: Will provide client with information on the dangers of low fluid intake while
taking a diuretic, and how to monitor sodium intake while on it.
Goals: Have the client drink more fluids throughout the day, eat more protein and
calories, and eat more nutrient dense foods.
Monitoring and Evaluation
Follow up with client to ensure that they understand the dangers of low fluid intake
especially when using a diuretic.
Evaluation: anticipate no problems following diet at home.

Works Cited

Mahan K.L, Escott-Stump S., Raymond J.L., Krause's Food and the Nutrition Care Process, St.
Louis, MI: Saunders, an imprint of Elsevier Inc.; 2012
Lacey K, Long Roth S, Nelms M, Sucher K.P, Nutrition Therapy & Pathophysiology, Belmont,
CA: Wadsworth, Cengage Learning; 2011
MedlinePlus Website. http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm Accessed.
September 16, 2014
Lab Tests Online Website. http://labtestsonline.org/understanding/analytes/prealbumin/tab/test/
Accessed. September 16, 2014