Answer the questions to this Nutrition Case Study. Please write your answers in green. Do not write a book report or an essay. Just answer these questions providing answers to all the questions thoroughly. I have listed below the top sources to use to answer these questions and the ADIME chart at the end. Use the Nelms and Krause sources first, if you do not find the answers in these two sources then go on and use other sources listed or whatever good references you find that answer the question. You have to have a knowledge in nutrition to answer these questions. My professor is more concerned with providing good answers then whether if this case study is well-written. Please contact me if there are any questions. Here are the list of references but feel free to use others:
Nelms, Sucher, Lacey, Long Roth: Nutrition Therapy and Pathophysiology. 3rd ed., Cengage Learning 2014
ISBN-13:978-1-305-11196-7
https://www.coursesmart.com/IR/1845467/9781305111967?__hdv=6.8
Nahikian-Nelms M, Long-Anderson S. Medical Nutrition Therapy: A Case Study Approach 4th ed. Belmont, CA: Wadsworth; 2013.
ISBN: 978-1-133-59315-7
Gylis BA, Wedding ME: Medical Terminology Systems (with Termplus 3.0): A Body Systems Approad (with medicallanguagelab.com), 7th Edition
ISBN: 978-0-8036-3575-3
eNCPT: https://ncpt.webauthor.com/
Brown JE, Isaacs J et al: Nutrition through the Life Cycle. 5th ed. Wadsworth 2014
ISBN-10: 1133600492, ISBN-13: 9781133600497
Nutrition Care Manual: https://www.nutritioncaremanual.org/member-pricing
Mahan LK, Escott-Stump S, Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, Missouri: Elsevier/Saunders; 2012. ISBN: 978-1-4377-2233-8
American Dietetic Association / American Diabetes Association. Choose Your Food: Exchange Lists for Meal Planning. 2008. (Either Diabetes or Weight Management booklet).
https://www.nhlbi.nih.gov/health/educational/lose_wt/eat/fd_exch.htm#1 also shows exchange lists, as do many other sites (.edu can be considered reliable for this purpose).
Pronsky ZN. Food Medication Interactions. 17th ed. Birchrunville. PA 2012. (optional; encouraged if on Dietetics Track)
ISBN: 0-9710896-4-7. Note: Choose your source – prices vary greatly!
Alternatively, consult epocrates, or rxlist.com for information on food-drug interactions.
Stedman’s Medical Dictionary for Health Professionals. 7th ed. Baltimore, MD: Williams and Wilkins; 2011 (optional; if not purchased use online medical dictionary i.e. https://www.medterms.com/script/main/hp.asp)
Wallach: Handbook of Interpretation of diagnostic tests. Current ed., Lippincott. Or any similar handbook on (human) diagnostic tests.
The following 4 books are resources for more in-depth studying:
Edelstein S and Sharlin J: Life Cycle Nutrition: An Evidence Based Approach. Jones and Bartlett 2009. ISBN 13: 978-0-7673-3810-5 (assigned chapters are included in the required textbook)
Samour P Q, King K: Pediatric Nutrition, 4th ed., Jones and Bartlett, 2012. ISBN-13: 978-0-7637-8450-8 (assigned chapters are included in the required textbook)
Chernoff R. et al.: Geriatric Nutrition: The Health Professional’s Handbook. Jones and Bartlett, 3rd ed., 2006. ISBN-13: 978-0-7637-3181-6 (assigned chapters are included in the required textbook)
McArdle WD, Katch FI, Katch VL: Sports and Exercise Nutrition, Wolters Kluwer, 4th ed., 2013. ISBN-13 978-1-4511-1806-3
Professional journals in nutrition and bio-medical disciplines (available in paper or online)
Rich website on the biology of aging and its relationship to diseases: American Federation for Aging Research https://www.afar.org/
Full-text journals – High-Wire press – https://highwire.stanford.edu/
Phytochemical and Ethnobotanical Database https://www.ars-grin.gov/duke/
FDA on Dietary Supplements: https://www.fda.gov/Food/DietarySupplements/default.htm
Additional References from American Nutritional Society – www.nutrition.org
PubMed – https://www.ncbi.nlm.nih.gov/pubmed/
The above are the best sources to use but feel free to use others after having used those.
Case study:
Note: This case study is based on cases in the Nelms books in combination with other cases to generate an original case study.
Pt Summary: FDE is an 85 year-old African American widower admitted through the emergency room from home for multiple abrasions and a non-healing wound on the right hip.
Patient has a Stage III full thickness non-pressure wound (laceration with purulent drainage and foul odor.
History:
Onset of disease: Pt was having difficulty taking care of his life-long home and immediate medical needs and has lived in a ground-floor apartment of his son’s home for the past 2 years. A nurse’s aide comes twice a day during daytime, and the son takes care of the patient when he is not working. The patient had been combative at times but is currently controlled, with current medications.
FDE had tripped on the steps to the main house 1 year ago and fractured his right hip. He underwent an open reduction/internal fixation surgery to repair the fracture. Blood loss during surgery was 350cm3. FDE was in inpatient rehabilitation for 10 days after discharge from the surgical service and then returned home. He ambulates with a walker.
Medical history: s/p MI x 2 at ages 45 and 62; HTN x 44 years, osteoporosis Dx 1 year ago
Surgical history: s/p 4 vessel CABG at age 62. R hip surgery 1 year ago
Medications at home: Furosemide 80mg daily, atenolol 25mg daily, Lisinopril 20mg daily, Zocor 40mg daily, haloperidol 0.5mg AM and PM, warfarin 5mg daily, donepezil 10mg PM; usually uses acetaminophen 500mg three times daily for pain.
Tobacco use: 1ppd x 45 years, quit 20 years ago.
Alcohol use: no
Family history: Father, uncles and brother all died before age 50 of MI, mother: dementia, not specified
Demographics:
Marital status: widower for 4 years
Years education: HS diploma
Language: English only
Occupation: electric company service technician
Ethnicity: African American
Religious affiliation: none
Admitting Hx/PE
CC: Patient reported to son that he fell and hit his hip on the corner of a table. He is admitted for evaluation of this non-healing wound.
General appearance:frail, thin elderly gentleman who is obviously confused and agitated. Well groomed but the clothes are loose fitting
Vital Signs: Temp: 100.3?, Pulse: 85, RR: 32, BP: 130/80,
height: 5’6”,
weight: 110lbs., usual body weight 140lbs (1 year ago, prior to hip surgery)
Heart: PMI sustained and displaced laterally, normal S1, S2+S3 at apex
HEENT: Head: WNL
Eyes: Pupils are small and react to light sluggishly, ocular fundus is pale, negative thyromegaly and adenopathy. +JVD – increased 4 cm above sternal angle at 45?
ears: clear
nose: clear
mouth: ill-fitting dentures, sore beneath bottom plate; cracks/fissures at corners of mouth (angular cheilitis), tongue is dry and pale without ulcers or plaques
throat: pharynx clear without postnasal drainage
genitalia: normal
neurologic: disoriented to time, place and person
extremities: no edema, Bruising. 2+ radial pulses, 1+ dorsalis pedis, and 1+ posterior tibial pulses bilaterally. DRT 2+ and symmetrical; strength 2/5 throughout DTR 2+ and symmetrical throughout
skin: pale, warm and dry, “ashy”-appearing patches of dryness and flaking to elbows and lower extremities. Multiple ecchymoses; open, draining purulent wound approximately 2cm x 2cm x 8cm located on right posterior thigh
chest/lungs: CTA and percussion with no rubs
abdomen: bowel sounds x4, nontender
Nursing Assessment (1 day ago)
Abdominal appearance (concave, flat, rounded, obese, distended) flat
Palpation of abdomen (soft, rigid, firm, masses, tense) Soft
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color Light brown
Stool consistency Soft to liquid
Tubes/ostomies N/A
Genitourinary
Urinary continence catheter
Urine source catheter
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue, tea) Clear, yellow
Integumentary
Skin color Pale
Skin temperature (DI=diaphoretic, W=warm, dry, CL-cool, CLM=clammy, CD+=cold, M=moist, H=hot) CL
Skin turgor (good, fair, poor, TENT=tenting) fair
Skin condition (intact, EC-ecchymosis, A=abrasions, P=petechiae, R=rash, W=weeping, S-sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis) EC
Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae, R=rash, W=weeping, S-sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis) Intact
Other components of Braden score: special bed, sensory pressure, moisture, activity, friction/shear (>18=no risk, 15-16=low risk, 13-14=moderate risk, ? 12=high risk) Activity, 13
Admissions orders:
Culture wound exudate
Scheduled for initial wound debridement with consult for wound management
Rx: Start 1.5g of ampicillin-sulbactam IV every six hours
(continued from home) Furosemide 80mg daily, atenolol 25mg daily, Lisinopril 20mg daily, Zocor 40mg daily, haloperidol 0.5mg AM and PM, warfarin 5mg daily, donepezil 10mg PM; acetaminophen 500mg three times daily for pain
Nutrition consult
Soft diet
Nutrition:
Usual dietary intake (24 hour recall, reported by son and nursing aide):
Breakfast: 1 jelly doughnut, 1 slice white toast with 2 tbsp. jelly, 1 cup coffee
Lunch: 2 butter cookies, 1 cup chicken and rice soup, 6 saltine crackers, 2 cups tea
Dinner: 1 slice white bread with 2 Tbsp jelly, 2 Tbsp peanut butter, 2 butter cookies.
Pt. had been refusing snacks and fruits and most vegetables since the hip surgery
Total calories: 1270, 25g/d protein, 42 g fat, 201 g carbohydrate; 153mg Ca, 6mg Fe
Reference range 1 day ago
Chemistry
Sodium (mEq/L) 136-145 136
Potassium (mEq/L) 3.5-5.5 3.5
Chloride (mEq/L) 95-105 96
Carbon dioxide (CO2, mEq/L) 23-30 27
BUN (mg/dL) 8-18 22
Creatinine serum (mg/dL) 0.6-1.2 1.3
Glucose (mg/dL) 70-110 82
Phosphate, inorganic (mg/dL) 2.3-4.7 2.5
Magnesium (mg/dL) 1.8-3 1.9
Calcium (mg/dL) 9-11 9
Bilirubin, direct (mg/dL) <0.3 0.1
Protein, total (g/dL) 6-8 5.5
Albumin (g/dL) 3.5-5 2.5
Prealbumin (mg/dL) 16-35 10
Ammonia (NH3, µmol/L) 9-33 24
Alkaline phosphatase (U/L) 30-120 80
ALT (U/L) 4-36 25
AST (U/L) 0-35 21
C-reactive protein (mg/dL) <1.0 5.1
CPK (U/L) 30-135 F
55-170 M 56
Cholesterol (mg/dL) 120-199 155
HDL-C (md/dL) >55 F, >45 M 33
LDL (mg/dL) <130 121
LDL/HDL ratio <3.22 F
<3.55 M 3.67
Triglycerides (mg/dL) 35-135 F
40-160 M 153
HbA1C (%) 3.9-5.2 4.6
Coagulation (Coag)
PT (sec) 12.4-14.4 13.1
PTT (sec) 24-34
Hematology
WBC (x 103/mm3) 4.8-11.8 16.0
RBC (x 106/mm3) 4.2-5.4 F
4.5-6.2 M 5.1
Hemoglobin (Hgb, g/dL) 12-15 F
14-17 M 13.5
Hematocrit (Hct, %) 37-47 F
40-54 M 37
Mean cell volume (µm3) 80-96 77
Mean cell Hgb (pg) 26-32 24
Mean cell Hgb content (g/dL) 31.5-36 30
Platelet count (x 103/mm3) 140-440 145
Transferrin (mg/dL) 250-380 F
215-365 M 165
Ferritin (mg/mL) 20-120 F
20-300 M 18
Hematology, Manual Diff
Lymphocyte (%) 15-45 10
Monocyte (%) 3-10 5
Eosinophil (%) 0-6 1
Segs (%) 0-60 50
Case study questions
1. Define dementia. Define Alzheimer’s disease (AD). How do they differ?
2. What are the current medical interventions available for the management of AD? What are the goals of these interventions?
3. FDE has a Stage III full thickness non-pressure wound. What does that mean?
4. Describe the normal stages of wound healing.
5. Name a minimum of three factors that support wound healing. Name a minimum of three factors tha may impair wound healing. Identify the most probable factors that may have contributed to FDE’s poor wound healing.
6. Describe the potential roles of zinc, vitamin A, vitamin C, copper, glutamine and arginine in wound healing.
Nutrition assessment
7. Assess this patient’s available anthropometric data. Calculate %UBW and BMI. Which of these is the most pertinent in identifying the patient’s nutrition risk? Why? (Note: assess means you also have to write if that is significant etc.)
8. Discuss the progressive weight loss FDE has experienced. Why is this of concern? What factors may have contributed to his weight loss?
9. Calculate energy and protein requirements for FDE and indicate a healthy distribution of macronutrients at that energy level (g protein, fat, CHO).
10. How would you determine the levels of micronutrients that FDE needs?
11. Identify all the medications that FDE is taking and complete the table below.
Medication Function Drug-nutrient interaction
Ampicillin-sulbactam
Furosemide
Atenolol
Lisinopril
Zocor
Haloperidol
Warfarin
Donepezil Acetylcholinesterase inhibitor N/D/V, muscle cramps, fatigue, anorexia;
acetaminophen
12. Which lab values can be used to further assess FDE’s nutritional status:
13. Which lab measures are related to the wound?
14. Select two nutrition problems and complete the PES statement for each.
15. For each of the PES statements that you have written, establish an ideal goal based on the signs and symptoms and an appropriate intervention, based on the etiology.
FDE’s oral intake is <50% of foods provided. He is observed to be coughing during feeding. A speech pathologist determines that he needs a level I dysphagia diet. On this diet, FDE’s intake declines further, to <25% of intake. After 3 days, another nutrition consult is ordered.
16. Is he a candidate for enteral feeding? Outline the pros and cons for recommending nutrition support for this patient. What are the ethical consideration?
The following feeding formulas are available:
Category DM standard Special protein Isotonic w/fiber High protein w/fiber
Product name Glucerna Select Boost Prostat Jevity 1.0 Osmolite 1.5
Usage oral/tube, B oral oral oral/tube TF
Indications can be sole source ok for TF
impaired glucose
tolerance
Allergies lactose-free lactose-free lact-free lactose-free
low osmolality has corn, milk gluten-free gluten-free
egg free has soy kosher kosher
low residue
Standard serving 8 fl.oz – 1 L 8 fl.oz 8 fl.oz./1 L 8 fl.oz./1 L
Nutrient values
kcal 240/ 8 fl.oz 60 /1fl oz. 250 8 fl.oz. 355/8 fl.oz.
kcal/cc 1.0 1.0 1.1 1.5
% H2O 84 84 76
kcal to meet 100% DV 1420 1400 1500
ml to meet 100% DVs 1420 1321 1000
protein g 10/ 8 fl.oz 15 /1 fl.oz. 10.4 /8 fl.oz. 14.9 /8 fl.oz.
protein g/L 50.0 44.3 62.7
Fat g 4/ 8 fl.oz 8.2 / 8 fl.oz. 11.6 /8 fl.oz.
fat g/l 54.4 34.7 49.1
CHO g 41/ 8 fl oz 36.5 /8 fl.oz. 48.2 /8 fl.oz.
CHO g/L 95.7 154.7 203.6
Sodium mg 940.0 548.5 930.0 1400.0
Potassium mg 1687.8 1800.0
Phosphorus mg 1000.0
mOsm/kg H2O 470.0 300.0 525.0
Fiber 11.8 0.0 14.4
Flavors Vanilla Vanilla
Chocolate Chocolate
Product name Glucerna Select Boost Prostat Jevity 1.0 Osmolite 1.5
17. Complete a tube feeding order form for this patient, to add to his level I dysphagia diet.
Formula:
Provides:
Kcal:
Protein:
CHO:
Fat:
Water:
Feeding method: continuous / intermittent / cyclic
Initiation and progression: (___cc/hr, adv. Every 8 hrs by ___ cc until goal rate achieved)
Goal rate: _____cc/hr, x ___hrs/d
Flushes: __x ___cc (____ cc)
Total water provided: ______ cc
18. Complete the ADIME sheet (before the tube feeding).
A – Assessment
S – Subjective
Chief Complaint:
UBW:
Weight change: gain / loss
Appetite:
Chewing / swallowing problem / sore mouth
Nausea / vomiting / diarrhea / constipation
Food intolerance / allergies:
Diet prior to admit: Nutritional supplement:
Vitamins / herbs:
Food preparation:
Factors affecting food intake:
Social / cultural / religious / financial
Other:
O – Objective
Current Diet Order:
Medical Diagnosis:
Past Medical History:
Nutrition Focused Physical Signs & Symptoms:
Age:
Gender: Male ?
Female ? Ht: Wt: Admit ?
Current ? DBW: BMI:
% UBW:
% wt ?: % DBW: Other:
Nutritionally Relevant Laboratory Data:
Drug Nutrient Interaction:
A – Assessment (A)
State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis Terminology sheet
ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :
1.
2.
Nutrition Intervention (I)
P – Plan
List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems (diagnoses).
Goal(s):
Plan for Monitoring and Evaluation (M E)
List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the plan for monitoring would indicate if interventions are addressing the problems).