University of Maryland

Chandler RayUniversity of MarylandCollege Park

Dietetic Internship

2014-2015 MINI CASE STUDY

Nutrition Assessment: Medical Diagnosis - Acute on Chronic Renal Failure

Age: 70Gender: WMWeight: 187 lb (85.6 kg)Height: 61(186 cm)BMI: 25 (overweight: 25-30 kg/m^2) IBW: 184 lb (83.7 kg)PMH:UTI (last hospitalization this year)

Type II DMEsophageal cancer s/p esophagectomy

Kidney cancer s/p nephrectomy

Hyperlipidemia (HLD)Benign prostatic hyperplasia (BPH)SmokerChronic renal failure Major Depressive Disorder Symptoms:Abdominal pain

Dehydration

Nausea

Vomiting (bile) >10x a day for 2 days ptaUrinaryretention- foley catheter placementDecreased appetite/weight loss >15 lbs.

Constipation x1 week- last bowel movement (10/13)Hiccupping/belching

Irritated throat (difficulty swallowing pills)

Diet History: Pt reports poor appetite pta and currently, consuming 0-25% of meals. Pt states he only has had a few bites of yogurt and broth since admission. Reports weight loss over past year due to loss of appetite + n/v. Nurse reports pt has been eating poorly & didnt consume any of his breakfast- states pt only drank liquids, including tea, apple juice, & water with Miralax. Pt has been very depressed since the death of his wife 1 year ago. Lives alone and wont cook for himself; only eats cereal and canned goods- concerning due to uncontrolled DM. Son expresses his concern that father wont eat.

Labs: 10/21 10/23Na: 138 137K: 4.8 4.0Cl: 105 104BUN: 28 H 20Cr: 2.0 H 2.10 HCa: 9.0 8.5Albumin: 3.7 3.7WBC: 11.1 H 5.5 HGlucose Lvl Random: 298, 213 HGlucose Bedside: (10/21): 355, 286, 279, 245, 174 H (10/23): 203, 173, 220 HLipase Lvl: 480 HHbA1C (10/21): 6.7% HMedications:

Atorvastatin (statin)Insulin Glargine (long-acting basal insulin) Lispro SSI- Medium (fast-acting insulin)Pantoprazole (anti-gerd)Miralax (osmotic-type laxative)Docusate-Senna (stool softener/stimulant laxative) Reglan (anti-gerd)Zofran (helps prevent n/v)

Current Diet:(10/21) NPO with IV hydration until pt is able to tolerate food & GI issues are under control (10/23) Cardiac Med CHO Diabetic Diet ~ (60 g)

Nutrition Diagnosis utilize PES Statements

Initial:

NC-3.2: Involuntary weight loss related to nausea/vomiting & constipation as evidenced by wt loss >15 lbs per chart

NI- 2.1: Inadequate oral intake related to poor appetite & abdominal pain; current diet order as evidenced by NPO, unable to keep food downCurrent:

NC-3.2: Involuntary weight loss related to poor appetite as evidenced by wt loss >15 lbs per chartNI- 2.1: Inadequate oral intake related to constipation & abdominal pain as evidenced by consuming 0-25% of his meals per pt report

Nutrition Intervention Nutrition prescription, Interventions with goals

Nutrition Prescription

2,067 - 2,285 kcal Cardiac Consistent Carb Diabetic Diet- Medium (60 g)(Kcal-Mifflin St. Jeor with activity factor 1.3 + adjustment factor 0)

Intervention with goalsFood and/or Nutrient Delivery

ND-1.2 Recommend liberalize diet to Regular/No Salt on Tray given poor po intake.

ND-1.4 Offer food, fluids, supplements as desired/tolerated

ND-2.1 If PO intake does not improve in 5-7 days, recommend NGT for temporary nutrition support; RD available for recs

Goal: PO intake >50% of meals and/or supplements

Goal: Patient will tolerate diet advancement

Nutrition-Related Medication Management ND-1.6 Consider a more aggressive bowel regimen. Goal: Achieve normal bowel + GI functionCoordination of Nutrition Care NC-1.5 Recommend SW consult. Goal: Talk with SW to consider if pt needs a community meal assistance program prior to discharge (i.e.: Meals on Wheels) NC- 1.4 Consider SLP consult given pt report difficulty swallowing; will propose. Goal: Resolve chewing/swallowing difficulties

Nutrition Monitoring and Evaluation

Indicator

1. AD-1.1.2 Weight2. FH-1.1.1.1 PO intake/tolerance3. Carb-controlled4. PD-1.1.5 GI function

5. BD-1.2,1.5 Nutrition-related labs

6. FH- 6.1.4 Participation in community programs

Criteria

1. Check weight weekly to trend- prevent weight loss2. Pt consumes >50% of meals and/or supplements

3. Limit to 60 g per day

4. No reports of N/V/D/C; bowel sounds return to normal

5. Will monitor electrolyte and renal profile, as well as glucose levels, A1C

6. Signs up with meals on Wheels on Wheels or delivery service program

SourceKcal requirementsProtein requirementsFluid requirements

Facility standards2,067- 2,285 kcal(Mifflin St Jeor- Activity Factor 1.3) 86 -100g

(1.0-1.25gm/kg- using actual weight) 2,140 2,568 mL (25-30 mL/kg)

EALN/A N/AN/A

Online nutrition care manual2,176 kcals 80-100 gm protein/day

2,200-2,400 cc fluids/day

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 November 2, 2014. http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5545&lv2=16997&ncm_toc_id=16997&ncm_heading=Nutrition%20Care http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5546&lv2=16668&ncm_toc_id=16668ncm_heading=&Evidence Analysis Library. Academy of Nutrition and Dietetics Web site. www.adaevidencelibrary.com. Accessed November 2, 2014. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=621