Download Michaela M. Phillips NTR 517 Sage Nutrition Science Department

Michaela M. Phillips
NTR 517
Sage Nutrition Science Department - NCP Form
Patient: R M
Referred for: Difficulty eating; choking during meals.
NUTRITION ASSESSMENT
Food and Nutrition Related History: Mostly liquids because solids are hard to swallow. Usual intake (not meeting needs) before swallowing
difficulty: Breakfast: ½ scrambled egg, ½ slice of toast or English muffin, 1 tsp jelly, coffee with 2% milk and artificial sweetener.
Lunch: ½ ham or turkey sandwich, 6-7 chips, iced tea with artificial sweetener.
Dinner: ¾ spaghetti with ½ c. meat sauce, 2-3 tbsp green peas or other vegetable, ½ c. canned fruit cocktail, ½ slice bread with 1 tsp butter, iced
tea with artificial sweetener.
Anthropometric Measurements
Age:
Gender
Ht: 60”
Wt: 90 LBS (40.9 Kg)
BMI: 40.9/1.52
69
Female
(1.5 m)
Wt Hx: 110 LBS (6 months previous)
% Wt change: 18% (severe weight
18.2 (underweight)
loss)
Biomedical Data, Medical Tests & Procedures
Labs/Date Albumin
Glucose HbA1C
BUN
Creat
Na+
K+
Hgb
Hct
MCV
Prealbu
min
2/13
3.2g/dL
78mg/d
NA
14mg/dL 1.1mg/dL 145mEq/ 4.1mEq/L 11.5g/dL
35% (2 % 74 µm3
15 mg/dL
(low)
L
L
(low)
low)
(6 under) (low)
Ca
Cholest
WBC
erol
8.9
109
11.9
mg/dL
mg/dL
x103/mm
3 (high)
(low)
(low)
Medical Diagnosis/PMH/Relevant Conditions: Parkinson’s x10 years; Presented with fever and increased white blood cell count; family relates she
has increasing difficulty eating; she often coughs and appears to choke during meals.
Pertinent Medications
Medications at home: Sinemet: carbidopa/levodopa, 50/200 mg controlled release tablet 2x daily; citalopram 20mg/day; omega-3 fatty acids
1000mg/day.
In hospital: azithromycin 500mg/day (antibiotic for infection)
Skin status: X Intact □ Pressure Ulcer/Non-healing wound; Comments: Skin warm, dry, poor turgor.
Physical Assessment: Dry hair; sunken cheeks, temporal wasting, stomatitis
Estimated Nutritional Needs Based on Comparative Standards: Based on IBW of 106 lbs
Calories: 1364-1687 kcal
Protein: 48g (1g/Kg IBW)
Fluid: 1.4 – 1.7 L (1mL/kcal)
(30-35 cal/kg IBW (106lbs/48.2kg)
Diet Order
Feeding Ability
Oral Problems
Intake
□ Independent
□ Chewing Problem
□ Good (> 75%)
NPO
□ Limited Assistance
□ Swallowing Problem
□ Fair (approx. 50%)
□ Extensive/Total Assistance
□ Mouth Pain
□ Poor (<50%)
X N/A
X None of the Above
□ Minimal – (<25%)
X NPO
□ No Nutritional Diagnosis at this time
x Proceed to Nutrition Diagnosis Below
NUTRITION DIAGNOSIS
P (problem) NI-2.1 Inadequate oral intake
____________________________related to:
E (Etiology) Decreased ability to consume
sufficient energy
as evidenced by:
P (problem)NC 2.2 Altered Nutrition-related
Laboratory Values_____________related to:
E (Etiology) Nutrient deficiency
________________________as evidenced by:
S (Signs & Symptoms): Difficulty swallowing
food and consumption of liquid diet.
Low prealbumin 15 g/dL (reference 16-35)
indicating protein energy malnutrition
S (Signs & Symptoms)
Prealbumin of 15 g/dL (reference 16-35)
Transferrin level of 392 (reference 250-380
mg/dL) also indicates low iron stores
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Michaela M. Phillips
NTR 517
Calcium is slightly low at 8.9 mg/dL (reference
9-11) indicating a possible Calcium and vitamin
D deficiency
Hemoglobin (Hgb) level is low at 11.5 g/dL
(reference 12-15 for females)
INTERVENTION
Nutrition Prescription: Pending Swallow Evaluation by the Speech Language Pathologist. If the patient has difficulty swallowing, may recommend
NDD Level 1 pureed diet, 1600 Kcal, 50% carbohydrate, 30% protein, 20% fat to build structure. Redistribute most protein to the evening meal.
Recommend 1200mg calcium in the form of dairy or supplement if dairy is not consumed. If less than 60% of the meal is consumed add snacks and
nutritional supplements.
Food or Nutrient Delivery:
Nutrition education: Provide patient and family with information on the
Meals and snacks; vitamins and mineral supplements (calcium
NDD. Avoid foods that contain L-dopa (fava beans). Interactions
1200mg/d)
between pyridoxine and l-dopa.
Nutrition Counseling: Impact of progression of Parkinson’s Disease
related to ability to eat, chew, swallow and self-feed.
Coordination of Care (refer to): Speech and language pathologist for
swallow evaluation; evaluate for PEG placement.
Goal(s): Initiate NDD within 24 hrs; consume more than 75% of needs within 3 days of receiving the oral diet.
MONITORING & EVALUATION
Indicators:
Calcium
Albumin
Prealbumin
Cholesterol
Hgb
Transferrin
Weight gain:
Criteria:
10 (ref 9-11)
3.5 (ref: 3.5-5)
20 (ref 16-35)
120 (ref 120-199)
13 (ref 12-15)
350 (ref 250-380)
1-2 pounds per week until 106lbs (IBW) is reached.
I. Understanding the Diagnosis and Pathophysiology
1. Describe our current understanding of the pathophysiology of Parkinson’s disease.
The current pathophysiology is not clear. Environmental and genetic factors are thought to play a role.
More than 10 genes related to PD have been found. There is a loss of dopaminergic neurons
(substantia nigra) and loss of the limiting enzyme for dopamine, tyrosine hydroxylase (Kraus, p. 952)
2. How does this pathophysiology translate into the cardinal signs and symptoms of Parkinson’s? Which may
contribute to nutritional risk? Which of these are noted in Mrs. McCormick’s history and physical?
Signs and symptoms include slower and reduced movement, muscular stiffness, tremor, postural
instability, and decrease in the transmission of dopamine to the basal ganglia. The decrease in
dopaminergic neurons reduces the amount of dopamine transmitted to the basal ganglia causing these
signs and symptoms. Because diet can create oxidative stress that may contribute to the oxidative
stress, certain nutrients (Folate levels, plasma homocysteine, fiber and reduced calories) are being
evaluated for their function in dopaminergic neuron oxidation (Kraus, p. 952). Mrs. McCormick is
coughing and choking and has trouble eating.
4. Identify and describe the primary medical interventions that are used for treatment of Parkinson’s disease.
The primary target for medical intervention includes treating the symptoms including tremor, rigidity,
and bradykinesia. This is accomplished through drugs such as levodopa and Exelon (approved by the
FDA in 2006).
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Michaela M. Phillips
NTR 517
Levodopa is a precursor to dopamine and Exelon, a cholinesterase inhibitor, is used to treat PD
dementia (Kraus, p. 952).
Physical Therapy
Occupational Therapy
II. Understanding the Nutrition Therapy
6. Define dysphagia. What medical and nutritional complications may be associated with dysphagia?
Dysphasia is difficulty swallowing. People may aspirate foods and liquids into the lungs causing
aspiration pneumonia. Difficulty swallowing could mean longer meal times and nutritional deficiency
because a person might just give up and stop eating.
8. What is an MBS? What information will this test provide? An MBS is a modified barium swallow study.
Barium is added to food and liquids. Then, an x-ray is taken while the person swallows different
consistencies of food and liquids. This allows the speech and language pathologist to determine the
consistency and thickness of the food or liquid that is causing the swallowing difficulty
(http://www.urmc.rochester.edu/urmcmedia/hh/servicescenters/pmr/documents/ModifiedBariumSwallow.pdf).
III. Nutrition Assessment
13. After examining Mrs. McCormick’s history and physical, identify any clinical signs and symptoms that may
alert you to a nutrient deficiency. What further assessments can you make to assess her risk for
malnutrition? Mrs. McCormick has lost 18% of body weight in 6 months which is considered severe weight
loss. Based on her 24hr net I/O of fluid of +620, she seemed dehydrated upon admission. She also has dry
hair, sunken cheeks and temporal wasting.
14. Evaluate Mrs. McCormick’s laboratory values. List all abnormal values and explain the likely cause for each
abnormal value.
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Her blood calcium is slightly low at 8.9 mg/dL (reference 9-11) indicating a possible Calcium and vitamin
D deficiency. She has very little milk or calcium rich food/drink in her diet. Low calcium is also
secondary to low albumin.
Her blood protein is slightly low based on total protein 5.8 g/dL (reference 6-8), Albumin of 3.2 g/dL
(reference 3.5-5) and prealbumin of 15 g/dL (reference 16-35). This is due to malnutrition.
Cholesterol is low at 109 mg/dL (reference 120-199) and HDL-C of 42 mg/dL (reference >55 for female)
due to protein-calorie malnutrition (Kraus, p194). Low HDL is due to physical inactivity.
Increased white blood cell count (WBC) of 11.9 (reference 4.8-11.8) is an indicator of PEM or infection.
PEM is more likely due to severe weight loss.
RBC OF 3.9 X108/mm3 is low (reference 4.2-5.4 for female) due to nutritional deficit.
Hemoglobin (Hgb) level is low at 11.5 g/dL (reference 12-15 for females) indicating nutritional deficit.
Hematocrit (Hct) is low at 35% (reference 37-47 for female) indicating nutritional deficit.
Hct and Hgb are also indicators of iron deficiency (Kraus, p. 200)
Mean cell volume (MCV) of 74 (reference 80-96 µm3) and MCH (mean cell Hgb) of 23 pg (reference 2632) indicates iron deficiency.
MCHC (Mean cell Hgb content) is low at 28 g/dL (reference 32-26) due to iron deficiency.
Transferrin level of 392 (reference 250-380 mg/dL) also indicates low iron stores (Kraus, p199)
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Michaela M. Phillips
NTR 517
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Ferritin level of 11 (reference 20-120 mg/mL) indicating microcytic anemia (Kraus, p199)
16. Assess Mrs. McCormick’s diet prior to having difficulty swallowing. Compare her energy and protein intakes
to her estimated nutrient needs. Mrs. McCormick, prior to her recent swallowing difficulty, consumed
about 50% of her daily energy needs (978 kcal of about 1500 kcal) and only 41% of her protein needs (2oz
of 5.5oz target).
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Michaela M. Phillips
NTR 517
V. Nutrition Intervention
19. The National Dysphagia Diet defines three levels of solid foods and four levels of fluid consistency to be
used when planning a diet for someone with dysphagia. Describe each of these levels of diet modifications.
 Level 1 – Pureed. Food should be like pudding with no raw or coarse foods. People on this diet
have moderate to severe dysphasia, poor oral phase and difficulty protecting the airway. Liquids
can be thin, nectarlike, honeylike, or spoon-thick depending on the SLP swallow evaluation.
 Level 2 – Mechanically altered: Foods are soft, moist and easy to chew and swallow. Can include
all level 1 foods and liquids. People on this diet have mild to moderate oral pharyngeal dysphasia
and may tolerate mixed textures (requires evaluation).
 Level 3 – Transition to regular diet: Food excludes hard, sticky or crunchy food. Food should be
moist and bite sized. People on this diet have mild oral or pharyngeal phase dysphasia. Liquids can
include those from level 1 and 2. (Kraus, Appendix 35, p1122-1126)
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NTR 517
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