Download EXAM 1 Case Study

Ashley Holmes
Exam 1 Case Study
Part 1
1. Based on the DETERMINE screening, ML’s case history reveals that her nutritional
and functional status could be impacted by her poor eating, mouth pain, economic
hardship, reduced social contact and interaction, involuntary weight loss, need for
assistance with self-care and elder at an advanced age.
2. Ml’s battle with depression can be a source of concern for nutritional problems. In
ML’s case, depression has prevented ML from engaging in physical activity. Her
financial burden has prevented her from purchasing wholesome, fresh, healthy foods.
Her social isolation not only contributes to her depression, but also prevents an active
lifestyle. A medical history of osteoporosis mostly likely contributed to her hip fracture
and its subsequent effects. Her decreased taste perception as well as ill fitting dentures
may reduce the amount of (calories deficit) food eaten as well as type such as meats
(difficult to chew, resulting in a protein deficiency).
Part 2
3. ML’s BMI is 18 kg/m2 which according to standards for BMI is considered
underweight. Using ML’s weight of 6 months ago of 125 and determining her percent
weight loss to her current weight of 110, results in a 12% weight loss and according to
standards, over a 10% wt loss in 6 months is classified as severe weight loss. Her BMI
and high weight loss percentage is indicative of malnourishment which according to
ML’s medical history could have several confounding factors.
4. Total number of calories= (25g Protein) (4 kcal/ g Protein) + (201g CHO)( 4 kcal/g
CHO) + ( 42g Fat) (9 kcal/g fat) = 1282 kcal/ day based on 24 hour recall.
Protein % = 100 kcal Protein/ 1282 kcal = ~8 %
Fat % = 378 kcal fat/1282 kcal= ~30%
CHO% = 804 kcal CHO/1282 kcal= ~ 63%
5. 110 # / 2.2 = 50 kg
50 kg * 1.5 g/kg = 75 g/d Protein (ML is only getting 25 g/day)
Caloric Requirements
50 kg * 35 kcal/kg = 1750 kcal/d
6. ML’s 24 hour recall indicates that she only consumes 25 g/d protein, which according
to standards; she needs to consume about 75 g/d protein for repletion. This is evidenced
by her lack of protein rich foods (meet, cheese, etc) in her 24 hour recall. Caloric intake
also fails to meet standards calculated for ML (1750 kcal/d) while only attaining about
1300 kcal according to 24 hour recall. ML’s diet is significantly lacking in nutrient dense
foods. Her intake lacks substance and is high in carbohydrates, specifically simple sugars
(white bread, cookies, jelly doughnuts). These simple sugars could also be associated
with an insulin intolerance resulting in high blood glucose levels which could lead to
complications such as diabetes. Also noted in her recall is lack of variety, fresh foods,
and fruits & vegetables. This can be attributed to her minimal income, impaired
mobility, lack of energy and resources to consume well-balanced meals.
7. - Inadequate Energy Intake (NI-1.4)
- Inadequate oral food/beverage intake (NI-2.1)
-Inadequate fluid Intake (NI-3.1)
-Inadequate protein-energy intake (NI-5.3)
-Inappropriate intake of food fats (ML’s percentage of kcal from fat is not
unreasonable, however, ML is lacking the consumption of ‘good’ fats (omega 3’s,
polyunsaturated) and is mostly likely consuming hydrogenated oils and trans fats.
-Inadequate protein intake (NI-52.1)
-Inappropriate carbohydrate intake (Again, ML’s percentage of kcal from CHO is not
necessarily unreasonable; however her high consumption of simple sugars could
negatively affect her health) (NI- 53.3)
-Inadequate fiber intake (NI-53.5)
-Inadequate Vitamin Intake (NI-54.1)*
-Inadequate Mineral Intake (NI-55.1)*
*While lab values are absent to confirm the inadequate vitamin and mineral deficiencies,
based on the recall, it can be speculated that with a lack of fruit and vegetable intake,
deficiencies are eminent. Also ML’s medicine intake states no consumption of vitamins
or calcium in supplement form.
8. A review of ML’s assessment reveals severe weight loss that was involuntary
indicating malnutrition (low caloric and protein intake). Osteoporosis discovered when
hip fracture was repaired indicates a calcium deficiency. Food lacking taste, decreases her
desire and ability to consume food. Depression also contributes to this.
9. ML’s hematology values fall into the low values for standard ranges. Her Hgb was
11g/dl (normal: 11-16 g/dL) and Hct was 33.0% (normal: 33-43%) are indicative of iron
deficiency and malnutrition. ML also has low albumin 2.5g/dl (normal: 3.5-4-5) which is
indicative of her severe malnourishment and inadequate protein Protein breakdown of
muscle to attain amino acids for albumin synthesis results in muscle atrophy ( as
evidenced by ML’s frailness) Low albumin could be responsible for her edema, because
low albumin fails to maintain plasma oncotic pressure. While nothing else indicates liver
malfunction it is still a plausible cause of ML’s low albumin, because albumin is made in
the liver.
10. Fluoxetine commonly known as Prozac has proven DNI related to amino acid
absorption. With ML’s obvious protein intake deficiency this is doubly as negative.
Her protein status is quite bleak and she is suffering from muscle wasting because of it
11. -Swallowing difficulty NC-1.1
-Altered nutrition-related laboratory values NC-2.2
-Food-medicine interaction NC-2.3
-Underweight NC-3.1
-Involuntary weight loss NC-3.2
12. ML has several behavioral-environmental issues contributing to her health
complications. Her limited income poses problems in attaining healthy, fresh foods. Her
depression decreases her desire to care for her self i.e. no physical activity because no
motivation. Her decrease in taste has lessened her desire to eat, thus resulting in
malnutrition. Her immobility decreases her ability to attain food. She lives alone and is
essentially socially isolated. ML makes poor food choices overall and does not
supplement to counteract her poor dietary intake.
Part 3:
13.
Involuntary weight loss R/T poor appetite, inability to purchase/prepare food
AEB 15 lb wt loss over 6 months.
Inadequate protein intake R/T lack of protein dense food intake AEB average
daily intake of protein 50% of estimated need
Part 4:
14. ML diet can easily be modified to improve her nutritional status. First, ML’s protein
deficiency is causing detrimental damage to her skeletal muscle, causing fluid retention,
iron deficiency anemia, etc. Adding protein to the diet will combat these complications.
DNI related to amino acid absorption would be improved by a supplementation or a
decrease/discontinuation of the Prozac. Ml’s involuntary weight loss and underweight
status can be improved by an increase in caloric dense foods, with high amounts of
polyunsaturated fatty acids. ML’s constipation can be improved by increasing her fiber
intake. According to standards for fluid intake at her age, ML is taking in about half of
the fluid necessary to maintain sufficient hydration. Ml’s lack of physical activity is
contributing to her muscle wasting and frailness.
15. To improve the nutritional status of ML, the following recommendations are
presented: to increase calorie and protein intake, lean cuts of meat such as chicken and
turkey should be added to her diet. With her chewing difficultly, thin sliced deli meats
could be tolerated easier. Preferably an introduction of fresh fruits and vegetables would
be ideal, but with ML’s financial status, at lease a multivitamin as well as a calcium
supplementation would be beneficial. Meals on Wheels and food stamps are also
recommended for ML. Increasing the amount of whole grains and complex
carbohydrates will help improve ML’s constipation. Specific suggestions are bran cereal
and whole wheat bread. Also, an increase in fluid intake would alleviate her
constipation.
16. To properly assess ML’s true overall health status, more lab values and measurements
are required, for examples: to address her IDA- transferrin, for hydration status- BUN
and creatinine, for ML’s osteoporosis, calcium lab values.
17. See Attachment