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ADIME Nutrition Documentation Form
Name: Caroline Pelley, Caroline Ripp, Raye Maudlin
Nutrition Note: Case Study 26
Date: 5/5/15
Section: Tuesday 8:00am
Time: 8:00am
A: Nutrition Assessment (Assessment info related to Nutrition Dx)
Client Hx:
Dx: Stage 1 COPD 5 yrs ago
Hx of bronchitis and upper
respiratory infections during
winter months
Rx: Combivent
Tobacco: 46 yrs 1PPD
Family Hx: CA
Patient reports increased SOB,
poor appetite, early satiety,
difficulty with meal prep, bitter
taste, poor fitting dentures, and
unintended weight loss
Nutrition-Focused Physical
Findings:
Heart: mild jugular distension noted
Extremities: 1+ bilateral edema
Chest/Lungs: Decreased breathing
sounds, percussion hyperresonant,
prolonged expiration with wheezing,
rhonchi throughout; using accessory
muscles at rest
Skin color: pale
Skin turgor: fair
MAC: 19.05cm, CDC <5th percentile
TSF: 15mm, CDC 14th percentile
http://www.cdc.gov/nchs/data/series/sr_
11/sr11_252.pdf
AMA: 16.35 cm
AFA: 12.5 cm
TAA: 28.77 cm
Food/Nutrition-Related Hx & Comparative
Standards(Usual Intake, Recent Intake, Diet
Order, PA):
EER:1490-1790kcals/day
1352.25-1622.7 (25-30kcal/kg recommended in
text) factor of 1.1 for infection =14901790kcals/day
EPR: 70.3-86.4g protein/day (1.3-1.6 g/day)
Text suggest factor of 1.2-1.7 g/day, that
seemed broad so we narrowed the range based
on her small stature, but muscle wasting and
inflammation
Diet order: Standard, Milk free based on patient
preference
Usual Intake: 931kcals, 15%protein, 8% fat,
80% cho, 345 mg calcium, 3 ug Vitamin D
Recent 24 hour Intake: 603 kcals, 5% pro, 9%
fat, 90% cho, 125 mg calcium, 0 ug Vitamin D
PA: Sedentary
Anthropometrics:
Ht: 160.02 cm
Wt: 54.09kg
BMI: 21.12 (due to
edema, the 54.09kg is
not her dry weight,
which means BMI is
actually lower and she
is likely underweight)
UBW: 65.91-68.18kg
Usual BMI: 26.19
% UBW: 80.7%
Biochemical, Medical Tests & Procedures:
1/25:
Carbon dioxide: 32 mEq/L
Protein: 5.8g/dL
Albumin: 3.3g/dL
Hemotology:
WBC: 15.0 x 103 /mm3
RBC: 4x 106 /mm3
Hgb: 11.5 g/dL
Hct: 35%
Lymphocyte: 10%
Segs: 83%
ABG:
pH: 7.29
pCO2: 50.9 mmHg
SO2:92%
CO2:31 mmol/L
O2:12%
Base deficit: 3.6mEq/L
HCO3-:29.6mEq/L
1/27:
pH: 7.4
pCO2: 40.1 mmHg
SO2:90.2%
CO2:29.8mmol/L
O2:18%
HCO3-:24.7mEq/L
______________________________________________________________________
D: Nutrition Diagnosis (PES statement)
1. Inadequate oral intake related to anorexia, early satiety, dysgeusia, poorly fitted
dentures, and fatigue AEB recent intake of 52-62% EER and 39-48% EPR, usual intake
of 34-40% EER and 8-11% EPR, weight loss of 19.3 % UBW over 5 years, MAC <5th
%ile, TSF bw 5-10th %ile, lab values (protein=5.8g/dL and albumin=3.3g/dL), and
patient self reports.
2. Self feeding difficulty related to fatigue, poor fitting dentures, and nutrition related
knowledge deficit AEB recent intake of 52-62% EER and 39-48% EPR, usual intake of
34-40% EER and 8-11% EPR, weight loss of 19.3 % UBW over 5 years, lab values
(protein=5.8g/dL and albumin=3.3g/dL), and patient self reports.
3. Unintended weight loss related to inadequate oral intake (usual intake of 34-40% EER),
increased caloric needs with COPD, self feeding difficulty AEB anthropometric data
(weight loss of 19.3% UBW over 5 years) and patient self reports.
_____________________________________________________________________
I: Nutrition Intervention (Prescription, Goal and Intervention)
Prescription:
1. Request lab values of ferritin to rule out anemia
2. Recommend multivitamin
Goals:
1. Improve oral intake to 75% EER over hospital stay. Increased energy intake at home to
1490 - 1790 kcal per day to maintain weight. Record lab values important for monitoring
malnutrition and refeeding syndrome (protein, albumin, electrolytes, fluid shift)
2. Long term goal of weight maintenance at home
3. Improved protein intake to 1.3-1.6 g/kg (70-86 g /day).
4. Once patient reaches goal oral intake and has maintained weight for one year, modify
composition of meals/ snacks to moderate level of carbohydrate to prevent excessive
CO2 production from metabolism
5. Reduce fatigue and early satiety associated with eating
Education:
Include daughter and family in education if possible due to difficulty with self-feeding.
1. For increasing oral intake: Explain to patient that her body is working harder than
the average person, and that therefore she need more calories and protein to
maintain her weight. Provide examples of high calorie dense food (butter,
sauces and gravies) that can be added to meals to improve calorie consumption.
Also provide a list of foods that are high in protein (meat, fish, dairy products). If
necessary and affordable for patient, discuss meal supplements, like Ensure
Protein Plus, that can be added to meal plan. Discus favorite meals with patient
and make suggestion for added protein and calories (ex: sprinkle cheese on the
top or a casserole, use whole fat dairy products for soups). Ask about food
preferences for meal orders during hospital stay to improve overall intake but be
sure to educate on healthful diet for home meals. Consider barriers to eating
more and provide acknowledgement for the difficulty with fatigue and bitter taste.
Propose water solution as a rinse before and after meals to improve enjoyment
of food. Favorite hard candies could also be consumed between meals to mask
taste. To prevent fatigue, the patient can try resting prior to meal prep.
Encourage the family to help with meal preparation to make meal assembly
easier. The patient can also try sitting at the table while cutting and prepping
items. Look into favorite recipes that can be prepared ahead of time or come
frozen. Suggest to the patient to increase the frequency of meals to 5-6 small
meals per day to reduce bloating and to combat early satiety. Eating largest meal
in the morning and have calorie dense foods. Drinking could also be avoiding
during meal to encourage consumption of more calorie dense items. Motivate the
patient to use a diet journal for self monitoring calorie and protein consumption.
2. For dairy concerns: Encourage the addition of more fruits, vegetables, dairy
products, and whole grains. Explain that dairy products can also be an example
of a calorie dense addition to a meal. Discuss patient’s opinion toward dairy
products explain that dairy should not increase phlegm production, but the
patient can decide if this is right decision for her. Educate that COPD patients are
at greater risk of osteoporosis and calcium would be a necessary supplement if
the patient is set on avoiding dairy. Patient can experiment with skim milk or nondairy milks for mucus concerns. It is recommended that the patient consumes
either through food or supplement, 1200mg-1500mg of calcium and 400 IU of
vitamin D. It may be necessary to provide Lactaid with re-introduction of milk,
depending on GI tolerance.
3. To prevent early fullness and bloating: Encourage the avoidance of gas
producing foods (common items include: beans, broccoli, brussels sprouts,
cabbage, cauliflower, fruits, such as apples, peaches and pears but it will vary
person to person). Small frequent meals will also help. Avoidance of carbonated
beverages or carbonated beverages with meals instead of between can also
reduce bloating. When drinking beverages do not use a straw because this will
add swallowed air. The diet journal can also include additional notes for targeting
foods or patterns increasing bloating especially since triggers are somewhat
variable person to person. Request medications for appetizer stimulants if
energy goal cannot be achieved.
4. Refer patient to a dentist about dentures. Identify texture or specific food items
that give the patient difficulty when chewing. Provide suggestion for altering
meals texture.
5. Ask pt to reinstate educational points
6. After weight has been maintained for a year recommend diet composition for this
patient at about 20% protein, 40% carbohydrate, and 40% fat. Explain to the
patient that a moderate carbohydrate diet is better for COPD patients because it
reduces the amount of CO2 produced with use of the macronutrient. Since the
patient is having trouble removing CO2 this is more important. Increase protein
intake with protein dense foods. reducing carbohydrates, limit grain and fruits to
the recommended levels. Use MyPlate to show patient how to make a balanced
plate with all food groups. Focus on the fact that this does not mean to eliminate
CHO or that less is good so even less is better. It just means to be conscious of
balancing meals.
_____________________________________________________________________
M & E: Monitoring and Evaluation
1. Monitor recent intake with records and reports from patient and assigned nurse during
hospital stay
2. Evaluate lab values to ensure prevention of refeeding syndrome or worsened edema
(fluid shifting) during hospital stay
3. Weigh patient once (at each follow up visit, or during hospital stay, or at first follow up) at
dry weight if possible to evaluate a more accurate BMI. Continue to weigh patient at
follow up appointments every 3 months.
4. Perform a 24 hr recall at follow up appointment. Evaluate calorie and protein
consumption with recall and also self reported usual recent intake.
5. Review recent intake to examine attempts for addition of calorie dense and high protein
food items, as well as moderation of carbohydrate intake
6. Evaluate patient knowledge by asking them to identify calorie dense and protein dense
food items.
7. Review journal for additional comments with meal times. Discuss patterns for bloated
feelings or early satiety. Review any detail or ask about improvement of chewing with
appropriately fitting dentures.
8. Monitor difficulty with increased PA by talking with patient about any activities she has
started and is enjoying. Encourage continuance
9. Evaluate any chewing and texture concerns associated with new dentures after dentist
appointment.
10. Monitor dairy consumption and calcium and vitamin D intake. Review diet journal for
intake of types of dairy or dairy substitutes and evaluate if Ca and vitamin D needs are
being met.
Nutrients Target Average Eaten
Status
Total Calories
2000 Calories
931
Under
Calories
Protein (g)***
46 g
34 g
Protein (%
Calories)***
10 - 35%
Calories
15%
OK
Calories
Carbohydrate
(g)***
130 g
186 g
Carbohydrate (%
Calories)***
45 - 65%
Calories
80%
Over
Calories
Dietary Fiber
25 g
5g
Under
Total Sugars
No Daily
Target or
Limit
134 g
No Daily
Target or
Limit
Added Sugars
No Daily
Target or
Limit
96 g
No Daily
Target or
Limit
Under
OK
Total Fat
20 - 35%
Calories
8%
Under
Calories
Saturated Fat
< 10%
Calories
2%
OK
Calories
Polyunsaturated
Fat
No Daily
Target or
Limit
2%
No Daily
Calories Target or
Limit
No Daily
Target or
Limit
3%
No Daily
Calories Target or
Limit
Linoleic Acid
(g)***
12 g
2g
Linoleic Acid (%
Calories)***
5 - 10%
Calories
2%
Under
Calories
α-Linolenic Acid
(% Calories)***
0.6 - 1.2%
Calories
0.1%
Under
Calories
α-Linolenic Acid
(g)***
1.1 g
0.1 g
Under
Omega 3 - EPA
No Daily
Target or
Limit
12 mg
No Daily
Target or
Limit
Omega 3 - DHA
No Daily
Target or
Limit
16 mg
No Daily
Target or
Limit
Cholesterol
< 300 mg
73 mg
OK
Minerals
Target Average
Eaten
Status
Calcium
1000 mg 345 mg
Under
Potassium
4700 mg 1103 mg
Under
Sodium**
< 2300
mg
691 mg
OK
Copper
900 µg
293 µg
Under
Monounsaturated
Fat
Under
Iron
18 mg
11 mg
Under
Magnesium
310 mg
112 mg
Under
Phosphorus 700 mg
602 mg
Under
Selenium
55 µg
47 µg
Under
Zinc
8 mg
6 mg
Under
Vitamins
Nutrients Target Average Eaten
Target Average
Eaten
Status
Vitamin A
700 µg
RAE
301 µg RAE
Under
Vitamin B6
1.3 mg
1.0 mg
Under
Vitamin B12 2.4 µg
2.3 µg
Under
Vitamin C
75 mg
36 mg
Under
Vitamin D
15 µg
3 µg
Under
Vitamin E
15 mg
AT
1 mg AT
Under
Vitamin K
90 µg
4 µg
Under
Folate
400 µg
DFE
491 µg DFE
OK
Thiamin
1.1 mg
0.8 mg
Under
Riboflavin
1.1 mg
1.1 mg
OK
Niacin
14 mg
16 mg
OK
Choline
425 mg
122 mg
Under
Status
Total Calories
2000 Calories
603
Under
Calories
Protein (g)***
46 g
8g
Under
Protein (%
Calories)***
10 - 35%
Calories
5%
Under
Calories
Carbohydrate
(g)***
130 g
135 g
Carbohydrate (%
Calories)***
45 - 65%
Calories
90%
Over
Calories
Dietary Fiber
25 g
3g
Under
Total Sugars
No Daily
Target or
Limit
101 g
No Daily
Target or
Limit
Added Sugars
No Daily
Target or
Limit
90 g
No Daily
Target or
Limit
Total Fat
20 - 35%
Calories
9%
Under
Calories
Saturated Fat
< 10%
Calories
4%
OK
Calories
Polyunsaturated
Fat
No Daily
Target or
Limit
2%
No Daily
Calories Target or
Limit
Monounsaturated No Daily
Target or
Fat
Limit
3%
No Daily
Calories Target or
Limit
OK
Linoleic Acid
(g)***
12 g
1g
Linoleic Acid (%
Calories)***
5 - 10%
Calories
2%
Under
Calories
α-Linolenic Acid
(% Calories)***
0.6 - 1.2%
Calories
0.1%
Under
Calories
α-Linolenic Acid
(g)***
1.1 g
0.1 g
Under
No Daily
Target or
Limit
0 mg
No Daily
Target or
Limit
Omega 3 - EPA
Under
Omega 3 - DHA
No Daily
Target or
Limit
0 mg
No Daily
Target or
Limit
Cholesterol
< 300 mg
14 mg
OK
Minerals
Target Average
Eaten
Status
Calcium
1000
mg
125 mg
Under
Potassium
4700
mg
425 mg
Under
Sodium**
< 2300
mg
831 mg
OK
Copper
900 µg
294 µg
Under
Iron
18 mg
9 mg
Under
Magnesium
310 mg
56 mg
Under
276 mg
Under
Phosphorus 700 mg
Selenium
55 µg
19 µg
Under
Zinc
8 mg
1 mg
Under
Vitamins
Target Average
Eaten
Status
Vitamin A
700 µg
RAE
199 µg RAE
Under
Vitamin B6
1.3 mg
0.1 mg
Under
Vitamin B12 2.4 µg
0.1 µg
Under
Vitamin C
75 mg
21 mg
Under
Vitamin D
15 µg
0 µg
Under
Vitamin E
15 mg
AT
0 mg AT
Under
Vitamin K
90 µg
2 µg
Under
Folate
400 µg
DFE
66 µg DFE
Under
Thiamin
1.1 mg
0.3 mg
Under
Riboflavin
1.1 mg
0.4 mg
Under
Niacin
14 mg
3 mg
Under
Choline
425 mg
34 mg
Under
Chronic disease related malnutrition r/t smoking AEB Dx of COPD, lab values (ABGs,
hematology, protein, albumin), wt loss I think COPD would be part of the etiology on this one
right? Chronic disease related malnutrition r/t smoking and COPD AEB abnormal lab values
(ABGs, hematology, protein, and albumin) and weight loss of 19.3% over 5 years.