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Overview of Patient
Initials: A.C.
Gender: Male
Age: 87
Admitted on 7/11/13
Seen on 10/23/13 and 11/6/13
Psychosocial
Lives with his wife at home; reported he does most of the cooking and grocery shopping
Never received Meals on Wheels or SNAP
White, non-Hispanic
Opted for DNR/DNI in an emergency
Was an investigator at Pratt & Whitney
Has a good attitude overall; was impatient toward the end
Physical Signs
In a wheelchair
Glasses
Partial dentures
Skin, eyes, mouth, and hair were all in good condition
Anthropometric Data
Height: 5 feet 7 inches
Weight (10/23/13): 126.5 lbs
BMI: 19.85 (normal, but on the low end & has had significant weight loss)
IBW: 148 lbs ± 10%
%IBW: 85.5% (mild malnutrition)
Clinical Data (taken 10/14/13): BP- 110/58 Temperature- 92.6°F
Nutrition History
Likes: Lobster, steak, shrimp, chocolate cake (eats it every
night)
Dislikes: Ensure, fortified pudding (provided by MM), and
chicken
Meal Pattern: Breakfast, Lunch, Dinner, Snack
Appetite: Currently taking Megace, so his appetite is very
good. Now eats 100% of his meals. Prior to medication, he only consumed 60-85% of his meals.
Medical History
Stage 3 Pressure Ulcer (sacral wound)
GI Bleeding
Pneumonia, SOB worsening
COPD
Unspecified Essential HTN
Clostridium difficile infection colitis
UTI, site not specified
Pulmonary Embolism
Depression
2 Chief Diagnoses 1st = Severe Weight loss
Date: Weight (lbs):
Weight Lost (lbs):
% Change:
Classification:
6/28/13 158 - - Normal (BMI=24.8)
8/1/13 145 13-8.2%
(lost in 1 month)
Severe wt loss
9/8/13 130.75 14.25-9.2%
(lost in 1 month)
Severe wt los
9/18/13 127.5 3.25-2% (lost
in 1 week)
Significant wt lost
10/16/13 129.7 2.2+1.4%
(gain in 1 month)
Not significant
10/23/13 126.5 3.2-2% (lost
in 1 week)
Significant wt lost
Summary of Weight Loss
020406080
100120140160180
Weight Trend (lbs)
Weight Trend (lbs)
A.C. had a 19.9% loss of weight in 4 months severe wt loss
Chief Diagnosis (cont.)
2nd = Stage 3 Pressure Ulcer
Stage: Description:
Stage IA reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop.
Stage II The skin blisters or forms an open sore. The area around the sore may be red and irritated.
*Stage IIIThe skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin.
Stage IVThe pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
Medications
FeSO4- hematinic, antianemic mineral supplement A.C. lost iron from blood loss with GI bleed &
has protein malnutrition
Megace- appetite stimulant Symptoms: nausea, dyspepsia
Coumadin- anticoagulant Symptoms: taste changes, N/V, cramps, diarrhea
Metoprolol- antihypertensive Symptoms: dry mouth, N/V, diarrhea, dyspepsia,
constipation, flatulence
Medications (cont.)
Remeron- antidepressant Symptoms: dry mouth, N/V, abdominal pain,
constipation
Pantoprazole- anti-GERD, antisecretory Symptoms: abdominal pain, nausea, diarrhea
Sertraline- antidepressant Symptoms: dry mouth, N/V, dyspepsia,
diarrhea, constipation
Biochemical Data
Chloride Maintains body water & acid/base balance Normal Range: 98-106 mmol/L Patient’s Results: 110 mmol/LHigh value can indicate renal failure, use of
potassium-sparing diuretics, acidosis, cell damage, dehydration, diabetes out of control, addison’s disease, SIADH, hypoaldosteronism,
sepsis, shock, or pneumonia
Biochemical Data (cont.)
BUN (Blood Urea Nitrogen) Detoxified product of protein metabolism &
indicates recent protein intake Normal Range: 10-20 mg/dL Patient’s Results: 36 mg/dLHigh value can indicate dehydration,
increased protein intake, renal failure/insufficiency, increased catabolism of protein D/T infection, tumors, starvation, stress, trauma, MI, DM, increased age,
bleeding ulcers, GI hemorrhage, pneumonia, multiple myeloma, pancreatitis, CHF, and renal vein thrombosis.
Biochemical Data (cont.)
Na+ 138 mmol/L
K+ 4.8 mol/L
HCO3- 22
mmol/L
Creatinine 0.8 mg/dL
Glucose 73 mg/dL*All of these lab values fell within normal ranges, therefore, were not concerning
Medical Nutrition Therapy
Increase calorie, protein, and fluid intake Calorie: 35-40 kcals/kg
40 kcal x 57.5 kg= 2,300 Protein: 1.5 g/kg
1.5 g x 57.5 kg= 86 g Fluid: 1 mL/kcal
1 mL x 2,300 kcal= 2,300 mL (~10c)
Zinc, Vitamin C, & protein supplements for wound healing Protein supplements: magic cup, super cereal, &
prosource
Multivitamin supplement to increase mineral levels
Diet Order
Cardiac Diet, Regular Consistency
A regular consistency diet allows the pt to consume all foods in their naturally prepared state, with no mechanical modifications made to them
The cardiac diet includes limiting sodium, saturated, trans, and total fats in the diet as well as cholesterol. Additionally, the cardiac diet encourages eating more omega-3 fats, fiber, and plant based meals
Nutritional Needs
Calories: 2,300 kcal 40 kcal/kg
Carbohydrates: 316 g/day 55% CHO
Protein: 1.5 g/kg 86 g/day 15% Protein
Fat: 77 g/day 30% Fat
Fluid: 2,300 mL (~10c) 1 mL/kcal
Pertinent Vitamins & Minerals
Zinc 200 mg/day Protein structure, immune function, & wound
healing
Vitamin C 1000 mg/day Wound healing, immune function, & collagen
synthesis
Multivitamin supplement Iron, B Vitamins, Vitamin A ,and Vitamin E Increase mineral levels & increase healing
Sample MenuBreakfast
1c super cereal w/ 1c skim milk
1/2c cranberry juice 1 apple 16 fl oz coffee w/ 2tbsp
half and half + 1tbsp sugar
Mid-morning Snack
1/2c canned peaches 1/4c low sodium
cottage cheese
Lunch Salad- 1c lettuce,
2hardboiled eggs, 2tbsp reduced fat Italian dressing, 1/4c tomatoes, 1/4c cucumbers
1 banana 2/3c whole wheat pasta 1/2c tomato sauce
Afternoon Snack 12 saltines 1c grapes 1 Magic Cup (provided by
MM)
Sample Menu (cont.)
Dinner
3oz shrimp, stir fry with 1/2c broccoli, 1/2c carrots, 1/2c green beans
2/3c brown rice
Evening Snack
2" chocolate cake 1 Mighty Shake
(provided by MM)
Total calories: 2,275 kcalTotal Protein: 117 g
Nutrition Care Process
Diagnosis: Unintended weight loss Inadequate protein intake
PES statements: Unintended weight loss related to decreased
appetite/intake not meeting needs, as evidenced by 19.9% weight loss over four months (severe), 158 lbs to 126.5 lbs.
Inadequate protein intake related to increased protein needs as evidenced by stage 3 pressure ulcer on sacrum.
Nutrition Care Process
Intervention Increase weight
Patient will consume 85-100% of each meal (nurse to monitor) Patient will continue to take Megace medication to stimulate
appetite Increase protein intake
Patient will consume protein supplements including mighty shakes, super cereal, and magic cup
Promote wound healing Patient will supplement with Vitamin C, Zinc, and multivitamin
daily
Monitoring & Evaluation Follow up with tolerance of supplements Continue to monitor weight closely by taking weekly
weights RD to request albumin, BUN, Hgb &Hct labs
Works Cited: Mahan, L. Kathleen., and Sylvia Escott-Stump. Krause's Food, Nutrition, & Diet Therapy.
Philadelphia: Saunders, 2004. Print.
Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: Food-Medication Interactions, 2012. Print.
"Zinc." — QuickFacts. N.p., n.d. Web. 25 Nov. 2013. <http://ods.od.nih.gov/factsheets/Zinc-QuickFacts/>.
"MedlinePlus - Health Information from the National Library of Medicine." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 24 Nov. 2013. <http://www.nlm.nih.gov/medlineplus/>.
Mayo Clinic. Mayo Foundation for Medical Education and Research, n.d. Web. 24 Nov. 2013. <http://www.mayoclinic.com/>.
"NCM Nutrition Care Manual Eat Right." Public Home Page. N.p., n.d. Web. 25 Nov. 2013. http://nutritioncaremanual.org/
“Stages of Pressure Ulcers.” [Image] https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1008&bih=491&q=stage+3+pressure+ulcer&oq=stage+3+pressure+ulcer&gs_l=img.3..0l4j0i5j0i24l5.997.5062.0.5178.22.17.0.5.5.0.129.1498.13j4.17.0....0...1ac.1.32.img..0.22.1520.MjZtSNemdEI#facrc=_&imgdii=_&imgrc=DXivIyM8JbWl0M%3A%3B8iDyEs45F-7Y5M%3Bhttp%253A%252F%252Fimg.webmd.com%252Fdtmcms%252Flive%252Fwebmd%252Fconsumer_assets%252Fsite_images%252Fmedia%252Fmedical%252Fhw%252Fh9991533_002.jpg%3Bhttp%253A%252F%252Fwww.webmd.com%252Fskin-problems-and-treatments%252Ffour-stages-of-pressure-sores%3B460%3B300