Case Study 1
Case Study 1
Case Study 1
Chief complaint: I am always short of breath, especially when I am doing any kind of physical
activity and my husband thinks I am confused in the morning.
Patient Hx: Stella Bernhardt is a 62-year-old Caucasian retired office manager who is married
and has 4 grown children. Mrs. Bernhardt was initially diagnosed with type I COPD
(emphysema) five years ago. She has a 46-year history of smoking, but quit 1 year ago. She
states: Im hardly able to do anything for myself right now. Even taking a bath or getting
dressed makes me short of breath. I feel that I am gasping for air. I am coughing up a lot of
stuff that is dark brownish-green. Mrs. Bernhardt is wondering if her symptoms are related to
her COPD.
Type of treatment:
PMH: COPD type I (emphysema), bronchitis and upper respiratory tract infections (mostly
during winter months), four live births, and two miscarriages
Meds: Combivent inhaler
Allergies: None
Smoker: 1 ppd
Family Hx: Father deceased at age 52 from pneumonia, mother still living
Physical Examination:
General appearance: Very thin, middle aged woman, evident temporal and interosseous wasting,
in no acute distress
Vitals: Temp 99.1 F, BP 135/70, HR 77 BPM, RR 21
Skin: Warm, skin pallor
Nail bed: mild koilonychias
Eyes: pale conjunctiva
Height: 53
Weight: 92 lbs
Mid arm muscle circumference (MAMC): < 5th percentile,
Exhibits generalized loss of muscle in shoulders and thighs. Subcutaneous fat loss is evident in
triceps.
Clinical Examination:
The nervous system is intact. Chest/lung examination reveals decreased breath sounds,
percussion hyperresonant, prolonged expiration with wheezing, rhonchi throughout. Pt has
poorly fitting dentures.
From the initial nutrition screen documented by dietetic technician:
Nutrition Hx:
General: Mrs. Bernhardt states that her appetite is poor. She says I fill up so quickly after just
a few bites. She also relates that meal preparation is difficult: By the time I fix a meal, I am too
tired to eat. And things just dont seem to taste as good either. In the previous two days, she
states that she has eaten very little. Increased coughing has made it very hard to eat. Her
normal adult weight was 145-150 lbs (~3 years ago). She estimates that she weighed ~120 lbs
about 6 months ago. She states that her family constantly tells her how thin she has gotten. She
states that she hasnt weighed herself for a while, but that she knows her clothes feel baggy.
Laboratory data:
Lab Test
Day 1
Day 2
Day 3
Normal Range
Units
Glucose
92
103
88
70 - 110
mg/dL
Na
139
137
140
136 - 145
mEq/L
Cl
101
100
99
95 - 107
mEq/L
K+
3.7
3.6
3.6
3.5 - 5.0
mEq/L
8 - 25
mg/dL
Cr
0.9
0.9
0.8
0.6 - 1.5
mg/dL
Phosphorus
2.3
2.5
3.0
2.6 - 4.5
mEq/L
Mg++
1.5
1.7
1.5 - 2.2
mEq/L
Calcium
8.2
8.1
3.0 7.0
mg/dL
Albumin
8.0
8.5 10.5
mg/dL
4.5
6 8.5
g/dL
BUN
Prealbumin
Alkaline Phosphatase
Lab Test
8.0
4
220
219
217
200 - 400
mg/dL
Day 1
Day 2
Day 3
Normal Range
Units
115
25 - 160
U/L
Hemoglobin (Hgb)
10.5
12.5 17.0
g/dL
Hematocrit (Hct)
33
36.0 50.0%
65
80.0 98.0
fL
pH
7.29
7.35 7.45
PCO2
50.9
35 - 45
mmHg
77
80 - 100
mmHg
24.7
22 - 26
mEq/L
PO2
HCO3
NUTRITION ASSESSMENT
Dietary Intake Data
1. From Mrs. Bernhardts typical dietary intake, calculate the total number of calories she
consumed. Also calculate the energy distribution of calories for protein, carbohydrate, and fat.
For this question, you must use the Exchange Lists for Meal Planning (Use Appendix 34 in the
back of the Krause text: See pp. 1110-1121 (13th ed.) and Module III, An Introduction to the
Exchange Lists for Meal Planning), and complete each of the steps outlined below, showing
your calculations.
Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate
that is designated as such under Other Carbohydrate or Combination lists as simply
Carbohydrate rather than Starch, and then count these separately under Other
Carbohydrates in the table for Step 2. Complete the table below. (10 points)
Breakfast
1 slice whole wheat toast
1 tsp butter
1 poached egg
16 oz. coffee
1 Tbsp half and half
cup orange juice
Lunch
3 chicken nuggets (fast food)
cup mashed potatoes
1 Tbsp reduced fat margarine
1 biscuit (plain)
16 oz. coffee
1 Tbsp non-dairy creamer
Dinner
1 cup cream of mushroom soup made
with water
1 slice whole wheat toast
1/2 large (8 oz) banana
36 oz. Diet Pepsi
Evening (HS) Snack
3 saltine crackers
1 oz. American cheese
Step 2: Add the totals from the table in step 1. Count all items that were listed anywhere
besides the STARCH list, that counted as carbohydrate exchanges, under the Other
carbohydrate section in the table below. Count as starches ONLY those foods listed
specifically on the STARCH list. (10 points)
Total
servings/
day
Exchange Group
CHO
(g)
Protein
(g)
Fat
(g)
15
Use 0
15
15
12
12
12
12
4.5
Starch
Non-Starchy Vegetables
Fruit
1.75
Other Carbohydrates
Fat-Free Milk
Low-Fat Milk (1/2 - 1%)
Whole Milk
Lean Meats/Substitutes
2.5
1
3.5
Fats
TOTAL grams
138.75
38
38
X4=
X4=
X9=
TOTAL KCALS
555
152
342
1049
52.9%
14.5%
32.6%
Anthropometric Data
2. A. Calculate Mrs. Bernhardts ideal weight using the Hamwi equation. (2 points)
115 lbs.
B. Calculate the % ideal weight and % usual body weight she is at her current weight. (4
points)
Ideal
92/115 = 80%
Usual
Its a range of 145-150lbs.
92/145 = 63.4%
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C. Calculate Mrs. Bernhardts BMI. Into which category does she fall, based upon the
National Institutes of Health, National Heart, Lung, and Blood Institutes Clinical
Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults, which was provided in the Nutrition Assessment II: Anthropometry notes? (2
points)
BMI
16.29
Underweight classification
D. Evaluate Mrs. Bernhardts current weight in terms of change from usual body weight
over time (be specific). If she has lost weight, is it clinically significant? Explain. (4
points)
% weight loss
in 6 mo.
120-92/120 X 100 = 23.3%
severe weight loss category
3. Evaluate Mrs. Bernhardts dietary intake, anthropometric, PE/clinical, and biochemical data
pertinent to her pulmonary status. When appropriate, compare her data to standard/normal
values. Be as thorough and SPECIFIC as possible, and then clearly identify at least ONE
piece of data that is of concern from a nutritional standpoint within each data category
as you begin to prioritize the most prominent nutrition issues that need to be addressed.
EXPLAIN your rationale for each issue that you mention.
A.
Dietary intake data (Refer back to what you found in question #1 and evaluate Mrs.
Bernhardts intake in terms of major nutrients or food groups that appear to be
lacking, and any obvious problems you think she is having with intake) (2 points):
She is not consuming any lean meats, milk, or vegetables. Mrs. Bernhardt is lacking
essential nutrients that are readily available in these foods, such as vitamin B,
vitamin D, iron, and riboflavin. I think she is filling up on free foods in her diet,
which dont allow her to desire any other foods with nutrients. She seeks convenience
with foods, which oftentimes means fast food or pre-packed foods. Soups, chicken
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nuggets, and mashed potatoes are all high in sodium and contribute to her high
starch and fat intake.
B.
C.
D.
4. Calculate Mrs. Bernhardts serum osmolality from her admission labs, as one indicator of her
hydration status upon admission. What does this value you calculated suggest about her
hydration status at admission? Mention any relevant clinical/PE data to support your
evaluation. (6 points)
On Day 1, upon admission, her serum osmolality was at 286.32. This value suggests that the
patient was normally hydrated upon admission. Her electrolyte value of Na+ and K+
confirm this as they are also in normal range.
5. Review all four of Mrs. Bernhardts current medications, and describe any relevant foodmedication interactions. If there are no relevant food-medication interactions for a particular
medication, be sure to state that. (4 points)
Solu-medrol (Methylprednisolone): Grapefruit juice may increase blood levels and effects of
drug.
Ancef: Consuming alcohol with this antibiotic may reduce the effectiveness, cause upset
stomach, drowsiness, and dizziness.
Ipratropium Bromide: May slow down the movement of food through the stomach, allowing
patient to develop low blood sugar. May also exacerbate symptoms of COPD.
Albuterol Sulfate: No relevant food-medication interactions.
6. Look at Mrs. Bernhardts arterial blood gas report when she was admitted.
Using your Assessment of Acid-Base Balance notes, assess Mrs. Bernhardts acid-base
status at admission. She could be in one of 4 conditions (see the summary chart at the end of
the note set): Specify whether she is in respiratory or metabolic (one or the other, depending
upon the origin of the disorder) acidosis or alkalosis. Use specific values to support your
answer. (4 points)
Based on her lab values, the patient has respiratory acidosis that is uncompensated. Because
her pH value is lower than the normal range and PCO2 is above the normal range, this
indicates a respiratory issue. She also has COPD, which is known to be a respiratory issue.
She has acidosis because her pH is 7.29, below the normal range. She falls into the
uncompensated category because her bicarbonate value are normal, meaning her kidney is
not doing anything to make up for the other arterial blood gases being out of range.
Refer to the guidelines given in Module II: Energy, Protein, and Fluid Requirements in
the Clinical Setting and Module IX: Pulmonary Disorders to complete the following.
Show your work and specify the source for your answers, and explain your reasoning for
making the choices you made.
A.
B.
C.
Estimate Mrs. Bernhardts protein requirement. Explain your thinking and show
your work. (2 points)
Protein requirement: 50g 70.9g
1.2 1.7 g/kg of body weight.
Patient is recommended to start at the lower end and increase gradually to promote a
positive nitrogen balance.
D.
Using guidelines given in Module II, estimate Mrs. Bernhardts fluid needs. Show
your work. (2 points)
Fluid Needs: 1251 mL
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Patient is 62 years old and falls into the older adults category for fluid needs. 30
mL/kg is recommended for her.
E.
Now go back to what you calculated as Mrs. Bernhardts typical total energy and
protein intake from Question #1, and compare it to your estimated total daily energy
requirement from part A. of this question (7A) and to your estimated total daily
protein requirement calculated in part C. of this question (7C). In other words, how
does her typical energy and protein intake compare to what you think are her actual
needs? You should express any differences in whole numbers and also as a
percentage of estimated needs (i.e. actual intake/estimated needs X 100). (2 points)
NUTRITION DIAGNOSIS
8. Based on your assessment in question # 3, refer to the four required supplemental articles on
malnutrition listed under September 4th in the course schedule of the syllabus to determine if
Mrs. Bernhardt meets the definition of a specific category of malnutrition. Explain your
rationale with specific data relevant to the malnutrition characteristics. (2 points)
According to the Journal of Parenteral and Enteral Nutrition, I believe the patient fits into
the category of chronic condition malnutrition. Mrs. Bernhardt has developed COPD and
pneumonia, both contributing stress on her body. Higher amounts of protein are required for
her to fight these illnesses.
9. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record
Documentation and your nutrition diagnoses pages from the IDNT Reference Manual. Based
on what you discovered in earlier questions, identify TWO of Mrs. Bernhardts most
prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL
and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS) using the standard Nutrition
Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each
nutrition diagnosis you write. Even if you determined in the preceding question that she is
malnourished, choose two nutritional diagnoses OTHER than malnutrition that you can
address as the RD. In other words, think about the reasons why she is malnourished as you
identify her most important nutrition diagnoses.
A.
B.
B.
Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE short- and long-term goal that you will establish collaboratively
with Mrs. Bernhardt. Remember that the goals should be clear, measureable,
achievable, and time-defined. (4 points)
Short-term goal (i.e. between now and the next visit):
Patients energy intake will increase from 70% of her required energy intake to
80% of her required energy intake between now and her next visit (approx. 3
weeks).
C.
Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of
care with the patient)
State what nutrition-related action(s) you as the RD will take to address the
problem identified in part As PES statement. Be sure that the
INTERVENTION will specifically address the nutrition-related diagnosis
and/or its underlying etiology described in your PES statement. This
information will be documented in the Intervention section of your ADIME
chart note. (2 points)
Patient received Meals on Wheels food service prepared food delivered straight
to her door.
D.
Measurable Outcome: State what nutrition care indicator you will MONITOR in
order to EVALUATE the progress of the patient resulting from your
INTERVENTION described in part C. Nutrition care indicators are clearly defined
markers that can be observed and measured and are used to quantify the changes that
are the result of nutrition care. For example, food and nutrient intake data, laboratory
values, etc. Keep in mind that you may also identify clinical/laboratory parameters
that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is
the intervention you identified for your PES. Be sure that the nutrition care indicator
can be used specifically to evaluate the success of your nutrition intervention. This
information will be documented in the Monitoring/Evaluation section of your
ADIME chart note. (2 points)
Monitor
Patients weight gain will be monitored during office visits to ensure that she is
receiving adequate caloric intake from the Meals on Wheels program.
Evaluate
Patient was able to eat breakfast, lunch, dinner, and snacks from the food provided
by Meals on Wheels and will be able to successfully plan one day of meals using
Meals on Wheels recipes as reference for portion and consumption.
10.2
A. PES #2: (3 points)
Patient has impaired ability to prepare food related to low iron levels as evidenced by
fatigue following meal preparation.
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B. Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE short- and long-term goal that you will establish collaboratively
with Mrs. Bernhardt. Remember that the goals should be clear, measureable,
achievable, and time-defined. (4 points)
Short-term goal (i.e. between now and the next visit):
Patients hemoglobin will by 20% of her level upon admission within 3 weeks.
Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of
care with the patient)
State what nutrition-related action(s) you as the RD will take to address the problem
identified in part As PES statement. Be sure that the INTERVENTION will
specifically address the nutrition-related diagnosis and/or its underlying etiology
described in your PES statement. This information will be documented in the
Intervention section of your ADIME chart note. (2 points)
Patient received nutrition counseling and education to support her through the process of
preparing meals.
D.
Measurable Outcome: State what nutrition care indicator you will MONITOR in
order to EVALUATE the progress of the patient resulting from your
INTERVENTION described in part C. Nutrition care indicators are clearly defined
markers that can be observed and measured and are used to quantify the changes that
are the result of nutrition care. For example, food and nutrient intake data, laboratory
values, etc. Keep in mind that you may also identify clinical/laboratory parameters
that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is
the intervention you identified for your PES. Be sure that the nutrition care indicator
can be used specifically to evaluate the success of your nutrition intervention. This
information will be documented in the Monitoring/Evaluation section of your
ADIME chart note. (2 points)
Monitor
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Patients iron levels will be monitored by blood tests during office visits to ensure
that her hemoglobin levels are rising from the heme and non-heme iron sources of
her diet.
Evaluate
Patient was able to prepare and eat breakfast, lunch, dinner and snacks from her
rising iron levels and feels comfortable preparing meals without being easily
fatigued.
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