University of Minnesota - Department of Food Science & Nutrition FScN 4665 - Medical Nutrition Therapy I - Fall 2013 Case

2 100 Points Due Date: Tuesday, October 22 Some useful resources for solving the Case: 1. Lecture notes on Nutrition Assessment I-History and Physical Examination 2. Lecture notes on Nutrition Assessment II- Anthropometry 3. Lecture notes on Nutrition Assessment III-Biochemical/Laboratory 4. Module I: Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation 5. Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting 6. Module III: An Introduction to the Exchange Lists for Meal Planning 7. Academy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines (Food and Nutrition for Older Adults Promoting Health and Wellness Recommendations). Link to the EAL website is posted in Moodle 8. Jensen GL, Hsiao PY, Wheeler D. Adult Nutrition Assessment Tutorial. J Parenter Enteral Nutr 2012;36(3): 267-274. 9. White JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr 2012;36(3):275-283. 10. Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness. J Acad Nutr Diet 2012;112:1255-1277. 11. Muscaritoli M, Anker SD, Argiles J, et al. Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) cachexia anorexia in chronic wasting diseases and nutrition in geriatrics. Clin Nutr 2010;29:154-159. 12. Gallagher D, DeLegge M. Body composition (Sarcopenia) in obese patients: Implications for care in the intensive care unit. J Parenter Enteral Nutr 2011;35(1):21S-28S. 13. IDNT Manual.

14. Krauses Food and the Nutrition Care Process, 13th edition (Chapter 9: Food-Drug Interactions; Chapter 21: Nutrition in Aging). The case of Mr. Kowalski (Excerpted from Nelms MN, Long S, Lacey K. Medical Nutrition Therapy: A Case Study Approach. 3rd ed. Belmont, CA: Wadsworth; 2009.) Edmund Kowalski, an 85-year-old male, has been brought to the hospital emergency room because of a change in his mental status. Mr. Kowalski suffers from several chronic diseases that are currently treated with multiple medications. Patient history: Onset of disease: Sudden onset of confusion that has been increasing over the past 24 hours. Patient moved to live with daughter and her family almost 3 years ago. Daughter states that her father is responsible for his own medicine. She is really not even aware of everything he takes. He does his own insulin injections and his blood glucose monitoring. Type of Tx: Currently treated for CAD, type 2 DM, peripheral neuropathy, and renal insufficiency PMH: CAD; type 2 DM; renal insufficiency; peripheral neuropathy; osteoarthritis; prostate CA; diverticulitis/diverticulosis Meds: Diovan; Prilosec; Neurontin; Furosemide; Trazodone; Aspirin; Multivitamin; and NPH and regular insulin. Smoker: No Ethnicity: Caucasian (Polish descent) Chief complaint: We brought my father to the hospital because he has become quite confused. Sometimes he forgets little thingshe is 85, you know, but he generally is not confused. I checked his blood glucose first, but that was normal. I thought I had best bring him in to make sure everything was OK.

Physical exam: General appearance: Cheerful elderly gentleman who is confused and appears slightly restless Height: 55 Current weight: 196 lbs, UBW: 225 lbs Vitals: Temp 92.7 F, BP 105/65 mm Hg, HR 75 bpm, RR 16 bpm Neurologic: Inconsistent orientation to time, place, and person Extremities: Significant neuropathy present Skin: Warm to touch; numerous pinpoint hemorrhages; fragile; poor skin turgor Mouth: Loose-fitting dentures; membranes dry

Physical activity: Daughter reports that the pt is limited in mobility because of osteoarthritis and peripheral neuropathy and is mostly sedentary. Additionally, she reports that her father has had difficulty getting up from his chair over the past 9-12 months.

Results from a nutrition assessment conducted by a RD one week ago at the outpatient clinic: i. Handgrip strength results indicate loss of muscle strength. ii. Five-times-sit-to-stand test confirmed that Mr. Kowalski is indeed compromised in his ability to rise from a chair. iii. A Dual energy X-ray absorptiometry (DXA) scan that was conducted 3 months ago assessed his percent appendicular skeletal muscle mass. Mr. Kowalskis percent muscle mass was found to be 2 standard deviations (SD) below the mean measured in young adults (Muscaritoli et al., 2010; Gallagher and DeLegge 2011). Nutrition Hx: General: Daughter states that his appetite is goodprobably too good! She prepares most meals. He weighed almost 225 lbs when he came to live with her and her family almost 3 years ago. His weight has been stable for the past year. Her biggest concern nutritionally is that her father never seems to drink fluids except at mealtime. I will pour him a glass of water between meals. He will take one sip, and then he just lets it sit there. She reports that she tries to limit his calories and simple sugars, but it has been difficult. She states, He prefers starchy, sweet, and high-fat foods. I was trying to give him chicken breast instead of kielbasa and other favorite higher-fat meats like liverwurst and brats, but he wouldnt eat it, saying its too dry. Now I let him have the sausage, but just try to limit it to a small serving during dinner. I just dont feel my father will tolerate my being any more restrictive than that. I figure at 85, well just do the best we can. Usual dietary intake: AM: 1 egg scrambled with 1 oz cheddar cheese, 2 slices of pork bacon, 2 slices white bread with 2 Tbsp regular grape jelly, 1 c cranberry juice, 1 small (4 oz) banana, 3 c coffee with fat-free creamer. Lunch: Usually from senior center, diabetic lunch: 3 - 4oz lean meat, 1 c raw vegetable, 1 small roll with butter, c fruit, 6-8 oz sugar-free iced tea Dinner: 1 oz portion of grilled kielbasa, 2 c mashed potatoes, 6-8 oz unsweetened iced tea, 1 small slice (2 oz) angel food cake with strawberries Snacks: Usually 2-3 X daily; Sugar-free Jell-O, low-fat yogurt, microwave popcorn Food allergies/intolerances/aversions: NKA Food purchase/preparation: Daughter Vit/min intake: Multivitamin daily

Previous nutrition therapy? Yes, when first diagnosed with diabetes over 15 years ago. He has attended diabetic classes in the past. Arterial Blood Gases (ABGs): NOTE: Use this ABG data only for answering question #1, for practice assessing acid-base disturbances. Do not use this data as part of your assessment of biochemical data in question #3D.

Data

Normal Range 7.35 - 7.45 35 45 80 100 22 26

Units

pH PCO2 PO2 HCO3-

7.47 46 83 32

mmHg mmHg mEq/L

Biochemical/Lab Data: Lab Test Data Normal Range 70 110 < 5.7% 136 - 145 95 - 107 3.5 - 5.0 8 - 25 0.6 - 1.5 mEq/L mEq/L mEq/L mg/dL mg/dL Units

Glucose HbA1C Na+ ClK+ BUN Cr

172 8.2 150 97 3.3 32 0.9

mg/dL

Phosphorus Mg++ Calcium Albumin C-reactive protein

4.0 1.3 7.8 3.4 40

2.6 - 4.5 1.5 - 2.2 8.5 10.5 3.5 - 5.0 <1

mEq/L mEq/L mg/dL g/dL mg/L

NUTRITION ASSESSMENT 1. Practice assessing acid-base disturbances by using Mr. Kowalskis arterial blood gas values. Determine: A) what is the acid-base disturbance (if any), and which system is the primary underlying cause of the disturbance (i.e. metabolic or respiratory); and B) state if the acid-base disturbance you identify is compensated or uncompensated. C) Explain your rationale, citing specific data that support your conclusion. In doing this, you are making a differential diagnosis, so keep that in mind as you make your explanation (i.e. be specific and clear). A. Does Mr. Kowalski have an acid-base disturbance? Select ONE of the following choices from the drop down menu below, based upon your assessment of his ABGs. (2 points) Metabolic Alkalosis B. Is the acid-base disturbance compensated, partially uncompensated, or uncompensated? (2 points) The acid-base disturbance is partially compensated

C. Explain why you came to the conclusion you did regarding Mr. Kowalskis acidbase status. To support your answer, cite specific data from his current and previous medical history that could be contributing to this disorder. (4 points) Mr. Kowalski has a pH value greater than 7.45 (7.47), which is evidence of alkalosis. Pt also has a HCO3 value of 32, which is much higher than the normal range of 22 to 26 and this marks alkalinity in arterial blood gases. His alkalosis is partially compensated because his PCO2 value is 46, which actually is a marker

for acidosis. This reveals that the respiratory system is likely attempting to compensate for the metabolic alkalosis by releasing less CO2, and hence the high PCO2 value. Since pts pH value is not within the normal range of 7.35 to 7.45, this state is considered partially compensated. Anthropometric Data

2.

A. Calculate Mr. Kowalskis ideal weight using the Hamwi equation. (2 points) IBW = (106 lbs) + (6 lbs)*(5) = 136 lbs +/- 10% B. Calculate the % ideal weight and % usual body weight he is at his current weight. (4 points) %IBW = 196 lbs / 136 lbs = 144% %UBW = 196 lbs/ 225 lbs = 87%

C. Calculate Mr. Kowalskis BMI. Into which category does he 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? (4 points) 196 lbs/2.2 = 89.1kg 55 = 1.65m BMI = 89.1kg/2.72 = 32.76kg/m2 (Obesity, Class I) D. Evaluate his current weight in terms of change from usual body weight over time (be specific). If he has lost weight, is it clinically significant? Explain. (4 points) Usual body weight = 225 lbs Admission weight = 196 lbs % weight loss = (225-196/225) x 100 = 12.88% (~13%) According to the case, it is not specified when Mr. Kowalski was experienced weight loss. If Mr. Kowalski lost greater than 10% of his weight in 6 months, his body weight change is clinically significant and would be classified as severe weight loss. However, if Mr. Kowalski lost his weight gradually over the past 3 years, this would not be considered clinically significant (<10% loss in 6 months). 3. Evaluate Mr. Kowalskis dietary intake, anthropometric, PE/clinical, and biochemical data. When appropriate, compare his 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. (10 points) A. 1. Dietary intake data (2 points): Mr Kowalskis dietary intake data indicates insufficient consumption of vegetables, which also would likely mean deficiency of minerals. His intake of vitamins is supplemented by his multivitamin intake. Pt also eats a large amount of sweet, starchy, and high fat foods, such as angel food cake and microwave popcorn, which will be detrimental to the state of his diabetes, CAD, and obesity. At home, the majority of Mr. Kowalskis calories comes from high fat foods such as egg scramble with cheddar cheese, pork bacon, and grilled kielbasa. Mr. Kowalskis diet is low in fiber intake , as he consumes regularly only 1 cup of raw vegetable and around 3 fruit choices per day, and these vegetable and fruit choices are often not ones that are particularly high in fiber, such as cranberry juice and strawberries. Mr. Kowalskis usual diet intake does not account any whole-grain or other high-fiber grain options. 2. Refer to his usual dietary intake provided in the nutrition history. Take an estimate of how many grams of protein he is currently consuming in each of his meals and the total grams of protein consumed during the day. Show how you got your numbers. (2 points): Protein consumed each meal: AM: Egg scramble with cheddar cheese (14g), pork bacon (7g) and white bread (6g) Lunch: Lean meat (21-28g), raw vegetable (2g), small roll (3g) Dinner: Grilled kielbasa (7g), mashed potatoes (12g) Total protein consumed throughout the day = 72-79g protein B. Anthropometric data (refer back to your answers in question #2) (2 points): Mr. Kowalskis current BMI of 32.76kg/m2 is still classified as being Class 1 obesity although he has lost more than 10% of his usual body weight for the past 3 years. He is now 87% of his usual body weight in the past 3 years. As it is not specified when did Mr. Kowalski experience weight loss, we cant determine whether if Mr. Kowalski is clinically significant or malnutrition. If Mr. Kowalski lost more than 10% of his usual body weight in 6 month, then it is clinically significant.

Additionally, Mr. Kowalski has relatively very low percent muscle mass, at 2 standard deviations below the mean measured in young adults. Although this comparison is not with men of his own age group, these findings are still of concern, especially paired with some of his PE/clinical results (below), and one potential cause of this body composition abnormality is malnutrition. C. PE/clinical findings (2 points):

Pts observed confusion is abnormal. His inconsistent orientation to time, place, and person is of concern. Poor skin turgor indicates dehydration. Significant neuropathy is also indicative of abnormal health, possibly thiamin deficiency. Loss of muscle strength and compromised ability to rise from a chair is also concerning, and is indicative of recent muscle wasting. Vital signs are classified based on normal ranges (given by Ohio State University - Wexner Medical Center <http://medicalcenter.osu.edu/PATIENTCARE/healthcare_services/emergency_services/no n_traumatic_emergencies/vital_signs/Pages/index.aspx>). Pts body temperature of 92.7 degrees Fahrenheit falls below the 97.8 - 99 degrees considered normal. Pts heart rate of 75 bpm falls within the normal range of 60 - 100 bmp. RR of 16 bpm is within the normal 1520 bpm. BP of 105/65 mmHg is also considered normal as it falls below the 120/80 mmHg recommended upper limit. D. Biochemical data (Note: Do not discuss his Arterial Blood Gases here, but rather, focus on all the other biochemical data) (2 points):

Albumin levels show mild depression. This could be revealing of either insufficient protein intake or increased protein degradation. Phosphorous, chlorine, potassium, and chromium levels are within normal range. With the hypoalbuminemia taken into account, corrected calcium is (4.0-3.4)*0.8 + 7.8 = 8.28 mg/dL, which is still below the 8.5-10.5 mg/dL considered to be normal. Corrected Mg++ with hypoalbuminemia in account is 1.3 mEq/L + 0.005 (40-34)= 1.33 mEq/L, which is also still below the normal values of 1.5-2.2 mEq/L. C-reactive protein is much greater than the normal value of below 1 (ideally below 0.8 mg/dL), and this is evidence of high inflammatory response in pts body. BUN is much greater than 25 mg/dL, at 32 mg/dL, and sodium at 150 mEq/L is greater than 145 mEq/L, the highest value considered normal. These values are indicative of dehydration. Also indicative of dehydration is the higher than normal value of glucose at 172 mg/dL when normal range is 70-110 mg/dL. HbA1c at 8.2% is greater than 5.7%, and even greater than 7%, which is the value recommended for diabetics to keep under (National Institutes of Health). 4.

A. Calculate Mr. Kowalskis serum osmolality from his admission labs, as one indicator of his hydration status upon admission. What does this value you calculated suggest about his hydration status at admission? Mention any relevant clinical/PE data to support your evaluation. (6 points) Serum Osmolality = mOsm/kg = (Serum Na x 2) + (BUN/2.8) + (Glucose/18) = (150 x 2) + (32/2.8) + (172/18) = 320.98 mOsm/kg ~ 321 mOsm/kg Mr. Kowalskis serum osmolality is 321 mOsm/kg, which is above the normal range (275-295 mOsm/kg). This value suggests that Mr. Kowalski is experiencing dehydration. Mr. Kowalski is admitted to the hospital with fragile and poor skin turgor, and dryness of the mouth, suggesting that he is dehydrated. Elevated sodium level (150mEq/L) and high BUN/Cr ratio (>20) are indicating Mr. Kowalski is experiencing dehydration.

B. Why do you think he is in this state of hydration? What might be the pathophysiologic reason behind his current hydration state? (2 points) Mr. Kowalskis high serum osmolality suggests that he is dehydrated. His hypernatremia condition (high sodium level) is the pathophysiologic reason behind his current dehydration state. Hypernatremia dehydration occurs when the lost fluid contains less sodium than the blood. Relatively less sodium than water is lost. Extravascular water shifts to the intravascular space due to the serum sodium is high, minimizing intravascular volume depletion for a given amount of total body water loss.

5. Identify the mechanism of action for each medication that Mr. Kowalski is currently taking. Determine any drug-drug interactions and drug-nutrient interactions. (9 points) Medicati on Rationale for Use/Action DrugDrug Interaction DrugNutrient Interaction

Diovan

Blocks actions of natural substances (angiotensin II) from tightening blood

aliskiren, a diabetes drug, interacts with this drug.

may increase serum potassium levels limit potassium in diet and

vessels treats high blood pressure

Possible negative consequences if taken with non-steroidal anti-inflammatory medications (e.g. aspirin) or other high blood pressure medications. Possible interactions or negative consequences when taken with many drugs, including certain antibiotics, anticoagulants, benzodiazepines, diuretics, iron supplements, ketoconazole, St. Johns wort, and antifungal medications.

potassium supplementation. Can have side effects of nausea and diarrhea, and unexpected weight gain. Taken before meals as whole capsule with full glass of water. Because of increased gastric pH (decreased acidity), vitamin B12 is more inhibited from being released from its protein and binding to intrinsic factor. Taking Prilosec then can increase risk for vitamin B12 deficiency due to impaired intake. (Krause 215) This decreased gastric acidity can also impair iron absorption. Possible side effects of constipation, diarrhea, and vomiting.

Prilosec

inhibits proton pump; inhibits gastric acid secretion; increases gastric pH used to treat GERD

Neuronti n

Taken for seizure control in those with epilepsy anticonvulsant. Also

Antacids need to be taken at least 2 hours before neurontin ingestion. These

Can cause vomiting, dry mouth, and constipation.

taken to relieve the pain of diabetic neuropathy

antacids, if they contain aluminum or magnesium, may interfere with neurontins absorption. Sucralfate, cholestyramine, and colestipol can decrease the absorption of this drug. Ethacrynic acid and lithium also can interact with this drug. May affect blood sugar level and reduce potassium level in blood. Also lowers calcium, sodium, and magnesium status.

Furosemi de

Increases urinary excretion of calcium, magnesium, potassium, and sodium. Used to reduce extra body fluid (edema) caused by heart failure or kidney disease. Also used to control high blood pressure and hypercalcemia. antidepressant improves mood, appetite, and energy level, controls anxiety and insomnia related to depression.

Trazodo ne

Many drugs can interfere with the action of this drug, including other antidepressants, certain anti-seizure medications, high blood pressure medication.

Tryptophan and St. Johns wort can have potentially harmful interactions with this drug. Some herbal products have potential to increase toxicity for trazodone. Low levels of serum potassium and magnesium can exacerbate QT prolongation, a potential side effect of this drug.

Zocor (Simvast in)

HMG CoA reductase inhibitor. Lowers LDLcholesterol and raises

Drugs used to thin the viscosity of blood may interact with this drug (e.g. warfarin,

Grapefruit and related citrus fruits may increase the level of this drug to toxic

HDL-cholesterol levels. Used to decrease risk for heart disease

cyclosporine, danazol). Certain drugs such as antifungals and HIV medication can affect the removal of this drug from the body. Repaglinide and rosiglitazone may interact with this drug. Flu vaccinations, acetazolamide, blood thinners, coricosteroids, methotrexate, pemetrexed, and herbal medications may create interactions with aspirin of serious consequence.

amount.

NPH and regular insulin Aspirin

Used to control blood sugar levels in the body for diabetics. salicylate platelet inhibitor. Taken to reduce fever and swelling relieve pain, and also may be taken to reduce risk for heart attack and stroke by preventing blood clots. This is considered a blood thinner.

Lowers blood glucose levels.

Aspirin may cause GI irritation and bleeding. It can also decrease uptake of vitamin C by leukocytes and increase vitamin Cs excretion through the urine. It lowers systemic levels of many minerals: iron, sodium, potassium, and the vitamin folic acid. Pts must be especially careful with longterm use. (Krause 11001106)

Multivita min

Taken as dietary supplement to ensure adequate vitamin intake.

Antacids and some antibiotics, as well as some other drugs, affect the absorption of iron from the multivitamin, if it contains iron. If the multivitamin contains folic acid, care should be taken with antiseizure medication.

Information gathered from Krauses Food and the Nutrition Care Process, 13th edition, p.11001106, WebMD Drugs and Medication Site, and MedlinePlus: NIH Drug Information Site.

6. Refer to the Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness. J Acad Nutr Diet 2012;112:1255-1277 and the Krause text (Chapter 9: Food-Drug Interactions; Chapter 21: Nutrition in Aging) to answer the following questions: A. Define polypharmacy. Do you think that Mr. Kowalskis medications represent polypharmacy? (3 points) According to Krauses chapter 21, polypharmacy is defined as taking five or more medications or over-the-counter drugs daily. Mr. Kowalskis medications represent polypharmacy as he is taking more than five medications every day, for example: Diovan, Prilosec, Furosemide, Trazodone, Aspirin, Multivitamin, NPH and regular insulin.

B.

Why is polypharmacy a concern among the elderly? (2 points) Polypharmacy is a concern among the elderly because they have higher risk of food-drug interactions due to physical changes related to aging. An example of such a physical change is impairment of kidney function, which would slow drug excretion from the body and increase likelihood for drug interactions. Malnutrition and dehydration are also more common with the elderly, and this also increases the risk of harmful interactions in the body. Other illnesses such as dysfunction of endocrine system, and restricted diet increase the risk of food-drug interactions. How could the healthcare team minimize this issue? (1 point) To minimize food-drug interactions issue and maintain good nutrition status, the healthcare team should work together to plan and coordinate the medication regimen and diet and nutritional supplements.

C.

Calculation of Nutrient Needs 7. Refer to the guidelines given in Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting and the EAL to complete the following. An additional resource you may also find helpful is Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness. J Acad Nutr Diet 2012;112:1255-1277. Show your work and specify the source for your answers, and explain your reasoning for making the choices you made.

A.

Using an appropriate prediction equation (with or without activity/stress or injury factor, as you deem appropriate), estimate Mr. Kowalskis total energy requirement. As always, explain your thinking and show your work. (4 points) According to Frankenfield and Ashcraft, RMR can be accurately predicted in about 80% of non-obese and overweight people (BMI <30) and in about 70% of obese people by using Mifflin St Jeor equation. In this case, Mr. Kowalskis BMI of 32.76kg/m2 indicates that he is obese, and he is not physically active. However, Mr. Kowalski is not acutely ill and has has been losing weight and shows signs of malnutrition, and so it was difficult to determine which equation to use. We decided to use the Mifflin St.Jeor equation because we did not think it was necessary for his energy requirements to be adjusted so that he would lose weight, since he has already been progressively losing weight and muscle mass of concerning amount. Mifflin St.-Jeor equation: RMR = 9.99*(89.1kg) + 6.25*(165cm) - 4.92*(85) + 5 = 890.1 + 1031.25 - 418.2 + 5 = 1508.2 kcal In Mr. Kowalskis case, weight maintenance is the goal although he is obese currently. This is because he is losing muscle mass currently Therefore, stress factor of 1.0-1.15 is used to account his sedentary lifestyle: (TEE=RMRxSF) 1508 x (1.0-1.15) = 1508 - 1734 kcals. This value is reasonable for Mr. Kowalski to maintain his body weight. Another factor to consider is estimated physical activity level. To estimate Mr. Kowalskis total energy requirement, activity factor of 1.0-1.1 is used to account Mr. Kowalski sedentary lifestyle for the past 9-12 months due to he is limited in mobility because of osteoarthritis and peripheral neuropathy: (TEE=RMRxAF) 1508 x (1.0 - 1.1) = 1508 - 1659 kcals

B.

Cross-check your answer found in 7A by calculating what your assessed total energy requirement is on a kcal/kg basis. You do this by taking the total energy requirement estimated by your prediction equation method and dividing it by Mr. Kowalskis weight to get kcal/kg. How does the number you calculate compare to the consensus numbers provided in Module II (i.e. is it within the range of what RDs tend to use, even though this practice is not evidence-based per se)? Show your calculations. (4 points) 1508-1734/89.1 is ~17-20 kcal/kg RDs tend to use 25- 30 kcal/kg actual body weight to estimate TEE for healthy and nonobese patients; A range of 11- 14 kcal/kg actual body weight is recommended by ASPEN for obese, critically ill patients. In this case, Mr. Kowalski is non critically ill patients,

hence, our estimated energy requirements fall within the range that RDs tend to use in practice to maintain Mr. Kowalskis body weight. C. Estimate Mr. Kowalskis protein requirement. Explain your thinking and show your work. (2 points) According to article titled Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness, RDA of 0.8g/kg body weight is adequate to meet minimum daily dietary needs for most older adults. 89.1kg x 0.8g protein = 71.28 grams protein per day However, some experts suggest that higher protein intake of 1.0-1.6g/kg daily is safe and adequate to meet the needs of healthy older adults as higher protein intake may be beneficial to enhance muscle protein anabolism and reduce progressive loss of muscle mass with aging. 89.1kg x (1.0-1.6g protein) = 89.1 - 142.56 grams protein per day D. Refer back to question 3A.2. How does his current protein intake compare to what you estimated in the previous question? (2 points) Mr. Kowalski current protein intake is around 72-79 grams. Mr. Kowalski meet the RDA recommendation of protein intake of 0.8g/kg body weight, which is 71.28 grams protein/day. However, Mr. Kowalski might need to increase his protein intake to minimum of 89.1 grams protein/day in order to enhance muscle protein anabolism, according to some nutrition professionals. E. Using guidelines given in Module II, estimate Mr. Kowalskis fluid needs. Show your work. (2 points) Rule of thumb method: 1 mL/kcal = 1508 - 1734 mL fluid per day Another method is: Older adults- 30 mL/kg = 89.1kg x 30 mL fluid = 2673 mL fluid per day Holliday-Segar Method: 1500mL + 20 mL(89.1kg-20) = 2882 mL fluid/day NUTRITION DIAGNOSIS 8. A. Based on your assessment in question 3, refer to the Jensen et al. (2012) tutorial and the ASPEN/Academy Consensus Statement by White et al. (2012) to determine if Mr. Kowalski meets the definition of a specific category of malnutrition. Explain your rationale. (2 points)

Patient exhibits symptoms of the Chronic Disease-Related category of Malnutrition. Weight loss, loss of muscle mass, and handgrip strength test indicate adult malnutrition. Inflammation was present in pt, with c-reactive protein values at abnormally high levels. However, his malnutrition was not related to acute disease or injury, but more with chronic diseases such as sarcopenic obesity and cancer. B. Regardless of whether you decided that Mr. Kowalski is malnourished or not, is there any other descriptive term that could also characterize his current physiologic/nutritional status relating to his muscle mass and body fat? (Refer to Jensen et al. (2012) tutorial; Muscaritoli et al. (2010); Gallagher and DeLegge (2011); and Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults (2012)) (1 point) Sarcopenic obesity 9. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation and your IDNT Reference Manual. Based on what you discovered in earlier questions, identify TWO of Mr. Kowalskis most prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL and/or BEHAVIORALENVIRONMENTAL 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 he is malnourished, choose two nutritional diagnoses OTHER than malnutrition that you can address as the RD. In other words, think about the reasons why he is malnourished as you identify his most important nutrition diagnoses.

A.

Nutrition Diagnosis #1: (3 points) Inability to manage self-care (NB-2.3) Nutrition Diagnosis #2: (3 points) Thiamin deficiency (NI-5.9.1 [6])

B.

NUTRITION INTERVENTION, MONITORING AND EVALUATION 10. Now go back to your two nutrition diagnoses. For each one, write a complete nutrition diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling each section (P, E, and S) appropriately. Identify your short- and long-term goals, an appropriate intervention strategy to address the problem, and

measurable outcomes you will monitor to evaluate the effectiveness of your intervention. You may want to use Module II, your IDNT manual, and the What is ADIME document on the course web site under Reference Materials and Resources for Clinical Cases to help you with this question. 10.1 A. PES #1: (3 points) Inability to manage self-care (NB-2.3) (P) related to poor food choices and lack of value for behavior change (E) as evidenced by diabetes/high blood glucose (172mg/dL), high HbA1c level (8.2%), and obesity condition (BMI=32.76kg/m2) (S).

B. Intervention Step 1: Planning (i.e. jointly establish goals with the patient) State one short-term goal that you will establish collaboratively with Mr. Kowalski. Remember that the goal should be clear, measureable, achievable, and time-defined. (4 points) By the next visit, Mr. Kowalski to replace his consumption of high fat/high sugar food choices at home to low fat/low sugar food choices, such as consume chicken breast instead of grilled kielbasa. Mr. Kowalski to consume at least 30 mL/kg fluid every day to replete his hydration status, which is around 2673 mL per day. Mr. Kowalski to increase his physical activity at least 30 minutes every day.

Long-term goal (i.e. over the next several visits, or longer): Over the next several visits, Mr. Kowalski to consume at least 17kcal/kg and 30 mL/kg fluid via diet recall. Mr. Kowalski to eliminate high fat foods from his diet. Mr. Kowalski to make proper food choices regarding MyPlate guidelines that sustains his diabetes, obesity, and other disease condition, such as consume less than 10% saturated fats of total daily calories, 2.5 cups vegetables daily, and 6 oz of grain foods every day. 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 would be documented in the Intervention section of your ADIME chart note. (2 points) Educate pt on the importance of healthy food choices such as low fat, high fiber diet can help improve his current obesity and diabetes condition, and discuss examples of proper daily dietary intake for diabetes health issue. Encourage family members involvement such as control pts dietary intake by removing high sugar/high fat foods from the house and monitor pts medications schedules. Help pt establish criteria for rewards for desirable behaviors such as keeping a food diary and also improve diet progress by decreasing high sugar/high fat food choices.

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 would be documented in the Monitoring/Evaluation section of your ADIME chart note. (2 points) Review pts food diary to see whether pt follow the dietary instructions, which is limiting high sugar/high fat foods. Pts family members able to report pts medications schedules, explain the purposes of the medicines, and verbalize pts meal preparation which containing healthier food choices. Laboratory data changes, such as lowered in blood glucose and HBA1c level. 10.2 A. PES #2: (3 points) Thiamin deficiency (NI-5.9.1 [6]) (P) as related to food and nutrition related knowledge deficit concerning food sources of thiamin (E) as evidenced by patients disorientation, confusion, and peripheral neuropathy (S). B. Intervention Step 1: Planning (i.e. jointly establish goals with the patient)

State a long-term goal related to this nutrition problem (PES#2) that you will establish collaboratively with Mr. Kowalski. Remember that the goal should be clear, measureable, achievable, and time-defined. (4 points)

Long-term goal (i.e. over the next several visits, or longer): Patient will improve his thiamin status to adequacy by meeting his DRI of 1.2 mg/day. 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 would be documented in the Intervention section of your ADIME chart note. (2 points) Patient will attend two one-on-one 30 minute educational sessions with daughter for both to learn about the risks of thiamin deficiency, foods that are high in thiamin content, and how to incorporate those foods into the diet. 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 would be documented in the Monitoring/Evaluation section of your ADIME chart note. (2 points) The achievement of this goal will be measured in 6 months by observing thiamin intake from detailed food diaries over the past two weeks and physical examination that shows no disorientation, confusion, and peripheral neuropathy.