Your Name and/or Name of Partner (if working with one): .

ay&or ,asand

University of Minnesota - Department of ood !"ien"e # Nutrition FScN 4665 - Medical Nutrition Therapy I - Fall 2013 Case 1 $%% Points ue ate! Thursday" Septe#$er 26 P&ease 'e sure to do the fo&&owing: !how a&& "a&"u&ations( and e)p&ain your rationa&e* +a&"u&ations do not have to 'e typed* ,nswer a&& -uestions dire"t&y on this form* .ype a&& answers (e)"ept "a&"u&ations)* !u'mit in hard "opy in "&ass on the due date* You wi&& 'e dedu"ted one point per day after the due date unti& the hard "opy is turned in* You may work ,/0N1 or with 0N1 other person* Do not share your work with other individua&s 'eyond your group* 2f you work with a partner( you shou&d hand in on&y 0N1 "ase with your name and your partner3s name "&ear&y &isted at the top of the first page* !ome resour"es needed for so&ving the +ase: $* /e"ture notes and supp&ementa& readings posted under the "&ass topi" 4526 infe"tion and ,2D!7 in Mood&e site 8* /e"ture notes on Nutrition ,ssessment 2-5istory and Physi"a& 1)amination 9* /e"ture notes on Nutrition ,ssessment 22- ,nthropometry :* /e"ture notes on Nutrition ,ssessment 222-;io"hemi"a&//a'oratory <* Modu&e 2: Nutrition +are Pro"ess( Nutrition Diagnosis and Medi"a& =e"ord Do"umentation >* Modu&e 22: 1nergy( Protein( and &uid =e-uirements in the +&ini"a& !etting ?* Modu&e 222: ,n 2ntrodu"tion to the 1)"hange /ists for Mea& P&anning @* ,"ademy of Nutrition and Dieteti"s: 1viden"e ,na&ysis /i'rary Nutrition Auide&ines (5uman 2mmunodefi"ien"y 6irus/,2D!)* /ink to 1,/ we'site is posted in Mood&e B* 2DN. Manua& $%* Crause3s ood and the Nutrition +are Pro"ess( $9th edition From the admitting physicians note: Chie% co#plaint! 42 have 'een throwing-up everything 2 try to eat( and 2 have terri'&e diarrhea*7 &atient '(! Mr* D is a 9@-year-o&d ma&e who emigrated to the U*!* from Dim'a'we ten years ago* 5e is admitted to the hospita& with nausea( vomiting( and diarrhea* Mr* D* has 'een diagnosed with 526 for seven years* 5is wife died from 526-re&ated "omp&i"ations three years ago* 5e is emp&oyed as a ta)i driver* Mr* D* states he on&y smokes when he is out with friends( appro)imate&y $-8 "igarettes per week* No other re"ent hea&th "omp&aints*
$

Type o% treat#ent! &M'! 526 positive( ora& "andidiasis( pneumonia( vira& gastroenteritis Meds! 1pivir( Derit( +ri)ivan( &u"onaEo&e )ller*ies! None S#o+er! 0""asiona& Fa#ily '(! ather de"eased at age <8 from pneumonia( mother sti&& &iving( wife de"eased at age 99 from 526-re&ated "omp&i"ations &hysical ,(a#ination! General appearance: .hin young ma&e in no a"ute distress Vitals: .emp BB*$F ( ;P $9</?%( 5= ?? ;PM( == 8$ Skin: Garm( dry( no pete"hia or e""hymoses Height: <3$%7 Weight: $<< &'s Mid arm muscle circumference (MAMC): H <th per"enti&e 1)hi'its genera&iEed &oss of mus"&e in shou&ders and thighs* !u'"utaneous fat &oss evident in tri"eps From the initial nutrition screen documented by dietetic technician: Nutrition '(! General: ,ppetite fair* Mr* D* usua&&y skips 'reakfast and eats for the first time during the midd&e of the day* 5is work s"hedu&e is sporadi" and he eats when he fee&s &ike it- often at friends3 homes or a &o"a& "afI in his neigh'orhood* 5e is "onstant&y drinking "offee* 5is reported U;G (J8 months ago) is $?8 &'s* Typical dietary intake: ;reakfast: Usua&&y skips* $> oE* "offee( 9 .* ha&f and ha&f( K "up sugar( @ oE* Lui"e /un"h: @ oE* "offee( $ .* ha&f and ha&f( 8 .* sugar( $ M "up "hi"ken nood&e soup( 8 "ups "u'ed "anta&oupe( 8 oE* 'ag of potato "hips Dinner: @ oE* "offee( $ .* ha&f and ha&f( 8 .* sugar( 9 oE* 'aked skin&ess "hi"ken 'reast( $ "up ri"e( M "up "ooked greens 5! !na"k: one 'anana( one s&i"e app&e pie !!d allergies"int!lerances"a#ersi!ns: None $re#i!us M%T& Mr* D* met with an outpatient dietitian when he first esta'&ished a primary "are physi"ian at the 2nfe"tious Disease +&ini"* ,t that time( 'asi" we&&-'a&an"ed eating and food safety tips were dis"ussed* !!d purchase"preparati!n: Mr* D* pur"hases and prepares his own food or he eats at restaurants/fast food out&ets* Vit"Min !r !ther supplements: Cava root Acti#ity: Ga&ks J9% minutes dai&y( moderate pa"e (J$*< mi&es) Treat#ent &lan! =/0 vira& or 'a"teria& gastroenteritis( dehydration( ora& "andidiasis =outine vita&s N @ hours( +/ diet (advan"e as to&erated) /a's: +;+( +D:( +D@( 526 vira& &oad( stoo& samp&e for 0#P Meds: 1pivir 88< mg ;2D( Derit ?< mg .2D( +ri)ivan >%% mg .2D( &u"onaEo&e( M62 O 8

minera&s P=N Meds: M0M( My&anta( .y&eno& 26 : D<N! O 8% m1- C+/ at ?< m&/hour 'ospital course! .he patient is diagnosed with vira& gastroenteritis and "ontinues to run &ow-grade fevers* 0n hospita& day >( Mr* D is fee&ing we&& enough to advan"e his diet to so&id foods* 5is vomiting and diarrhea have su'sided 'y hospita& day @ when he is dis"harged to home* 5e is s"hedu&ed to see his primary physi"ian in ten days* -a$oratory data!
-a$ Test A&u"ose NaO +&CO ;UN +r Phosphorus MgOO Uri" ,"id +a&"ium ,&'umin .ota& protein Prea&'umin .ransferrin ,&k Phos G;+ .A +ho& 5D/-+ /D/-+ 526 vira& &oad +D: +D@ ay 1 $$B $:B $%$ :*% 8@ %*B 8*8 $*9 :*8 @*@ 9*: > $@*$ 8<$ $%$ >*> $%> $@< :< $8B $%(%%% :8@ 9%? >*9 <*? ay 2 $$$ $:? $%% 9*? 89 $*% 8*? $*: :*% B*% 9*% ay 3 $$@ $:< BB 9*@ $@ $*% 8*@ $*< :*$ @*B 8*@ Nor#al .an*e ?% - $$% $9> - $:< B< - $%? 9*< - <*% @ - 8< %*> - $*< 8*> - :*< $*< - 8*8 9*% P ?*% @*< P $%*< 9*< - <*% > P @*< $> - 9% 8%% - :%% 8< - $>% :*% - $%*< % - $<% $%%-$BB 9?-?% (men) H$9% % <@B-$<%< 98<-BB? /nits mg/d/ m1-// m1-// m1-// mg/d/ mg/d/ m1-// m1-// mg/d/ mg/d/ g/d/ g/d/ mg/d/ mg/d/ U// Q $%9 "e&&s/mm9 mg/d/ mg/d/ mg/d/ mg/d/ mm9 mm9 mm9

-a$oratory in%or#ation prior to ad#ission! ,nnua& +;+ and &ipid profi&e- GN/
9

N/T.ITI0N )SS,SSM,NT ietary Inta+e ata $* rom Mr* D3s typi"a& dietary intake( "a&"u&ate the tota& num'er of "a&ories he "onsumed* ,&so "a&"u&ate the energy distri'ution of "a&ories for protein( "ar'ohydrate( and fat* or this -uestion( you must use the 1)"hange /ists for Mea& P&anning (Use ,ppendi) 9: in the 'a"k of the Crause te)t: !ee pp* $$$%-$$8$ ($9th ed*) and Modu&e 222( 4,n 2ntrodu"tion to the 1)"hange /ists for Mea& P&anning7)( and "omp&ete ea"h of the steps out&ined 'e&ow( showing your "a&"u&ations* Step 1! Determine what ea"h food "ounts as( in terms of e)"hanges* P&ease "ount "ar'ohydrate that is designated as su"h under 40ther +ar'ohydrate7 or 4+om'ination7 &ists as simp&y 4+ar'ohydrate7 rather than 4!tar"h7( and then "ount these separate&y under 40ther +ar'ohydrates7 in the ta'&e for !tep 8* +omp&ete the ta'&e 'e&ow* ($% points) 1rea+%ast $> oE* "offee ('&a"k) 8 .'sp ha&f and ha&f : .'sp sugar @ oE* orange Lui"e $ g&aEed doughnut (8 oE) -unch $> oE* "offee ('&a"k) 8 .'sp ha&f and ha&f 8 .'sp sugar $ M "up "hi"ken nood&e soup 8 "ups "u'ed "anta&oupe $ M oE* 'ag potato "hips inner 9 oE* 'aked skin&ess "hi"ken 'reast $ "up "ooked white ri"e M "up "ooked greens @ oE* "offee ('&a"k) $ .'sp ha&f and ha&f 8 .'sp sugar ,2enin* 3'S4 Snac+ $ 'anana (: oE) $ s&i"e app&e pie (8 "rusts) C!unts As (Specify '(changes) ree ood $ fat : "ar' other 8 ruit 1)"hanges 8 "ar' other 8 fats ree ood $ fat 8 "ar' other $*< "ar' other 8 fruit 8 star"h 9 &ean Meat 1)"hanges 9 !tar"h 1)"hanges $ non star"hy 6egeta'&e 1)"hange ree ood *< fat 8 "ar' other $ ruit 1)"hange 9 "ar' other 8 fat

Step 2! ,dd the tota&s from the ta'&e in step $* +ount a&& items that were &isted anywhere 'esides the 4!.,=+57 &ist( that "ounted as "ar'ohydrate e)"hanges( under the 40ther "ar'ohydrate7 se"tion in the ta'&e 'e&ow* +ount as star"hes 0N/Y those foods &isted spe"ifi"a&&y on the !.,=+5 &ist* ($% points) 1)"hange Aroup !tar"h Non-!tar"hy 6egeta'&es ruit 0ther +ar'ohydrates at- ree Mi&k ($/8 R) /ow- at Mi&k ($R) =edu"ed- at Mi&k (8R) Gho&e Mi&k 6ery /ean Meats/!u'stitutes /ean Meats/!u'stitutes Medium at Meats/!u'stitutes 5igh at Meats/!u'stitutes ats T0T)- *ra#s eter#ine +cals $y #ultiplyin* T0T)- *ra#s T0T)- 5C)-S 6.)N T0T)- 5C)-S 3C'0 7 protein 7 %at4 .ota& servings/ day < $ < $:*< % % % % % 9 % % >*< +50 (g)
$<

Protein (g)
9

at (g)
Use %

?<
<

$<
8

%
%

<
$<

8
%

%
%

?<
$<

%
%

%
%

8$?*<
$8

%
@

%
%

$8

$8

<

$8

Use %

%
%

8$
?

B
<

<

% 9?8*< Q:S $:B%

% 9@ Q:S $<8 8%$<*<

98*< :$*< QBS 9?9*<

<

Step 3! Determine the R k"a&s provided 'y +50* (8 points) $:B%/8%$<*< ) $%%S?9*BR

Step 4! Determine the R k"a&s provided 'y protein* (8 points) $<8/8%$<*< )$%%S?*<R

Step 5! Determine the R k"a&s provided 'y fat* (8 points) 9?9*</8%$<*<S$@*<R

)nthropo#etric ata 8* ,* +a&"u&ate Mr* D3s 4idea&7 weight using the 5amwi e-uation* (8 points) $%>O (>) $%)S$>> &'s*

;* +a&"u&ate the R 4idea&7 weight and R usua& 'ody weight he is at his "urrent weight* (: points) R idea& weightS$<</$>>) $%%SB9*:R R usua& 'ody weightS$<</$?8 ) $%%SB%*$R

>

+* +a&"u&ate Mr* D3s ;M2* 2nto whi"h "ategory does he fa&&( 'ased upon the Nationa& 2nstitutes of 5ea&th( Nationa& 5eart( /ung( and ;&ood 2nstitute3s +&ini"a& Auide&ines on the 2dentifi"ation( 1va&uation( and .reatment of 0verweight and 0'esity in ,du&ts( whi"h was provided in the 4Nutrition ,ssessment 22: ,nthropometry7 notesT (8 points) <V$% and $>> &'s* $ &'S%*:< kg $<<&'sS?%*9 kg $ in"h S%*%8 m ?% in"hesS $*?@ m ;M2Skg/mW8 ?%*9/($*?@) $*?@)S?%*9/9*$>S88*: 5e is in the norma& weight range D* '#aluate Mr* D3s "urrent weight in terms of "hange from usua& 'ody weight over time ('e spe"ifi")* 2f he has &ost weight( is it "&ini"a&&y signifi"antT 1)p&ain* (: points) Mr* D went from $?8 &'s to $<< &'s* in the &ast two months* 5owever( he is sti&& in the norma& weight range (;M2) 'ased on the guide&ines* ;ut sin"e he &ost$? &'s in two months it is important to "a&"u&ate the signifi"an"e of his weight &oss* $?8-$<</$?8 ) $%%SB*@@R ,""ording to the given guide&ines( Mr* D has &ost greater than ?*<R of his usua& 'ody weight in &ess than 9 months( whi"h wou&d put his weight &oss as "&ini"a&&y severe*

9* 1va&uate Mr* D3s dietary intake( anthropometri"( P1/"&ini"a&( and 'io"hemi"a& data pertinent to his 526 status* Ghen appropriate( "ompare his data to standard/norma& va&ues* ;e as thorough and !P1+2 2+ as possi'&e( and then clearly identi%y at least 0N, pie"e of data that is o% concern %ro# a nutritional standpoint 8ithin each data cate*ory as you 'egin to prioritiEe the most prominent nutrition issues that need to 'e addressed* ,9&-)IN your rationale %or each issue that you #ention: ,* ietary inta+e data (=efer 'a"k to what you found in -uestion U$ and eva&uate Mr* D3s intake in terms of maLor nutrients or food groups that appear to 'e &a"king( and any o'vious pro'&ems you think he is having with intake) (8 points):

5e is on&y getting over 9% g of protein* 5e shou&d 'e getting a&most 9) as mu"h as that* 5e needs to a&so in"rease his vegeta'&e intake and his dairy (he is getting Eero dairy)* De"rease his "ar'ohydrate to &ess than >%R of his dai&y "a&ories* 5e shou&d then in"rease his protein intake to a'out $<R* 5is fat per"entage "an stay the same* 5e shou&d 'e in the re"ommended guide&ines( and he is not for those two food groups*

;*

)nthropo#etric data (refer 'a"k to your answers in -uestion U8) (8 points):

,nthropometri" Data-5is height and weight are in the norma& range( 'ut sin"e he &ost a signifi"ant amount of weight without trying (a&most $%R over the period of two months)( he shou&d definite&y 'e "he"ked out*

+* &,;clinical %indin*s (8 points): 6ita&s are pretty norma&* 1)"ept for the fa"t he has visi'&e signs of mus"&e and fat &oss* 2t is espe"ia&&y noti"ea'&e in his arms* 5is mid arm "ir"umfran"e is &ess H<R whi"h verifiies he is mus"&e and fat defi"ient*

D*

1ioche#ical data (8 points):

5is a&'umin &eve&s are &ower than idea&* ,&so( his 526 vira& &oad is o'vious&y sus'stantia& "onsidering the "ir"umstan"es* 5is &ow a&'umin &eve&s "an 'e a resu&t of &ow protein intake and the severity of his 526(the severity of his i&&ness)* 2t is a&so important to note that his '&ood g&u"ose &eve&s were a'ove the norma& range 'e"ause of his high "ar'ohydrate intake* 5is +D: &eve&s are a&so :8@ putting him in the +ategory ; meaning his is symptomati" of 526*

:* +a&"u&ate Mr* D3s serum osmo&a&ity from his admission &a's( as one indi"ator of his hydration status upon admission* Ghat does this va&ue you "a&"u&ated suggest a'out his hydration status at admissionT Mention any re&evant "&ini"a&/P1 data to support your eva&uation* (> points) m0sm/kgS (!erum Na ) 8) O ;UN/8*@ O A&u"ose/$@S ;UNS89 A&u"oseS$$> !erum NaS$:? 8B:O@*8O>*:S9%@*> m0sm/kg 5e is a'ove the norma& range( this means he is dehydrated* 5e is not drinking anything 'esides "offee and one g&ass of Lui"e in his dai&y routine* 5is '&ood g&u"ose &eve&s are higher and that wou&d make the num'er from this e-uation 'e higher* 5is skin was dry from his physi"a& e)am*

<* 2dentify the me"hanism of a"tion for ea"h medi"ation that Mr* D is "urrent&y taking* Determine any food-medi"ation intera"tions and nutrition re"ommendations for "onsumption* (> points) Medi"ation =ationa&e for Use/,"tion !&ow progress of 526 1pivir ood-Medi"ation 2ntera"tions +an "ause &a"ti" a"idosis* Nutrition =e"ommendations /imit dairy intake* .ake with food*

!&ow Progress of 526 Derit

+an "ause &a"ti" a"idosis*

/imit dairy produ"ts( May'e swit"h to soy 'ased mi&k* .ake with food*

!&ow Progress of 526

+an "ause hemo&yti" anemia*

+ri)ivan

5e needs to 'e more hydrated to take this medi"ine to prevent kidney stones* ,&so( he needs to take on an empty stoma"h or with &ow "a&orie foods* 2ts taken every eight hours* +an 'e taken with or without food* Usua&&y on"e per day( may'e twi"e per day if it3s the first dosage*

.reat funga& infe"tions &u"onaEo&e

.his medi"ine is to prevent opportunisti" infe"tions*

>* +an Mr* D 'e "&assified as having ,2D!T Ghy or why notT (8 points) No he "annot* 5is +D: &eve&s are :8@ putting him in the symptomati" 526 "ategory* , +D: &eve& 'e&ow 8%% wou&d "&assify him as having ,2D!*

$%

Calculation o% Nutrient Needs ?* =efer to the guide&ines given in 4Modu&e 22: 1nergy( Protein( and &uid =e-uirements in the +&ini"a& !etting7 and the 1,/ to "omp&ete the fo&&owing* ,n additiona& resour"e you may find he&pfu& as you "omp&ete the rest of this "ase is the Position !tatement on 526 infe"tion (Position of the ,"ademy of Nutrition and Dieteti"s: Nutrition 2ntervention and 5uman 2mmunodefi"ien"y 6irus 2nfe"tion ) Acad %utr *iet 8%$%X$$%:$$%<-$$$B)* !how your work and spe"ify the sour"e for your answers( and e)p&ain your reasoning for making the "hoi"es you made* ,* Using an appropriate predi"tion e-uation (with or without a"tivity/stress or inLury fa"tor( as you deem appropriate)( estimate Mr* D3s total ener*y re<uire#ent* ,s a&ways( e)p&ain your thinking and show your work* (: points) C"a&/kgS?%*:< kg*)9% "a&S8$$9*< k"a&s/day* .his 'asi" e-uation was "hosen 'e"ause it is a simp&e estimate for someone in the norma& weight range who is not "riti"a&&y i&&* 5is indire"t "a&orimetry wasnVt avai&a'&e( so we had to use a formu&a for estimated re-uirements* Ge "hose to use 9% k"a&s 'e"ause he shou&d 'e somewhere in the midd&e 'e"ause he did &ose a signifi"ant amount of weight in the &ast two months( 'ut it is not ne"essary to put him on the higher end of the 8<-9< range*

;*

Cross-chec+ your ans8er %ound in =) $y calculatin* 8hat your assessed total ener*y re<uire#ent is on a +cal;+* $asis: You do this 'y taking the tota& energy re-uirement estimated 'y your predi"tion e-uation method and dividing it 'y Mr* D3s weight to get k"a&/kg* 5ow does the num'er you "a&"u&ate "ompare to the "onsensus num'ers provided in Modu&e 22 (i*e* is it within the range of what =Ds tend to use( even though this pra"ti"e is not eviden"e-'ased per se)T !how your "a&"u&ations* (8 points) 8$$9*</?%*:<S9% k"a& .his num'er fa&&s within the norma& range 'e"ause that is the predi"tion e-uation we used* 2 on&y mu&tip&ied his weight in kg ) thirty (getting us the num'er 9% again here)* .his is 'e"ause he has &ost a de"ent amount of weight without trying in the &ast two months and he demonstrates fat and mus"&e &oss*

+*

1stimate Mr* D3s protein re-uirement* 1)p&ain your thinking and show your work* (8 points) $*<g) ?%*:<S$%<*? grams of protein* 5e is not "onsuming enough protein* +urrent&y( he is on&y getting a'out 9@ grams of protein per day( so we aimed at the higher end of the range for suggesting a protein re-uirement* Protien is on&y "onsisting of @R of Mr* DVs diet( so it is ne"essary to aim high to he&p him rep&enish his 'ody defi"its*

$$

D*

Using guide&ines given in Modu&e 22( estimate Mr* D3s f&uid needs* !how your work* (8 points) 9< m//kg* 9<) ?%*:<S8*< / of f&uid per day*

1*

Now go 'a"k to what you "a&"u&ated as Mr* D3s typi"a& tota& energy and protein intake from Nuestion U$( and "ompare it to your estimated tota& dai&y energy re-uirement from part ,* of this -uestion (?,) and to your estimated tota& dai&y protein re-uirement "a&"u&ated in part +* of this -uestion (?+)* 2n other words( how does his typi"a& energy and protein intake "ompare to what you think are his actual needsT You should express any differences in whole numbers and also as a percentage of estimated needs (i.e. actual intake/estimated needs X !!". (8 points) 8%$< "a&ories/8$$9*< ) $%%S B<R 9@g/$%<*? ) $%%S9>R Mr* D is eating around the right num'er of "a&ories (he is getting a'out B<R of his "a&ories that are suggested( 'ut on&y a'out 9>R of his re"ommended protein* ) $ oES%*%8B? / :@ oES$*:/ $*://8*</S <>R of ade-uate f&uid intake

N/T.ITI0N I)6N0SIS @* ;ased on your assessment in -uestion U 9 ( refer to the Yensen arti"&e (Yensen A/( 5siao PY( Ghee&er D* ,du&t Nutrition ,ssessment .utoria&* ) $arenter 'nteral %utr 8%$8X9>(9): 8>?8?:*) and the ,!P1N/,"ademy +onsensus !tatement (Ghite Y6( Auenter P( Yensen A/( Ma&one ,( !"hofie&d M* +onsensus !tatement of the ,"ademy of Nutrition and Dieteti"s/,meri"an !o"iety for Parentera& and 1ntera& Nutrition: +hara"teristi"s =e"ommended for the 2dentifi"ation and Do"umentation of ,du&t Ma&nutrition (Undernutrition)* ) $arenter 'nteral %utr 8%$8X9>(9):8?<-8@9*) to deter#ine i% Mr: > #eets the de%inition o% a speci%ic cate*ory o% #alnutrition: ,(plain your rationale: (8 points B* =efer to Modu&e 2: the Nutrition +are Pro"ess( Nutrition Diagnosis and Medi"a& =e"ord Mr* D shows signs of moderate ma&nutrition* 5is weight &oss is greater than ?*<R in 9 months (it was a&most $%R in two months) 'ut he on&y &ost some of his mus"&e mass from his arm area( a""ording to his re"ords* 5is weight &oss puts him in moderate to severe ma&nutrition a""ording to the Ghite ,rti"&e( and his mus"&e mass defi"it/atrophy puts him at a'out mi&d ma&nutrition or mi&d &oss of 'ody fat* !o we wou&d put Mr* D in'etween the two "ategories of moderate ma&nutrition* $8

Do"umentation and your 2DN. =eferen"e Manua&* ;ased on what you dis"overed in ear&ier -uestions( identi%y T?0 of Mr D3s #ost pro#inent nutrition-related pro$le#s within any of the domains (2N.,C1( +/2N2+,/ and/or ;15,620=,/- 1N62=0NM1N.,/ D0M,2N!) using the standard Nutrition ia*nostic Ter#inolo*y and INC-/ , the C0 , @ from the 2DN. manua& for ea"h nutrition diagnosis you write* 1ven if you determined in the pre"eding -uestion that he is ma&nourished( "hoose two nutritiona& diagnoses 0.51= than ma&nutrition that you "an address as the =D* 2n other words" thin+ a$out the reasons 8hy he is #alnourished as you identify his most important nutrition diagnoses* ,* Nutrition ia*nosis @1! (8 points)

2nade-uate Protein 2ntake $%>>>

;*

Nutrition ia*nosis @2! (8 points)

2nade-uate &uid 2ntake $%>:B

N/T.ITI0N INT,.A,NTI0N" M0NIT0.IN6 )N ,A)-/)TI0N $%* Now go 'a"k to your two nutrition diagnoses* For each one" 8rite a co#plete nutrition dia*nostic state#ent in &,S %or#at 3pro$le#" etiolo*y" si*ns and sy#pto#s4" la$elin* each section 3&" ," and S4 appropriately: 2dentify your short- and &ong-term goa&s( an appropriate intervention strategy to address the pro'&em( and measura'&e out"omes you wi&& monitor to eva&uate the effe"tiveness of your intervention* You may want to use Modu&e 22( your 2DN. manua&( and the 4Ghat is ,D2M17 do"ument on the "ourse we' site under 4=eferen"e Materia&s and =esour"es for +&ini"a& +ases7 to he&p you with this -uestion* $%*$ ,* &,S @1! (9 points)
(P)Protein defi"ien"y re&ated to (1)inade-uate protein intake as eviden"ed 'y (!)de"reased mus"&e mass and on&y 9>R of protein intake needs were met*

$9

;*

Inter2ention Step 1! &lannin* (i*e* Loint&y esta'&ish goa&s with the patient) State at least 0N, short- and &ong-term goa& that you wi&& esta'&ish "o&&a'orative&y with Mr* D* .e#e#$er that the goa&s shou&d 'e "&ear( measurea'&e( a"hieva'&e( and time-defined* (: points) Short-ter# *oal (i*e* 'etween now and the ne)t visit):
2n the ne)t two weeks( eat 'reakfast 9 times ea"h week* 2n"&ude a protein sour"e for ea"h 'reakfast su"h as eggs or 'reakfast sausage* Grite your 'reakfasts down in a food diary or food &og*

-on*-ter# *oal (i*e* over the ne)t severa& visits( or &onger):

;y the time 2 see you in si) months( your goa& is to have norma& a&'umin &eve&s and you shou&d 'e a'&e to eat different protein sour"es at ea"h of your 'reaksfasts* You shou&d eat 'reakfasts five days per week with a variety of eggs( meats( "heeses and peanut 'utter* .hese "an rep&a"e some of the "ar'ohydrates he was eating*

+*

Inter2ention Step 2! I#ple#entin* (i*e* "arrying out and "ommuni"ating your p&an of "are with the patient) State 8hat nutrition-related action3s4 you as the =D wi&& take to address the pro$le# identified in part ,3s P1! statement* 1e sure that the INT,.A,NTI0N 8ill speci%ically address the nutrition-related dia*nosis and;or its underlyin* etiolo*y des"ri'ed in your P1! statement* .his information wi&& 'e do"umented in the 42ntervention7 se"tion of your ,D2M1 "hart note* (8 points)
Nutrition 1du"ation* 2 wi&& edu"ate Mr* D* on different protein sour"es and the importan"e of protein in the diet in re&ation to mus"&e strength *

$:

D*

Measura$le 0utco#e! State 8hat nutrition care indicator you 8ill M0NIT0. in order to ,A)-/)T, the progress of the patient resu&ting from your 2N.1=61N.20N des"ri'ed in part +* Nutrition "are indi"ators are "&ear&y defined markers that "an 'e o'served and measured and are used to -uantify the "hanges that are the resu&t of nutrition "are* or e)amp&e( food and nutrient intake data( &a'oratory va&ues( et"* Ceep in mind that you may a&so identify "&ini"a&/&a'oratory parameters that you wi&& use to esta'&ish to&eran"e and/or effi"a"y of a feeding regimen( if that is the intervention you identified for your P1!* ;e sure that the nutrition "are indi"ator "an 'e used spe"ifi"a&&y to eva&uate the su""ess of your nutrition intervention* .his information wi&& 'e do"umented in the 4Monitoring/1va&uation7 se"tion of your ,D2M1 "hart note* (8 points)
1va&ution: 5ave Mr* D "ome in with a food diary to go over his rep&a"ement of "ar'ohydrates with new protein sour"es* Ge wi&& a&so measure his a&'umin &eve&s to see his progress*

$%*8 ,* &,S @2! (9 points)

2nade-uate f&uid intake re&ated to not drinking any water as eviden"ed 'y dry skin and high serum osmo&a&ity &eve&s*

;* Inter2ention Step 1! &lannin* (i*e* Loint&y esta'&ish goa&s with the patient) State at least 0N, short- and &ong-term goa& that you wi&& esta'&ish "o&&a'orative&y with Mr* D* .e#e#$er that the goa&s shou&d 'e "&ear( measurea'&e( a"hieva'&e( and time-defined* (: points) Short-ter# *oal (i*e* 'etween now and the ne)t visit):
;etween now and the ne)t visit 2 wi&& give him a water 'ott&e this visit and have him 'ring it to work with him every shift*

$<

-on*-ter# *oal (i*e* over the ne)t severa& visits( or &onger):

De"rease "offee intake to on&y 8: oE* per day( and to drink >: oE of water* 5e shou&d 'e doing this 'y his visit with me in > months*

+*

Inter2ention Step 2! I#ple#entin* (i*e* "arrying out and "ommuni"ating your p&an of "are with the patient) State 8hat nutrition-related action3s4 you as the =D wi&& take to address the pro$le# identified in part ,3s P1! statement* 1e sure that the INT,.A,NTI0N 8ill speci%ically address the nutrition-related dia*nosis and;or its underlyin* etiolo*y des"ri'ed in your P1! statement* .his information wi&& 'e do"umented in the 42ntervention7 se"tion of your ,D2M1 "hart note* (8 points)
Nutrition 1du"ation on the importan"e of water( and how "offee is taking the p&a"e of 'eneifi"ia& water* 5e a&so wi&& &earn the importan"e of water on a&& his medi"ation*

D*

Measura$le 0utco#e! State 8hat nutrition care indicator you 8ill M0NIT0. in order to ,A)-/)T, the progress of the patient resu&ting from your 2N.1=61N.20N des"ri'ed in part +* Nutrition "are indi"ators are "&ear&y defined markers that "an 'e o'served and measured and are used to -uantify the "hanges that are the resu&t of nutrition "are* or e)amp&e( food and nutrient intake data( &a'oratory va&ues( et"* Ceep in mind that you may a&so identify "&ini"a&/&a'oratory parameters that you wi&& use to esta'&ish to&eran"e and/or effi"a"y of a feeding regimen( if that is the intervention you identified for your P1!* ;e sure that the nutrition "are indi"ator "an 'e used spe"ifi"a&&y to eva&uate the su""ess of your nutrition intervention* .his information wi&& 'e do"umented in the 4Monitoring/1va&uation7 se"tion of your ,D2M1 "hart note* (8 points)
Mr* D wi&& a&so &og his f&uid intake on an average of three times per week* 2 wi&& monitor his progress 'y having sporadi" dietary re"a&&s and on his visit in two weeks and then in si) months*

$>