Emina Rovcanin

DIE 3213
Alireza Jahan-Mihan
September 7, 2014
Case Study 1

Case Study One

1. Convert her height and weight to centimeters and kilograms. Calculate her %
IBW, % UBW, and BMI. Interpret her weight and weight change based on these
parameters.
Height: 67 inches converts to 67x2.54=170.18 cm1
Weight: 140 pounds converts to 140/2.2=63.63 kg 1
Usual Body Weight (UBW): 160, six months ago
Ideal Body Weight (IBW): 100+5(7)=135 1
%IBW: (current weight/IBW)x100
(140/135)x100= 103.703% 1
%UBW: (current weight/usual weight)x100
(140/160)x100=87.5% 1
Body Mass Index (BMI): (weight lb/ (height inches^2)) x703
(140/(67^2))x703=21.93

Percent Weight Loss: (usual weight-current weight)/(usual weight)

(160-140)/(160)=.125
.125x100=12.5% 1
From the time of the patients husbands death 6 months ago she shows weight loss of
12.5 %. The general rule is if there is unintentional weight loss of 5-10% in less than 6
months there is a high chance it is due to malnutrition. Although her BMI is in the normal
standings for individuals 20 and older, long hospital stays normally increase the
unintentional weight loss for reasons such as, quality of food, food acceptance, emotional
and dietary health, and social factors of eating .2

2. Calculate her nutritional requirements (calories, protein, and fluid) and compare
her current intake to her needs.
According to Choosemyplate for a 76-year-old, 140 pounds, 67 inches female the
recommended caloric intake for the patient is 1600 calories, and 5 ounces of protein per
day3. Daily reference intakes (DRI) values for the patients stage of life recommend
46g/d of protein and 2.7 L/d of fluids.2
After entering in her usual diet into Choosemyplate Super Tracker it shows the
patient is only consuming around 938 calories per day. This is close to 700 calories below
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what she is recommended to intake per day.3 She is recommended to consume 5 ounces
of protein daily, but based on her food log she consumes about 4.5 ounces of protein per
day.2, 3
Also the patient did not log that she consumed any water throughout her day. Her
usual diet reveals the she consumes about .826 L/d of fluids out of the estimated 2.7 L/d
according to the DRI values.2 She drinks, coffee, decaffeinated and sweet tea, she should
consume more water due to her use of diuretics such as coffee and furosemide (Lasix). 2
3. Are any major food groups and nutrients obviously missing from her diet? (2
points) Explain your answer. (3 points)
Recommended vs. Actual Intake for the Patients Usual Diet by Food Group
Food Group
Choosemyplate
Consumed by patient (usual
recommended values
diet)
Grains
5 oz.
2.5 oz.
Vegetables
2 cups
1/2 cups
Fruit
1 cups
1 cup
Dairy
3 cups
0 cups
Protein
5 oz.
4 oz
Chart created by information provided choosemyplate.gov 3
The patient is close to meeting her fruit and protein estimated values due to the
Choosemyplate allowance, being short only a cup of fruit per day and .5 ounces of
protein. The major food groups she is deficient in are grains, vegetables and dairy. Since
the patient stated she avoids milk due to food preference she can satisfy this group with
other products such as cheeses, pudding or yogurt. She needs to be getting calcium in
another way, which may also satisfy the dairy group. She is also deficient in the grains
group by 2.5 ounces. She only consumes a cup of rice or potato, a slice of toast and 4
unsalted crackers a day in the grains group. The patient is also 1 cup short in the
vegetable group. The only vegetable she mentioned in her usual diet was a cup of
spinach or carrots.3

4. Do you think she could be experiencing any drugnutrient interactions? (2

points) If so, what dietary suggestions would you make? (3 points)
The patient is prescribed 20mg furosemide (Lasix) per day. This is a loop diuretic,
which can interfere with nutrient reabsorption by the kidneys. It is primarily known to

increase the excretion rate of potassium, which can cause hypokalemia. Hypokalemia is
when there is a lower than normal amount of potassium in the blood. The patients lab
results show her potassium levels are 3.2 mEg/L and the normal levels are 3.5-5.0
mEg/L.2 The dietary suggestions I would make due to her low levels of potassium are to
increase her intake of potassium rich foods such as bananas, apricots, or juice such as
grapefruit, prune or carrot juice.3 These items require minimal prep and cooking. Since
she is not eating between meals I would recommend she utilize this time to snack on a
potassium rich food once a day. Her blood potassium level is not low enough to consider
supplementation.2
Furosemide can also increase the excretion of magnesium, sodium, chloride, and
calcium in smaller amounts than potassium. These levels should be monitored especially
if she is prescribed this medication for a long period of time.2 A dietary suggestion I
would make for this patient is to eat more green vegetables such as spinach to increase
her magnesium and calcium levels. For her sodium and chloride levels I would
recommend using a small amount of sea or table salt in one of her meals per day. In
addition to green, leafy vegetables I would recommend a serving of yogurt or pudding
per day to stabilize the patients calcium levels.3 These levels may be highlighted because
the diuretic also causes dehydration.2 This means the client should increase her fluid
intake while taking this medication.
5.Interpret her serum albumin and prealbumin. (2 points) In addition to nutritional
intake, what factors can cause these indices to drop? (2 points) What factors would
cause them to be elevated? (1 point)
The patient has albumin levels of 3.2 g/dL compared to normal levels, which are
3.5-5.5 g/dL. Albumin levels are not a great indicator of nutrition status because they
have a long half-life of about 3 weeks. Albumin is preserved in the body during
marasmus. Marasmus is when something is preserved in the presence of starvation. But it
could signify a mild protein or energy depletion in her diet.2
Some factors that are not diet related that could cause albumin levels to drop are
burns, diarrhea, stress, inflammation, cancer, age, and eclampsia. Some reasons albumin
levels could be elevated are dehydration and being on medications such as corticosteroids
and anabolic hormones.2

The patients prealbumin levels are 11mg/dL while normal levels are 16-40
mg/dL. This means the patient has low prealbumin levels. Prealbumin is a better indicator
of nutrition because it has a short half-life of 2 days. The shorter half-life indicates more
sensitivity of protein- energy balance. This is because prealbumin levels are faster
responding to nutrition intervention.2
Some non-dietary indices that cause prealbumin levels to drop are stress or
trauma, which the patient has experienced with the loss of her husband 6 months ago and
her femur fracture. The femur fracture can also be an indicator of the lower than normal
prealbumin level because it could be a negative acute phase reactant. Factors that can
cause increase in prealbumin levels are dehydration, Hodgkins disease and renal failure.2
6.Describe how factors in her anthropometric, biochemical, clinical, and dietary
nutritional assessment data all fit together to form a picture of her nutritional
health. (5 points)
The patient had a 12.5% weight loss six months prior to her husband passing away,
this may have caused depression, stress or anxiety for her and in all started the spiral of
poor nutrition. As a couple they may have dined or shopped for groceries together and
now she lacks that companionship during those activities. Another possibility is her
husband did most of the cooking in their home and when he passed away she was left
with the knowledge of simple things that are easy to make or eat. Her usual diet
consists of really simple foods that require little or no prep and cook time. Not knowing
how to prepare food can lead to poor nutritional choices. We also know her albumin and
prealbumin levels are low which can be an accurate depiction of nutritional status.
Prealbumin having a very short half-life is a great indicator of nutritional status. Having
low prealbumin levels is a clinical assessment that is taken into consideration when
malnutrition is assumed. The patient is also taking Lasix which is a loop diuretic
prescribed for her hypertension, causing the patient to excrete many nutrients and liquids
in her body. She already does not intake the DRI recommended amount of liquid per day.
This leads to excretion of vital nutrients in her body that play a role in her overall
nutrition. The medication is causing her to be dehydrated and have poor skin turgor as
well as ill-fitting dentures. The poorly fitting dentures may cause the patient pain while
eating certain food items, which can also explain why she only consumes so little
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calories. All of these factors could indicate why the patients dietary journal showed that
she does not intake adequate amount of grains, vegetables, dairy or liquids.2
7.Write a PES statement based on the nutritional assessment data available. (5
points)
Unintentional weight loss related to not enough energy consumption evidenced by the
patients weight loss of 12.5 % in <6 months and inadequate caloric intake of -662
calories per day.1
8.What dietary and social changes would you suggest to improve her nutritional
intake? (5 points)
To satisfy the groups she is deficient in there are some dietary changes I would
recommend. Some calcium rich foods in the dairy group are oranges, almonds, kale, and
white legumes. Some foods are fortified with calcium such as oatmeal, cheerios, and
orange juice. She already consumes a cup a day of orange juice so she could increase
that to a larger serving or a cup twice a day. She could also start eating cheerios or
oatmeal for breakfast. Also start including kale, or white beans in a light salad or
hummus for lunch or for a snack between meals. I would ask the patient if it is simply
milk itself that she does not like and if she would consider other milk products such as
cheese, cottage cheese, sour cream, yogurt, or puddings that she could incorporate with
her diet.
Another food group she is deficient in is grains. Her usual diet consists of white
toast, unsalted crackers and cup of rice or potato. I would recommend including
oatmeal in her diet, which would help satisfy the calcium and grains group. Also she
could increase her serving of toast in the morning from one slice to two. It states that she
likes chicken noodle soup, she could consider adding more pasta or rice to the soup so it
can be considered a serving of grains. To help satisfy the grains and calcium group she
may consider snacking on unsalted pretzels or pita chips with a white bean hummus dip
or canned salmon (high in calcium).
This patient is also very low in the vegetable group consuming only 1/2 cup out of
the 2 cups recommended daily. Her usual diet states she eats cup of spinach or carrots
for breakfast. The simplest advice would be to increase the serving size of what she
already eats and enjoys. Also I would recommend she drinks a V8 a day. This provides
you with a full serving of vegetables in an easy to consume beverage. She could start
5

making salads with leafy green vegetables, add kale, white beans, and canned salmon
which would help satisfy the calcium, grains and vegetable groups.3
To fulfill her dietary reference intake for liquid the patient should also start
sipping on more water throughout the day. Since she likes tea she could consume a
decaffeinated unsweetened tea as well to meet her DRI of 2.7 L/d of liquids. Caffeinated
tea and coffee are diuretics and would increase the water released from her body, adding
to her dehydration.2
Some social changes that I would recommend for the patient are that she sees a
dentist for the poorly fitting dentures because this may affect the food she is able to eat
and enjoy. She may also want to start seeing old friends and dining with them. She may
not eat as much because she is used to eating with her husband and she does not like to
eat alone. Also she may want to consider home care or moving to a nursing home facility.
This would ensure she gets the amount of food that is required due to her stage in life by
the DRI and Choosemyplate and she would be around people that may have also lost
their partner and enjoy each others company. Choosemyplate also stated that at this stage
of life, with the anthropometric measures as they are for this patient she should get about
150 minutes of exercise per week. After her femur fracture heals properly she could walk
around a nearby park with a friend, or do some of the activities that are provided at the
nursing community.3
The medication the patient is prescribed is a loop diuretic as previously mentioned
and induces the excretion of potassium from the patients body2. If there is not another
medication she can get prescribed by her doctor to help treat her hypertension then we
will have to increase the amount of potassium rich foods in her diet. I would recommend
adding foods such as dark leafy greens, bananas, and dried apricots. To satisfy the
potassium deficiency as well as calcium she could start to include salmon, or yogurt into
her regular diet.3
9.What are your nutritional goals for her (2 points), and how would you monitor the
effectiveness of your interventions from question #8? (3 points)
The nutritional goals for this patient would include halting of the weight loss and an
increase of 200 calories every two weeks in her diet until she is comfortable eating 1600
calories per day as recommended for this patient. To monitor this intervention we would

have the patient come back every two weeks for weight check ins. If she increases her
caloric intake she will slowly start to increase in weight. When she gets close to her ideal
body weight of 135 pounds we will assess her caloric intake so she does not gain excess
weight. Another way to monitor this intervention is ask the patient to keep a log of her
new and improved diet and come back each week so a registered dietician can assess her
food journal to see if she is on track with her energy requirements for each food group.
Another nutritional goal is to ensure her the regular use of furosemide (Lasix) is not
creating potassium or calcium deficiency such as hypokalemia in the patient. After
educating her on foods that are rich in these nutrients I would give her a few weeks to
implement them in her regular diet. After about one month I would do monthly blood
work to insure levels of potassium and calcium in her blood are improving. This would
depict if she were following the nutritional advice she was given about adding these
nutrient dense foods in her diet.
10.Write a note documenting your assessment in SOAP or ADIME format. (5
points)
(S)Subjective: Patient was admitted to the hospital after tripping over her cat and
developing a femur fracture. Has a history of hypertension. Does not smoke or drink
alcohol. Husband died six months prior and has experienced some weight loss. She rarely
eats between meals and avoids milk and egg products because of food preference.
(O)Objective: Patient is 76-year-old female, 67tall, BMI 21.93, UBW 160lbs,
weight 120. 12.5% weight loss. BP 128/65 mmHg. Oral mucosa dry, skin turgor
decreased, upper and lower dentures fit poorly. Albumin levels at 3.2 g/dL (normal levels
at 3.5-5.5g/L), prealbumin levels at 11 mg/dL (normal levels at 16-40 mg/L). Adequate
energy intake estimated at 1600 calories, patient only consumes 938 based on usual food
log. Consumes .826 L/d while DRI recommends 2.7 L/d. Prescribed 20 mg Furosemide
per day, takes no dietary supplements.
(A)Assessment: Unintentional weight loss related to not enough energy
consumption evidenced by the patients weight loss of 12.5 % in <6 months and
inadequate caloric intake of -662 calories per day. Adequate protein intake is 46g/d. May
be due to stress and depression caused by loss of husband. Her regular use of
Furosemide causes excretion of fluids and nutrients, mainly potassium and calcium.

Usual diet does not mention dairy so calcium needs to be introduced in the diet. Diet
analysis shows high in empty calories. Low in potassium, calcium, dietary fiber and
vitamins A, B6 and D.
(P) Plan: Educate the patient on the adverse effects of her medication. She may
not understand that it is a diuretic and that she is dehydrated because of it. She should
increase her fluid consumption to about 2.7 L/d, which may benefit her skin turgor and
oral mucosa. Also provide her with information about the recommended diet of 1600
calories per day and the food groups she is lacking in such as dairy. Give her non-milk
options to help achieve her calcium and vitamin D in the diet. Her goals would be
increasing her diet by 200 calories each week and stopping her weight loss pattern. Every
two weeks she will have a weight check in and a meeting with a registered dietician to
make sure her food intake for that week is meeting her deficient food groups. Make sure
to give the patient a number for a dentist to consult her dentures, nursing home facility
brochures, and information about widow support groups. Also if necessary, flyers for at
home food delivery services. 1,2,3

Reference List
Emery EZ. Clinical Case Studies for the Nutrition Care Process. Jones & Bartlett
Publishers; 2011.
Escott-Stump, S., Mahan, K. L., &Raymond , J.L. (2012) Krause's Food & the Nutrition
Care Process.13th edition. St. Louis, MO: Elsevier.
Supertracker. In United States Department of Agriculture. Choosemyplate.gov.
Available at www.supertracker.usda.gov. Accessed on September 7, 2014.
Nelms, M.N., & Roth, S. L. (2014) Case 21: Anemia in Pregnancy. Medical Nutrition
Therapy: A Case Study Approach (4th edition). Belmont, CA: Cengage Learning.
Gropper, S. S., & Smith J., L (2013) Advanced Nutrition and Human Metabolism (6th
edition). Belmont, CA Cengage Learning.