Nutritional Risk Factors Age

Poor appetite x 5 days 70

Past Medical History
DM, HLD, CVA, Neurogenic bladder
Admitting Diagnosis
Onset CHF
Current Diet Order
2 gm Na, 1800 kcal carb consistent

Ht Wt UBW IBW %IBW BMI

61 118lb N/A 105lbs (94.5- 112% 22.3
115.5) (overweight) (Normal)
Medications
Insulin: Levemir, Humalog, Lasix, Calcium w/ Vitamin D, Folic Acid, Mirtazapine, Bethanechol
Chloride, doxazosin Mesylate, Lisinopril, Coreg, Heparin subq

Labs Na-148 Cl-114 BUN-43, K-4.5, creatine-1.60 glucose, 117 HCO3-26

Current Food Intake

___X___ Poor (0-50%) ______Fair (50-75%) ________Good (75-100%)

Nutrition Kcal 1608-1876 Kcals ( 30-35 ) kcal/kg *53.6kg

Requirements Protein 64.32-80.4 gm/pro ( 1.2-1.5 ) gm/kg
Fluid 1608 ml ( 30 ) ml/kg
Nutrition Assessment
70 yo F came in with c/o dry cough, wheezing, SOB, B/L LE swelling x 5 days that has been getting
worse. Pt had an incident of hypoglycemia in the AM, PTA with FS in 30s that resolved after PO intake.
Chest xray shows pulmonary congestion. Pt appears to be generally in poor health, mild JVD in neck,
2+ pitting edema up to the shins. Pt states she has had poor appetite x 5 days 2/2 SOB. Pt eats most
meals at home, however much of it is pre-prepared food from supermarket, cans, and sometimes
frozen. Pt, A1C is 6.8%, H, due to her glucose level and she is DM. BP stable, pt will repeat BNP test
tomorrow. According to pt lab value her BUN is 43H on day 3 and creatinine is 1.60H on day 3, this is
due to her AKI. Pt glucose level is 117H- she is diabetic, sodium, 148H, - cause is AKI, Albumin level
low-2+ pitting edema, PROBNP H- because of CHF.
_________________________________________________________________________________
Nutrition Diagnosis (PES)
1) Undesirable food choices related to lack of knowledge to nutrition related information as
evidenced by patient states eating pre-prepared, cans and frozen foods.
2) Excessive mineral intake of sodium related to much of pts meals are pre-prepared, cans and
frozen foods as evidenced by diet history.
_____________________________________________________________________________
Nutrition Recommendations (Intervention)
Nutrition education-Recommended modifications- low Na diet
Provided pt with verbal/printed education material. Pt understood the material and will follow
through.
Strategies- Goal setting
Pt will prepare healthier meal alternatives at home. Will avoid pre-prepared meals/frozen and
cans that are high in Na. Family or AID will be of assistance to help with the cooking at home.

Monitoring
Biochemical data-
BUN and Creatinine
Sodium, chloride, phosphorus, Glucose, casual
Protein profile-Albumin
Food and Beverage Intake- types of food/meals
Adherence to low sodium diet recommendations.
Behavior-self-management as agreed upon- pt understanding of the printed and educational
materials, and address questions/concerns.
Nutrition focused physical findings- skin, 2+ pitting edema up to the shins.

Goals
Sodium intake will be low within 5 days.
Patient will cook most meals at home within 1 week
Food and beverage will be bought with low sodium ingredients within 1 week
Pt will understand the printed materials and use them as reference in selection of low Na foods
within 2 days.
Lab values: sodium, phosphorus, glucose and albumin will be normal levels within 3 days.
Bun and creatinine will be normal lab values within 7 days.
_______________________________________________________________________________
_________________________________________________________________________________

11/14/2016

Zinaida Isakova
FNES 366
QUESTIONS

1. The pt was diagnosed with new onset CHF. One of her symptoms includes B/L LE
edema. Explain the pathophysiology of leg edema in CHF. What is meant by 2+ pitting
edema?
Answer: In CHF, fluid starts to build up in parts of the body, this will cause edema in ankles,
legs and feet. The fluid buildup is due to the reduced blood flow out of the heart causing blood
returning to the heart through the veins to back up. (heartfailurematters.org)

2+ pitting edema is - swelling of body tissues due to fluid buildup that may be shown by
applying pressure to the swollen area. If the pressing causes an indentation that persists for some
time after the release of the pressure, the edema is referred to as pitting edema. Grade 2+ edema
pits from 2 to 4 millimeters and disappears in 10 to 15 seconds. There are four types of grades 1+
to 4+ (reference.com)
2. What is the role of sodium restriction in the treatment of heart failure? What are the
recommendations?
Answer: Eating too much salt causes the body to keep or retain too much water, worsening
the fluid buildup that happens with heart failure. Following a low-salt diet helps keep high
blood pressure and swelling (edema) under control. It can also make breathing easier if you
have heart failure. The recommendations are: You should have no more than 2,000
milligrams of sodium each day if youve got heart failure. Less than 1,500 mg a day is ideal.
(webmd.com)

3. Should the pt be placed on a fluid restriction? If so, why? What foods are typically
counted as fluid?
Answer: Yes the patient should definitely be placed on fluid restrictions because she has
2+ pitting edema up to the shins and it is B/L swelling x 5 days that has been
progressively worsening and she also has AKI. The foods that are typically counted as
fluid- are foods that are liquid at room temperature. They are Jell-o, popsicles, ice cream,
ice chips, sherbet, gelatin, coffee/tea, apple/orange juice. (davita.com)

4. The pt has AKI noted likely 2/2 Lasix. What type of medication is Lasix? How may it
cause AKI? Are there any FDI with Lasix?
Answer: Lasix- diuretic (water pill) that prevents your body from absorbing too much
salt. This allows the salt to instead be passed in the urine. Lasix can lead to pre-
renal acute renal failure because of impaired renal blood flow as a result of true
intravascular depletion and decreased effective circulating volume to the kidneys. Food
and Drug interaction of Lasix is alcohol, sleeping pill, narcotic pain medicine, muscle
relaxer, or medicine for anxiety, depression, heart or blood pressure medicine.
(drugs.com)

5. Pt has an elevated PROBNP. What is the significance of this lab value?

Answer: PROBNP- is primarily used to help detect, diagnose, and evaluate the severity
of heart failure. (labtestsonline.org, 2015)

6. Discuss any other abnormal lab values and possible etiology of abnormal values. Be sure
to discuss trends (up or down) where applicable.
Answer: Pt has high Bun, 43 and creatinine 1.60 on day three: the reason for this because
of AKI. Chloride is high 114, this is due to dehydration since her fluid volume is out. She
is left with less water in her blood vessels. The test is ordered, since pt has difficulty
breathing (respiratory distress), heart failure, and kidney disease. (labtestsonline.org)
Glucose is high, 117, on day 3, because pt is metabolically stress and thus glucose goes
up because body is looking to build and thus providing energy for survival. Also she has
a history of DM and is taking insulin for it.
 Phosphorous high on day 3, 5.1- a high level indicates there is a kidney problem, since
the kidney filters the phosphorous out and into the urine. (webMD.com)
Day 3, sodium high 148, kidney dysfunction, dehydration, and diuretics.
(merckmanuels.com)
Day 2, AST high, 83 because heart failure and kidney damage. (webMd.com)
Day 2, ALK phosphatase is high, 164, higher than normal is because of heart failure.
Usually the test is done to indicate there is a problem with liver or the gallbladder. Only
in rare cases it indicates heart failure. (healthline.com).
Day 2, albumin is low 2.6. Reason is edema, pt has high fluid volume and thus albumin
leaves and water follows. Albumin is like a sponge takes water with it.
Day 2, total protein is 5.9 L, - pt is stressed albumin is out of her blood vessels and thus
protein will be low, since total protein measures the total amount of albumin in your
body. Also an indication of kidney disorder. (labtestonline.org)
Day 1, PROBNP, 35941 H, the reason this is high is because she has edema in her legs
and has trouble breathing and thus use this test to check for heart failure, which the pt
has. (clevelandclinic.org)
Day 2, HgA1C, 6.8% H, her glucose is high and she is on insulin, Levemir and Humalog.
Pt states that she is not always compliant with her diabetic diet.
Day 3, calcium level is low, 7.9, the reason for this may be is kidney dysfunction, which
results in more calcium being excreted in her urine. (merckmanuels.com)

7. The pts calcium is low. Calculate the corrected calcium lab value. Is she really
hypocalcemic?
Answer: The formula is: corrected calcium=serum calcium+0.8(4-serum albumin)
7.9+0.8(4-2.6) =9.0mg/dL . No she is not hypocalcemic, since the lab values that
indicate within a normal range is 8.5-10.1MG/DL.

8. Calculate the following and include classifications for each: IBW, %IBW, %UBW, %
weight change, BMI.
Answer:
IBW %IBW BMI
105lbs (94.5-115.5) 112% 22.3
(overweight) (Normal)
IBW female is first 5 feet is 100 lbs + an additional 5 pounds for every inch, the pt is 61, 100+5=105lbs
%IBW =actual BW/IBW x100. The pt is 118lb/105lbs x100=112% classification is overweight.
%UBW=N/A
BMI=118 X 703/61X61=22.3, classification is normal
% weight change =N/A
(Mahan and Raymond, 2012)
 9. Calculate the pts energy and protein needs. Explain your rationale.
Answer:
Kcal 1608-1876 ( 30-35 ) kcal/kg * based on 53.6 kg
Protein 64.32-80.4 ( 1.2-1.5 ) gm/kg
Kcal 30X53.6kg=1608
35X 53.6kg=1876
The pt has had poor appetite for 5 days, she is on a 1800 kcal carb consistent and restriction of 2 gm Na.
she has AKI and CHF. She is mild stress and she is limited in her amount of calorie intake.

Protein: 1.2X53.6kg=64.32gm/pro
1.5X53.6kg=80.4gm/pro
She gets this amount of protein due to metabolic stress- mild and since she has had poor appetite
for the past 5 days, we need to make sure she does not break down her proteins, since not getting
much carbohydrate right now.
(Mahan LK and Raymond, 2012)

10. From the INDT terminology, complete 2 PES statements

Answer: For each PES statement, establish an intervention and an ideal goal. Use INDT
terminology.
Answer:
1. Undesirable food choices related to lack of knowledge to nutrition related information as
evidenced by patient states eating pre-prepared, cans and frozen foods.

2) Excessive mineral intake of sodium related to much of pts meals are pre-prepared, cans
and frozen foods as evidenced by diet history.

Intervention:

Nutrition education-Recommended modifications- low Na diet

Provided pt with verbal/printed education material. Pt understood the material and will follow
through.
Strategies- Goal setting
Pt, will prepare healthier meal alternatives at home. Will avoid pre-prepared meals/frozen and
cans that are high in Na. Family/AID will be of assistance to help with the cooking at home.
Goal:
Sodium intake will be low within 5 days.
Patient will cook most meals at home within 1 week
Food and beverage will be bought with low sodium ingredients within 1 week
Pt will understand the printed materials and use them as reference in selection of low Na foods
within 2 days.
Lab values will become normal: sodium, phosphorus, glucose and albumin will be at normal
levels within 3 days.
Bun and creatinine will be normal lab values within 7 days.
12) From the INDT terminology, what would you monitor and evaluate?
Answer:
Biochemical data-
BUN and Creatinine
Sodium, chloride, phosphorus, Glucose, casual
Protein profile-Albumin
Food and Beverage Intake- types of food/meals
Adherence to low sodium diet recommendations.
Behavior-self-management as agreed upon- pt understanding of the printed and educational
materials, and address questions/concerns.
Nutrition focused physical findings- skin, 2+ pitting edema up to the shins

13. Complete the assessment form provided.

References

1) ALP [Fact sheet]. (n.d.). Retrieved November 14, 2016, from healthline website:
http://www.healthline.com/health/alp#Uses2
2) AST [Fact sheet]. (n.d.). Retrieved November 14, 2016, from WebMD website:
http://www.webmd.com/digestive-disorders/aspartate-aminotransferase-ast#1
3) BNP [Fact sheet]. (n.d.). Retrieved November 14, 2016, from lab tests online website:
https://labtestsonline.org/understanding/analytes/bnp/tab/test/
4) chloride [Fact sheet]. (n.d.). Retrieved November 14, 2016, from lab tests online website:
https://labtestsonline.org/understanding/analytes/chloride/tab/test/
5) Food that Counts as Fluid on the Kidney Diet [Fact sheet]. (n.d.). Retrieved November 14,
2016, from Davita website: https://www.davita.com/kidney-disease/diet-and-
nutrition/diet-basics/food-that-counts-as-fluid-on-the-kidney-diet/e/6965
6) Hypocalcemia [Fact sheet]. (n.d.). Retrieved November 14, 2016, from Merck manual
website: https://www.merckmanuals.com/home/hormonal-and-metabolic-
disorders/electrolyte-balance/ hypocalcemia-low-level-of-calcium-in-the-blood
7) INCREASED SWELLING OF THE LEGS OR ANKLES [Fact sheet]. (n.d.). Retrieved
November 14, 2016, from heartfailurematters.org website:
http://www.heartfailurematters.org/en_GB/Warning-signs/Increased-swelling-of-the-legs-
or-ankles
8) Heart Failure and a Low-Salt Diet [Fact sheet]. (n.d.). Retrieved November 14, 2016,
from webMD website: http://www.webmd.com/heart-disease/heart-failure/low-
sodiumeating#1
9) lasix [Fact sheet]. (n.d.). Retrieved November 14, 2016, from drugs.com website:
https://www.drugs.com/lasix.html
10) Mahan, K. L., Escott-Stump, S., Raymond, J. L., & Krause, M. (2012). St. Louis, Mo.:
Elsevier Saunders, c2012: Krause's Food and the Nutrition Care Process (13th ed).
11) What is the pitting edema scale? [Fact sheet]. (n.d.). Retrieved November 14, 2016, from
Reference website: https://www.reference.com/health/pitting-edema-scale-
91ab66ffae5e8be6?qo=cdpArticles#