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Your Name and/or Name of Partner (if working with one):Sydney BoehnleinKaela PittmanUniversity of Minnesota - Department of Food Science & NutritionFScN 4665 - Medical Nutrition Therapy IFall 2014Case 1100 PointsDue Date: THURSDAY, OCTOBER 9th Please be sure to do the following:Show all calculations, and explain your rationale. Calculations do not have to be typed.Answer all questions directly on this form. Type all answers (except calculations). Submit in hard copy in class on the due date. You will be deducted one point per day after the due date until the hard copy is turned in.You may work ALONE or with ONE other person. Do not share your work with other individuals beyond your group. If you work with a partner, you should hand in only ONE case with your name and your partner’s name clearly listed at the top of the first page. Some resources needed for solving the Case:Lecture notes on Nutrition Assessment I-History and Physical ExaminationLecture notes on Nutrition Assessment II- AnthropometryLecture notes on Nutrition Assessment III-Biochemical/LaboratoryLecture notes on Assessment of Acid-Base BalanceModule I: Nutrition Care Process, Nutrition Diagnosis and Medical Record DocumentationModule II: Energy, Protein, and Fluid Requirements in the Clinical SettingModule III: An Introduction to the Exchange Lists for Meal PlanningModule IX: Pulmonary DisordersAcademy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines (Chronic Obstructive Pulmonary Disease). Link to the EAL website is posted in MoodleIDNT Reference Manual nutrition diagnoses pagesKrause’s Food and the Nutrition Care Process, 13th edition. Chapter 35: Medical Nutrition Therapy for Pulmonary Disease.Appendix 34 (1110-1121)From the admitting physician’s note:Chief complaint: “I am always short of breath, especially when I am doing any kind of physical activity and my husband thinks I am confused in the morning.”Patient Hx: Stella Bernhardt is a 62-year-old Caucasian retired office manager who is married and has 4 grown children. Mrs. Bernhardt was initially diagnosed with type I COPD (emphysema) five years ago. She has a 46-year history of smoking, but quit 1 year ago. She states: “I’m hardly able to do anything for myself right now. Even taking a bath or getting dressed makes me short of breath. I feel that I am gasping for air. I am coughing up a lot of stuff that is dark brownish-green.” Mrs. Bernhardt is wondering if her symptoms are related to her COPD. Type of treatment: PMH: COPD type I (emphysema), bronchitis and upper respiratory tract infections (mostly during winter months), four live births, and two miscarriages Meds:Combivent inhaler Allergies: NoneSmoker: 1 ppdFamily Hx: Father deceased at age 52 from pneumonia, mother still livingPhysical Examination: General appearance: Very thin, middle aged woman, evident temporal and interosseous wasting, in no acute distress Vitals: Temp 99.1° F, BP 135/70, HR 77 BPM, RR 21Skin: Warm, skin pallorNail bed: mild koilonychiasEyes: pale conjunctivaHeight: 5’3”Weight: 92 lbsMid arm muscle circumference (MAMC): < 5th percentile, Exhibits generalized loss of muscle in shoulders and thighs. Subcutaneous fat loss is evident in triceps. Clinical Examination: The nervous system is intact. Chest/lung examination reveals decreased breath sounds, percussion hyperresonant, prolonged expiration with wheezing, rhonchi throughout. Pt has poorly fitting dentures.From the initial nutrition screen documented by dietetic technician:Nutrition Hx:General: Mrs. Bernhardt states that her appetite is poor. She says “I fill up so quickly – after just a few bites.” She also relates that meal preparation is difficult: “By the time I fix a meal, I am too tired to eat. And things just don’t seem to taste as good either.” In the previous two days, she states that she has eaten very little. Increased coughing has made it very hard to eat. Her “normal” adult weight was 145-150 lbs (~3 years ago). She estimates that she weighed ~120 lbs about 6 months ago. She states that her family constantly tells her how thin she has gotten. She states that she hasn’t weighed herself for a while, but that she knows her clothes feel baggy.Typical dietary intake:Breakfast: 1 poached egg, 1 tsp butter, 1 slice whole wheat toast, 16 oz. coffee, 1 T. half and half, ? cup orange juice Lunch: 3 chicken nuggets (fast food), ? cup mashed potatoes, 1 T. reduced fat margarine, 1 biscuit (plain), 16 oz. coffee, 1 T. half and halfDinner:1 cup cream of mushroom soup made with water, 1 slice whole wheat toast, ? large (8 oz.) banana, 36 oz. Diet PepsiHS Snack:3 saltine crackers, 1 oz. American cheeseFood allergies/intolerances/aversions: NonePrevious MNT? Mrs. Bernhardt has never met with a Registered Dietitian in the past, but her primary physician has told her she needs to increase calorie consumption.Food purchase/preparation: Mrs. Bernhardt purchases and prepares her own food or she eats at restaurants/fast food outlets. She avoids milk because she has heard it can increase mucous production.Vit/Min or other supplements: NoneActivity: NoneTreatment Plan:O2 1 L/min via nasal cannula with humidity – keep oxygen saturation (SaO2) 90 – 91%IVF: D5 ? NS with 20 mEq KCl @75 ml/hrLabs/Tests: ABGs q 6 hours, CXR – EPA/LAT, sputum cultures and gram stainDiet order: RegularMeds: Solumedrol 10 mg/kgq 6 hrAncef 500 mg q 6 hrIpratropium bromide via nebulizer 2.5 mg q 30 minutes X 3 treatments then q 2 hrAlbuterol sulfate via nebulizer 4 mg q 30 minutes X 3 doses then 2.5 mg q 4 hrHospital course:Mrs. Bernhardt was diagnosed with acute exacerbation of COPD secondary to bacterial pneumonia. This was confirmed by CXR (chest X-ray) and sputum culture. She responded well to aggressive medical treatment for her emphysema. She will be discharged on home oxygen therapy for the first time, and referred to outpatient pulmonary rehabilitation. Her discharge medications will be the same (Combivent), but she will complete an oral course of corticosteroids and an additional 10-day course of Keflex. A nutrition consultation is ordered, with recommendations for nutrition follow-up through the outpatient pulmonary rehabilitation program.Laboratory data:Lab TestDay 1Day 2Day 3Normal RangeUnitsGlucose921038870 - 110mg/dLNa+139137140136 - 145mEq/LCl-1011009995 - 107mEq/LK+3.73.63.63.5 - 5.0mEq/LBUN9888 - 25mg/dLCr0.90.90.80.6 - 1.5mg/dLPhosphorus2.32.53.02.6 - 4.5mEq/LMg++1.51.71.5 - 2.2mEq/LCalcium8.28.08.13.0 – 7.0mg/dLAlbumin8.08.5 – 10.5mg/dLPrealbumin44.56 – 8.5g/dLAlkaline Phosphatase220219217200 - 400mg/dLLab TestDay 1Day 2Day 3Normal RangeUnitsWhite Blood Cells (WBC)11525 - 160U/LHemoglobin (Hgb)10.512.5 – 17.0g/dLHematocrit (Hct)3336.0 – 50.0%%Mean corpuscular volume (MCV)6580.0 – 98.0fLArterial Blood Gases:pH7.297.35 – 7.45PCO250.935 - 45mmHgPO27780 - 100mmHgHCO324.722 - 26mEq/LLaboratory information prior to admission:Annual CBC and lipid profile- WNLNUTRITION ASSESSMENTDietary Intake DataFrom Mrs. Bernhardt’s typical dietary intake, calculate the total number of calories she consumed. Also calculate the energy distribution of calories for protein, carbohydrate, and fat. For this question, you must use the Exchange Lists for Meal Planning (Use Appendix 34 in the back of the Krause text: See pp. 1110-1121 (13th ed.) and Module III, “An Introduction to the Exchange Lists for Meal Planning”), and complete each of the steps outlined below, showing your calculations.Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate that is designated as such under “Other Carbohydrate” or “Combination” lists as simply “Carbohydrate” rather than “Starch”, and then count these separately under “Other Carbohydrates” in the table for Step 2. Complete the table below. (10 points)BreakfastCounts As (Specify Exchanges)1 slice whole wheat toast1 starch1 tsp butter1 fat1 poached egg1 medium fat meat16 oz. coffeeFree food1 Tbsp half and half? saturated fat? cup orange juice1 fruitLunch3 chicken nuggets (fast food)? carbohydrate, 1 medium fat meat, ? fat? cup mashed potatoes1 starch1 Tbsp reduced fat margarine1 fat1 biscuit (plain)1 starch16 oz. coffeeFree food1 Tbsp non-dairy creamerFree foodDinner1 cup cream of mushroom soup made with water1 carbohydrate & 1 fat1 slice whole wheat toast1 starch1/2 large (8 oz) banana1 fruit36 oz. Diet PepsiFree foodEvening (HS) Snack3 saltine crackers? starch1 oz. American cheese1 high fat meatStep 2: Add the totals from the table in step 1. Count all items that were listed anywhere besides the “STARCH” list, that counted as carbohydrate exchanges, under the “Other carbohydrate” section in the table below. Count as starches ONLY those foods listed specifically on the STARCH list. (10 points)Exchange GroupTotalservings/dayCHO(g)Protein(g)Fat(g)Starch4.51567.5313.5Use 0Non-Starchy Vegetables0520Fruit2153000Other Carbohydrates1.51522.500Fat-Free Milk01280Low-Fat Milk (1/2 - 1%)01280Reduced-Fat Milk (2%)01285Whole Milk01288Lean Meats/Substitutes007 3Medium Fat Meats/Substitutes20714510High Fat Meats/Substitutes107788Fats4 00520TOTAL grams12034.538Determine kcals by multiplying TOTAL gramsX 4 =X 4 =X 9 =TOTAL KCALS480138342GRAND TOTAL KCALS (CHO + protein + fat)960Step 3: Determine the % kcals provided by CHO. (2 points)480 kcals CHO/960 kcals = 0.5 *100 = 50% kcals provided by CHOStep 4: Determine the % kcals provided by protein. (2 points)138 kcals Pro/960 kcals= .14*100 = 14% kcals provided by proteinStep 5: Determine the % kcals provided by fat. (2 points)342/960 = .36 *100 = 36% kcals provided by fatAnthropometric DataA. Calculate Mrs. Bernhardt’s “ideal” weight using the Hamwi equation. (2 points)IBW = 100 + (5*3) = 115 pounds Calculate the % “ideal” weight and % usual body weight she is at her current weight. (4 points)% IBW = (92 lbs/115 lbs) *100= 80%%UBW = (92 lbs/145 lbs) * 100 = 63%Note: 145lbs was determined as pts’ usual body weight because the evaluation of changes of body weight over time is the most useful (See Nutrition Assessment II: Anthropometry, slide 9)Calculate Mrs. Bernhardt’s BMI. Into which category does she fall, based upon the National Institutes of Health, National Heart, Lung, and Blood Institute’s Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, which was provided in the “Nutrition Assessment II: Anthropometry” notes? (2 points)5.25ft/3.28 ft per meter = 1.6 m92 lbs /2.2 lbs per kg = 41.8 kgBMI = 41.8/1.6^2 = 16BMI Classification: UnderweightEvaluate Mrs. Bernhardt’s current weight in terms of change from usual body weight over time (be specific). If she has lost weight, is it clinically significant? Explain. (4 points)In 3 years: [(145 lbs – 92 lbs) /145 lbs]*100=36.6% weight loss. In 6 months: [120 – 92)/120] *100 = 23% weight loss.According to Nutrition Assessment II: Anthropometrics, Slide 9, pts’ weight loss is considered clinically severe weight loss because she has lost over 10% of her usual body weight in the last 6 months. Evaluate Mrs. Bernhardt’s dietary intake, anthropometric, PE/clinical, and biochemical data pertinent to her pulmonary status. When appropriate, compare her data to standard/normal values. Be as thorough and SPECIFIC as possible, and then clearly identify at least ONE piece of data that is of concern from a nutritional standpoint within each data category as you begin to prioritize the most prominent nutrition issues that need to be addressed. EXPLAIN your rationale for each issue that you mention. Dietary intake data (Refer back to what you found in question #1 and evaluate Mrs. Bernhardt’s intake in terms of major nutrients or food groups that appear to be lacking, and any obvious problems you think she is having with intake) (2 points):Mrs. Bernhardt is lacking in her vegetable (3-4 serving less than the suggested number of vegetables serving per day), fruit (1 serving less than the suggested number of fruit serving per day) and dairy (2 servings less than the suggested number of dairy servings per day) intake, according to the Academy of Nutrition Dietetics MyPlate’s suggestions. At the same time, the patient has excessive fat intake. Based on her dietary intake data, one primary concern from a nutritional standpoint is the thought that she is not getting enough of the vitamins and minerals that come from produce as she should. There is no claim that she has been taking a multivitamin either. Anthropometric data (refer back to your answers in question #2) (2 points):Mrs. Bernhardt is 23 pounds underweight, her BMI is 16 (which classifies her as underweight), she is only 80% of her ideal body weight and 63% of her usual body weight. In the last 3 years she has lost 36.6% of her body weight and in the last 6 months she has lost 23 % of her body weight. Both weight loss percentages are considered severe weight loss when evaluated over time. Her mid arm muscle circumference percentile is under the 5th percentile, determining that patient is in muscle and fat deficit. Based on anthropometric data, one primary nutrition concern from a nutritional standpoint is her severe weight loss based on her current weight. PE/clinical findings (2 points):From Mrs. Benhardt’s physical examination the following the following conclusions can be made: based on general appearance , including her evident temporal and interosseous wasting, her thin body type, extremely low mid arm muscle circumference, noticeable general loss muscle in shoulders and thighs as well as subcutaneous fat loss in triceps all lead to the conclusion that the patient suffering from subcutaneous fat and muscle loss. Her body temperature is slightly higher than the normal value (normal being 98.6 degrees F). Her nail bed appetence (kolilonychia) and eye discharge (pale conjunctivia) both lead to the conclusion that patient is iron deficient. Based on clinical examination from a nutritional standpoint, one main concern would be the patient’s ill-fitting dentures because this may hinder her ability to eat and therefore consume the nutrients she needs. Biochemical data (2 points):Based on the patient’s laboratory data, while all other tests were measured in the normal range, Mrs. Bernhardt’s prealbumin and albumin levels were low days 1-3 which both indicate metabolic stress, inflammation, inadequate protein intake and the possibility of liver disease. Her phosphorous levels were low day 1 and 2 and her blood calcium was elevated day 1-3. One hypothesis for the patient’s high calcium would be that it is a result of her low prealbumin which is responsible for the transport of major blood constituents, including minerals like calcium. This low prealbumin could also be responsible for her elevated body temperature because this protein is no longer transporting enough thyroxine (which regulated body temperature).Because Phosphorous, Magnesium and Potassium were all measured to be low or at the low end of their normal range, it is important for these minerals to be watched and maintained to avoid the refeeding syndrome since the patient is currently receiving nutrition support.The patient exhibits elevated calcium levels, hypercalcemia, which would account for some of her muscle weakened and her anorexia.Mrs. Bernhardt also exhibited a low Hemoglobin, Hematocrit and Mean Corpuscular Volume indicating she has iron deficiency anemia. The patients low pH and pO2 and high pCO2, as well as her normal HCO3 lead to the conclusion that the patient has respiratory acidosis and high lung CO2 retention.Calculate Mrs. Bernhardt’s serum osmolality from her admission labs, as one indicator of her hydration status upon admission. What does this value you calculated suggest about her hydration status at admission? Mention any relevant clinical/PE data to support your evaluation. (6 points)Serum Osmolality, using the Day 1 admission measurements = (139 mEq/L*2) +(9 mg/dL/2.8)+(92mg/dL/18)= 286.3 mOsm/kg. The measurement indicated that she is euhydrated and within a normal hydration status. Physical examination and clinical data that support this evaluation include her within normal range blood pressure and heart rate and warm skin pallor. Review all four of Mrs. Bernhardt’s current medications, and describe any relevant food-medication interactions. If there are no relevant food-medication interactions for a particular medication, be sure to state that. (4 points)- Solumedrol: this anti-inflammatory/corticosteroid may cause hyperglycemia, negative nitrogen balance, and sodium & fluid retention and decreased absorption of calcium & potassium. The patient exhibits none of the side effects listed above. - Ancef: this antibiotic may cause a decreased intestinal flora and decreased vitamin K synthesis. Patient should maintain probiotic and vitamin K intake and watch for diarrhea caused by C. difficile. This should be tested before any anti-motility agent is prescribed. - Albuterol sulfate: a bronchodilator which does not exhibit any food-medication interactions. - Ipratropium bromide: an anticholinergic drug that does not exhibit any food-medication interactions. Look at Mrs. Bernhardt’s arterial blood gas report when she was admitted. Using your “Assessment of Acid-Base Balance” notes, assess Mrs. Bernhardt’s acid-base status at admission. She could be in one of 4 conditions (see the summary chart at the end of the note set): Specify whether she is in respiratory or metabolic (one or the other, depending upon the origin of the disorder) acidosis or alkalosis. Use specific values to support your answer. (4 points) Because the patient’s pH is low (at 7.29, when a normal range is 7.35-7.45), pCO2 is high (at 50.9, when a normal range is 35-45), p02 is low (at 77, when normal range is 80- 100) and HCO3 is normal (at 24.7, within the normal range of 22-26) the patient is considered to be exhibiting uncompensated respiratory acidosis with high lung CO2 retention (kidneys are not yet doing anything to compensate for acidosis. Calculation of Nutrient Needs7. Refer to the guidelines given in “Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting” and “Module IX: Pulmonary Disorders” to complete the following. Show your work and specify the source for your answers, and explain your reasoning for making the choices you made. Using an appropriate prediction equation (with or without activity/stress or injury factor, as you deem appropriate), estimate Mrs. Bernhardt’s total energy requirement. As always, explain your thinking and show your work. (4 points)Because the patient is not critically ill (and dependent on a ventilator) we chose to use the Mifflin-St. Jeor Equation v. the Penn State Equation when estimating her resting energy expenditure.REE = 655.1 + (9.56 *41.8kg) +(1.85*63 in) – (4.68*62yrs)= 1461.41TEE= 146* 1.4= 2119 kcals/dayWe used 1.45 as an adjustment factor for the Mifflin-St. Joer Equation as suggested by Module IX: Pulmonary Disorders, Slide 23.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 Mrs. Bernhardt’s 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. (2 points)2119kcal /41.8kg = 50.69 kcal/kg = total energy requirements based on kcal/kg basisThe consensus numbers provided in Module II would is 35 kcals/kg; this provide a TEE of 1463 kcals based on the patient’s weight. This is almost exactly what we calculated for the patient’s REE. However, the consensus numbers are not evidence based and do not account for the adjustment needed because of the patient’s pulmonary disorder. Estimate Mrs. Bernhardt’s protein requirement. Explain your thinking and show your work. (2 points)When managing COPD, it is important to have 1.2-1.7 g protein/kg body weight, as stated by Module IX: Pulmonary Disorders, Slide 27. 1.2g protein/kg * 41.8 kg = 50.16 g protein1.7 g protein/kg * 41.8 kg = 71.06 g proteinThe range of protein requirements for the patient is 50.16-71.06 g protein per day. It is important, when refeeding, to start out on the low end of protein requirement to avoid respiratory muscle fatigue. Our goal would be to gradually increase the patient’s protein intake within the necessary range to promote positive nitrogen balance for repletion. Amino acids have been shown improve the side effects of COPD. As protein administration advances, it is important to closely monitor its effect on pCO2 and RQ. Using guidelines given in Module II, estimate Mrs. Bernhardt’s fluid needs. Show your work. (2 points)Using the ‘Rule of Thumb’ method for assessing fluid needs, on Module II: slide 50, 1 mL/ kcal energy required is required. 1mL*2119kcal = 2119 mL (21.19 L) of fluid is needed by Mrs. Bernhardt. Now go back to what you calculated as Mrs. Bernhardt’s typical total energy and protein intake from Question #1, and compare it to your estimated total daily energy requirement from part A. of this question (7A) and to your estimated total daily protein requirement calculated in part C. of this question (7C). In other words, how does her typical energy and protein intake compare to what you think are her actual needs? You should express any differences in whole numbers and also as a percentage of estimated needs (i.e. actual intake/estimated needs X 100). (2 points)Typical total energy intake = 960 kcalsTypical protein intake = 34.5 g proteinTEE = 2119 kcalsTotal protein requirement = starting at 50.16, advancing to 71.06 g. (960 kcals/2219 kcals)*100 =45.3% TEE consumed(34.5g/71.06g)*100 = 48.6% --- (34.5g/50.16g)*100 = 68.8 % 54.9-77.8% protein requirement consumed Patient is consuming 1259 calories less than require (only 45.3% of her total energy expenditure). She is consuming 15.7-36.6g less than requires (only 48.6-68.8% of her total protein requirement).NUTRITION DIAGNOSISBased on your assessment in question # 3, refer to the four required supplemental articles on malnutrition listed under September 4th in the course schedule of the syllabus to determine if Mrs. Bernhardt meets the definition of a specific category of malnutrition. Explain your rationale with specific data relevant to the malnutrition characteristics. (2 points) According to the supplemental readings, the patient is reported to meet 4 out of the 6 characteristics for the diagnosis of malnutrition including inadequate energy intake (45.3 % of her caloric needs), severe weight loss (23% weight loss in months), loss of muscle mass (as evidenced by temporal and interosseous wasting, and MAMC < 5th percentile during physical exam) and subcutaneous fat loss (as evidenced by MAMC < 5th percentile and evident fat loss in triceps during physical examination). No lab results indicated inflammation; because of this, it is deduced that, based on the chart in the Krauss Text (Figure 34.4) & Welcome to Medical Nutrition Therapy I, Slide 11, the patient suffers from Starvation –Related Malnutrition. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation and your nutrition diagnoses pages from the IDNT Reference Manual. Based on what you discovered in earlier questions, identify TWO of Mrs. Bernhardt’s most prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS) using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each nutrition diagnosis you write. Even if you determined in the preceding question that she is malnourished, choose two nutritional diagnoses OTHER than malnutrition that you can address as the RD. In other words, think about the reasons why she is malnourished as you identify her most important nutrition diagnoses.Nutrition Diagnosis #1: (2 points)NI-1.2: Inadequate Energy IntakeNutrition Diagnosis #2: (2 points)NB-2.4: Impaired ability to prepare food/meals*Both Nutrition diagnosis #1 and #2 are focused on what would have caused the patient’s malnutrition. Certain nutritional diagnoses were considered, such as iron deficiency anemia, but were ruled out because the directions for question 9 call for “reasons why she is malnourished” and they such problems would have stemmed from the malnutrition itself. NUTRITION INTERVENTION, MONITORING AND EVALUATIONNow 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 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.10.1PES #1: (3 points)Patient presents with inadequate energy intake (NI-1.2) related to anorexia, ill-fitting dentures as evidenced by severe weight loss, insufficient calorie intake, muscle & subcutaneous fat wasting and pulmonary disorder.Intervention Step 1: Planning (i.e. jointly establish goals with the patient)State at least ONE short- and long-term goal that you will establish collaboratively with Mrs. Bernhardt. Remember that the goals should be clear, measureable, achievable, and time-defined. (4 points)Short-term goal (i.e. between now and the next visit):Within the next 3 weeks (before the next visit), patient should increase daily caloric intake starting with 750 more calories, advancing to 1100 more calories per day.Long-term goal (i.e. over the next several visits, or longer):Patient will increase bodyweight by 10% in the next 6 months (weight gain of 9.2 pounds)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 A’s PES statement. Be sure that the INTERVENTION will specifically address the nutrition-related diagnosis and/or its underlying etiology described in your PES statement. This information will be documented in the “Intervention” section of your ADIME chart note. (2 points)As the RD, nutrition related actions we will take include increasing nutrient intake of the patient by providing supplemental/enriched shakes and meals, deliver nutrition education and counseling to improve patients knowledge about personal nutrition requirements, conduct nutrition related cooking classes at hospital to increase patients desire to prepare and eat meals. We will also refer patient to a dentist to improve fit of dentures.Measurable Outcome: State what nutrition care indicator you will MONITOR in order to EVALUATE the progress of the patient resulting from your INTERVENTION described in part C. Nutrition care indicators are clearly defined markers that can be observed and measured and are used to quantify the changes that are the result of nutrition care. For example, food and nutrient intake data, laboratory values, etc. Keep in mind that you may also identify clinical/laboratory parameters that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is the intervention you identified for your PES. Be sure that the nutrition care indicator can be used specifically to evaluate the success of your nutrition intervention. This information will be documented in the “Monitoring/Evaluation” section of your ADIME chart note. (2 points)To ensure positive nutrition care we will monitor the following: patient’s weight and skin fold thickness measurements; conduct a follow up 3-day food record to evaluate caloric and protein intake.10.2PES #2: (3 points)Patient presents with impaired ability to prepare foods/meals (NB-2.4) related to anorexia, fatigue food aversion and time constraint as evidenced by patient’s nutrition screening statement, inadequate energy intake.Intervention Step 1: Planning (i.e. jointly establish goals with the patient)State at least ONE short- and long-term goal that you will establish collaboratively with Mrs. Bernhardt. Remember that the goals should be clear, measureable, achievable, and time-defined. (4 points)Short-term goal (i.e. between now and the next visit):Within the next 3 weeks (before the next visit), patient should prepare at least 3 quick and easy recipe at home per week, as supplied by dietitian, to increase ability and desire to prepare own meals.Long-term goal (i.e. over the next several visits, or longer):Within the next 6 months, patient will be able to create her own meal plan with recipes she is able to prepare, for 7 days a week, while enjoying consumption.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 A’s PES statement. Be sure that the INTERVENTION will specifically address the nutrition-related diagnosis and/or its underlying etiology described in your PES statement. This information will be documented in the “Intervention” section of your ADIME chart note. (2 points)As the RD, nutrition related actions we will take will similarly include delivering nutrition education and counseling to improve patient’s knowledge about personal nutrition requirements, conduct nutrition related cooking classes at hospital to increase patients desire to prepare and eat meals. In addition, we will refer patient to a psychologist to improve patient’s relationship with food. Measurable Outcome: State what nutrition care indicator you will MONITOR in order to EVALUATE the progress of the patient resulting from your INTERVENTION described in part C. Nutrition care indicators are clearly defined markers that can be observed and measured and are used to quantify the changes that are the result of nutrition care. For example, food and nutrient intake data, laboratory values, etc. Keep in mind that you may also identify clinical/laboratory parameters that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is the intervention you identified for your PES. Be sure that the nutrition care indicator can be used specifically to evaluate the success of your nutrition intervention. This information will be documented in the “Monitoring/Evaluation” section of your ADIME chart note. (2 points)To ensure positive nutrition care we will monitor the following: patient’s weight, conduct a follow up 3-day food record to evaluate caloric and protein intake, macronutrient diet proportional distribution, food group serving counts. ................
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