Case Study - FDNS 1447: MNT IIINutrition Therapy for Malnutrition in Chronic Disease

This assignment highlights my clinical nutrition skills through a comprehensive case study focused on nutrition therapy for a patient experiencing malnutrition related to chronic disease. It demonstrates my ability to assess nutritional status, interpret clinical data, and develop individualized, evidence-based nutrition interventions. I have included this work to showcase my understanding of medical nutrition therapy and my ability to apply the Nutrition Care Process to support effective patient care in a clinical setting.

1. (5) Outline the metabolic changes that occur during starvation/inadequate nutritional intake (not related to disease) that could result in weight loss.

Glycogen Depletion: Initially, the body relies on its glycogen stores for energy. Glycogen is a carbohydrate stored in the liver and muscles. As glycogen is broken down for energy, it releases water, leading to rapid initial weight loss due to fluid loss.

Gluconeogenesis: When glycogen stores are exhausted, the body shifts to gluconeogenesis, a process in which it synthesizes glucose from non-carbohydrate sources, such as amino acids and glycerol. Amino acids from muscle proteins may be used for gluconeogenesis, contributing to muscle wasting and further weight loss.

Lipolysis: As glycogen and glucose become depleted, the body turns to stored fat for energy. Fat cells release fatty acids into the bloodstream through lipolysis. The breakdown of fat leads to the utilization of triglycerides for energy, resulting in weight loss as stored fat is metabolized.

Ketogenesis: In the absence of sufficient glucose, the liver converts fatty acids into ketone bodies, which can be used as an alternative fuel source. Ketone bodies are used by various tissues, including the brain, which can help spare muscle tissue but may also lead to a decrease in appetite.

Muscle Protein Catabolism: In prolonged starvation, muscle protein catabolism continues to provide amino acids for gluconeogenesis. Muscle breakdown contributes to a significant loss of lean body mass, including muscle mass.

Reduced Basal Metabolic Rate (BMR): As the body experiences a negative energy balance, it may downregulate its basal metabolic rate to conserve energy. The reduction in BMR means that the body requires fewer calories for basic physiological functions, which can further contribute to weight loss.

Decreased Physical Activity: In response to energy deficits, individuals may experience reduced physical activity levels. This decrease in activity can further contribute to weight loss by conserving energy.

Hormonal Changes: Changes in hormones, such as increased levels of cortisol and decreased levels of insulin, occur during starvation. These hormonal shifts promote the breakdown of energy stores and muscle protein to provide the body with energy.

Appetite Suppression: As the body adapts to prolonged inadequate nutrition, appetite may be suppressed as a natural response to conserve energy. Reduced food intake due to appetite suppression contributes to further weight loss.

Electrolyte Imbalance: Loss of body fluids, especially during the initial stages of starvation, can lead to imbalances in electrolytes, potentially causing fluctuations in body weight. (Emery, 2005)

2. (10) Read the consensus statement of the AND/ASPEN: Characteristics recommended for the identification and documentation of adult malnutrition. Explain the differences between malnutrition associated with chronic disease and malnutrition associated with acute illness and inflammation.

Malnutrition Associated with Chronic Disease:

Degree of Inflammation: Mild to moderate and is also chronic. This means that there is an ongoing, low-to-moderate level of inflammation in the body over an extended period.

Examples: Common examples of chronic diseases associated with malnutrition include organ failure, pancreatic cancer, rheumatoid arthritis, and sarcopenic obesity (a condition characterized by both muscle loss and excess body fat).

Characteristic Features: In these cases, malnutrition is often a result of the chronic nature of the disease, which can lead to gradual, long-term nutritional deficits. Patients with these conditions may experience muscle wasting and weight loss over time.

Malnutrition Associated with Acute Illness & Inflammation:

Degree of Inflammation: Severe and acute. This means that there is a sudden and intense inflammatory response in the body due to an acute illness or injury.

Examples: Malnutrition associated with acute illness and inflammation is typically observed in patients with major infections, burns, trauma (fractures or surgery), or closed head injuries.

Characteristic Features: In these cases, malnutrition is often a result of the body's response to acute insult. This can lead to rapid muscle wasting, severe weight loss, and metabolic disturbances over a short period. The acute nature of the inflammatory response is a key feature in these cases.

Differences: The main differences between these two forms of malnutrition are related to the degree and nature of inflammation and the underlying conditions. Chronic disease-related malnutrition typically results from prolonged, low-to-moderate inflammation, leading to gradual nutritional deficits and muscle wasting. In contrast, malnutrition associated with acute illness and inflammation is characterized by sudden and severe inflammation, leading to rapid muscle wasting, severe weight loss, and metabolic disturbances.

 (White et al., 2012)

3. (4) Mr. Campbell was ordered a mechanical soft diet when he was admitted to the hospital. Describe how his meals will be modified with this diet order. Reference the new IDDS Dysphagia diet guidelines for moist and soft.

A mechanical soft diet is designed to provide foods that are easier to chew and swallow, making it suitable for individuals with swallowing difficulties or dysphagia. When following the IDDSI (International Dysphagia Diet Standardization Initiative) guidelines for a Level 5 diet, which is "Minced and Moist," here's how Mr. Campbell's meals will be modified:

Texture Modification: Foods on this diet level should be minced to a specific consistency. They should be moist, but not excessively wet or dry. The minced texture makes it easier to manage for individuals with dysphagia.

Meat and Protein: Meat and protein sources like chicken, fish, or beef will be finely minced to a uniform texture. These should be well-cooked and moist to facilitate swallowing.

Vegetables: Vegetables such as carrots, peas, and green beans will be cooked until soft and then finely minced. The goal is to make them easy to chew and swallow.

Starches: Starchy foods like potatoes or pasta will be cooked until soft and then finely minced. Adding in small amount of sauce or gravy to keep them moist.

Fruits: Fruits like bananas or cooked apples can be mashed or finely minced to maintain a moist and soft texture. Canned fruits can also be an option.

Dairy: Dairy products like yogurt and pudding are appropriate if they are of a soft and smooth consistency. Avoid products that are excessively thick or have chunks.

Foods should be presented in a visually appealing way, taking care to avoid any hard or crunchy textures. Consider using molds or shaping tools to make the meal visually appealing.

Portion Size: Smaller, more manageable portion sizes are encouraged to reduce the risk of choking or aspiration.

Avoidance of Small, Hard Objects: Small, hard objects like nuts, seeds, and bones are avoided in dishes to prevent choking hazards.

 (IDDSI, 2015)

4. (4) What is the Ensure Complete supplement that was ordered? Determine additional options for Mr. Campbell that would be appropriate for a high-calorie, high-protein beverage supplement. (hint: use resources from our previous chapters)

Ensure Complete is a nutritional supplement used to provide additional calories, protein, and essential nutrients for individuals who may have difficulty meeting their dietary requirements through regular food intake. This supplement is commonly prescribed for individuals with increased nutritional needs, such as those recovering from illness, surgery, or those who have difficulty maintaining adequate nutrition.

Additional options for high-calorie, high-protein beverage supplements for Mr. Campbell, beyond Ensure Complete, could include:

Boost High Protein: Boost offers several high-protein options, including Boost High Protein, which contains 20 grams of protein per serving and is designed to support muscle health and provide extra energy.

Nestlé Health Science Resource High Protein: Resource High Protein is a concentrated liquid protein supplement designed to support muscle maintenance and promote wound healing. It provides 20 grams of protein per serving.

Orgain Protein Shakes: Orgain offers organic, plant-based protein shakes that provide 21 grams of protein per serving. These are suitable for individuals with dietary restrictions or preferences.

Ensure Enlive: Ensure Enlive is another option from the Ensure product line, with 20 grams of protein and additional nutrients. It is designed for individuals who need extra nutrition support.

Magic Cup: Frozen Dessert supplies 290 calories, 9 grams of protein and is fortified with 20 vitamins and minerals in every 4oz cup. It is appropriate for individuals on a pureed diet and to assist in weight gain or maintenance.

5. (5) Assess Mr. Campbell’s height and weight. Calculate his MBI and % usual body weight.

Height: 191 cm 75 inches 

Weight: 71kg 156lbs 

BMI: 19.5 

%UBW: 70.9%

IBW:196 lbs.

Weight change: 29.1%

6. (6) After reading the physician’s history and physical, identify any signs or symptoms that support the diagnosis of malnutrition using the proposed definitions of malnutrition by AND/ASPEN malnutrition guidelines. (hint: there are at least six)

Weight Loss: The patient has experienced weight loss, as indicated by the chief complaint of dehydration, weight loss, generalized weakness, and signs of possible malnutrition. Weight loss is a common sign of malnutrition.

Loss of Appetite: The patient reports a loss of appetite. Reduced appetite is a symptom of malnutrition as it often leads to reduced food intake.

Decreased Lean Mass to Quadriceps and Gastrocnemius: The patient exhibits a reduction in lean muscle mass, particularly in the quadriceps and gastrocnemius muscles. This is a significant indicator of malnutrition as it reflects muscle wasting, which is a characteristic feature of malnutrition.

Dry Mucous Membranes: The patient has dry mucous membranes in the nose and throat, which can be related to poor hydration and nutritional deficiencies, both common in malnutrition.

Tenting Skin Turgor with Ecchymosis: Tenting skin turgor and ecchymosis are indicative of compromised skin integrity and potential vitamin and mineral deficiencies, which are commonly observed in malnutrition.

Dysphagia: The patient experiences dysphagia, requiring modified consistency for diet. Dysphagia can significantly impact an individual's ability to eat and contribute to malnutrition.

Early Satiety: The patient reports feeling full or satisfied with a small amount of food, often shortly after starting a meal. This can lead to reduced food intake and contribute to malnutrition.

7. (4) Evaluate Mr. Campbell’s initial nursing assessment (Abdomen, GI Assessment). What important factors noted in his nutrition assessment may support the diagnosis of malnutrition? (hint: there are at least 4)

Changes in Appetite: The patient reports a significant decrease in appetite, with poor oral intake, consuming less than 25% of meals, and early satiety. This decreased appetite is a common symptom of malnutrition.

Weight Loss: Mr. Campbell has experienced substantial weight loss of 29% in the past 1-2 years. This is a significant loss of unintentional body weight and is a key indicator of malnutrition.

Skin Changes and Poor Hydration: The assessment mentions dry skin with tenting skin turgor. Dry skin and poor skin turgor are physical signs often related to dehydration and inadequate nutritional intake.

Inadequate Dietary Intake: Mr. Campbell's dietary intake in the last 24 hours consists of foods that may not provide sufficient nutrition, such as cream of chicken soup, mashed potatoes, and rice. These choices, combined with his decreased appetite, contribute to potential nutritional deficiencies.

Supplement Usage: The patient has consumed half a can of Ensure Complete as part of his morning and evening snacks. The use of a nutritional supplement suggests an attempt to address potential malnutrition and nutrient deficits.

8. (5) What is a Braden score? Assess Mr. Campbell’s score. How does this related to his nutritional status?

The Braden Scale is a tool used to assess a patient's risk for developing pressure injuries (commonly known as pressure ulcers or bedsores). It consists of six subscales, each evaluating different factors that contribute to the risk of pressure injuries. The total score on the Braden Scale is used to categorize the patient's risk level for developing pressure injuries. The risk levels are as follows:

9 or Below = Very High Risk

10-12 = High Risk

13-14 = Moderate Risk

15-16 = At Risk

Mr. Campbell's Braden Score is 17, which means he is low at risk for developing a pressure ulcer.

Nutrition Subscale: One of the components of the Braden Scale is the "Nutrition" subscale, which evaluates the patient's nutritional status. Mr. Campbell received a score of 2 on this subscale, indicating "probably inadequate" nutrition. This means that he rarely eats complete meals and generally consumes only about half or less than the food offered. His protein intake is also noted as limited, and he occasionally takes dietary supplements. This suggests that his nutritional intake is insufficient, which is an important aspect of his overall health and well-being.

The Braden Score assesses various aspects of a patient's condition, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. While the score primarily addresses pressure injury risk, it indirectly reflects the patient's overall health and vulnerability. In Mr. Campbell's case, his low score on the nutrition subscale is a potential indicator of poor nutritional status, which can contribute to his overall vulnerability and health. (Agency for Healthcare Research and Quality, 2014)

9. (5) Identify any signs (including laboratory values) or symptoms from the H&P and nursing assessment that are consistent with dehydration. (hint: there are at least 5)

Weight Loss: The patient has experienced significant weight loss over the past 1-2 years, indicating fluid and nutritional deficits.

Dry Mucous Membranes: The patient has dry mucous membranes in both the nose and throat, a sign of dehydration.

Skin Tenting: The skin turgor is described as "tenting," which is a sign of dehydration. Skin loses its elasticity and does not return to its normal state when pinched.

Laboratory Values: Mr. Campbell has increased BUN (36 mg/dL) and creatinine serum (1.4 mg/dL) levels. These can indicate dehydration. High creatinine serum levels can also indicate dehydration. Dehydration can lead to an increase in both BUN and creatinine levels. When the body is dehydrated, there is a decrease in blood volume, which can result in the concentration of these waste products in the bloodstream.

Laboratory Values: Elevated Sodium (150 mmol/L) and Chloride (106 mmol/L) levels can be indicative of dehydration. Dehydration can lead to an increased concentration of sodium and chloride in the blood due to a relative lack of water.

Fluid Intake: The patient’s recommended fluid requirements are 2000- 2500 mL/day; however, the patient is only consuming 360 mL.

10. (5) Determine Mr. Campbell’s energy and protein requirements. Explain the rational for the method you used to calculate these requirements.

Activity Factor 1.2 Ambulatory with assistance for hospitalized adults:1864kcal 

1862kcal+250kcal=2114 kcal for weight gain to reach IBW of 196lbs. 

Energy Needs:1864-2114kcal

(26-29 kcal/kg/d)

Protein: (1.2-1.5) 

1.2x85kg=85g

1.5x71=106 g

(85-106 grams)

(Nelms & Sucher, 2020)

11. (5) Determine Mr. Campbell’s fluid requirements. Compare this with the information on the intake/output report.

Fluid:( 1864-2114mL) 1mL/1kcal 

His intake is less than his calculated requirements, he is only drinking 360 mL. It may indicate that he is not meeting his hydration needs, which could contribute to dehydration. Monitoring intake and output closely and adjusting as necessary is crucial to address his dehydration and maintain proper hydration.

12. (8) From the nutrition history, assess Mr. Campbell’s usual dietary intake USE ESHA. How does this compare to the requirements that you calculated for him? Can your evaluation of his dietary intake contribute to the evidence for diagnosing malnutrition?

Mr. Campbells daily intake is around 1386 kcal and 70 grams of protein, but he is only consuming 25% of that and using MFJ his daily calorie needs are around(1864-2114kcal), and protein needs are (85-106 grams)

Mr. Campbell's dietary intake is limited and does not meet his nutritional requirements. This is consistent with the report of decreased and poor oral intake, early satiety, and significant weight loss. Mr. Campbell is consuming some nutritional supplements (Ensure Complete) in both the morning and evening snacks, which can provide essential nutrients. However, they may not be sufficient to meet his overall nutritional needs. There is some variety in his food choices, which is positive for nutritional diversity. But the quantity consumed is a concern. 

13. (14) Identify the pertinent nutrition problems and the corresponding nutrition diagnoses and write at least two PES statements, with one focused on the clinical domain.

Inadequate energy intake related to patient’s decreased ability to consume sufficient energy as evidenced by patient’s 29.1% weight change within the last two years, client’s decreased appetite and early satiety over the last several months, patient’s failure to consume less than 75% estimated needs from diet, and patient’s partial glossectomy 5 years ago.

Dehydration related to inadequate fluid intake, as evidenced by laboratory abnormalities (elevated BUN, high sodium, low protein, concentrated urine), clinical indicators (tenting skin turgor), and patient history of dehydration. 

14. (10) Determine the appropriate intervention for each nutrition diagnosis.

Interventions for inadequate intake:

High Calorie and High protein 

Minced and Moist diet 

Oral nutrition supplements, Ensure Enlive 

Magic Cups 

Small frequent meals for early satiety 

Refer to RD for enteral nutrition 

Interventions for Dehydration: 

Fluid Replacement: Administer intravenous (IV) fluids or oral rehydration solutions if necessary to correct the immediate dehydration and restore electrolyte balance.

15. (10) Identify the steps you would take to monitor Mr. Campbell’s nutritional status while he is hospitalized. How would this differ if you were providing follow-up care through his physician’s office?

While Hospitalized:

Daily Clinical Assessment: Regularly assess clinical signs like weight, vital signs, and physical appearance. Monitor for any changes, including edema, dehydration, and malnutrition.

Laboratory Tests: Frequent blood tests, including complete blood counts, comprehensive metabolic panels, and inflammatory markers to assess hydration, nutritional status, and inflammation.

Fluid Balance: Monitor daily intake and output to ensure proper hydration. Assess urine output and laboratory values, such as BUN and creatinine, for signs of dehydration.

Nutritional Support: If put on Enteral nutrition, monitor tolerance and intake. 

Daily Weights: Measure Mr. Campbell's weight daily to track any fluctuations. Rapid changes may indicate fluid imbalances or malnutrition.

Follow-up Care through Physician’s Office:

Periodic Clinical Assessments: Schedule regular follow-up appointments with Mr. Campbell to monitor his clinical status. Assess weight and physical appearance during these visits.

Nutritional Counseling: Offer ongoing nutritional counseling to support Mr. Campbell's dietary intake and help him maintain a balanced diet.

Nutrition Education: Provide education on managing dysphagia, odynophagia, and modified diet consistency, emphasizing safe and nutritious food choices.

Review Laboratory Results: Periodically review laboratory results, especially if Mr. Campbell continues to experience chronic conditions or inflammation. Adjust dietary recommendations accordingly.

Hydration Assessment: Continue to assess Mr. Campbell's hydration status and address any signs of dehydration during follow-up appointments.

Monitoring in the physician's office will focus on outpatient care, nutritional counseling, and addressing chronic issues, whereas hospital monitoring is more intensive and immediate, with a focus on acute care and the management of acute illness and inflammation. Both approaches aim to ensure that Mr. Campbell's nutritional and hydration needs are met and that any underlying conditions are properly managed.

Citations:

Agency for Healthcare Research and Quality. (2014, October). Section 7. Tools and Resources (continued). Www.ahrq.gov. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html

‌ Albumin (Blood) - Health Encyclopedia - University of Rochester Medical Center. (2019). Rochester.edu. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=albumin_blood

‌ ASPEN/SCCM Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Guideline Summary. (n.d.). Guideline Central. Retrieved October 30, 2023, from https://www.guidelinecentral.com/guideline/39804/#:~:text=Based%20on%20expert%20consensus%2C%20we%20suggest%20the%20provision%20of%20trophic

‌ Emery, P. W. (2005). Metabolic changes in malnutrition. Eye, 19(10), 1029–1034. https://doi.org/10.1038/sj.eye.6701959

‌ White, J. V., Guenter, P., Jensen, G., Malone, A., & Schofield, M. (2012). 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). Journal of the Academy of Nutrition and Dietetics, 112(5), 730–738. https://doi.org/10.1016/j.jand.2012.03.012

‌ IDDSI. (2015, June 22). What is the IDDSI Framework? IDDSI. https://iddsi.org/framework/

‌‌ Nelms, M., & Sucher, K. (2020). Nutrition Therapy and Pathophysiology (4th ed.). Cengage.