Download Case Study Composite - Dawn Ortiz`s Portfolio

Recorder: Dawn Ortiz
September 17, 2012
N302L Case Studies
Nutrition Care Process (NCP)
Nutrition Assessment
Diagnosis: Bladder cancer
Nutrition‐related PMH, treatments, surgeries: Undergoing chemotherapy treatments
Age, gender: 55, female
Dietary intake: PO intake
Food preferences, allergies, intolerances: None known
Exercise habits: None known
Knowledge, readiness for change: Loss of appetite
Functional/behavioral factors: Unable to eat without nausea and vomiting
Resources for obtaining, preparing food: Unknown
Symptoms: Nausea and vomiting
Anthropometric measurements
Ht/wt: 5’5” / 165.1cm and 112# / 50.9kg
BMI= 18.7 kg/m2 (normal)
IBW= 125# /56.8kg, %IBW= 89.6% (mild malnutrition)
UBW=123# / 55.9kg, %UBW= 91% (mild malnutrition)
% Weight loss= 8.9% (mild degree of malnutrition)
Energy, protein and fluid needs
o Total Energy= 1998-2306 kcal/d
o Protein= 50.9-63.6 g/d
o Fluid= 1782 m/d
Basis for estimations
o For energy, used Harris-Benedict formula to determine REE then multiplied by activity
(1.3) & injury factor (1.31.5)
o For protein, used stress factor for tumor: 1.0-1.25 g PRO/kg
o For fluid needs, used 35ml/kg/day
Labs/tests – can indicate high or low, normal or abnormal
Total PRO= 5.5 g/dL, low (<6.0 g/dL)
Serum albumin= 2.8 g/dL, low (<3.8 g/dL)
Medications/supplements
Skin integrity
Fluid intake/output (I/O)
Bowel movements (BM)
Nutrition Diagnosis- PES format
Inadequate protein intake (or inadequate energy intake) related to poor appetite and nausea/
vomiting caused by chemotherapy as evidenced by <90% IBW, 8.9% weight loss, low total protein and
low serum albumin.
Nutrition Intervention
1. Meals and snacks
a) Supplemental protein drinks TID between meals
b) Protein rich foods such as; milk, red meat, chicken, fish, beans and nuts
2. Nutrition‐related medication management
a) REC appetite stimulant
Goals
1.
2.
3.
4.
Dietary intake to meet >75% estimated energy needs.
Weight gain of 1#/week until pt reaches UBW/IBW.
Protein need= 50.9-63.6 g/d
Increase total protein and serum albumin to within normal ranges in 4 weeks
Nutrition Monitoring and Evaluation
 Follow-up phone call after 3 days or 1 week later
 Ask patient to do 3-day food record and bring it to clinic to reassess body weight, protein intake
have increased from pervious visit.
 Re-assess total protein and serum albumin in 4 weeks to determine if within normal ranges.
 Consult MD if the patient needs a TPN in case the patient still has low blood albumin and loses
body weight
Recorder: Dawn Ortiz
September 25, 2012
N302L Case Studies
Hemoglobin/Hematocrit Assessment (NCP)
Nutrition Assessment
Age, gender: 22, female
Dietary intake: PO intake
Food preferences, allergies, intolerances: Vegetarian diet
Exercise habits: None known
Knowledge, readiness for change: Fatigued
Functional/behavioral factors: Lactation; not taking vitamin/mineral supplement
Resources for obtaining, preparing food: Unknown
Symptoms: Feeling “worn out” and fatigued
Anthropometric measurements
Ht/wt: 5’4” / 162.6cm and 108# / 49.1kg
BMI= 18.5 kg/m2 (normal)
IBW= 120# / 54.5kg, %IBW= 90.1% (mild malnutrition)
UBW= Unknown
Energy, protein and fluid needs
o Total Energy= 2174-2274 kcal/d
o Protein= 56-67 g/d
o Fluid= 2174-2274 ml/day
Basis for estimations
o For energy, used Mifflin-St. Jeor to determine REE then multiplied by activity (1.3) and
added 500 kcal for lactation
o For protein, used non-stress state factor : 0.8-1.0g PRO/kg then added 12gm pro/d for
lactation
o For fluid needs, used 1ml/KCal
Labs/tests
Hgb: 9.5 g/dl (low)
Hct: 30% (low)
Medications/supplements: Prescribed, but stopped taking
Nutrition Diagnosis- PES format
Inadequate total kcal and iron intake and stopped taking supplements related to low iron vegetarian
diet and needing more energy to support lactation, as evidenced by hematocrit and hemoglobin low
values, indicating low iron intake.
Nutrition Intervention
3. Meals and snacks
c) Eat iron rich plant based foods such as; broccoli, spinach and nuts.
4. Nutrition‐related medication management
b) Take prescribed supplements (multivitamin and mineral).
Goals
5.
6.
7.
8.
Increase total kcal intake by 95% immediately.
Start taking supplements immediately.
Increase Hct and Hgb lab values within the next 3-4 months.
Eat iron rich; plant based foods.
Nutrition Monitoring and Evaluation
 Follow-up phone call within 3 days.
 Ask patient about 3-day food record.
 Ask patient about supplement intake.
 Reassess lab values within 3-4 months.
 Find out if patient is still breast feeding, if not adjust kcal recommended intake.
 Consult MD if needed.
Recorder: Dawn Ortiz
October 4, 2012
N302L Case Studies
Triglyceride Assessment (NCP)
Nutrition Assessment
Diagnosis: Type II Diabetes Mellitus
Age, gender: 37, female
Dietary intake: PO intake
Food preferences: High kcal, High fat diet
Exercise habits: Limited
Anthropometric measurements
Ht/wt: 5’1” / 154.9cm and 152# / 69.1kg
BMI= 28.8 (overweight)
IBW= 105# / 47.7kg, %IBW= 144% (obese)
Adjusted BW= 116.75# / 53.1kg
Energy, protein and fluid needs
o Total Energy= 1593-1859 kcal/d
o Protein= 42-53 g/d
o Fluid= 1593-1859 ml/day
Basis for estimations (Based on Adjusted Body Weight)
o For energy, used Overweight energy requirements (moderate to active) 30-35kcal/kg
o For protein, used non-stress state factor : 0.8-1.0g PRO/kg
o For fluid needs, used 1ml/KCal
Labs/tests
Albumin: 4.2 g/dl (normal)
Hgb: 13.4 g/dl (normal)
Hct: 41% (normal)
Glucose: 145 mg/dl (high)
TG: 250 mg/dl (high)
Nutrition Diagnosis- PES format
Patient is overweight (close to obese range), R/T high fat and high kcal diet, AEB high BMI and TG
levels.
Nutrition Intervention
5. Meals and snacks
d) Reduce kcal intake and replace with low-fat/high fiber options, such as whole grains,
fruits and vegetables.
e) Refer to exercise physiologist.
f) Refer to diabetes educator to learn carbohydrate counting.
Goals
9.
10.
11.
12.
13.
Reduce kcal intake immediately.
Follow weekly provided menu.
Engage in physical activity within 2 weeks.
Lose 1-2 pounds per week, until IBW is reached and/or BMI is within normal range.
Lower BG and TG levels.
Nutrition Monitoring and Evaluation
 Follow-up phone call within 1 week.
 Ask patient about 3-day food record.
 Make sure patient is keeping a daily body weight log.
 Ask patient if met with diabetes educator.
 Ask patient if met with exercise physiologist.
 Reassess lab values for BG and TG within 3-4 months.
 Consult MD if needed.
Recorder: Dawn Ortiz
October 16, 2012
N302L Diet NCP
Nutrition Assessment
Age, gender: 30, female
Dietary intake: PO intake
Food preferences, allergies, intolerances: No allergies
Exercise habits: Moderately Active
Anthropometric measurements



Ht/wt: 5’4” / 162.6 cm and 110# / 50.0 kg
BMI= 18.8 (normal)
IBW= 120# /54.5 kg, %IBW= 91.7% (mild malnutrition)
Table 1. Nutrient Intake Data for 24-hour Recall
Calories
(Kcal)
CHO (g)
Fat (g)
Vit. C (mg)
Vit. A (RAE)
Iron (mg)
(ug)
Calcium
(mg)
Recall
2258
288
50
92
1170
20
704
DRI
2535
349
79
40
700
18
1000
Nutrition Diagnosis- PES format
Excessive Protein and Vitamin C intake and inadequate Calcium intake, R/T diet high Protein and Vitamin
C and low in Calcium, AEB 24-hour recall diet analysis and DRI.
Nutrition Intervention
•
Meals and snacks lower in Protein and Vitamin C and higher in Calcium
 Reduce Protein rich foods; milk, red meat, chicken, fish, beans and nuts
 Reduce Vitamin C rich foods; citrus fruits, tomatoes, broccoli
 Increase Calcium rich foods; milk, cheese, yogurt
•
Goals
Add Calcium dietary supplements
•
Meet the following DRI requirements within 1 week
 40 g PRO
 75 g Vit. C
 1000 mg Calcium
•
Start Calcium supplements within 1 week
Nutrition Monitoring and Evaluation
•
Do another 24-hour recall within 1 week to match dietary intake with DRI
Recorder: Dawn Ortiz
October 18, 2012
N302L Cholesterol NCP
Nutrition Assessment
Age, gender: 39, male
Dietary intake: PO intake
Dietary pattern: Breakfast—cereal with whole milk; Lunch—fast food; Dinner—meatloaf/fried
chicken, mashed potatoes with gravy, cheesy broccoli and whole milk
Food preferences, allergies, intolerances: None known
Exercise habits: No exercise
Knowledge, readiness for change: Joined a weight loss clinic and has been unsuccessful at losing
weight
Anthropometric measurements
Ht/wt: 6’1” / 185.4cm and 245# / 111.4kg
BMI= 32.6 (obese)
IBW= 184# /83.6kg, %IBW= 133% (obese)
Adjusted BW=199.3# / 90.6kg
Energy, protein and fluid needs
o Total Energy= 2718-3171 kcal/d
o Protein= 72.5-90.6 g/d
o Fluid= 2718-3171 ml/day
Basis for estimations (based on adjusted body weight)
o For energy requirements based on overweight status, moderate to active activity level:
30-35 kcal/kg
o For protein, used non-stressed state: 0.8-1.0 g PRO/kg
o For fluid needs, used 1ml/kcal/day
Labs/tests
Glucose: 93 mg/dl (normal)
Hgb: 15.2 g/dl (normal)
Hct: 43% (normal)
Albumin: 4.5 g/dl (normal)
Triglyceride: 123 mg/dl (normal)
Total cholesterol: 240 mg/dl (high)
Nutrition Diagnosis- PES format
Overweight and obesity R/T high kcal, high fat diet and no exercise AEB, BMI= 32.6 (obese), IBW=133%
(obese) and total cholesterol= 240 mg/dl (high).
Nutrition Intervention
Meals and snacks
 Promote general healthful diet consisting of low fat, high fiber and low kcal diet
 Appropriate Meal Options:
-Breakfast: High fiber cereal with berries and skim milk; egg white omelet with whole grain toast
and orange juice
-Lunch: Salad with grilled chicken; turkey sandwich on whole grain bread with spinach leaves,
tomato and onion
-Dinner: Steamed fish with vegetables and rice; whole grain pasta with vegetables and chicken



Goals
14.
15.
16.
17.
Nutrition education; recommended modifications
Coordination of nutrition care
Recommend exercise specialist
Lose 1-2# per week until BMI is less than 25.
Normalize cholesterol level (<200mg/dl) within 6 months
Reduce kcal intake to recommended value immediately
Start exercise plan within 1 week
Nutrition Monitoring and Evaluation
 Follow-up phone call within 1 week
 Ask patient to do 3-day food record within 2 weeks
 Ask for weekly weight log to track BMI
 Make sure patient is following diet plan
 Make sure patient is following exercise plan
 Reverse high blood cholesterol level within 3 months
Recorder: Dawn Ortiz
October 23, 2012
N302L HDL-C/LDL-C NCP
Nutrition Assessment
Diagnosis: Cardiac muscle damage
Nutrition‐related PMH, treatments, surgeries: Coronary artery bypass graft
Age, gender: 54, female
Dietary intake: PO intake
Food preferences, allergies, intolerances: High fat, high refined sugar dietary pattern
Exercise habits: No exercise
Knowledge, readiness for change: Recent cardiac surgery
Anthropometric measurements
Ht/wt: 5’4” / 162.6cm and 148# / 67.3kg
BMI= 24.9 (normal/overweight)
IBW= 120# / 54.5kg, %IBW= 123% (obese)
Energy, protein and fluid needs
o Total Energy= 1718-2127 kcal/d
o Protein= 84-101 g/d
o Fluid= 1718-2127 ml/day
Basis for estimations
o For energy requirements used Mifflin-St. Jeor multiplied by 1.3 activity factor, multiplied
by 1.05-1.3 postoperative stress factor
o For protein, used major surgery stress-factor: 1.25-1.5 g PRO/kg
o For fluid needs, used 1ml/kcal/day
Labs/tests
AST: 76 U/L (high)
ALT: 31 U/L (normal)
LDH: 322 U/L (high)
CPK: 268 U/L (high)
Bilirubin (Total): 0.5 mg/dl (normal)
Bilirubin (direct): 0.1 mg/dl (normal)
Triglyceride: 250 mg/dl (high)
Total cholesterol: 240 mg/dl (high)
HDL-C: 34 mg/dl (low)
LDL-C: 156 mg/dl (high)
Nutrition Diagnosis- PES format
Undesirable food choices R/T lack of nutrition knowledge regarding a healthy diet, AEB dietary intake of
120g/d fats vs. the DRI of 60g/d fats, %IBW is 123% (obese) and lipid profile values are high.
Nutrition Intervention
 Nutrition education to promote general healthful diet consisting of low fat, high fiber, low
sodium, low refined carbohydrates, high whole grains and high fruit and vegetable intake
 Recommend healthy meals and snacks that do not exceed REE
 Refer to exercise physiologist
 Refer to smoking cessation class
Goals
18.
19.
20.
21.
Implement healthy diet immediately
Engage in appropriate post-op physical therapy immediately
Stop smoking within goal set by smoking cessation class
Improve lipid profile within 3-6 months
Nutrition Monitoring and Evaluation
 Follow-up phone call within 1 week
 Ask patient to do 3-day food record within 2 weeks
 Smoking cessation plan follow up
 Ask for weekly weight log to track BMI
 Make sure patient is following healthy diet plan
 Make sure patient is following exercise plan
 Reverse lipid profile levels within 3-6 months
Recorder: Dawn Ortiz
302L/Dr. Hong
November 6, 2012
Calcium NCP
Nutrition Assessment
Age, gender: 67, male
Dietary intake: High protein intake; low calcium intake
Food preferences, allergies, intolerances: Lactose Intolerant
Knowledge, readiness for change: Loss of appetite
Functional/behavioral factors: Concerned about general health
Anthropometric measurements
Ht/wt: 5’8” / 172.7cm and 166# / 75.5kg
BMI= 25.2 (overweight)
IBW= 154# / 70.0kg, %IBW= 107.9% (ideal/overweight)
Energy, protein and fluid needs
o Total Energy= 1961-2061 kcal/d
o Protein= 61-76 g/d
o Fluid= 1961-2061 ml/day
Basis for estimations
o For energy, used Harris Benedict Formula to determine REE then multiplied by activity
factor (1.3), injury factor (1.0)
o For protein, used non-stress state factor : 0.8-1.0g PRO/kg
o For fluid needs, used 1ml/KCal
Labs/tests
Albumin: 3.8 g/dl (normal)
Glucose: 112 mg/dl (normal)
Cholesterol: 188 mg/dl (normal)
Triglycerides: 89 mg/dl (normal)
Serum Ca: 8.9 mg/dl (normal)
Urinary Ca: 300mg/d (high)
Nutrition Diagnosis- PES format
Imbalance of nutrients R/T very high protein intake and low calcium diet AEB, urinary calcium level is
high at 300 mg/d and current protein intake is high at 150g/d versus the protein DRI of 61-76 g/d.
Nutrition Intervention
6. Meals and snacks
g) Reduce protein intake to meet DRI range.
h) Increase calcium intake by including non-dairy Ca rich foods such as; Ca and Vit D
fortified orange juice, fortified cereals, broccoli, spinach, almonds and soy.
i) Drink 1961-2061 ml/day
7. Nutrition‐related medication management
c) Take 500 mg calcium supplement every day.
8. Provide nutrition education regarding appropriate protein and calcium intake
Goals
22.
23.
24.
25.
Meet protein DRI of 61-76 g/d immediately and do not exceed
Meet calcium DRI of 1000mg/d immediately from a combination of food and supplement
Meet fluid intake of 1961-2061 ml/day immediately
Normalize urinary calcium level to 100-240 mg/d within 2-3 weeks
Nutrition Monitoring and Evaluation
 Follow-up phone call within 3 days.
 Ask patient about 3-day food record, including fluid intake.
 Ask patient about supplement intake.
 Check protein and calcium intake.
 Reassess urinary calcium lab values within 2-3 weeks.
 Consult MD if needed.
Dawn Ortiz
N302L, MYH
Anthropometry NCP
November 1, 2012
Subject gender: Female
Subject Age: 30
1. Ideal Body Weight (IBW)
Weight: 114#, 52kg
Height: 64in, 162.5cm
Elbow Breadth: 2.36in, 6cm
Frame Size: Small
Life Insurance Table Weight Range: 114-127#, 52-58kg
Hamwi IBW: 120
%IBW: 95% (mild malnutrition)
Although the Life Insurance Table Weight Range gave a range of 114-127#, the Hamwi
IBW was 120, therefore with an actual body weight of 114# the subject had a normal
weight according to the Table and fell into the “mild malnutrition” category according to
the Hamwi IBW.
2. Body Mass Index (BMI)
BMI: 19.6 (normal)
3. Waist-to-Hip Ratio
Waist: 63.5cm
Hip: 94cm
Waist-to-Hip Ratio: .67 (normal)
The subject’s Waist-to-Hip Ratio is 0.67 which is normal because it is below the
preferred value of 0.8.
4. Arm Circumference and Triceps Skinfold Comparison
Triceps: 10mm, 5th percentile
Mid-arm Circumference: 246mm
Arm Muscle Area: 3000 mm2, 10th -25th percentile
Total arm area: 4800mm2
Arm Fat Area: 1800mm2, 10th-25th percentile (4800mm2-3000mm2=1800mm2)
5. Body Composition
A. Circumferences
Abdomen constant: 31
Thigh constant: 26
Subtotal: 57
Constant: 19
Subtotal: 38
Approximate body fat: 18% (38-20=18%)
B. Bioelectrical Impedance Analysis (BIA)
Body Fat: 16.5#, 14.5% (114# x 0.145=16.5# body fat)
C. Three Site Skinfolds (Women)
Site
Trial #1
Trial #2
Trial #3
Trial #4
Average
Triceps
10
10
9
9
9.5
Suprailiac
5
4
4
4
4.25
Thigh
19
24
23
23
22.25
SUM: 36mm => X2
Seven Site Skinfolds (Women)
Site
Trial #1
Trial #2
Trial #3
Trial #4
Average
Chest
3
4
3
3
3.25
Midaxillary
6
5
5
5
5.25
Triceps
10
10
9
9
9.5
Subscapular
7
7
7.5
8
7.4
Abdomen
10
9
10
9
9.5
Thigh
19
24
23
23
22.25
SUM: 61.4mm=> X3
Body density from 3 skinfolds sites: 1.0625525
(Hamwi Formula—Women: BD = 1.0994921 – 0.0009929 (36) + 0.0000023 (1296)2 –
0.0001392 (30) = 1.0625525)
Body density from 7 skinfolds sites: 1.066422584
(Hamwi Formula—Women: BD = 1.0994921 – 0.00046971 (61.4) + 0.00000056
(61.4)2 – 0.00012828 (30) = 1.066422584)
Three Site Skinfold Body Composition Results
Percent Body Fat: 16.98% (495/1.0625525 - 450 = 16.98)
Body Fat: 8.8kg (114# x 0.1698 = 19.36#/2.2 = 8.8kg)
Lean Body Mass: 43.2kg (52kg - 8.8kg = 43.2kg)
Percent Lean Body Mass: 83.0% (100% - 16.98% = 83.0%)
Seven Site Skinfold Body Composition Results
Percent Body Fat: 14.17% (495/1.066422584 - 450 = 14.17)
Body Fat: 7.3kg (114# x 0.1417 = 16.15#/2.2 = 7.3kg)
Lean Body Mass: 44.7kg (52kg – 7.3kg = 44.7kg)
Percent Lean Body Mass: 85.8% (100% - 14.17% = 85.8%)
D. Hydrostatic weighing
Residential Volume (RV): 1.259 (29.3 (162.5cm) + 7.6 (30) – 1680 = 1259 x 0.001=
1.259
Trial #1: 1.768, #2: 1.541, #3: 1.668 => Average: 1.659 (UWW)
Body Density: 1.05 (52kg/ 52- 1.659/0.99567 – 1.259 = 1.05)
Percent Body Fat: 21.43% (495/1.05 - 450 = 21.43)
Body Fat: 11.09 kg (114# x 0.214 = 24.4#/2.2 = 11.09kg)
Lean Body Mass: 40.9kg (52kg – 11.09kg = 40.9kg)
Percent Lean Body Mass: 78.6% (100% - 21.43% = 78.6%)
Results:
The subject’s body fat composition was measured using five different techniques. Each
technique provided a slight variance in the results. The Arm Circumference and Triceps
Skinfold Comparison gave an approximate body fat composition of 18%. The margin of
error in this test was due to the administrator measuring in the wrong area and possibly
misreading the measurements. The Bioelectrical Impedance Analysis (BIA) gave a body
fat composition of 14.5%. This test may have been slightly off due to the subject’s diet
and amount of fluid in the body. Based on body density the results of the 3-skinfold test
gave a body fat composition of 16.98% and the 7-skinfold test gave a body fat
composition of 14.17%. Although the administrator performed each skinfold test four
times and averaged the values there may have been error based on not pinching the
right area or amount of skin. Lastly, the body fat composition was measured using the
Hydrostatic Weighing method, resulting in a value of 21.43% body fat. This value is the
highest based on the fact that the subject may not have been able to release enough air
while holding breathe underwater. The average of all of the body fat composition
techniques is 17%, which may be the most accurate value to use given the variance in
results.