1. CLINICAL DIETETICS PRACTICUM I Manchester Manor December 3, 2014 DIET 3155 Esha Fletcher

2. PATIENT Name: AC  Age: 85BMI: 19.4 (normal)  Sex: FemaleIBW: 115 (105-125)  DOB: 7/23/29%IBW: 95%  Race: CaucasianAdmission Date: 10/15/14  Height: 5’3” or 63 inchesDate Seen: 10/29/14  Weight: 109.4 lbs or 49.6 kg

3. NUTRITION HISTORY  She has a small appetite, eats less than half of her food (25-50% consumption)  She is able to feed herself and likes eating in the dining room if she feels well  Has difficulty swallowing foods, must swallow foods slowly  Complains of normal food getting stuck in throat  No known food allergies

4. CHIEF DIAGNOSIS Dysphagia Oral Phase  Definition: When patient has difficulty swallowing meaning it takes more time and effort to move food or liquid from the mouth to the stomach. Patient is usually referred to a speech or swallowing therapist where exercises are used to coordinate swallowing muscles and trigger swallowing reflexes, along with learning to swallow techniques.  Can lead to:  Malnutrition  Dehydration  Respiratory Problems

5. MEDICAL NUTRITION THERAPY  Recommend protein supplement (i.e Ensure Plus)  Thickener added to liquids  Swallowing Therapy  Dietary changes: Mechanical Soft Foods  If needed, Feeding Tubes to prevent malnutrition

6. OTHER MEDICAL DIAGNOSES  Anxiety State  Pneumonia  Thyrotox w/o Goiter  Hyperlipidemia  Dementia  Essential Hypertension  Polymyalgia Rheumatica  Muscle Weakness  Atrial Fibrillation  Congestive Heart Failure (CHF)  Chronic Airway Obstruction (COPD)  Urinary Tract Infection  Difficulty Walking  Osteoporosis  Malignant Neoplasm of Breast

7. SIGNIFICANT MEDICATIONS  Ensure Plus: supplement; 350 calorie supplement/meal replacement, has essential nutrients to meet daily calorie total and increase protein  Megestrol Acetate: Poor Appetite; Used to increase your appetite and to prevent or reverse significant weight loss  Potassium Chloride: Supplement; Monitor serum K, Cl, Mg and renal function *Hold if Lasix is held for low BP  Omeprazole: GERD; Treats heartburn, stomach ulcers and GERD. Patient must avoid alcohol  Lasix: CHF, diuretic; Must take on empty stomach, food causes bioavailability. Monitor BP, electrolytes, Mg, Ca, glucose, uric acid, CO2 & renal function

8. OTHER MEDICATIONS  Atorvastatin Calcium  Hyperlipidemia  Cardura Tablet  HTN  Coreg Tablet  Cardiac Arrhythmia  Digoxin Tablet  Cardiac Arrhythmia  Diovan Tablet  HTN  Donepezil HCL Tablet  Dementia  Isosorbide Mononitrate ER Tablet  Angina  Methimazole Tablet  Hyperthyroidism  PARoxetine HCL  Depression  Xarelto  Afib  Advair Diskus Aerosol Powder  COPD  Clindamycin HCL  Pneumonia

9. TREATMENTS/THERAPIES  SLP: Swallow evaluation & consistency with speech therapist  Recreation Therapy: Musical entertainment, watching TV, magazines with other residents

10. BIOCHEMICAL DATA Lab NamePatients ResultsNormal Values WBC914.0-10.5 Albumin2.93.5-5.0 BUN357-17 Creatinine0.80.5-1.0 Potassium3.43.5-5.1

11. DIETARY SIGNIFICANCE  Current Diet Order  Regular Diet  Variety of foods from all food groups, to promote optimum health; no restrictions  Mechanical Soft Texture  Eliminates foods that are hard to chew & swallow such as raw fruits and vegetables, chewy breads and tough meats  Nectar Consistency  Thickener is added to drinks to make nectar-like consistency, less likely patient will aspirate. Appropriate?  Yes, patient diagnosed with Dysphagia Oral Phase, has difficulty swallowing and trouble with foods getting stuck. There is also a need for decreased sodium due to CHF

12. NUTRIENT NEEDS  Harris Benedict: 1,028 x 1.2 (activity factor) 1,233 + 200 kcal added = 1,433 calories  Total Calorie Needs: Carbs-55%, Protein-15%, Fat-30%  Possible Obstacles: Dementia, Anxiety State

13. SAMPLE MENU Breakfast  1 small banana  1 scrambled Egg  1 cup oatmeal  ½ cup Ensure Snack  1 8oz Chocolate Pudding Lunch  1 cup of Broccoli Cheese Soup Snack  1 slice low sodium cheddar cheese  ½ cup of Ensure Dinner  2 ounce of Fish  1 cup of Low Fat Milk  1 cup of Peas  ½ cup Mashed Potatoes Snack  1 8oz vanilla yogurt

14. FOLLOW UP  10/29/14: Original visit with patient, viewed chart and spoke with patient  11/5/14: First Follow Up  Reviewed chart  Found new medications and orders: Lasix Tab 20MG, Potassium Chloride Tab 20MEQ (Increased) and Patient to be supervised for all meals 11/12/14  11/12/14: Second Follow Up  Labs still the same  No significant changes in weight

15. NUTRITION CARE PROCESS  Nutrition Diagnosis: Dysphagia Oral Phase  PES Statement: Difficulty swallowing related to diagnosis of Dysphagia as evidenced by mechanical soft and nectar thickened liquids diet to reduce risk of aspiration.  Monitor & Evaluation: Monitor electrolytes, Mg, Ca, BP, glucose

16. QUESTIONS?

17. REFERENCES  http://www.drugs.com/omeprazole.html http://www.drugs.com/omeprazole.html  http://www.webmd.com/drugs/2/drug-3776-8043/lasix-oral/furosemide- oral/details http://www.webmd.com/drugs/2/drug-3776-8043/lasix-oral/furosemide- oral/details  http://www.mayoclinic.org/diseases- conditions/dysphagia/basics/definition/con-20033444 http://www.mayoclinic.org/diseases- conditions/dysphagia/basics/definition/con-20033444  http://medical-dictionary.thefreedictionary.com/bolus http://medical-dictionary.thefreedictionary.com/bolus