1. Nutrition Care Conference Manchester Manor By: Cassondra Hunter

2. Overview of Patient Initials: A.C. Initials: A.C. Gender: Male Gender: Male Age: 87 Age: 87 Admitted on 7/11/13 Admitted on 7/11/13 Seen on 10/23/13 and 11/6/13 Seen on 10/23/13 and 11/6/13

3. Psychosocial Lives with his wife at home; reported he does most of the cooking and grocery shopping Lives with his wife at home; reported he does most of the cooking and grocery shopping Never received Meals on Wheels or SNAP Never received Meals on Wheels or SNAP White, non-Hispanic White, non-Hispanic Opted for DNR/DNI in an emergency Opted for DNR/DNI in an emergency Was an investigator at Pratt & Whitney Was an investigator at Pratt & Whitney Has a good attitude overall; was impatient toward the end Has a good attitude overall; was impatient toward the end

4. Physical Signs In a wheelchair In a wheelchair Glasses Glasses Partial dentures Partial dentures Skin, eyes, mouth, and hair were all in good condition Skin, eyes, mouth, and hair were all in good condition

5. Anthropometric Data Height: 5 feet 7 inches Height: 5 feet 7 inches Weight (10/23/13): 126.5 lbs Weight (10/23/13): 126.5 lbs BMI: 19.85 (normal, but on the low end & has had significant weight loss) BMI: 19.85 (normal, but on the low end & has had significant weight loss) IBW: 148 lbs ± 10% IBW: 148 lbs ± 10% %IBW: 85.5% (mild malnutrition) %IBW: 85.5% (mild malnutrition) Clinical Data (taken 10/14/13): Clinical Data (taken 10/14/13): BP- 110/58 BP- 110/58 Temperature- 92.6°F Temperature- 92.6°F

6. Nutrition History Likes: Likes: Lobster, steak, shrimp, chocolate cake (eats it every night) Lobster, steak, shrimp, chocolate cake (eats it every night) Dislikes: Dislikes: Ensure, fortified pudding (provided by MM), and chicken Ensure, fortified pudding (provided by MM), and chicken Meal Pattern: Meal Pattern: Breakfast, Lunch, Dinner, Snack Breakfast, Lunch, Dinner, Snack Appetite: Appetite: Currently taking Megace, so his appetite is very good. Now eats 100% of his meals. Prior to medication, he only consumed 60-85% of his meals. Currently taking Megace, so his appetite is very good. Now eats 100% of his meals. Prior to medication, he only consumed 60-85% of his meals.

7. Medical History Stage 3 Pressure Ulcer (sacral wound) Stage 3 Pressure Ulcer (sacral wound) GI Bleeding GI Bleeding Pneumonia, SOB worsening Pneumonia, SOB worsening COPD COPD Unspecified Essential HTN Unspecified Essential HTN Clostridium difficile infection colitis Clostridium difficile infection colitis UTI, site not specified UTI, site not specified Pulmonary Embolism Pulmonary Embolism Depression Depression

8. 2 Chief Diagnoses 1 st = Severe Weight loss 1 st = Severe Weight loss Date:Weight (lbs):Weight Lost (lbs):% Change:Classification: 6/28/13158-- Normal (BMI=24.8) 8/1/1314513 -8.2% (lost in 1 month) Severe wt loss 9/8/13130.7514.25 -9.2% (lost in 1 month) Severe wt los 9/18/13127.53.25 -2% (lost in 1 week) Significant wt lost 10/16/13129.72.2 +1.4% (gain in 1 month) Not significant 10/23/13126.53.2 -2% (lost in 1 week) Significant wt lost

9. Summary of Weight Loss A.C. had a 19.9% loss of weight in 4 months  severe wt loss A.C. had a 19.9% loss of weight in 4 months  severe wt loss

10. Chief Diagnosis (cont.) 2 nd = Stage 3 Pressure Ulcer 2 nd = Stage 3 Pressure Ulcer Stage:Description: Stage I A reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop. Stage II The skin blisters or forms an open sore. The area around the sore may be red and irritated. *Stage III The skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Stage IV The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

11. Stage 3 Pressure Ulcer

12. Medications FeSO4- hematinic, antianemic mineral supplement FeSO4- hematinic, antianemic mineral supplement A.C. lost iron from blood loss with GI bleed & has protein malnutrition A.C. lost iron from blood loss with GI bleed & has protein malnutrition Megace- appetite stimulant Megace- appetite stimulant Symptoms: nausea, dyspepsia Symptoms: nausea, dyspepsia Coumadin- anticoagulant Coumadin- anticoagulant Symptoms: taste changes, N/V, cramps, diarrhea Symptoms: taste changes, N/V, cramps, diarrhea Metoprolol- antihypertensive Metoprolol- antihypertensive Symptoms: dry mouth, N/V, diarrhea, dyspepsia, constipation, flatulence Symptoms: dry mouth, N/V, diarrhea, dyspepsia, constipation, flatulence

13. Medications (cont.) Remeron- antidepressant Remeron- antidepressant Symptoms: dry mouth, N/V, abdominal pain, constipation Symptoms: dry mouth, N/V, abdominal pain, constipation Pantoprazole- anti-GERD, antisecretory Pantoprazole- anti-GERD, antisecretory Symptoms: abdominal pain, nausea, diarrhea Symptoms: abdominal pain, nausea, diarrhea Sertraline- antidepressant Sertraline- antidepressant Symptoms: dry mouth, N/V, dyspepsia, diarrhea, constipation Symptoms: dry mouth, N/V, dyspepsia, diarrhea, constipation

14. Protein Supplements Mighty Shakes Mighty Shakes Magic Cup Magic Cup Super Cereal Super Cereal Prosource Prosource

15. Biochemical Data Chloride Chloride Maintains body water & acid/base balance Maintains body water & acid/base balance Normal Range: 98-106 mmol/L Normal Range: 98-106 mmol/L Patient’s Results: 110 mmol/L Patient’s Results: 110 mmol/L High value can indicate renal failure, use of potassium- sparing diuretics, acidosis, cell damage, dehydration, diabetes out of control, addison’s disease, SIADH, hypoaldosteronism, sepsis, shock, or pneumonia High value can indicate renal failure, use of potassium- sparing diuretics, acidosis, cell damage, dehydration, diabetes out of control, addison’s disease, SIADH, hypoaldosteronism, sepsis, shock, or pneumonia

16. Biochemical Data (cont.) BUN (Blood Urea Nitrogen) BUN (Blood Urea Nitrogen) Detoxified product of protein metabolism & indicates recent protein intake Detoxified product of protein metabolism & indicates recent protein intake Normal Range: 10-20 mg/dL Normal Range: 10-20 mg/dL Patient’s Results: 36 mg/dL Patient’s Results: 36 mg/dL High value can indicate dehydration, increased protein intake, renal failure/insufficiency, increased catabolism of protein D/T infection, tumors, starvation, stress, trauma, MI, DM, increased age, bleeding ulcers, GI hemorrhage, pneumonia, multiple myeloma, pancreatitis, CHF, and renal vein thrombosis. High value can indicate dehydration, increased protein intake, renal failure/insufficiency, increased catabolism of protein D/T infection, tumors, starvation, stress, trauma, MI, DM, increased age, bleeding ulcers, GI hemorrhage, pneumonia, multiple myeloma, pancreatitis, CHF, and renal vein thrombosis.

17. Biochemical Data (cont.) Na + 138 mmol/L Na + 138 mmol/L K + 4.8 mol/L K + 4.8 mol/L HCO 3 - 22 mmol/L HCO 3 - 22 mmol/L Creatinine 0.8 mg/dL Creatinine 0.8 mg/dL Glucose 73 mg/dL Glucose 73 mg/dL *All of these lab values fell within normal ranges, therefore, were not concerning

18. Medical Nutrition Therapy Increase calorie, protein, and fluid intake Increase calorie, protein, and fluid intake Calorie: 35-40 kcals/kg Calorie: 35-40 kcals/kg 40 kcal x 57.5 kg= 2,300 40 kcal x 57.5 kg= 2,300 Protein: 1.5 g/kg Protein: 1.5 g/kg 1.5 g x 57.5 kg= 86 g 1.5 g x 57.5 kg= 86 g Fluid: 1 mL/kcal Fluid: 1 mL/kcal 1 mL x 2,300 kcal= 2,300 mL (~10c) 1 mL x 2,300 kcal= 2,300 mL (~10c) Zinc, Vitamin C, & protein supplements for wound healing Zinc, Vitamin C, & protein supplements for wound healing Protein supplements: magic cup, super cereal, & prosource Protein supplements: magic cup, super cereal, & prosource Multivitamin supplement to increase mineral levels Multivitamin supplement to increase mineral levels

19. Diet Order Cardiac Diet, Regular Consistency Cardiac Diet, Regular Consistency A regular consistency diet allows the pt to consume all foods in their naturally prepared state, with no mechanical modifications made to them A regular consistency diet allows the pt to consume all foods in their naturally prepared state, with no mechanical modifications made to them The cardiac diet includes limiting sodium, saturated, trans, and total fats in the diet as well as cholesterol. Additionally, the cardiac diet encourages eating more omega-3 fats, fiber, and plant based meals The cardiac diet includes limiting sodium, saturated, trans, and total fats in the diet as well as cholesterol. Additionally, the cardiac diet encourages eating more omega-3 fats, fiber, and plant based meals

20. Nutritional Needs Calories: 2,300 kcal Calories: 2,300 kcal 40 kcal/kg 40 kcal/kg Carbohydrates: 316 g/day Carbohydrates: 316 g/day 55% CHO 55% CHO Protein: 1.5 g/kg Protein: 1.5 g/kg 86 g/day 86 g/day 15% Protein 15% Protein Fat: 77 g/day 30% Fat Fluid: 2,300 mL (~10c) 1 mL/kcal

21. Pertinent Vitamins & Minerals Zinc Zinc 200 mg/day 200 mg/day Protein structure, immune function, & wound healing Protein structure, immune function, & wound healing Vitamin C Vitamin C 1000 mg/day 1000 mg/day Wound healing, immune function, & collagen synthesis Wound healing, immune function, & collagen synthesis Multivitamin supplement Multivitamin supplement Iron, B Vitamins, Vitamin A,and Vitamin E Iron, B Vitamins, Vitamin A,and Vitamin E Increase mineral levels & increase healing Increase mineral levels & increase healing

22. Sample Menu Breakfast 1c super cereal w/ 1c skim milk 1/2c cranberry juice 1 apple 16 fl oz coffee w/ 2tbsp half and half + 1tbsp sugar Mid-morning Snack 1/2c canned peaches 1/4c low sodium cottage cheese Lunch Salad- 1c lettuce, 2hardboiled eggs, 2tbsp reduced fat Italian dressing, 1/4c tomatoes, 1/4c cucumbers Salad- 1c lettuce, 2hardboiled eggs, 2tbsp reduced fat Italian dressing, 1/4c tomatoes, 1/4c cucumbers 1 banana 1 banana 2/3c whole wheat pasta 2/3c whole wheat pasta 1/2c tomato sauce 1/2c tomato sauce Afternoon Snack 12 saltines 12 saltines 1c grapes 1c grapes 1 Magic Cup (provided by MM) 1 Magic Cup (provided by MM)

23. Sample Menu (cont.) Dinner 3oz shrimp, stir fry with 1/2c broccoli, 1/2c carrots, 1/2c green beans 2/3c brown rice Evening Snack 2" chocolate cake 1 Mighty Shake (provided by MM) Total calories: 2,275 kcal Total Protein: 117 g

24. Nutrition Care Process Diagnosis: Diagnosis: Unintended weight loss Unintended weight loss Inadequate protein intake Inadequate protein intake PES statements: PES statements: Unintended weight loss related to decreased appetite/intake not meeting needs, as evidenced by 19.9% weight loss over four months (severe), 158 lbs to 126.5 lbs. Unintended weight loss related to decreased appetite/intake not meeting needs, as evidenced by 19.9% weight loss over four months (severe), 158 lbs to 126.5 lbs. Inadequate protein intake related to increased protein needs as evidenced by stage 3 pressure ulcer on sacrum. Inadequate protein intake related to increased protein needs as evidenced by stage 3 pressure ulcer on sacrum.

25. Nutrition Care Process Intervention Intervention Increase weight Increase weight Patient will consume 85-100% of each meal (nurse to monitor) Patient will consume 85-100% of each meal (nurse to monitor) Patient will continue to take Megace medication to stimulate appetite Patient will continue to take Megace medication to stimulate appetite Increase protein intake Increase protein intake Patient will consume protein supplements including mighty shakes, super cereal, and magic cup Patient will consume protein supplements including mighty shakes, super cereal, and magic cup Promote wound healing Promote wound healing Patient will supplement with Vitamin C, Zinc, and multivitamin daily Patient will supplement with Vitamin C, Zinc, and multivitamin daily Monitoring & Evaluation Monitoring & Evaluation Follow up with tolerance of supplements Follow up with tolerance of supplements Continue to monitor weight closely by taking weekly weights Continue to monitor weight closely by taking weekly weights RD to request albumin, BUN, Hgb &Hct labs RD to request albumin, BUN, Hgb &Hct labs

26. Works Cited: Mahan, L. Kathleen., and Sylvia Escott-Stump. Krause's Food, Nutrition, & Diet Therapy. Philadelphia: Saunders, 2004. Print. Mahan, L. Kathleen., and Sylvia Escott-Stump. Krause's Food, Nutrition, & Diet Therapy. Philadelphia: Saunders, 2004. Print. Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: Food-Medication Interactions, 2012. Print. Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: Food-Medication Interactions, 2012. Print. "Zinc." — QuickFacts. N.p., n.d. Web. 25 Nov. 2013.. "Zinc." — QuickFacts. N.p., n.d. Web. 25 Nov. 2013.. "MedlinePlus - Health Information from the National Library of Medicine." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 24 Nov. 2013.. "MedlinePlus - Health Information from the National Library of Medicine." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 24 Nov. 2013.. Mayo Clinic. Mayo Foundation for Medical Education and Research, n.d. Web. 24 Nov. 2013.. Mayo Clinic. Mayo Foundation for Medical Education and Research, n.d. Web. 24 Nov. 2013.. "NCM Nutrition Care Manual Eat Right." Public Home Page. N.p., n.d. Web. 25 Nov. 2013. http://nutritioncaremanual.org/ "NCM Nutrition Care Manual Eat Right." Public Home Page. N.p., n.d. Web. 25 Nov. 2013. http://nutritioncaremanual.org/ http://nutritioncaremanual.org/ “Stages of Pressure Ulcers.” [Image] https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1008&bih=491&q=stage+3 +pressure+ulcer&oq=stage+3+pressure+ulcer&gs_l=img.3..0l4j0i5j0i24l5.997.5062.0.5178.22.17.0.5.5.0.129.1 498.13j4.17.0....0...1ac.1.32.img..0.22.1520.MjZtSNemdEI#facrc=_&imgdii=_&imgrc=DXivIyM8JbWl0M%3A %3B8iDyEs45F- 7Y5M%3Bhttp%253A%252F%252Fimg.webmd.com%252Fdtmcms%252Flive%252Fwebmd%252Fconsumer_ assets%252Fsite_images%252Fmedia%252Fmedical%252Fhw%252Fh9991533_002.jpg%3Bhttp%253A%252F %252Fwww.webmd.com%252Fskin-problems-and-treatments%252Ffour-stages-of-pressure- sores%3B460%3B300 “Stages of Pressure Ulcers.” [Image] https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1008&bih=491&q=stage+3 +pressure+ulcer&oq=stage+3+pressure+ulcer&gs_l=img.3..0l4j0i5j0i24l5.997.5062.0.5178.22.17.0.5.5.0.129.1 498.13j4.17.0....0...1ac.1.32.img..0.22.1520.MjZtSNemdEI#facrc=_&imgdii=_&imgrc=DXivIyM8JbWl0M%3A %3B8iDyEs45F- 7Y5M%3Bhttp%253A%252F%252Fimg.webmd.com%252Fdtmcms%252Flive%252Fwebmd%252Fconsumer_ assets%252Fsite_images%252Fmedia%252Fmedical%252Fhw%252Fh9991533_002.jpg%3Bhttp%253A%252F %252Fwww.webmd.com%252Fskin-problems-and-treatments%252Ffour-stages-of-pressure- sores%3B460%3B300images%252Fmedia%252Fmedical%252Fhw%252Fh9991533_002.jpg%3Bhttp%253A%252F %252Fwww.webmd.com%252Fskin-problems-and-treatments%252Ffour-stages-of-pressure- sores%3B460%3B300images%252Fmedia%252Fmedical%252Fhw%252Fh9991533_002.jpg%3Bhttp%253A%252F %252Fwww.webmd.com%252Fskin-problems-and-treatments%252Ffour-stages-of-pressure- sores%3B460%3B300