Katie Sprague

Nutritional Assessment 6
10/29/15
Nutrition Assessment Section I
Patient name: E.B. Gender: M

Age: 84

Admission Date: 1/5/14

Date Seen: 10/20/15

Medical Problems/History/Diagnosis:
Dysphagia: This condition is characterized by difficulty swallowing due to
improper function of the muscles and nerves in the esophagus and throat
responsible for moving food to the stomach. This muscle and nerve dysfunction can
occur after a stroke, a brain or spinal cord injury, problems with the nervous system,
an immune system issue, and more. It can also occur if something is blocking the
throat or esophagus, preventing them from doing their job. This could be a result of
GERD, diverticula, esophageal tumors, ets. Some symptoms of dysphagia include
drooling, choking, coughing during meals, problems drinking through a straw, a
gurgly voice quality and more. An evaluation should be performed by a speech
language pathologist to assess the swallowing disorders, and then a RD can help
coordinate the evaluation process.
Some main concerns for people with dysphagia are malnutrition, weight loss
and anorexia. The MNT for dysphagia should start with an RD observing the patient
to see what issues they experience while eating and if their symptoms are
preventing them from getting the proper nutrients. The consistency of foods eaten
should be changed to suit the specific needs of the patient. It may be necessary to
employ a diet of mechanically soft or pureed foods to reduce the unpleasant
symptoms the patient experiences while eating. In severe dysphagia the patient will
need a feeding tube (nothing by mouth) and it should provide sufficient nutrients so
the patient does not become malnourished while using this type of feeding. For
patients with mild or moderate dysphagia, they will need total supervision while
eating and will have two or more consistency restrictions from their diet. Patients
with mild dysphagia may have one consistency restricted from their diet, but can be
more independent during feeding times and dont experience as many of the
unpleasant symptoms.
(Krause p. 929-931 & WebMD)
GI obstruction: This condition occurs when the large or small intestine is
either partly or completely blocked. This blockage prevents food, fluids and gas
from moving through the intestines properly and can be quite uncomfortable.
Mechanical obstructions such as scar tissue, tumors, twisting or narrowing of the
intestines can be the cause of the GI obstruction. Some other causes are cancer of
the large intestine, severe constipation, diverticulitis and IBD. Some symptoms
include cramping, bloating, vomiting and diarrhea. An abdominal X-ray or a CT-scan
can be done to diagnose GI obstruction.

The MNT for this condition can vary based on how severe the GI obstruction is
and also what the underlying cause of the GI obstruction is. A low fiber diet may be
recommended in which will be easier for the partially blocked intestine to digest, it
will reduce the volume and frequency of stools and causes less irritation to the GI
tract. Grain products consumed should have less than 2g of dietary fiber per
serving. Additionally, fats should be limited to less than 8 teaspoons per day and if
it is consumed, it should be healthy fats like canola and olive oils. Broth and
strained soups may be recommended if the condition is severe, and it may be
necessary to limit desserts. Raw/uncooked fruits and vegetables should be limited
or not consumed at all as well as tough meats and whole grain products.
(MayoClinic & Nutrition Care Manual)
Malnutrition: This is a condition that occurs when a person is not taking in
the sufficient nutrients needed to stay healthy and they become undernourished.
Malnutrition can range from mild to severe and can have physical as well as mental
implications. Some signs of malnutrition include weight loss, loss of muscle mass
and subcutaneous fat, insufficient energy intake, limited functional status, and
localized fluid accumulation. Malnutrition can occur because a person is not getting
the essential nutrients in their diet or because of a chronic health condition that
prevents the body from using or absorbing nutrients taken in. Some underlying
conditions that may lead to malnutrition are cancer, depression, liver disease,
chronic pain, and more. Patients experiencing malnutrition may feel cold more
easily than others and may have a weakened immune system causing them to get
sick more often.
The MNT for malnutrition depends on whether the patient has malnutrition
due to an underlying chronic illness, or if they have this condition because they are
not taking in the essential nutrients from their diet. Supplements may be
recommended as well as a diet complete in fruits, vegetables, whole grains, dairy
and protein. The patient will have increased calorie needs until their ideal body
weight is met or until they are medically stable. If there is an underlying condition,
then the patient may need to meet with an ST to help with swallowing difficulties,
an OT if feeding aids are necessary or meeting with an RD to see how to make
meals more appealing. The patient may also need to meet with social services if
they are having issues shopping or preparing meals for themselves. If the
malnutrition is severe then it may be necessary to use a tube feed.
(WebMD)
Anthropometric Data and Clinical Data:
Weight: 167.2 lbs (75.7kg)
(1.62m^2) = 28.8

Height: 54 (1.62m)

BMI of 25.0-29.9 classifies this patient as overweight.

IBW: 106 + 6(4) = 130lbs

DBW: not available
%DBW: (actual wt./desirable wt) x 100% = not available

BMI: W/H^2 = 75.7kg/

Adjusted body weight: (actual-ideal) x 0.25 + IBW= (167.2lbs - 130 lbs) x 0.25 +
130 lbs = 139.3lbs (63.3 kg)
The blood pressure of this patient is normal at 131/84.
His temperature of 98.7C is normal.
Physical Signs:

pink skin
warm temperature
ecchymotic areas on R. shoulder, elbow, wrist and L. wrist: a diet rich in vitamin K
helps with blood clotting as well as healing areas on the skin such as these
redness on left side of neck and scrotum
R. heel pressure ulcer: requires a diet including foods from all 5 food groups, foods
high in protein with every meal and snack to help in the healing process, and plenty
of fluids
(nutrition care manual)
Psychosocial Data:
E.B. is an 84 year old male resident of Riverside Long Term Care Facility. He is
single and is a white Roman Catholic. He has both medicare and medicaid to cover
his expenses while at Riverside. He has a history of mental retardation and is
nonverbal; he mostly communicates through facial expressions and body language.
He enjoys going to church and attending structured therapeutic recreation activities
at Riverside.
Summary of Nutrition History:

Although no interview was done with this patient, it was stated in his chart that he
is a poor historian and is at baseline mental status.
His food preferences, likes/dislikes, avoidances, etc. are unknown.
Nutrition Assessment Section II:
Medications:

metoclopramide: This drug is taken as an antiemetic, antigerd, and gastroparesis

treatment; it should be taken hour before meals; there are no diet or nutritional
concerns; some oral/GI concerns are dry mouth, increased gastric emptying,
nausea, diarrhea and constipation
digoxin: This drug is taken as a cardiotonic, antiarrhythmic, CHF treatment and as
an inotropic agent; diet should be maintained high in vitamin K, low in Na, adequate
Mg and Ca, caution with Ca and or vitamin D supplement, caution with some herbal
products; nutritional concerns are anorexia, decreased weight, Ca and vitamin D
induced hypercalcemia may increase drug effects; oral/GI side effects are N/V and
diarrhea
omeprazole suspension: taken as an antiulcer and antigerd; should be taken 3060 minutes before meals, taken with an acidic juice or applesauce; diet concerns ar
may decrease the absorption of iron and vitamin B12, Ca citrate may be

recommended; no nutritional concerns; oral/GI concerns are decreased gastric

secretions, increased gastric pH, nausea, abdominal pain and diarrhea
furosemide: Diuretic & antihypertensive; take on an empty stomach; diet concerns
are increasing vitamin K, increasing Mg, decreasing calcium and decreasing Na may
be recommended; natural licorice should be avoided; nutritional concerns are
anorexia, increased thirst, decreased sodium diet, increased risk of hyponatremia
metoprol tab: Antihypertensive & antiangina; should be taken with food; Na and
calcium should be decreased; natural licorice should be avoided; oral/GI side effects
are dry mouth, N/V, dyspepsia, flatulence, diarrhea, constipation
phenytoin: This drug is taken as an antiepileptic; may be taken with food or milk to
decrease GI irritation; diet concerns: take 1 mg Fol daily, may need Ca and vit D
supplements but should be taken before or after eating separated by 2 hours;
nutrition concerns: increase folate intake, increased drug metabolism and
decreased blood level, increased metabolism of vitamin D and K especially in
children, may cause rickets or osteomalacia; oral/GI side effects: gum hyperplasia,
altered taste, dysphagia, N/V, constipation
ipratropium: This drug is taken as a bronchodilator and anticholinergic; there are
no dietary or nutritional concerns; oral/GI side effects: dry mouth/throat,
metallic/bitter taste, nausea, dyspepsia
The possible side effects are bolded.
(Food Medication Interactions)
Treatments and/or Therapies:

PT: E.B. attended PT to help cope with his sepsis, rapid A-fib and spastic
quadriplegia
OT: E.B. attended OT for help coping with his hematuria and leukocytosis; he was
given an abductor pillow, a low air mattress and a head lift to help cope with these
conditions
Biochemical Data:

BUN: H 29 [9-20] high BUN could be due to renal failure, shock, dehydration,
infection, DM, chronic gout, excessive protein intake/catabolism, MI; Looking at
E.B.s diagnoses, he has a history of CVA and CHF and a UTI; these things could all
be contributing to his high BUN value
Cl-: L 97 [98-107] low Cl could be due to diabetic acidosis, fever, acute infections,
metabolic alkalosis, protracted vomiting, K deficiency, chronic respiratory acidosis
and SIADH; E.B. may have a low Cl- due to his malnutrition which could cause a K
deficiency, or possibly an acute infection such as his UTI
WBC: H 13.4 [3.2-10.6] high WBC could be due to leukemia, bacterial infection,
hemorrhage, trauma or tissue injury or cancer; E.B. could have this high level due to
a UTI or tissue injuries
Hgb: L 12.2 [14.6-17.5] low Hgb could be due to anemia, hyperthyroidism, cirrhosis,
many stemic diseases, HIV/AIDS; E.B. could have this low level due to his paraplegia
or another stemic disease
creatinine: 0.8 [0.7-1.3]
Na+: 138 [133-145]
K+: 3.8 [3.5-5.1]

random glucose: 128 [70-199]

Hgt: 37.3 [41-51]
there were no lab values for RBC, albumin, HgA1C, HDL, LDL, and cholesterol
(Food Medication Interactions)

Nutrition Assessment Section III:

Dietary Data:
The present diet order for the patient is NPO, 30cc liquid protein twice a day
via a G-tube; 2 cal HN 40mL/hr x 20 hours, hold from 8am to 10am and from 8pm to
10pm. E.B. also has mixed meds with 30 mL of water to flush before and after the
med administration. This diet order means that the patient cannot eat any food by
mouth and is only able to receive nutrition through a tube feed. The patient receives
30mL of liquid protein through his feeding tube (G-tube) twice a day along with 40
mL each hour of 2 cal HN which is continued for 20 hours. The patient is not to be
fed from 8am to 10am and 8pm to 10pm. The 2 cal HN that the patient consumes is
a nutrient rich formula that is designed to help meet increased protein and calorie
needs. It helps to maintain weight, increase lean body mass and assist with wound
healing. The type of feeding tube this patient has is a g-tube or a gastrostomy
tube. The tube is inserted through the skin and stomach wall, leading the tube
directly into the stomach. The insertion of this tube is done using an endoscopy
which looks inside the body using a small camera which is put in the mouth and
down the esophagus to the stomach. An incision is then made in the abdomen and
a small, hollow tube is put into the stomach, and then the incision is stitched back
up around the tube. These types of tubes may be used for both short term and
permanent conditions. Some reasons for needing a g-tube include babies with
certain birth defects, patients who cannot swallow properly, patients who cannot
take enough food by mouth and patients who breathe in food while eating. E.B. has
been using this feeding tube to to his condition of dysphagia which prevents him
from being able to properly swallow his food.
Previous Diet orders: Same as the present diet order with the addition of
81mg of ASA via the g-tube daily.
(abottnutrition.com & MedlinePlus)

Nutrient Needs:

Calorie needs- BEE formula: 66+ (13.7 x 63.3kg) + (5 x 162cm) (6.8 x 84 years
old) = 1172.01
Cal req. = BEE x activity factor x injury factor
kcals/day

=1172.01 x 1.2 x 1.2 = 1687.7

BUT recorded in dietary section of medical chart that patient is supposed to

consume 1800 kcal/day which consists of 1600kcal/day from the 2 cal HN and 200
kcal/day from the liquid protein
calorie calculation: 2 cal x 40 mL = 80 x 20 hours = 1600 kcal
1600 kcal/day + 200 kcal liquid protein/day = 1800 kcal/day

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CHO: 50% of daily calories- 1800 x 0.50 = 900 kcals from CHO per day; 900/4gm =
225 grams/day
2 cal HN: 51.8g CHO per 8 fl. oz.; 40 mL x 20 hours = 800 mL = 27 fluid oz.
27 fluid oz./8 fluid oz. = 3.375 x 51.8g = 174.8 g CHO/day from 2 cal HN
28g CHO from 2 oz. of liquid protein = 174.8 + 28 = 202.8 g CHO per day total
Protein: 20% of daily calories- 1800 x 0.20 = 360 kcals; 360/4gm = 90 grams/day
from OR 0.8gm x 63.6 kg = 51 grams/day
2 cal HN: 19.9 g per 8 fluid oz.; 3.375 x 19.9 = 67.1 g protein/day from 2 cal HN
liquid protein: 20 g protein per 2 oz.
67.1 g + 20 g = 87.1 g protein per day total
Fat: 30% of daily calories- 1800 x 0.30 =540 kcals from fat per day; 540/9 = 60
grams/day
2 cal HN: 21.5 g fat per 8 fluid oz.= 3.375 x 21.5 = 72.5 g of fat per day from 2
cal HN
liquid protein = 0 grams of fat
so total fat per day = 72.5 grams
Fluid needs: 30 mL per kg actual weight = 30mL x 75.7kg = 2271 mL
E.B.s calorie needs were recorded in the medical chart by the dietician to be
1800 kcal/day. He receives 1600 kcal/day from the 2 cal HN and 200 kcal/day from
the liquid protein. Looking on abbottnutrition.com, I was able to determine the
grams of fat, protein and carbohydrates E.B. is getting daily from the two products
in his tube feed. He is getting more than the suggested grams of protein per day,
less than the suggested amount of carbohydrates per day and more than the total
grams of fat per day as compared to the values given by the Harris Benedict
equation. Although these values do not correspond with those calculated by the
Harris Benedict equation, they are appropriate for E.B. because he needs both
increased protein and fat intakes in order to help him maintain his weight and
increase any healing that needs to be done.
Overall, E.B.s nutritional status appears to be poor from his diagnosis of
malnutrition, his other numerous diagnoses and his abnormal lab values of BUN, Cl-,
Hgb and WBC. The tube feed he is on now should help him overcome his
malnourishment, and ideally normalize his lab values.
E.B. should be sufficient in all vitamins, minerals and nutrients because the
proper amounts are supplied by the 2 cal HN and the liquid protein.
Nutrient Assessment Section IV:

The present diet order seems appropriate for E.B. because the formula he is
currently taking in is designed to help maintain/gain appropriate nutritional status,
gain lean body mass and help the body heal wounds.

One obstacle E.B. faces in meeting his nutrient needs is his dysphagia, which is why
he is currently on a feeding tube. Also, his mental retardation could be an obstacle.
It was reported that E.B. is at a low potential for ever graduating to P.O. feeding, but
he has a good tolerance for the tube feed. Even if he was physically able to eat P.O.,
his mental status may make it difficult to do so. Additionally, E.B. is non-verbal
which could be a barrier from meeting his nutritional needs; he is unable to
communicate verbally with the staff at Riverside.
Measurable Goals:

E.B. will continue to consume 40 mL of 2 cal HN x 20 hours per day and 200 calories
of liquid protein per day to meet his nutritional needs.
PES Statement:
Swallowing difficulty as related to coughing, choking, drooling and pain while
swallowing as evidenced by dysphagia.
(eNCPT)