NUTRITION CARE

PLAN
Brianna Sommer
Northern Illinois University Dietetic Intern
Summer 2019
Introduction to MR
• Admission Date: July 8, 2019
• 69-year-old male
• Admitted with gastrointestinal hemorrhage, profound anemia, iron deficiency,
hypovolemia, and chronic diarrhea
• Pertinent Past Medical History – arrythmia, atherosclerosis of coronary artery, A. Fib,
CHF, T2DM, HTN, HLD, pyelonephritis
• Screened at nutritional risk for 50# weight loss and decreased appetite resulting in
poor PO
• High nutrition risk due to severe chronic illness-related malnutrition
• Nutritionally assessed 3 times (initial assessment + 2 reassessments)
• Colonoscopy discovered adenocarcinoma of the rectum
• CT scan confirmed metastasis
Nutrition Assessment: Food &
Nutrition History
• Appetite pair to fair for the past 6 months
• Diet History: 2 meals per day + snacks
• Breakfast – eggs with English muffin and yogurt (Activia)
• Lunch/Snack – mandarin oranges or canned pineapple
• Dinner – dine out and at home
• Dine out – soup, salad, protein entrée
• At home – frozen/convenience meals of chicken, pork chops, meatloaf, or spaghetti with meat sauce

• No food allergies, ONS use PTA, or cultural/religious eating patterns

• Assessment of daily intake – Calories: 694 kcal, Protein: 50 g, CHO: 79 g, Fats: 19 g,
Na: 604 mg
Nutrition Assessment: Diet Orders &
PO Intake
• Diet Orders
• Clear Liquids  Cardiac with 2 gm Na restriction  Chopped with cardiac & 2 gm Na restriction
• PO Intake
• 100% of clear liquids
• Initial assessment – added Ensure Clear TID
• 70-100% of cardiac with 2gm Na+, then 0% after cancer diagnosis
• 1st reassessment – adjusted to Greek yogurt and chocolate pudding
• 2nd reassessment – adjusted to Glucerna 1x/day per patient preference
• Unable to assess PO intake for chopped due to discharge plans
• No issues with access to food
• Physical activity non-existent
 Nutrition Assessment:
Weight Record Weight in # Scale Type
Anthropometrics
7/16/2019 (used in 152.1 Standing Scale
body weight and
estimated needs
• Height: 5’11”
calculations) • CBW: 152.1#
7/15/2019 165.5 Bed Scale
(reassessment date) • IBW: 172#
7/14/2019 170.2 Bed Scale • 88% IBW
7/13/2019 163 Bed Scale
7/12/2019 160.4 Bed Scale
• UBW: 165#, Dec/2017 210#
7/11/2019 156 Bed Scale • 95% UBW, 72% UBW Dec/2017
7/10/2019 (initial 161.3 Bed Scale
• BMI: 21.20 kg/m2
assessment date)
7/8/2019 166.2 Bed Scale • Recent weight changes:
6/8/2019 172 Bed Scale • 20# (11.6%) severe unintentional weight
4/23/2018 193.2 Bed Scale loss in 1 month
12/12/2017 210 Bed Scale • 50# sudden unintentional weight loss over
occurred 1 year ago
Nutrition Assessment: Physical Exam
Findings
• Appeared pale
• At risk for skin breakdown with Braden score of 17
• No peripheral edema or pressure ulcers
• Denies nausea or vomiting
• Neurologically stable – during both reassessments, depressed and lethargic
• Nutrition-Focused Physical Exam
• Severe body fat depletion – triceps and rib cage
• Severe muscle mass depletion – clavicle, scapular, shoulder, dorsal palmar, thigh, and calf
regions
• During 2nd reassessment, significant weight loss of 13# (8%) occurred in 1 week adding to
existing depletion
 Nutrition Assessment:
Date
7/22/19
Stool Production
1
Physical Exam Findings
7/21/19 1
7/20/19 3 • Diarrhea production higher earlier in
7/19/19 0
stay
7/18/19 2
7/17/19 1 • 7/9/19 & 7/10/19 – true diarrhea
7/16/19 0 • 7/11/19 & 7/12/19 – colonoscopy
7/15/19 0 preparation
7/14/19 0
7/13/19 2 • Patient reported long-standing
7/12/19 15 diarrhea/loose stools PTA
7/11/19 11 • Decrease in stool production likely
7/10/19 6
related to limited PO intake
7/9/19 3
7/8/19 0
 Biochemical Indicator & Value Value Value Value Value Value Value Value Value Value
Normal Range 7/8/19 7/919 7/10/19 7/11/19 7/12/19 7/13/19 7/13/19 7/14/19 7/15/19 7/16/19
1617 0518 0641 0554 0634 0600 1620 0642 0540 0617
Glucose 120*(H) 87 90 91 89 90 -- 98 86 77
(79-99 mg/dL)
Sodium 135*(L) 137 135*(L) 135*(L) 138 140 -- 137 136 135*(L)
(136-145 mmol/L)
Potassium 4.4 3.7 4.0 3.9 3.3*(L) 3.4*(L) 4.4 4.1 3.8 3.6
(3.5-5.1 mmol/L)
Chloride 105 105 102 103 107 110 -- 107 104 102
(98-112 mmol/L)
CO2 21.0 22.0 24.0 20.0*(L) 24.0 22.0 -- 22.0 26.0 26.0

Nutrition
(21-32 mmol/L)
BUN 21*(H) 19*(H) 18 20*(H) 17 13 -- 11 9 9
(7-18 mg/dL)
Creatinine 1.43*(H) 1.24 1.21 1.08 0.97 0.94 -- 0.86 0.74 0.77

Assessment:
(0.7-1.3 mg/dL)
BUN/Cr Ratio 14.7 15.3 14.9 18.5 17.5 13.8 -- 12.8 12.2 11.7
(10.0-20.0)
Calcium 8.4*(L) 8.5 8.5 8.4*(L) 7.6*(L) -- -- 8.1*(L) 7.9*(L) 8.7
(8.5-10.1 mg/dL)

Biochemical
Osmolality 284 286 281 282 287 290 -- 283 280 277
(275-295 mOsm/kg)
Magnesium -- -- -- 2.0 1.9 1.8 -- 1.6 1.5*(L) 1.7
(1.6-2.6 mg/dL)

Data
Phosphorus -- -- -- 3.6 2.1*(L) 1.9*(L) -- 1.4*(L) 1.6*(L) 2.2*(L)
(2.5-4.9 mg/dL)
Folic Acid -- -- -- -- -- -- -- -- -- 5.6*(L)
(>= 8.7 ng/mL)
Hemoglobin 4.4*(L) 7.0*(L) 8.7*(L) 9.5*(L) 7.6*(L) 7.5*(L) -- 7.5*(L) 8.1*(L) 8.8*(L)
(13.0-17.5 g/dL)
Hematocrit 17.3*(L) 24.8*(L) 29.7*(L) 33.7*(L) 26.5*(L) 26.1*(L) -- 26.0*(L) 28.0*(L) 30.2*(L)
(39-53%)
Iron -- -- -- -- -- -- -- 16*(L) -- --
(65-175 ug/dL)
Transferrin -- -- -- -- -- -- -- 185*(L) -- --
(200-360 mg/dL)
Total Iron Binding Capacity -- -- -- -- -- -- -- 276 -- --
(240-450 ug/dL)
% Saturation -- -- -- -- -- -- -- 6*(L) -- --
(20-50%)
Nutrition Assessment: Biochemical
Data Interpretation
• Hypovolemia from blood loss • How were these problems handled?
• Low sodium levels • Hypovolemia improved with NS @ 125
• Elevated BUN and creatinine levels mL/hour
• Diarrhea • Diarrhea lessened by decreasing GI motility,
• Lowered CO2 then stimulating GI tract slowly with solid
• Reduced phosphorus, potassium, and food without exacerbation of symptoms
magnesium • Possible zinc deficiency to be monitored for
• Possible zinc deficiency with diarrhea and need for future supplementation
malignancy
• Iron deficiency anemia could be improved
• Iron deficiency anemia from blood loss with premier treatment of iron
• Hemoglobin and hematocrit levels lowered supplementation
• Abnormal anemia panel
• Folic acid deficiency resolved with folate
• Poor PO intake supplementation
• Reduced folic acid
Nutrition Assessment: Medical Tests &
Procedures
• Blood transfusions
• Two units transfused in ER
• Two units transfused in-patient
• Esophagogastroduodenoscopy (EGD) – hiatal hernia
• Sigmoidoscopy – benign anorectal mass
• Colonoscopy – malignant ulcerated rectal mass (source of GI bleed) & cecum
polyp (tubular adenoma)
• CT scan – metastasis of rectal cancer to lungs and surrounding lymph nodes
• Port placement for outpatient chemotherapy treatment
• Outpatient MRI needed for tumor staging, possible surgical resection of primary
mass
Nutrition Assessment: Client History
• Medical History
• Pertinent hx: CHF with cardiomyopathy & type 2 diabetes
• CHF with cardiomyopathy
• EF = 35% with medical management only
• Great risk for life-threatening arrythmias (existing hx)
• Overlapping symptoms: loss of appetite, nausea, distension, fatigue
• T2DM
• Presented in 2011
• Well-controlled, POC & serum BG WNL
• No glucose-lowering agents used PTA
• Short-acting insulin without CHO controlled diet while in-patient
• Family hx of maternal coronary artery disease
Nutrition Assessment: Client History
• Social History
• Lives at home with wife
• Wife does cooking and grocery shopping
• Dines out to stimulate appetite
• No hx of smoking or drug use, no current alcohol use, and mostly independent with ADLs
• Oral Health History
• No pertinent oral health hx
• Maintains original teeth
• Denies difficulty chewing & swallowing foods
• SLP evaluation determined mild-moderate dysphagia & downgrade for chopped diet consistency
Nutrition Assessment: Medication &
Supplements
• Pertinent PTA Medications • In-patient Medications
• Diarrhea as a side effect – • Novolog, Coumadin, Colace, Folic
Spironolactone, Carvedilol, Losartan Acid
Potassium • Education as intervention
• Diarrhea-combating Interventions • Protonix
• Limiting foods that contribute to • Vitamin B12 deficiency
diarrhea
• Encouraging 1+ cups of fluids for every
loose stool
• Initially clear liquids  gradual
advancement to lower fiber diet
• Possible probiotic introduction
Nutrition Diagnosis: Problems,
Etiologies, Signs & Symptoms
• Problems: Inadequate Oral Intake (NI-2.1), Increased Nutrient Needs (NI-5.1), Altered
Gastrointestinal (GI) Function (NC-1.4), Unintended Weight Loss (NC-3.2), Malnutrition (NC-4.1) 
Severe chronic disease or condition related malnutrition (NC-4.1.2.2)
• Etiologies: Alteration in gastrointestinal tract function (GI bleed, adenocarcinoma), physiological
causes increasing nutrient needs (adenocarcinoma), decreased ability to consume sufficient
energy (depression), & physiological causes resulting in anorexia or diminished intake (chronic
diarrhea, depression)
• Signs and Symptoms: Change in appetite and taste, anorexia, unintentional weight loss (6.4% in 1
month from initial assessment), severe loss of subcutaneous fat on triceps & rib cage, severe
muscle mass depletion of clavicle, scapular, shoulder, dorsal palmer, thigh & calf regions, intake
less than 75% of estimated needs for more than 1 month, chronic diarrhea, electrolyte/mineral
abnormalities (calcium, potassium, magnesium, sodium, phosphorus), malignant colorectal biopsy
results, abnormal anemia profile, changes in mental status (i.e., depression), conditions associated
with a diagnosis (i.e., rectal cancer), and client history of type 2 diabetes & congestive heart
failure
Nutrition Diagnosis: PES Statement
• Severe chronic disease or condition related malnutrition (NC-4.1.2.2) related to
physiological causes increasing nutrient needs (chronic diarrhea and
adenocarcinoma of rectum) as evidenced by 11# (6.4%) significant weight
loss in 1 month, energy intake <75% for more than 1 month, and severe
subcutaneous fat and muscle mass depletion.
 Nutritional
Problem Goals
Indicators
Halt weight loss
Weight Gradual
Loss weight gain as NUTRITION
able INTERVENTION:
Malnutrition
Patient to PLANNING
consume
greater than
PO Intake
75% of needs
via PO and
ONS intake
Improved GI
GI Function Diarrhea
status
Nutrition Intervention:
Implementation
• Initial Assessment
• Ensure Clear TID for added protein and calories
• Discussed importance of high-calorie, high-protein diet for weight maintenance & optimizing
PO intake
• 1st Reassessment
• Assess Ensure Clear tolerance, PO intake, improvement of GI status
• Call center discontinued Ensure Clear per patient preference
• Agreeable to high-protein, high-calorie snack addition – Greek Yogurt & Chocolate Pudding
• Recommended Glucerna as ONS option once home
• Encouraged small, frequent meals with emphasis on high-calorie, high-protein
• Provided AND’s High-Calorie, High-Protein Nutrition Therapy & High-Calorie, High-Protein
Recipes
Nutrition Intervention:
Implementation
• 2nd Reassessment
• Assess high-calorie, high-protein snack tolerance, PO intake, weight changes
• Patient lethargic and depressed
• PO intake extremely poor to non-existent
• Increased weakness
• Agreeable to initiation of Glucerna once daily
• Reinforced importance of continuation and increase of Glucerna once home
• Reinforced high-calorie, high-protein diet during chemotherapy treatments
Nutrition Intervention: Interdisciplinary
Connection
• Collaboration with other providers
• RN communication for ONS addition and adjustment
• RN communication of MR’s mood, appetite, and weight loss
• SLP communication for change in diet consistency
• Area of improvement in communication
• Communicate with MD for diet liberalization to optimize PO intake
Nutrition Intervention:
Estimated Needs
• Calories: 30-35 kcal/kg/day x 69 kg =
2070-2415 calories per day

• Protein: 1.2-1.5 g protein/kg/day x 69 kg =

83-104 g protein per day
Nutrition Monitoring & Evaluation:
Indicators & Measures to Monitor
• Food and Nutrient Intake Monitoring
• Adequacy of PO intake
• Tolerance of PO intake
• Adequacy of supplement intake
• Tolerance of supplement intake
• PO advancement
• Anthropometric Monitoring
• Weight
Nutrition Monitoring & Evaluation:
Discharge
• Discharge Date: July 22, 2019
• Discharged to Lexington of Elmhurst SNF
• Length-of-stay: 15 days
• Follow-up with RDN, oncologist, & cardiologist
• Continuation of care for malnutrition and cancer treatment-related symptoms
that may arise (i.e., diarrhea, anorexia, changes in taste, weight loss, nausea,
vomiting)
Primary Medical Diagnosis:
Adenocarcinoma of the Rectum
• Third most common cancer diagnoses in the US
• Develops in lining of large intestines as polyp
• MR’s symptoms: diarrhea, unexplained weight loss, anemia, weakness
• MR’s likely risk factors: over the age of 50 years, diabetes (though currently
well-controlled), limited consumption of vegetables
• MR’s cancer staging: TBD via MRI, however likely Stage 4 based on criteria
• MR’s treatment plan: chemotherapy and possible resection
Primary Medical Diagnosis: Colorectal
Cancer Nutrition Interventions
• AND’s NCM colorectal cancer nutrition therapy
• Emphasizing adequate protein and energy intake
• Adjusting food texture to achieve regular bowel movements
• Nutrition counseling to reduce decline in nutrition status, lessen treatment-related
toxicities, and improve functional ability during cancer tx
• Watch for future cancer cachexia and anorexia
• Frequent small meals highlighting high calorie and high protein intake
• Adequate fluid intake
• Scheduled mealtimes
• Utilizing easy-to-prepare meals & snacks
• Participating in light PA to stimulate appetite
• Use of ONS when eating results in fatigue
 MEDICAL
DIAGNOSES &
DISEASE
PATHOPHYSIOLOGY
OF MR
References
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