Clinical Case Studies for the Nutrition Care Process

Case 1: General Nutrition Assessment

Learning Objectives
1. Recognize anthropometric, biochemical, clinical, and dietary factors that impact on
nutritional status.
2. Calculate and interpret weight change and body mass index.
3. Determine adequacy of dietary intake.
4. Apply the Nutrition Care Process to an elderly patient.
Case Description Background
Adequate nutrition can be viewed as a state of balance between intake, requirements,
metabolism, and losses of nutrients. The term malnutrition usually refers to a state of
undernutrition, and has been associated with increased morbidity and mortality in the clinical
setting (1-4). The accurate identification and patients at risk for malnutrition and its associated
complications is both an art and a science; subjective and objective data are interpreted along
with clinical judgment to evaluate nutritional status. From the dietary standpoint, a full
evaluation considers not only calorie and protein intake but also vitamin and mineral status.
Surrogate markers of visceral protein stores such as serum albumin and prealbumin have
traditionally been measured for nutritional assessment. These parameters are now known to be
affected by many factors, including hydration, physiological stress, and inflammation.
Particularly during metabolic stress, serum proteins more specifically reflect severity of illness
than nutritional stores (1-7). While a low serum albumin is associated with an increased
morbidity and mortality, it cannot be used alone to measure nutritional status or repletion.
Conversely, a normal serum albumin cannot be used in isolation to rule out malnutrition. Serum
protein levels by themselves do not form the basis for nutrition diagnosis or intervention.
Individual assessment parameters should be considered as part of the biggest picture of
nutritional equilibrium. The client is a 76-year old woman with a history of hypertension
admitted to the hospital after tripping over her cat and falling at home. She is admitted for a
femur fracture. She is currently confined to bed.
Nutritional Assessment Data
1. Anthropometric Measurements.
Height: 67
Weight: 140lb
Usual weight: 160lbs 6 months ago. She has been unmotivated to cook since the loss of
her husband during the previous 6 months.
2. Biochemical Data, Medical Tests, and Procedures.
a. Labs
Parameter

Value

Sodium
Potassium
Chloride
Carbon dioxide
BUN
Creatinine

140 mEq/L
3.2 mEq/L
103 mEq/L
29 mEq/L
19 mg/L
1.0 mg/L

Normal Ranges*
(may vary by age, sex, and lab)
135-147 mEq/L
3.5-5.0 mEq/L
98-106 mEq/L
21-30 mEq/L
8-23 mg/L
0.7-1.5 mg/L

Glucose
Hemoglobin
Hematocrit
Albumin
Prealbumin

108 mg/L
12.0 g/L
38.1%
3.2 g/dL
11mg/dL

70-110 mg/L
12-16 g/L (female)
36-47% (female)
3.5-5.5 g/L
16-40 mg/L

b. Test results, if pertinent

X-ray indicates fracture of left femoral neck.
3. Nutrition-Focused Physical Findings
Blood pressure: 128/65 mm Hg
Oral mucosa dry. Has upper and lower dentures which are poorly fitting.
Skin turgor decreased.
4. Client History
Social Hx:
No smoking or alcohol
Husband diet 6 months ago and patient has lost weight since this time
Family Hx:
N/A
5. Food/Nutrition-Related History
Usual Diet
Breakfast:
1 cup (8oz) decaffeinated tea with 1 tbs half and half and 1 tsp sugar
1 slice white toast with 1 tsp margarine and 1tsp jelly or 1 frozen pancake with 1 tbs
syrup
cup orange juice
Lunch:
Canned soup, usually chicken noodle, 1 cup
4 unsalted crackers with 2 tbs peanut butter
cup sliced peaches in light syrup
Sweetened iced tea, 1 cup
Dinner:
Chicken thigh with skin, stewed
cup rice or potato with 1 tsp margarine
cup spinach or carrots
1 cup (8oz) decaffeinated tea with 1 tbs cream and 1 tsp sugar
Notes:
Rarely eats or drinks between meals.
Avoids eggs and milk due to food preferences.
Medications
Furosemide 20 mg daily
Supplements: none

1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW
(1 point), % UBW (1 point), and BMI (1 point). Interpret her weight and weight
change based on these parameters (2 points).
140lbs/2.2kg = 63.6kg , 160lbs/2.2kg = 72.7kg 67in x 2.54cm = 170cm
IBW=45.5kg/60in (+2.3kg/added inch) = 61.6kg/67in
%IBW = (Actual kg x 100)/IBW , (63.6kg x 100)/61.6kg = 103%
%UBW = (Actual kg x100)/UBW , (63.6kg x 100)/72.7kg = 87.5%
BMI = weight (lbs) / [height (in) x height (in)] x 703 , 140/[67]2 x 703 = 21.9
Based on these parameters her weight change has decreased over 15.5% in the past
six months. This is a significant weight change for an older individual. This weight
change could lead to malnutrition if she keeps losing weight over time. Although
she has a normal BMI and she is above her %IBW, she still needs to stabilize her
weight change. 1,2,3
2. Calculate her nutritional requirements (calories, protein, and fluid) (3 points) and
compare her current intake to her needs (2 points).
BMR: (9.99 x 63.6kg) + (6.25 x 170cm) (4.92 x 72) -161=1,182.62kcal
Total daily kcal requirements: (BMR x 1.2 (activity factor for sedentary
lifestyle)) , 1,182.62kcal x 1.2 = 1,419.97kcal
DRI for Protein: (0.8g/kg body weight) , 0.8g x 63.6kg =50.88g
Fluid requirement: (lbs/50=qt) , 140lbs/50 = 2.8qt , 2.8qt/0.25 cups = 11.2 cups
She is getting very little fluids in her diet. It says she rarely drink in between
meals and with her diet she is only getting two cups of tea and half a cup of
orange juice. It does not state that she is drinking any water, and her skin turgor is
decreased, which means that she is dehydrated. Her protein intake is actually
higher than her needs according to supertracker. On the other hand, her calorie
intake is a bit low, apx. 1221, compared to the above calculations. 4,5,6,7,8
3. Are any major food groups and nutrients obviously missing from her diet? (2
points) Explain your answer. (3 points)
The food group that is completely missing from her diet would be dairy. From her
usual diet, listed, she says she avoids milk due to food preference. She does not have
dairy coming from any of the other foods that she eats regularly. Dairy is a major source
of calcium, therefore she is missing this nutrient. Another food group that she is lacking
would be vegetables. She is only getting half a cup of vegetables a day, which is low
since her recommendations are two cups of vegetables daily. The nutrients that are
missing would include fiber since she is not eating whole grains, fruits and vegetables.
Since her intake of those food groups are so low, she is also lacking almost all of the
vitamins and minerals except iron, niacin and vitamin A. She is getting the iron and
niacin from the chicken and vitamin A from the carrots. 8

Elderly's Meals Report 09/14/14 - 09/14/14

Breakfast

Lunch

Dinner

1 regular slice
Bread, white

1 cup Chicken
noodle soup,
canned, low
sodium, ready-toserve

cup, slices
Carrots, raw

1 tablespoon Half
and half

4 square Cracker,
saltine, low
sodium

1 medium leg
Chicken, leg
quarter (drumstick
and thigh),
stewed, skin eaten

1 individual packet
Jelly, all flavors

cup Peaches,
cooked or canned,
in light or medium
syrup

1 tablespoon
Cream, half and
half

1 teaspoon
(individual
container)
Margarine, tub, 100
calories per Tbsp

2 tablespoon
Peanut butter

1 teaspoon
(individual
container)
Margarine, tub,
100 calories per
Tbsp

cup Orange
juice, carton, can,
or bottle

cup Rice, white,

regular, cooked
(no salt or fat
added)

1 medium (5"
across) Pancakes,
plain

1 teaspoon Sugar,
white, granulated
or lump

1 teaspoon Sugar,
white, granulated
or lump

Snacks
EMPTY

Elderlys Food Groups and Calories Report 09/14/14 - 09/14/14

Food Groups

Target

Average Eaten

Status

Grains

5 ounce(s)

4 ounce(s)

Under

Whole Grains

3 ounce(s)

ounce(s)

Under

Refined Grains

2 ounce(s)

4 ounce(s)

Over

2 cup(s)

cup(s)

Under

Dark Green

1 cup(s)/week

0 cup(s)

Under

Red & Orange

4 cup(s)/week

cup(s)

Under

Beans & Peas

1 cup(s)/week

0 cup(s)

Under

Starchy

4 cup(s)/week

0 cup(s)

Under

Other

3 cup(s)/week

0 cup(s)

Under

1 cup(s)

1 cup(s)

Under

Whole Fruit

No Specific Target

cup(s)

No Specific Target

Fruit Juice

No Specific Target

cup(s)

No Specific Target

3 cup(s)

0 cup(s)

Under

Milk & Yogurt

No Specific Target

0 cup(s)

No Specific Target

Cheese

No Specific Target

0 cup(s)

No Specific Target

5 ounce(s)

6 ounce(s)

Over

Seafood

8 ounce(s)/week

0 ounce(s)

Under

Meat, Poultry & Eggs

No Specific Target

4 ounce(s)

No Specific Target

Nuts, Seeds & Soy

No Specific Target

2 ounce(s)

No Specific Target

Oils

5 teaspoon

2 teaspoon

Under

Limits

Allowance

Average Eaten

Status

Total Calories

1600 Calories

1221 Calories

Under

121 Calories

293 Calories

Over

Solid Fats

174 Calories

Added Sugars

119 Calories

Vegetables

Fruits

Dairy

Protein Foods

Empty Calories*

Elderly's Nutrients Report 09/14/14 - 09/14/14

Nutrients

Target

Average Eaten

Status

Total Calories

1600 Calories

1221 Calories

Under

Protein (g)***

46 g

51 g

OK

Protein (% Calories)***

10 - 35% Calories

17% Calories

OK

Carbohydrate (g)***

130 g

146 g

OK

Carbohydrate (% Calories)***

45 - 65% Calories

48% Calories

OK

Dietary Fiber

21 g

9g

Under

Total Sugars

No Daily Target or Limit

60 g

No Daily Target or
Limit

Added Sugars

No Daily Target or Limit

30 g

No Daily Target or
Limit

Total Fat

20 - 35% Calories

37% Calories

Over

Saturated Fat

< 10% Calories

10% Calories

Over

Polyunsaturated Fat

No Daily Target or Limit

9% Calories

No Daily Target or
Limit

Monounsaturated Fat

No Daily Target or Limit

15% Calories

No Daily Target or
Limit

Linoleic Acid (g)***

11 g

12 g

OK

Linoleic Acid (% Calories)***

5 - 10% Calories

9% Calories

OK

-Linolenic Acid (% Calories)***

0.6 - 1.2% Calories

0.6% Calories

OK

-Linolenic Acid (g)***

1.1 g

0.8 g

Under

Omega 3 - EPA

No Daily Target or Limit

13 mg

No Daily Target or
Limit

Omega 3 - DHA

No Daily Target or Limit

51 mg

No Daily Target or
Limit

Cholesterol

< 300 mg

135 mg

OK

Minerals

Target

Average Eaten

Status

Calcium

1200 mg

205 mg

Under

Potassium

4700 mg

1258 mg

Under

Sodium**

1500 mg

1704 mg

Over

Copper

900 g

708 g

Under

Iron

8 mg

8 mg

OK

Magnesium

320 mg

140 mg

Under

Phosphorus

700 mg

605 mg

Under

Selenium

55 g

52 g

Under

Zinc

8 mg

6 mg

Under

Vitamins

Target

Average Eaten

Status

Vitamin A

700 g RAE

742 g RAE

OK

Vitamin B6

1.5 mg

0.8 mg

Under

Vitamin B12

2.4 g

0.5 g

Under

Vitamin C

75 mg

49 mg

Under

Vitamin D

15 g

0 g

Under

Vitamin E

15 mg AT

6 mg AT

Under

Vitamin K

90 g

29 g

Under

Folate

400 g DFE

288 g DFE

Under

Thiamin

1.1 mg

0.8 mg

Under

Riboflavin

1.1 mg

0.9 mg

Under

Niacin

14 mg

17 mg

OK

Choline

425 mg

150 mg

Under

4. Do you think she could be experiencing any drugnutrient interactions? (2 points) If

so, what dietary suggestions would you make? (3 points)
She is currently taking 20mg of Furosemide daily. This is a water pill that reduces
swelling and water retention caused by medical problems.9 Furosemide and ethanol have
an added effect that will lower ones blood pressure. She should avoid any alcohol while
taking this drug.10
She should also avoid a high sodium diet since sodium causes water retention.
Therefore further suggestions would include, a low sodium diet with potassium rich
foods. These foods include bananas, avocados, raisins, prunes and orange juice. I would
also recommend that she drinks plenty of fluids in order to maintain homeostasis between
the fluids and salt in her body.9
5. Interpret her serum albumin and prealbumin. (2 points) In addition to nutritional
intake, what factors can cause these indices to drop? (2 points) What factors would
cause them to be elevated? (1 point)
Her serum albumin and serum prealbumin are low in comparison to the normal
ranges. Factors that could cause these indices to drop include the bodys ability to absorb

protein and liver or kidney disease. Factors that would cause her serum albumin levels to
be high would be dehydration, or a high protein diet.11,12
6. Describe how factors in her anthropometric, biochemical, clinical, and dietary
nutritional assessment data all fit together to form a picture of her nutritional
health. (5 points)
She has had a significant weight loss, 20lbs over 6 months, since her husband
passed away. Her weight loss makes sense in comparison to her diet. She is eating very
small meals, because she has been unmotivated to cook ever since she lost her husband.
She may also only eat certain foods, or decreased amounts of foods, because her dentures
do not fit her and her oral mucosa is dry. She also has a decreased skin turgor which
represents her dehydration. Her biochemical data shows that she is getting lower amounts
of potassium and albumin than needed. Elderly individuals with significant weight loss
are at a higher risk for infection, depression and death. The leading cause for sudden
weight loss, in elderly, is depression. She is most likely depressed after her husband
passed away and does not want to put in the effort to make sure she is getting her
required nutrients. This assessment shows that she is at a risk of declining overall health
and becoming malnourished.3, 13
7. Write a PES statement based on the nutritional assessment data available. (5 points)
Involuntary weight loss (NC- 3.2) related to inadequate energy intake (NI-1.2) as
evidence by diet history and 20lb weight loss over the last 6 months. 14,15
Inadequate fluid intake (NI-3.1) related to self-monitoring deficit (NB-1.4) as
evidence by decreased skin turgor. 14,15
8. What dietary and social changes would you suggest to improve her nutritional
intake? (5 points)
I would first suggest that she change her dentures since they do not seem to fit
her, and could be the reason why she is not eating certain foods. I would then suggest that
she make an effort to eat more vegetables, fruits, dairy and whole grains on a daily basis.
Although she does not drink milk due to food preferences, she could incorporate dairy
into her meals. I would suggest low fat cheese, yogurt, and using the milk in recipes. She
should look for foods high in fiber, high in potassium and low in salt. I would also
suggest that she find a way to incorporate eggs in foods, to raise her serum albumin
levels. She could purchase cook books to help her with meals and recipes. I think it may
be in her best interest if she finds someone that may be able to help her cook her meals at
home, if she cannot or is not willing to start cooking more. If she is unwilling to have
someone help her, I would recommend healthy ready to eat options that are quick and
easy for her to prepare. She can easily get fruits and vegetables without having to put in
much effort, she can also eat yogurt and cheese without much preparation. She should
also buy breads that are whole grains and high in fiber. She could also join a support
group for widows in order to re-gain her motivation after the loss of her husband.16,17

9. What are your nutritional goals for her (2 points), and how would you monitor the
effectiveness of your interventions from question #8? (3 points)
My goals for her would be to stabilize her weight by getting the necessary amount
of calories for her age, weight and activity factor. Another goal would be to get the daily
nutrient requirements, for her age, by putting in more effort with her food choices; this
goal should also include stabilizing serum albumin and prealbumin levels. Another
significant goal would be to get the 11 cups of fluid a day to decrease her dehydration. In
order to make sure these goals are achieved I would have her come back weekly for the
first month, to monitor weight change, skin turgor, and to test albumin and prealbumin
levels. Once weight has been stabilized, the albumin levels and prealbumin levels are in
the normal ranges, and her skin turgor is back to normal, I would then have her come
back monthly to monitor her diet choices. 16
10. Write a note documenting your assessment in SOAP or ADIME format. (5 points)
A.
72 y/o Female
Pertinant labs: Albumin - 3.2g/dL , Prealbumin - 11mg/dL , Potassium 3.3mEq/L
BMI: 21.9
Wt. 140 Ht. 57
IBW: 135.5
%IBW: 103%
UBW: 160
%UBW: 87.5%
Medications: Furosemide 20mg a day
Physical findings: poorly fitted dentures, skin turgor decreased
D.
-Involuntary weight loss (NC- 3.2) related to inadequate energy intake (NI-1.2) as
evidence by diet history and 20lb weight loss over the last 6 months.
-Inadequate fluid intake (NI-3.1) related to self-monitoring deficit (NB-1.4) as
evidence by decreased skin turgor.
I.
Goals:
Stabilize weight.
Stabilize serum albumin and serum prealbumin levels.
Consume the necessary amount of calories for her age, weight and activity
factor.
Make an effort to eat more vegetables, fruits, dairy and whole grains on a
daily basis.
Increase motivation to consume the daily nutrient requirements.
Consume more fluids daily.
Recommendations:
Change dentures since they do not fit properly.

Incorporate dairy into meals. I would suggest low fat cheese, yogurt, and
using the milk in recipes.
Look for foods high in fiber, high in potassium and low in salt.
Incorporate eggs in foods, to raise serum albumin levels.
Use cook books to help with meals and recipes.
Find someone to help cook meals at home.
Join a support group for widows to re-gain motivation.

M/E.
Monitor/Evaluation
Follow up weekly, for one month, to monitor weight change, skin turgor,
serum albumin and serum prealbumin levels.
Once stabilized follow up monthly, for 6 months, to assess the diet and
weight change, test serum prealbumin and albumin levels.
Self- monitor weight weekly.

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