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From the admitting physicians note:

Chief complaint: I am always short of breath, especially when I am doing any kind of physical
activity and my husband thinks I am confused in the morning.
Patient Hx: Stella Bernhardt is a 62-year-old Caucasian retired office manager who is married
and has 4 grown children. Mrs. Bernhardt was initially diagnosed with type I COPD
(emphysema) five years ago. She has a 46-year history of smoking, but quit 1 year ago. She
states: Im hardly able to do anything for myself right now. Even taking a bath or getting
dressed makes me short of breath. I feel that I am gasping for air. I am coughing up a lot of
stuff that is dark brownish-green. Mrs. Bernhardt is wondering if her symptoms are related to
her COPD.
Type of treatment:
PMH: COPD type I (emphysema), bronchitis and upper respiratory tract infections (mostly
during winter months), four live births, and two miscarriages
Meds: Combivent inhaler
Allergies: None
Smoker: 1 ppd
Family Hx: Father deceased at age 52 from pneumonia, mother still living
Physical Examination:
General appearance: Very thin, middle aged woman, evident temporal and interosseous wasting,
in no acute distress
Vitals: Temp 99.1 F, BP 135/70, HR 77 BPM, RR 21
Skin: Warm, skin pallor
Nail bed: mild koilonychias
Eyes: pale conjunctiva
Height: 53
Weight: 92 lbs
Mid arm muscle circumference (MAMC): < 5th percentile,
Exhibits generalized loss of muscle in shoulders and thighs. Subcutaneous fat loss is evident in
triceps.
Clinical Examination:
The nervous system is intact. Chest/lung examination reveals decreased breath sounds,
percussion hyperresonant, prolonged expiration with wheezing, rhonchi throughout. Pt has
poorly fitting dentures.
From the initial nutrition screen documented by dietetic technician:
Nutrition Hx:
General: Mrs. Bernhardt states that her appetite is poor. She says I fill up so quickly after just
a few bites. She also relates that meal preparation is difficult: By the time I fix a meal, I am too
tired to eat. And things just dont seem to taste as good either. In the previous two days, she
states that she has eaten very little. Increased coughing has made it very hard to eat. Her
normal adult weight was 145-150 lbs (~3 years ago). She estimates that she weighed ~120 lbs
about 6 months ago. She states that her family constantly tells her how thin she has gotten. She
states that she hasnt weighed herself for a while, but that she knows her clothes feel baggy.

Typical dietary intake:


Breakfast:
1 poached egg, 1 tsp butter, 1 slice whole wheat toast, 16 oz. coffee, 1 T.
half and half, cup orange juice
Lunch:
3 chicken nuggets (fast food), cup mashed potatoes, 1 T. reduced fat
margarine, 1 biscuit (plain), 16 oz. coffee, 1 T. half and half
Dinner:
1 cup cream of mushroom soup made with water, 1 slice whole wheat
toast, large (8 oz.) banana, 36 oz. Diet Pepsi
HS Snack:
3 saltine crackers, 1 oz. American cheese
Food allergies/intolerances/aversions: None
Previous MNT? Mrs. Bernhardt has never met with a Registered Dietitian in the past, but her
primary physician has told her she needs to increase calorie consumption.
Food purchase/preparation: Mrs. Bernhardt purchases and prepares her own food or she eats at
restaurants/fast food outlets. She avoids milk because she has heard it can increase mucous
production.
Vit/Min or other supplements: None
Activity: None
Treatment Plan:
O2 1 L/min via nasal cannula with humidity keep oxygen saturation (SaO2) 90 91%
IVF: D5 NS with 20 mEq KCl @75 ml/hr
Labs/Tests: ABGs q 6 hours, CXR EPA/LAT, sputum cultures and gram stain
Diet order: Regular
Meds:
Solumedrol 10 mg/kgq 6 hr
Ancef 500 mg q 6 hr
Ipratropium bromide via nebulizer 2.5 mg q 30 minutes X 3 treatments then q 2 hr
Albuterol sulfate via nebulizer 4 mg q 30 minutes X 3 doses then 2.5 mg q 4 hr
Hospital course:
Mrs. Bernhardt was diagnosed with acute exacerbation of COPD secondary to bacterial
pneumonia. This was confirmed by CXR (chest X-ray) and sputum culture. She responded well
to aggressive medical treatment for her emphysema. She will be discharged on home oxygen
therapy for the first time, and referred to outpatient pulmonary rehabilitation. Her discharge
medications will be the same (Combivent), but she will complete an oral course of
corticosteroids and an additional 10-day course of Keflex. A nutrition consultation is ordered,
with recommendations for nutrition follow-up through the outpatient pulmonary rehabilitation
program.

Laboratory data:
Lab Test

Day 1

Day 2

Day 3

Normal Range

Units

Glucose

92

103

88

70 - 110

mg/dL

Na

139

137

140

136 - 145

mEq/L

Cl

101

100

99

95 - 107

mEq/L

K+

3.7

3.6

3.6

3.5 - 5.0

mEq/L

8 - 25

mg/dL

Cr

0.9

0.9

0.8

0.6 - 1.5

mg/dL

Phosphorus

2.3

2.5

3.0

2.6 - 4.5

mEq/L

Mg++

1.5

1.7

1.5 - 2.2

mEq/L

Calcium

8.2

8.1

3.0 7.0

mg/dL

Albumin

8.0

8.5 10.5

mg/dL

4.5

6 8.5

g/dL

BUN

Prealbumin
Alkaline Phosphatase
Lab Test

8.0

4
220

219

217

200 - 400

mg/dL

Day 1

Day 2

Day 3

Normal Range

Units

White Blood Cells (WBC)

115

25 - 160

U/L

Hemoglobin (Hgb)

10.5

12.5 17.0

g/dL

Hematocrit (Hct)

33

36.0 50.0%

Mean corpuscular volume (MCV)

65

80.0 98.0

fL

pH

7.29

7.35 7.45

PCO2

50.9

35 - 45

mmHg

77

80 - 100

mmHg

24.7

22 - 26

mEq/L

Arterial Blood Gases:

PO2
HCO3

Laboratory information prior to admission:


Annual CBC and lipid profile- WNL

NUTRITION ASSESSMENT
Dietary Intake Data
1. From Mrs. Bernhardts typical dietary intake, calculate the total number of calories she
consumed. Also calculate the energy distribution of calories for protein, carbohydrate, and fat.
For this question, you must use the Exchange Lists for Meal Planning (Use Appendix 34 in the
back of the Krause text: See pp. 1110-1121 (13th ed.) and Module III, An Introduction to the
Exchange Lists for Meal Planning), and complete each of the steps outlined below, showing
your calculations.
Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate
that is designated as such under Other Carbohydrate or Combination lists as simply
Carbohydrate rather than Starch, and then count these separately under Other
Carbohydrates in the table for Step 2. Complete the table below. (10 points)
Breakfast
1 slice whole wheat toast
1 tsp butter
1 poached egg
16 oz. coffee
1 Tbsp half and half
cup orange juice
Lunch
3 chicken nuggets (fast food)
cup mashed potatoes
1 Tbsp reduced fat margarine
1 biscuit (plain)
16 oz. coffee
1 Tbsp non-dairy creamer
Dinner
1 cup cream of mushroom soup made
with water
1 slice whole wheat toast
1/2 large (8 oz) banana
36 oz. Diet Pepsi
Evening (HS) Snack
3 saltine crackers
1 oz. American cheese

Counts As (Specify Exchanges)


1 starch
1 fat
1 medium fat meat
Free food
0.5 fat
1 fruit
0.75 CHO + 1.5 medium fat meat
1 starch
1 fat
1 starch
Free food
Free food
1 CHO + 1 fat
1 starch
2 fruits
Free food
0.5 starch
1 high fat meat

Step 2: Add the totals from the table in step 1. Count all items that were listed anywhere
besides the STARCH list, that counted as carbohydrate exchanges, under the Other
carbohydrate section in the table below. Count as starches ONLY those foods listed
specifically on the STARCH list. (10 points)
Total
servings/
day

Exchange Group

CHO
(g)

Protein
(g)

Fat
(g)

15

Use 0

15

15

12

12

12

12

4.5

Starch

Non-Starchy Vegetables

Fruit

1.75

Other Carbohydrates

Fat-Free Milk
Low-Fat Milk (1/2 - 1%)

Reduced-Fat Milk (2%)

Whole Milk

Lean Meats/Substitutes

Medium Fat Meats/Substitutes


High Fat Meats/Substitutes

2.5
1
3.5

Fats

TOTAL grams

138.75

38

38

Determine kcals by multiplying TOTAL grams

X4=

X4=

X9=

TOTAL KCALS

555

152

342

GRAND TOTAL KCALS (CHO + protein + fat)

1049

Step 3: Determine the % kcals provided by CHO. (2 points)

52.9%

Step 4: Determine the % kcals provided by protein. (2 points)

14.5%

Step 5: Determine the % kcals provided by fat. (2 points)

32.6%

Anthropometric Data
2. A. Calculate Mrs. Bernhardts ideal weight using the Hamwi equation. (2 points)

115 lbs.

B. Calculate the % ideal weight and % usual body weight she is at her current weight. (4
points)

Ideal
92/115 = 80%
Usual
Its a range of 145-150lbs.
92/145 = 63.4%
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C. Calculate Mrs. Bernhardts BMI. Into which category does she fall, based upon the
National Institutes of Health, National Heart, Lung, and Blood Institutes Clinical
Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults, which was provided in the Nutrition Assessment II: Anthropometry notes? (2
points)
BMI
16.29
Underweight classification

D. Evaluate Mrs. Bernhardts current weight in terms of change from usual body weight
over time (be specific). If she has lost weight, is it clinically significant? Explain. (4
points)
% weight loss
in 6 mo.
120-92/120 X 100 = 23.3%
severe weight loss category

3. Evaluate Mrs. Bernhardts dietary intake, anthropometric, PE/clinical, and biochemical data
pertinent to her pulmonary status. When appropriate, compare her data to standard/normal
values. Be as thorough and SPECIFIC as possible, and then clearly identify at least ONE
piece of data that is of concern from a nutritional standpoint within each data category
as you begin to prioritize the most prominent nutrition issues that need to be addressed.
EXPLAIN your rationale for each issue that you mention.
A.

Dietary intake data (Refer back to what you found in question #1 and evaluate Mrs.
Bernhardts intake in terms of major nutrients or food groups that appear to be
lacking, and any obvious problems you think she is having with intake) (2 points):
She is not consuming any lean meats, milk, or vegetables. Mrs. Bernhardt is lacking
essential nutrients that are readily available in these foods, such as vitamin B,
vitamin D, iron, and riboflavin. I think she is filling up on free foods in her diet,
which dont allow her to desire any other foods with nutrients. She seeks convenience
with foods, which oftentimes means fast food or pre-packed foods. Soups, chicken
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nuggets, and mashed potatoes are all high in sodium and contribute to her high
starch and fat intake.

B.

Anthropometric data (refer back to your answers in question #2) (2 points):


Patient has undergone severe weight loss in the last 6 months and is considered
underweight for her height. Patient is only at 80% of her ideal body weight, which is
contributing to her wasting appearance.

C.

PE/clinical findings (2 points):


Patient has very thin appearance with evident temporal and interosseous wasting. No
acute distress is seen. She had a temperature of 99.1F, a blood pressure of 135/70, a
heart rate of 77 beats per minute, and a resting rate of 21 beats per minute. Patients
skin is warm to the touch and has skin pallor, most likely from malnutrition. Her nail
beds show mild koilonychias, or spoon-shaped nails. Her eyes show pale conjunctiva.
Patient falls into the less than 5th percentile for mid arm muscle circumference and
exhibits generalized loss of muscle in shoulders and thighs. Subcutaneous fat loss is
evident in triceps. She is 53 and weighs 92 lbs. Clinical findings show her nervous
system is intact. A chest/lung examination shows decreased breath sounds, percussion
hyperresonant, prolonged expiration with wheezing, and rhonchi throughout.
Patients dentures are fitting poorly.

D.

Biochemical data (2 points):


Overall, patients lab values are mostly in the normal range. Calcium levels are high
and prealbumin levels are low. Hemoglobin, hematocrit, and mean corpuscular
values are all low, indicating that she is not getting a sufficient amount of iron in her
diet. Looking at the patients arterial blood gases, pH level and PO2 level are too low
and PCO2 is higher than normal, indicating a respiratory issue. The bicarbonate is
in a normal range, meaning the kidneys are not compensating for this disturbance.

4. Calculate Mrs. Bernhardts serum osmolality from her admission labs, as one indicator of her
hydration status upon admission. What does this value you calculated suggest about her
hydration status at admission? Mention any relevant clinical/PE data to support your
evaluation. (6 points)

On Day 1, upon admission, her serum osmolality was at 286.32. This value suggests that the
patient was normally hydrated upon admission. Her electrolyte value of Na+ and K+
confirm this as they are also in normal range.
5. Review all four of Mrs. Bernhardts current medications, and describe any relevant foodmedication interactions. If there are no relevant food-medication interactions for a particular
medication, be sure to state that. (4 points)

Solu-medrol (Methylprednisolone): Grapefruit juice may increase blood levels and effects of
drug.
Ancef: Consuming alcohol with this antibiotic may reduce the effectiveness, cause upset
stomach, drowsiness, and dizziness.
Ipratropium Bromide: May slow down the movement of food through the stomach, allowing
patient to develop low blood sugar. May also exacerbate symptoms of COPD.
Albuterol Sulfate: No relevant food-medication interactions.

6. Look at Mrs. Bernhardts arterial blood gas report when she was admitted.
Using your Assessment of Acid-Base Balance notes, assess Mrs. Bernhardts acid-base
status at admission. She could be in one of 4 conditions (see the summary chart at the end of
the note set): Specify whether she is in respiratory or metabolic (one or the other, depending
upon the origin of the disorder) acidosis or alkalosis. Use specific values to support your
answer. (4 points)
Based on her lab values, the patient has respiratory acidosis that is uncompensated. Because
her pH value is lower than the normal range and PCO2 is above the normal range, this
indicates a respiratory issue. She also has COPD, which is known to be a respiratory issue.
She has acidosis because her pH is 7.29, below the normal range. She falls into the
uncompensated category because her bicarbonate value are normal, meaning her kidney is
not doing anything to make up for the other arterial blood gases being out of range.

Calculation of Nutrient Needs


7.

Refer to the guidelines given in Module II: Energy, Protein, and Fluid Requirements in
the Clinical Setting and Module IX: Pulmonary Disorders to complete the following.
Show your work and specify the source for your answers, and explain your reasoning for
making the choices you made.

A.

Using an appropriate prediction equation (with or without activity/stress or injury


factor, as you deem appropriate), estimate Mrs. Bernhardts total energy
requirement. As always, explain your thinking and show your work. (4 points)
TEE = 1483kcal
Patient is has acute/chronic illness and needs to gain weight. RMR was determined to
be 1059kcal, then it was multiplied by 1.4 for a stress factor to find a range of energy
she needs to consume.

B.

Cross-check your answer found in 7A by calculating what your assessed total


energy requirement is on a kcal/kg basis. You do this by taking the total energy
requirement estimated by your prediction equation method and dividing it by Mrs.
Bernhardts weight to get kcal/kg. How does the number you calculate compare to
the consensus numbers provided in Module II (i.e. is it within the range of what RDs
tend to use, even though this practice is not evidence-based per se)? Show your
calculations. (2 points)
Assessed TEE: 35.6kcal/kg
This value seems reasonable and is within the range of what RDs tend to use when a
patient is underweight and promoting energy repletion.

C.

Estimate Mrs. Bernhardts protein requirement. Explain your thinking and show
your work. (2 points)
Protein requirement: 50g 70.9g
1.2 1.7 g/kg of body weight.
Patient is recommended to start at the lower end and increase gradually to promote a
positive nitrogen balance.

D.

Using guidelines given in Module II, estimate Mrs. Bernhardts fluid needs. Show
your work. (2 points)
Fluid Needs: 1251 mL

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Patient is 62 years old and falls into the older adults category for fluid needs. 30
mL/kg is recommended for her.

E.

Now go back to what you calculated as Mrs. Bernhardts typical total energy and
protein intake from Question #1, and compare it to your estimated total daily energy
requirement from part A. of this question (7A) and to your estimated total daily
protein requirement calculated in part C. of this question (7C). In other words, how
does her typical energy and protein intake compare to what you think are her actual
needs? You should express any differences in whole numbers and also as a
percentage of estimated needs (i.e. actual intake/estimated needs X 100). (2 points)

Energy comparison: Patient should be getting 1483kcal/day, but she is getting


1049kcal/day. She is only getting 70.7% of her recommended energy intake.
Protein comparison: Patient should be getting 50 70.9 g/day, but she is getting 38
g/day. She is only getting 53.6% to 76% of her recommended protein intake.

NUTRITION DIAGNOSIS
8. Based on your assessment in question # 3, refer to the four required supplemental articles on
malnutrition listed under September 4th in the course schedule of the syllabus to determine if
Mrs. Bernhardt meets the definition of a specific category of malnutrition. Explain your
rationale with specific data relevant to the malnutrition characteristics. (2 points)
According to the Journal of Parenteral and Enteral Nutrition, I believe the patient fits into
the category of chronic condition malnutrition. Mrs. Bernhardt has developed COPD and
pneumonia, both contributing stress on her body. Higher amounts of protein are required for
her to fight these illnesses.

9. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record

Documentation and your nutrition diagnoses pages from the IDNT Reference Manual. Based
on what you discovered in earlier questions, identify TWO of Mrs. Bernhardts most
prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL
and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS) using the standard Nutrition
Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each
nutrition diagnosis you write. Even if you determined in the preceding question that she is
malnourished, choose two nutritional diagnoses OTHER than malnutrition that you can
address as the RD. In other words, think about the reasons why she is malnourished as you
identify her most important nutrition diagnoses.
A.

Nutrition Diagnosis #1: (2 points)


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Patient has inadequate energy intake (NI-1.2 10634).

B.

Nutrition Diagnosis #2: (2 points)


Patient has impaired ability to prepare foods/meals (NB-2.4 10785).

NUTRITION INTERVENTION, MONITORING AND EVALUATION


10. Now go back to your two nutrition diagnoses. For each one, write a complete nutrition
diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling
each section (P, E, and S) appropriately. Identify your short- and long-term goals, an
appropriate intervention strategy to address the problem, and measurable outcomes you will
monitor to evaluate the effectiveness of your intervention. You may want to use Module II
and the What is ADIME document on the course web site under Reference Materials and
Resources for Clinical Cases to help you with this question.
10.1
A.

PES #1: (3 points)


Patient has inadequate energy intake related to difficult meal preparation as
evidenced by poor appetite.

B.

Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE short- and long-term goal that you will establish collaboratively
with Mrs. Bernhardt. Remember that the goals should be clear, measureable,
achievable, and time-defined. (4 points)
Short-term goal (i.e. between now and the next visit):
Patients energy intake will increase from 70% of her required energy intake to
80% of her required energy intake between now and her next visit (approx. 3
weeks).

Long-term goal (i.e. over the next several visits, or longer):


Patients required energy intake will be met over several visits or longer (10+
weeks).
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C.

Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of
care with the patient)
State what nutrition-related action(s) you as the RD will take to address the
problem identified in part As PES statement. Be sure that the
INTERVENTION will specifically address the nutrition-related diagnosis
and/or its underlying etiology described in your PES statement. This
information will be documented in the Intervention section of your ADIME
chart note. (2 points)
Patient received Meals on Wheels food service prepared food delivered straight
to her door.

D.

Measurable Outcome: State what nutrition care indicator you will MONITOR in
order to EVALUATE the progress of the patient resulting from your
INTERVENTION described in part C. Nutrition care indicators are clearly defined
markers that can be observed and measured and are used to quantify the changes that
are the result of nutrition care. For example, food and nutrient intake data, laboratory
values, etc. Keep in mind that you may also identify clinical/laboratory parameters
that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is
the intervention you identified for your PES. Be sure that the nutrition care indicator
can be used specifically to evaluate the success of your nutrition intervention. This
information will be documented in the Monitoring/Evaluation section of your
ADIME chart note. (2 points)
Monitor
Patients weight gain will be monitored during office visits to ensure that she is
receiving adequate caloric intake from the Meals on Wheels program.
Evaluate
Patient was able to eat breakfast, lunch, dinner, and snacks from the food provided
by Meals on Wheels and will be able to successfully plan one day of meals using
Meals on Wheels recipes as reference for portion and consumption.

10.2
A. PES #2: (3 points)

Patient has impaired ability to prepare food related to low iron levels as evidenced by
fatigue following meal preparation.
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B. Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE short- and long-term goal that you will establish collaboratively
with Mrs. Bernhardt. Remember that the goals should be clear, measureable,
achievable, and time-defined. (4 points)
Short-term goal (i.e. between now and the next visit):
Patients hemoglobin will by 20% of her level upon admission within 3 weeks.

Long-term goal (i.e. over the next several visits, or longer):


Patient will consume 3-5 servings of heme and non-heme iron sources per day
(10+ weeks).
C.

Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of
care with the patient)
State what nutrition-related action(s) you as the RD will take to address the problem
identified in part As PES statement. Be sure that the INTERVENTION will
specifically address the nutrition-related diagnosis and/or its underlying etiology
described in your PES statement. This information will be documented in the
Intervention section of your ADIME chart note. (2 points)

Patient received nutrition counseling and education to support her through the process of
preparing meals.

D.

Measurable Outcome: State what nutrition care indicator you will MONITOR in
order to EVALUATE the progress of the patient resulting from your
INTERVENTION described in part C. Nutrition care indicators are clearly defined
markers that can be observed and measured and are used to quantify the changes that
are the result of nutrition care. For example, food and nutrient intake data, laboratory
values, etc. Keep in mind that you may also identify clinical/laboratory parameters
that you will use to establish tolerance and/or efficacy of a feeding regimen, if that is
the intervention you identified for your PES. Be sure that the nutrition care indicator
can be used specifically to evaluate the success of your nutrition intervention. This
information will be documented in the Monitoring/Evaluation section of your
ADIME chart note. (2 points)

Monitor

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Patients iron levels will be monitored by blood tests during office visits to ensure
that her hemoglobin levels are rising from the heme and non-heme iron sources of
her diet.
Evaluate
Patient was able to prepare and eat breakfast, lunch, dinner and snacks from her
rising iron levels and feels comfortable preparing meals without being easily
fatigued.

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