MCPHS University School of Nursing1```

NUR 207
Case Study– Nutrition
Adapted from Case Studies in Nursing Fundamentals by Margaret Sorrell Trueman

Student Name: Navjeet Dhindsa Date: February 23, 2019

Directions: Complete the following case study prior to class. Use your available resources in
completing the case study. Each case study must be completely filled in with no questions left
blank. Points will be deducted for incomplete answers. Completion of this case study will count
toward 1 hour of out of class activity.
As part of his clinical rotation, Sean Martin is assigned to work with the nutritional support
team at the hospital. The team includes a registered nurse, registered dietitian, pharmacist,
and medical physician. Patients with actual or potential nutritional issues are referred to this

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team for management of their nutritional care as well as support for those caring for these

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patients including the nursing staff and family.

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The census list for consultation for the day’s rotation includes the following patients:

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• Mrs. Sharon Feinstein, an 81-year-old female with dementia and weight loss
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• Mr. Adam Belcher, a 37-year-old male with severe hypertension
• Ms. Amelia Stroupe, a 77-year-old female with right-sided weakness and mild
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dysphagia
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• Ms. Michelle Ryan, a 42-year-old female with difficulty breathing secondary to

exacerbation of COPD
Ms. Ryan tells Sean, “I just don’t have much of an appetite anymore and I know I need to
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eat to get better.”

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1. What measures might be used to stimulate Ms. Ryan’s appetite at mealtimes?

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Offering foods that Ms. Ryan enjoys and an attractive presentation of the food can stimulate
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appetite. Also, allowing ample time to eat will encourage her to eat since a sense of having to
rush through a meal can decrease enjoyment and cause distraction, which leads in inadequate
intake of food. Increasing awareness of good nutrition may also help facilitate her intake.
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The nurse tells Sean that Mrs. Feinstein has the characteristics of malnutrition.
2. What results would support this interpretation? Consider applicable laboratory and body
composition data.

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 Patients with malnutrition are expected to have longer length of stay at the hospitals with the
average of 11 days. The nutrition-focused physical examination (NFPE) is an essential
component for diagnosing malnutrition. The NFPE is very sensitive for assessing nutritional
status, which is more likely to be low when an individual is suffering from malnutrition. It would
be important to focus on general characteristics such as edema, muscle wasting and
subcutaneous fat loss due to specific micronutrient related deficiencies.
It would be important to monitor albumin, prealbumin, nitrogen and transferrin in blood
stream. Albumin which is a carrier for various minerals, fatty acids and hormones can be used to
determine malnutrition in a client. Patient with less albumin levels can be considered to be mal-
nutritious. Similarly, prealbumin that also serves as a transport protein for thyroxine is also
helpful in finding if the patient is suffering from malnutrition. Both albumin and prealbumin are
used as a more reliable indicator of acute changes in a patient’s nutritional status. Moreover,
high levels of transferrin in blood stream due to increased amount of iron absorption is also a

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good indicator. Another important indicator is nitrogen. Nitrogen balance is also helpful in

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determining client’s protein intake. Negative nitrogen balance means there is more loss than

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intake, which can be used as a marker for assessing malnutrition.

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3. What physical assessment data should Sean anticipate finding in this situation?
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Seam must look for edema, weight loss, insufficient energy intake, muscle wasting or
subcutaneous fat loss due to nutrition related deficiencies. Local or generalized accumulation
can also be a sign of malnutrition.
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The family wishes to try enteral feedings for 6 weeks to enhance Mrs. Feinstein’s quality of
life. Orders are received to place a feeding tube in preparation for enteral feedings.
4. Which type of feeding tube is indicated for this situation? Why?
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Enteral tube would be the best choice for Mrs. Feinstein that uses gastrointestinal tract to
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deliver calories/nutrients. Due to dementia, patient might get confused and can harm herself
with the tubes inserted in the veins by pulling them out when agitated.
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5. After the feeding tube is inserted the placement of it must be confirmed. What
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techniques can be used to check for tube placement for this patient situation?
The use of radiographic confirmation is one of the reliable methods of confirming tube
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placement. Auscultation of an air bolus to assess tube placement is another

way of determining gastric tube placement, however, it is not considered
very effective and reliable.
6. What strategies should to nurse use to prevent Mrs. Feinstein’s tube from clogging?
What strategies can be used if the tube does become clogged?

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 To prevent Mrs. Feinstein’s tube from clogging, it is important to make sure that routine flushing
of the tube is performed with 30 mL of water every four hours, before and after administering
medication. It must be confirmed with the pharmacist that all the medications given through
the tube are compatible with the EN formula and that the medications can be easily cleared
from the tube with adequate flushing. Flushing with warm water can be helpful to unclog the
tube. If water fails to unclog the tube, a solution with pancreatic enzyme can be flushed through
the tube, however, the enzyme solution requires permission from the doctor.

Mrs. Stroupe has been placed on aspiration precautions for her dysphagia.
7. What is dysphagia?
Dysphagia is difficulty swallowing means it takes more time and effort to move food or liquid
from your mouth to your stomach. Dysphagia may also be associated with pain.

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8. Mrs. Stroupe’s foods and liquids might come in different form due to her dysphagia and

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risk for aspiration. What levels/forms of liquid food might be prescribed for her? What

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levels/forms of semisolid/solid food might be prescribed for her?

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Suggested forms of food for Mrs. Stroupe would be liquid or semi-solid food so that the patient
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does not have difficulty swallowing. Liquid and semi-solid food will also facilitate ingestion
without causing food to enter or block the respiratory tract.
9. What techniques should Sean implement during meal times to prevent Mrs. Stroupe
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from aspirating?
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To prevent aspiration, Sean must elevate the head of the bed to 45 degrees or higher during
eating and for a minimum of 45 minutes after eating. The head of the bed must be kept at 30
degrees at all other times to prevent entry of saliva into the respiratory tract. Encouraging Mrs.
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Stroupe to slow eating patterns can also avoid risk for aspiring.
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Mr. Belcher needs dietary instruction in regard to calorie reduction and sodium restriction.
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10. He comments to Sean, “I just don’t feel like I am that overweight like the doctor says I
am. I’ve always been big boned and played football—I still do some pickup games. I am 6
feet tall and only 265 pounds and in great shape.” What is this patient’s body mass index
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(BMI)? What is this patient’s BMI classification?

BMI of the patient is 36.8 and the classification of the BMI is class II obesity.

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