Ariella Krapin

Plan
NTR 417

Nutrition Care
Spring 2016

Nutrition Care Narrative: Dr. K

SOCIAL HISTORY: Dr. K is a 68 year old white male who resides at a nursing home in
Albany, NY. He is a retired neurologist. He is not stable on his feet and spends most of
his time in a wheelchair. His family reports him having a very good appetite in the past.
He also has no history of smoking or alcohol consumption.
Nutritional Implications: Dr. K receives around the clock support from the nursing
home staff. His diet is very well controlled since he resides in a nursing home. However,
sometimes he refuses to eat and is noncompliant with medications. Incorporating
nutritional counseling into Dr. K's treatment plan could help assist him in slowly
increasing his appetite with foods that he used to eat frequently.
MEDICAL HISTORY: Dr. K is 70 inches (178 cm) and 154 lbs (70 kg), a BMI of
approximately 30. His has a history of tremor in his right hand, kyphosis, and dyskinetic
movements since the onset of his Parkinson's disease. He also has a history of poor
dentition, sialorrhrea, chronic dry eye, and constipation. Recently, he developed DVT in
his lower limbs after being admitted to the ICU s/p falls. Additionally, Dr. K has an
ongoing history of anxiety and depressive symptoms. He remains very alert and oriented.

Nutritional Implications: Dr. K's medical problems adversely affect his nutritional
status. His resting tremor and dyskinetic movement put him at a greater risk for
catabolism and as a result, malnourishment. He has difficulty serving himself food with
the tremor and dyskinetic movements. His sialorrhea, along with his head drooping, can
put Dr. K at a greater risk for aspiration or choking. His dentition, which consists of tooth
decay and edentulous sites, requires most of his food to be pureed.
DIET HISTORY:
Dr. K's appetite is very inconsistent; he either will eat too much or barely eat at all. These
fluctuations are dependent on his mood. His overall diet is a regular puree diet, always
including the option of peanut butter and jelly sandwich, chocolate milk, or Ensure Plus.
His diet also includes a daily 4 oz of prune whip for his constipation. His current diet
order provides him with 1538 calories and 77 grams of protein per day.

Nutritional Implications:
To complement Dr. K's current pureed dysphagia diet, he should have straws and other
adaptive eating devices offered to him to further reduce risk of aspiration. Dr. K is not
getting his optimal amount of calories per day since does not always eat all meals
provided. His current protein intake of 77 grams is lower than the 83 g (1g/kg)
recommended amount to maintain anabolism. Dr. K is not receiving adequate hydration.
In addition to more fluids, he needs more fiber included in his diet to improve his
ongoing constipation. Dr. K's diet is sufficient in copper and iron, phosphorus and
selenium. He is deficient in calcium, zinc, magnesium, and potassium, which all have
anti-inflammatory components important in managing his disease and DVTs. Magnesium
and zinc also could improve his mental state and neurologic deficits relating to muscle
tone and range of motion.
MEDICATIONS:
-Levodopa-Carbidopa (Sinemet) 25/100 po tid: a combination medicine used in which
Levodopa converts to dopamine via Dopa decarboxylase in the brain. Sinemet helps
control movement and Carbidopa prevents the breakdown of Levodopa in the
bloodstream so more levodopa can enter the brain. Carbidopa also may reduce Levodopa
side effects such as nausea and vomiting.
(http://www.webmd.com/drugs/2/drug-3394-41/carbidopa-levodopa-oral/carbidopalevodopa-oral/details)
Nutritional Implications: The absorption of Sinemet is decreased when taken with
protein. Dr. K should limit his protein intake when takes his Sinemet. Vitamin B 12
should also be limited during these times as well. Dissolving Sinemet in carbonated
drinks such as ginger ale can provide improved efficacy.
-Enoxaparin (Lovenox) 1mg/kg SC bid:
an anti-coagulant therapy that helps prevent the formation of blood clots
Nutritional Implications: No food limitation, monitor for bleeding
-Quetiapine (Seroquel) 25mg daily (minimal extrapyramidal side effects or EPSE):
an antipsychotic drug to improve his hallucinations
Nutritional Implications: May trigger chronic drowsiness. Dr. K may fall asleep in
his wheelchair, which will droop his head down even further, increasing risk of aspiration
if eating.
-Biscodyl (Dulcolax) 5mg po daily:
a stimulant laxative to treat constipation
Nutritional Implications: N/A

-Bumex 0.5mg po bid: Potent diuretic used to treat fluid retention and high blood
pressure
Nutritional Implications: Bumex can decrease electrolytes, resulting in
hypokalemia, hypomagnesemia, and hypocalcemia. Dr. K's diet indicated hypokalemia,
which may be exacerbated by Bumex. He can increase potassium with bananas, prunes,
and orange juice.
PATHOPHYSIOLOGY:
Definition: Parkinson's disease (PD) is a chronic and progressive neuro-degenerative
motor disorder that affects the dopaminergic neurons in the substantia nigra. The disease
is characterized by cardinal symptoms of slow, limited movement (bradykinesia),
muscular rigidity, resting tremor, and postural instability (Mahan 2012). PD is diagnosed
by patients exhibiting at least two of these four major symptoms. Approximately 10-15
percent of patients with PD have close relatives with parkinsonian symptoms (Mandal).
Etiology: The cause of PD is not yet known, although it is suspected that is may be
multifactorial, including risk factors such as age, genetic factors (Parkin, PINK1,
LRRK2, DJ-1, and glucocerebrosidase, gene mutations, among others), environmental
factors (chemical known as MPTP), viral episodes and lack of smoking or alcohol intake.
Furthermore, a gene on chromosome 4 may be associated with Parkinson's in some
families (Mandal).
Occurrence of the disease: The onset of PD is age related, usually occurring after age 40.
Approximately one million Americans are diagnosed with PD. It is a slowly progressive
neurological disorder (Mahan 2012).
There is a gradual loss of cells in the substantia nigra in the brain. These cells are
responsible for the production of dopamine. Dopamine is a neurotransmitter, which
transmits signals between areas of the brain that coordinate movement. A decrease in
dopamine in the striatum leads to nerve cells continually firing without any control. The
result is uncontrollable movements or dyskinesia, which leads to the initial symptoms of
PD. With the progression of the disease, multiple areas of the brain and spinal cord
degenerate, causing a more profound movement disorder. (Mandal)
Typical medications used to treat PD lead to an increase in dopamine. LevodopaCarbidopa (Sinemet) is the gold standard for treating progressive symptoms of PD.
Ropinerole (Requip) is a dopaminergic agent used to treat stiffness and muscle spasms.
Amantadine (Symmetrel) is an anticholinergic agent, which can indirectly increase
dopamine. Along with these medications, the patient should maintain constant weight,
ensure a high fiber diet with ample fluids, and limit proteins, especially when taking
Sinemet.

ASSESSMENT:
Dr. K has a variety of health issues, with the primary concern being his Parkinson's
disease. His fluctuations in mood make him noncompliant in taking his medications and
maintaining a decent appetite. When Dr. K does not take his medications, his dyskinesia
worsens, exacerbating his nutrition state. His IBW is 73 kg. His current BW is 70 kg,
which frequently fluctuates. Overall, Dr. K is undernourished and needs to have sufficient
calorie, protein, fluid, and fiber intake. His calcium, vitamin D, C, magnesium,
potassium, and polyunsaturated fat intake are low as well, all which have antiinflammatory indications for PD.
Dr. K's estimated energy needs are 1772 calories per day according to the Mifflin St. Jeor
equation and his estimated protein needs (based on 1 gm/kg of BW) is 70 grams. His
current diet provides 1538 calories and 77 grams of protein per day. His estimated fluid
needs (based on 30 ml/kg) is 2,100 ml per day. Also, Dr. K's estimated fiber needs are 30
grams per day; his diet only provides 19 grams per day. His current mineral intake of
calcium is 843 mg (DRI of 1000 mg), vitamin D is 8 ug (DRI of 15 ug), vitamin C is 75
mg (DRI is 90 mg), magnesium is 264 mg (DRI of 420 mg), and of potassium is 2386 mg
(DRI of 4700 mg). Although there is no specified target for PUF, a higher amount is
recommended in PD patients.
Dr. K requires continual assistance to keep his head up straight while eating to avoid
aspiration. Physical therapy could help with this. Dr. K's current diet may give him
enough calories if it is entirely consumed but it needs to have higher fiber, fluid, calcium,
Vitamin D, potassium, and other minerals of anti-inflammatory value.
PES statement is:
Inadequate energy intake related to chronic illness (Parkinson's Disease) as
evidenced by noncompliance, need for more eating assistance, and a UBW three
kilograms less than IBW
INTERVENTION:
Prescription: Provide ~ 1772 calories, 83 grams protein, and 2.1 L of fluid per day to
form an anabolic state to adequately nourish Dr K, improve hydration status, prevent
further DVTs, infections, and promote anti-inflammatory action.
Meals & Snacks
Pureed or easy to chew food as applicable
Initiate a low fat, high fiber diet for his DVTs, control his weight, and offer dark
chocolate to inhibit platelet appreciation.
Enrich diet with polyunsaturated fats and omega-3, to provide neuroprotective and antiinflammatory effects

Vitamin and Mineral Supplement Therapy:

Recommend Vitamin C (500mg po daily) & Zinc 220mg po daily) for DVT wound
healing
1200 IU of vitamin D3 to support bone health
Enteral Nutrition: Initiate Jevity 1.5 via bolus feed (22 g fiber per L). This formula uses
less volume to meet the patient's needs and flushes are not needed which may upset the
stomach. Separate boluses from protein and discontinue Ensure Plus
Coordination of Nutrition Care: refer patient to physical therapy or occupational therapy
if needed to maintain balance while standing, position neck in an upright position, assist
to ambulate a few feet safely, and improve his gait ability with a front wheeled walker
Feeding assistance: Implement adaptive feeding devices as needed and help ensure
upright feeding position
MONITORING AND EVALUATION:
-Initiate a neurological evaluation to determine if adjustment needed with Sinemet; if so
then separate dosing from high protein meals
-Swallow evaluation; G-tube evaluation
-Dental evaluation; monitor for infection, Continue Vitamin C, Zinc
-Check vitals daily; monitor for infection, BP status
-Monitor urinary input/output; monthly labs, BUN/SCR hydration marker, CRP, ESR
inflammatory markers
Short-term goals
Improve oral intake to maximize calories
Prevent falls, DVT, control PD with prn medication adjustments
Maintain weight of 73 kilograms
Long-term goals
Adjust calories, fluid, and protein needs based upon regular weight monitoring
Consider G-tube evaluation
Continue Physical therapy to achieve optimal positioning of neck to eat and socialize
Consider surgical options for PD, such as DBS (Deep Brain Stimulation)
Increase Polyunsaturated Fats intake

REFERENCES
Mahan, L. K., Escott -Stump, S., Raymond, J. L., & Krause, M. V. (2012). Krause's food
& the nutrition care process (13th ed.). St. Louis, Mo.: Elsevier/Saunders.
Mandal, Ananya. n.d. Parkinson's Disease Pathophysiology, News Medical: Lifestyle and
Medicine