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Mini Case Study

Claire Pomorski, a 72-year-old female with multiple chronic conditions including end stage renal disease, diabetes, and multiple myeloma, was admitted for unexplained syncopal episodes. Labs showed abnormalities including low potassium, chloride, hemoglobin, and hematocrit. The patient has a history of weight loss and difficulty eating. The registered dietitian diagnosed the patient with severe malnutrition and increased nutrient needs related to her conditions. The nutrition care plan includes liberalizing her diet to regular textures, adding oral nutrition supplements twice daily and pudding three times daily, recommending a renal multivitamin, assisting with feeding, and coordinating a speech therapy evaluation for chewing and swallowing difficulties. Monitoring will include weekly weight,

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257 views3 pages

Mini Case Study

Claire Pomorski, a 72-year-old female with multiple chronic conditions including end stage renal disease, diabetes, and multiple myeloma, was admitted for unexplained syncopal episodes. Labs showed abnormalities including low potassium, chloride, hemoglobin, and hematocrit. The patient has a history of weight loss and difficulty eating. The registered dietitian diagnosed the patient with severe malnutrition and increased nutrient needs related to her conditions. The nutrition care plan includes liberalizing her diet to regular textures, adding oral nutrition supplements twice daily and pudding three times daily, recommending a renal multivitamin, assisting with feeding, and coordinating a speech therapy evaluation for chewing and swallowing difficulties. Monitoring will include weekly weight,

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Claire Pomorski

University of Maryland
College Park
Dietetic Internship
2019-2020 MINI CASE STUDY

Nutrition Assessment: Medical Diagnosis – Admitted for several unexplained syncopal episodes
Age: ​72 Labs​:
Gender: ​Female ​ 02/11​ ​02/12​ ​02/17
Weight​: 54kg (119lb) K+ ​ ​3.6​ 3.5 (​ L) ​ 3.2​(L)
Ideal Body Weight: 125lb CL ​95​(L)​ ​97 96
Height​: 5’5” (165.1cm) BUN ​42​(H)​ 46​(H)​ 12
BMI​: 19.8 (normal) GLU ​ 161​(H)​ 107​(H) ​ 115​(H)
% IBW change: 95.2% Phos ​4.7​(H)​ 2.2​(L)
% UBW change: 91.5% WBC 5.77 ​4.39​(L)​ ​ 6.22
UBW: ​130lbs HCT ​27.9​(L)​ 25.1​(L)​ 28.5​(L)
HGB ​9.0​(L)​ 8.2​(L)​ 9.3​(L)

PMH
AICD (automatic cardioverter/defibrilator), Medications​:
Amyloid heart disease, DM2, ESRD on Acyclovir (antiviral)
dialysis, HTN, hypothyroidism, multiple B-Complex Vitamin
myeloma (outpatient chemo), sarcoidosis Vitamin D3
of lung Florinef (adrenocortical steroid--adrenal insufficiency,
BP on Admit: 138 postural HTN)
HR on Admit: 152/84 Lopressor (beta blocker)
Proamatine (BP support)
Torsemide (loop diuretic)
Symptoms Tramadol (narcotic)
weakness, light-headed, fainted several Venetoclax (treat lymphocytic leukemia)
times after d/c from SH 3 days prior

Current Diet
Diet History
Soft and chopped foods, boost BID Renal hemodialysis (no protein restriction, 80 mEq K, 2000
mg Na), No fluid restriction -- ED diet order
Social History: ​lives independently with a
husband who provides care as well as
caregiver for 4-hrs/day x 5 days/week.

Nutrition Diagnosis – utilize PES Statements

Severe malnutrition in the context of an acute disease or injury related to multiple myeloma, ESRD as
evidenced by dry weight wt loss of 8.2# (7% body weight) x 1 week; moderate muscle wasting (temporal,
interosseous, clavicle, shoulder); severe fat loss (triceps). Malnutrition present on admission

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Claire Pomorski
Increased nutrient needs (protein-calorie) related to ESRD and CA as evidenced by pt reported difficulty
chewing foods and relying on nutrition supplements and soft, east to eat foods

Nutrition Intervention – Nutrition prescription, Interventions with goals


Nutrition Prescription Intervention with goals
Calorie needs: 1700-2000kcal NP-1.1 ​Recommend liberalizing diet to regular, with texture
(30-35kcal/kg d/t HD and advanced age) modification (minced and bite sized) secondary to poor po
Protein: 70-87g (1.2-1.5g/kg) intake
Fluid Needs: Oliguria - 1000mL + urine Goal: immediately after consultation <24hrs after admit
output ND-3.1​ Medical food supplement: add ONS Nepro BID and
Boost Pudding TID
Goal: within 24hrs of admit
ND-3.2 ​Vitamin and mineral supplement: Recommend renal
MVI (nephrocaps)
Goal: within 24 hrs of admit
ND-4:​ feeding assistance: meal set up, removal of lids on
containers as pt reports not being able to open lids
Goal: nursing or catering to assist pt at each meal
RC-1.4: ​Coordination of care: Recommend SLP for
consultation for chewing/swallowing difficulties
Goal: within 12-24 hours of admit

Nutrition Monitoring and Evaluation


Indicator Criteria

1. AD-1.1.2: Weight 1. pt to not lose >2% body weight per week during
2. FH-1.1.1.1: PO intake/tolerance admission
3. FH 1.5.2.2 High biological protein intake 2. Pt to consume 50% of meals and at least 2 ONS daily
by next RD f/u
3. Pt is consuming HBV protein at each meal

Source Kcal requirements Protein requirements Fluid requirements


Facility standards 30-35kcal/kg 1.2-1.5g/kg 1000mL + urine output
1700-2000kcal 70-87g
EAL Based on Mifflin St n/a n/a
Jeor (with AF of 1.2)
1,261kcals
Other Source
Online nutrition care Stage 5 ESRD on HD: >1.2g/kg with 50% 100mL + urine output
manual 30-35kcal/kg ABV Protein
1700-2000kcal 70g

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Claire Pomorski
References:

NCM:
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5537&lv2=255666&lv3=27
2534&ncm_toc_id=272534&ncm_heading​=& Accessed Feb 22, 2020

EAL:

https://www.andeal.org/​ Accessed: Feb 22, 2020

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