Case Study: Malnutrition Associated With Chronic Disease
Acute phase proteins are defined as proteins that either increase (positive acute phase protein) or decrease (negative acute phase protein) their serum concentration by greater than 25% in response to inflammation. During an inflammation response, the level of visceral proteins can be increased or decreased based on if the specific protein is positive or negative acute phase protein. Negative acute phase proteins such as transferrin, and albumin level are decreased in favor of the synthesis of the positive acute phase proteins such as C-reactive protein (CRP).
CRP increases rapidly and dramatically in response various infectious or inflammatory conditions and it is frequently evaluated during an inflammation process. When the clinician attempts to use the specific protein level to diagnose the nutrition or inflammation status of a patient, he or she should be aware of “no single clinical lab parameter can be recommended as an indicator of comprehensive nutritional status” and the specific level of a particular protein cannot determine the severity of the inflammation. Therefore, the clinician should evaluate these acute phase proteins in the context of the patient’s overall clinical picture. Other lab values such as decreased prealbumin, elevated blood glucose, increased or decreased white blood cell count, increased neutrophils percentage in the cell differential can be used to confirm the presence of inflammation. However, the specificity, sensitivity, and reliability of the different visceral proteins are different, so the clinician should take these differences into consideration in order to provide an accurate nutrition assessment.
Mechanical soft diet is an alternative diet of the Dysphagia Mechanically Altered diet that allows the consumption of rice, bread, and cake. The main goal is to provide a balanced diet with adequate amounts of nutrients and calories for those who have chewing problems. In general, foods in this diet should be moist and soft textured and the ease of chewing can be improved by mashing, chopping, or blending. For the milk products in Mr. Campbell’s diet, smooth yogurt, cottage cheese and soft sliced/diced cheese are allowed. In addition, hard cheese or yogurt with nuts and granola should be avoided. For protein food, the general rule is that large chunks or hard (crispy) pieces are not allowed, so cooked meat should be soft, moist, and finely grounded or diced. Beans and legumes need to be well cooked, moistened and mashed the served. For vegetables, they all need to be soft cooked to the point that can be easily mashed by fork. Potatoes, legumes, squash, etc. , should be served without skin. Fruits in mechanically soft diet should be soft ripped or canned (syrup or juice in canned food should be drained if thin liquid is not allowed for patient), pureed fruits is also appropriate. For grains, soft bread/ rolls/ muffins, soft pancake moistened with syrup or sauce, soft pasta with sauce, moistened white rice, cereal softened with milk can all be served. Avoid dry, coarse, hard, crispy texture grains products such as breads with pieces of seeds or nuts. Fats such as butter, margarine, or oils should not be a big concern but. Lastly, all fluids is allowed unless the patient has been told to thicken his or her liquid.
The AND/ASPEN malnutrition guidelines listed six clinical characteristic including insufficient energy intake, unintended weight loss, loss of body fat, loss of muscle mass, fluid accumulation, and reduced grip strength to help identify the nutrition status. In the patient’s history, he stated that he has lost 60 lb in past 1-2 years which is -29. 1% of weight change and identified as severe weight los, feeling weak and doesn’t have the energy to do anything. It is also noted that the patient has temporal wasting, appear cachectic and older than his age. There is also decreased muscle and loss of lean mass noted in the extremities, 1+ edema. These are signs and symptoms of the characteristics described by ASPEN guidelines, therefore they support the Mr. Campbell’s diagnosis of malnutrition. His urine appears cloudy and amber is consistent with the signs of dehydrate. He has dry skin and mucous membrane and has the appearance of ecchymosis and petechiae which might due the Vitamin C deficiency (Appendix G). In addition, he has tenting skin turgor which mean the skin turns back to normal state very slowly when “pinched”. The tenting indicates a severe dehydration. Hypoactive bowel sounds could indicate constipation which is associated with dehydration.
In Mr. Campbell’s assessment, he states that he is lethargic, and it is also indicated that he has dry skin, dry mucous membrane which are signs and symptoms related to dehydration. In addition, it is reportd that the urine is of a dark amber color and his fluid intake P. O is only 360 mL with the recommendation of 2000-2500 mL. His lab results are also consistent with his dehydration diagnosis. It is reported that he has elevated sodium level (150 mEq/L) which indicates hypernatremia and implies a deficit of total body water. BUN and creatinine levels are used to evaluate kidney function. His BUN and creatinine level is found high which are often seen in dehydration. In addition, his urine specific gravity and serum osmolality are both elevated due to body water imbalance. In Mr. Campbell’s urinalysis, ketone is found positive which is consistent with dehydration. Mr. Campbell is not acutely ill, so the Mifflin-St. Joer equation is utilized to calculate his energy need Because his BMI is within the normal range, his current weight is used to calculate his needs. In addition, I added 100 Kcal to the calculated energy need because Mr. Campbell is experiencing a severe weight lost and needed some extra calories to regain back to his ideal body weight. Protein requirements are affected by trauma, metabolic stress, and disease. It is recommended that patient with these conditions to have 1. 0-1. 5 g protein/kg/day. For Mr. Campbell, the upper scale of the range is utilized to calculate his protein need because he has signs of muscle wasting (muscle atrophy in cachexia: can dietary protein tip the balance).
According the Food Processor, Mr. Campbell usually consumes 1230 Kcal daily compares to the calculated daily requirement of 1665 Kcal. According to the ASPEN, it is considered severe malnutrition if the energy intake is less than 75% of estimated energy need for greater than a month. Mr. Campbell has been consuming only 73. 9% of his energy requirement for the past few months which contributes to his diagnosis of malnutrition.
a. unintended weight loss related to poor appetite as evidenced by 60 lb of weight loss in the past 1-2 year.
b. inadequate oral intake related to difficulty in eating due to partial glossectomy as evidenced by intake of less than 5% of the meals.
Incorporate nutritional supplements such as Ensure Plus supplement three time daily between meals. 30 minutes session to discuss with Mr. Campbell about the his preferred and well-tolerated food and incorporates the food he likes into the diet which could possibly increase his appetite. Encourage him to drink fluid more frequently such as 1 cup fluid every hour.
Modify his diet following the mechanical soft diet guideline with ground or finely chopped protein/ meat and soft fruits and vegetable. Avoid hard, dry and coarse food and also large chunks. Referral to therapist to improve the chewing/swallowing ability. The first part is to monitor his food and fluid intake. Ask nurse about how many percent of food Mr. Campbell consume on his tray, if he drinks the Ensure Plus Supplement as prescribed, and how much fluid he drinks daily. An alternative is to have Mr. Campbell take a picture of his tray when he finishes.
The second part is to take anthropometric measurement such as his weight to see if his weight status has been improved or worsened. If improvement shown, it means that the intervention is appropriate and should be continued; if the status is worsened or remained static, intervention plan should be adjusted accordingly. The third part is to keep monitoring the laboratory data. One should focus on the previously abnormal lab value to see if it has returned to the normal rang which is an indication of nutrition status improvement. The last part is monitoring Mr. Campbell’s nutrition-focused physical findings especially on skin and muscle conditions which were shown malnourished his physical assessment. In generally, we need to compare the current findings with the previous status, nutrition intervention goals, and reference standards to evaluate the overall impact of the nutrition intervention on the patient’s health outcomes.
