Medical Nutrition Therapy Essay Discussion Paper
Study Approach book.
Stamm, Emelia, Female, 74 y.o. Allergies: NKA Pt. Location:
MICU RM 614 Code: FULL Physician: P. Haus Isolation: Airborne infection isolation room Admit Date: 4/25 Patient Medical Nutrition Therapy Essay Discussion Paper
Summary: Acute exacerbation of COPD, increasing dyspnea, hypercapnia, agnosia—r/o SARS-CoV-2. History: Onset of disease: Initially diagnosed with mild COPD (GOLD 1 criteria) 14 years ago. Medical history: Recurrent upper respiratory infections since diagnosis after caring for her grandchildren. Also with T2DM for the last 25 years that is well managed with diet and metformin. Surgical history: No surgeries Medications at home: Ipratropium and albuterol inhaler—1 inhalation 4 times daily (each inhalation delivers 20 mcg ipratropium bromide; 100 mcg albuterol sulfate) Tobacco use: Yes. 46 years, 1 PPD history—has not smoked for past year. Alcohol use: No Family history: What? Cancer. Who? Father—lung cancer Demographics: Marital status: Married, lives with husband (aged 76) who also has T2DM Years education: Some high school Language: English only Occupation: Assists with care of her grandchildren Hours of work: M-F, 8 a.m.-1 p.m. Ethnicity: Caucasian Religious affiliation: Christian, nondenominational Admitting History/Physical: Chief complaint: Taken by spouse as patient is intubated. “About one week ago, she started com-plaining of a loss of appetite because food tasted bland. Since then she has been increasingly tired and this morning she spiked a fever of 101.4°F. She seemed confused all morning so I called an ambulance. We haven’t really been around anyone over the last two weeks other than my neigh-bor, but one of them just told me they tested positive for the coronavirus. Do you think she has the virus? Will she be OK?” Vital Signs: Temp: 101.4°F BP: 90/76 Pulse: 91 Height: 5’4″ Resp rate: 24 Weight: 156 lbs
HEENT: Eyes: PERRLA, no hemorrhages Ears: slight redness Nose: nasal congestion Throat: sore throat Cardiac: Regular rate and rhythm; mild jugular distension noted. Pulmonary/Chest: Decreased breath sounds, cough, orthopnea, prolonged expiration with wheezing; using accessory muscles at rest; pulse oximeter at 87%. Medical Nutrition Therapy Essay Discussion Paper
Orders: Admission to MICU. RT to manage ventilator settings—keep O2 IVF D5 / NS with 20 mEq KCl @ 75 cc/hr. Isolation: Airborne infection isolation room Admit Date: 4/25 saturation 91-93%. Midazolam (100 mg/100 mL) in 0.9% NaCl, start with 0.5 mg and titrate as needed. Start insulin drip (1 unit regular insulin in 0.9% NaCl) with target BGL of 180 mg/dL. Accuchecks q 6 hrs. Notify MD if >400 mg/dL. R/o SARS-CoV-2; sputum cultures and Gram stain, nasal specimen. ABGs q 6 hours; CXR—PA/LAT. Nutrition: General: Spouse states recent lack of appetite and poor sense of taste. She does most of the cook-ing, but they do order takeout a few times per week because she gets tired easily. Highest adult weight was 162 lbs (2 years ago), but she has been trying to eat well this last year and lost a few pounds. She is really good about watching what they eat because they both have T2DM. Usual dietary intake: AM: Lunch: Snack: Tea—black, dry cereal, nondairy yogurt Usually soup, sandwich, or salad. Lately, she has been skipping this because nothing tastes good. Chips, pretzels, or crackers. Sometimes fruit. Dinner/evening meal: Meat, potato, and vegetable. Drinks Diet Pepsi® (usually 3 12-oz cans). Anthropometric data: Ht. 5’4″, Wt. 156 lbs, UBW 153-158 lbs. Food allergies/intolerances/aversions: Avoids milk: “People say it will increase mucus production.” Previous nutrition therapy? Yes, diabetes education over 10 years ago Food purchase/preparation: Self; Takeout 3-4 times per week Vit/min intake: Multivitamin most days Medical Nutrition Therapy Essay Discussion Paper
THE QUESTION TO ANSWER IS AS FOLLOWS
Assume you are an RD seeing Emilia Stamm at her second visit to pulmonary rehabilitation. She
provides you with the information from her food record. Her weight is now 150 lbs. She explains
adjustment to her medications and oxygen at home has been difficult, so she hasn’t felt like eating
very much. When you talk with her, you find she is hungriest in the morning, and often by evening she
is too tired to eat. She is having no specific intolerances, but she does tell you she hasn’t consumed
any dairy products because she thought they would cause more sputum to be produced.
a. (5 points) Use the 2-day diet in EMR to estimate calorie and protein intake.
b. (4 points) Calculate current calorie and protein goals.
c. (2 points) Is she meeting her calorie and protein goals? What percent of her estimated calorie
and protein needs did she consume?
d. (5 points) Would you recommend Emilia starts on enteral nutrition? Why or why not? List at
least 3 factors that would go into your decision.
e. (5 points) Assume Emilia is admitted to the hospital and she is started on enteral nutrition to
provide her nutrition needs (not eating anything orally). Using “ready to hang” Pulmocare1.5,
write a 24 hour EN prescription to meet her needs. Show your work for how you calculated
f. (4 points) What advice would you tell her regarding the use of dairy products/milk and
sputum production? Source at least 1 evidence-based article.
g. (15 points) Using information from her food diary, her lab values, and your assessment of her
current status and intake, Medical Nutrition Therapy Essay Discussion Paper