CASE 3 QUESTIONS

Case Questions
I. Understanding the Diagnosis and Pathophysiology

1. Outline the metabolic changes that occur during starvation/inadequate nutritional

intake (not related to disease) that could result in weight loss.

Firstly, our stored glycogen will be depleted in approximately 24 hours. After the depletion of
glycogen, our body will get glucose by breakdown of protein amino acids. Then, the depressed
glucose level will lead to decreased insulin secretion and increase glucagon secretion. Protein
catabolism will reduce, and hepatic gluconeogenesis decrease during the adaptive state of
starvation. During the starvation, our body respond to a reduction in food intake by reducing
its overall energy needs; the basal metabolic rate is reduced so that fewer kcalories are need.
Starvation also will decrease need for glucose utilization and it will make utilization of lipid as
main source of energy. During the starvation, body will preserve the lean mass which would
deplete our fat storage(lipolysis), and continued requirement for glucose will continued
breakdown of lean body mass to support gluconeogenesis.

(Krause 2012, p.777)

(Nelms 2016, p.676)

2. Read the consensus statement of the Academy of Nutrition and Dietetics/American

Society of Parenteral and Enteral Nutrition: Characteristics recommended for the
identification and documentation of adult malnutrition. Explain the differences
between malnutrition associated with chronic disease and malnutrition associated
with acute illness and inflammation.

Base on the consensus statement, there are six characteristics is used to find the difference
between malnutrition associated with chronic disease and malnutrition associated with acute
illness and inflammation. Firstly, the severe malnutrition associate acute illness and
inflammation have the problem of the past energy intake is less than 50%of estimated energy
requirement for more than 5 days, but the severe malnutrition associated with chronic disease
have the problem the past energy intake is less than 75%of estimated energy requirement for
more than 1 month. Secondly, the severe malnutrition associate acute illness and
inflammation have problem of weight loss for more than 2% in one week, more than 5% in
one month, and more than 7.5% in 3 months, but the severe malnutrition associated with
chronic disease have the problem of weight loss for more than 5% in 1 month, more than
7.5% in 3 month, more than 10% in 6 months, and more than 20% in 1 year. Thirdly, the
severe malnutrition associate acute illness and inflammation will have moderate loss of
subcutaneous fat, but the severe malnutrition associated with chronic disease will have severe
loss of subcutaneous. Fourthly, the severe malnutrition associate acute illness and
inflammation will have a moderate muscle loss, but the severe malnutrition associated with
chronic disease will have a severe muscle mass loss. Fifthly, the severe malnutrition associate
acute illness and inflammation will have moderate to severe fluid accumulation, but the severe
malnutrition associated with chronic disease will have severe fluid accumulation. Sixthly, both
malnutrition associated with chronic disease and malnutrition associated with acute illness and
inflammation have an measurably reduced grip strength.

https://dietitiansondemand.com/wp-content/uploads/2017/09/ASPEN-AND-2012-Consensus-
Statement-Regarding-Malnutrition-Diagnosis-1.pdf
 3. Find the current definitions of malnutrition in the United States using the ICD 10
codes. List all of them and describe the criteria for one of the diagnoses.

The malnutrition in the United States is defined as “Inadequate intake of protein and/or
energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting
including starvation-related malnutrition, chronic disease-related malnutrition, and acute
disease or injury-related malnutrition” by American Dietetic Association International Dietetics
and Nutrition Terminology.

 E40 Kwashiorkor
 E41 Nutritional marasmus
 E42 Marasmic kwashiorkor
 E43 Unspecified severe protein-calorie malnutrition
 E44 Protein-calorie malnutrition of moderate and mild degree
 E45 Retarded development following protein-calorie malnutrition
 E46 Unspecified protein-calorie malnutrition

For the criteria for diagnoses of E45 Retarded development following protein-calorie
malnutrition, it is applicable to 1) nutritional short stature, 2) nutritional stunting, and
3)Physical retardation due to malnutrition.

https://jandonline.org/article/S2212-2672(11)01836-3/abstract#secd8081818e89

https://www.icd10data.com/ICD10CM/Codes/E00-E89/E40-E46

https://www.icd10data.com/ICD10CM/Codes/E00-E89/E40-E46/E45-/E45

4. Current ICD definitions of malnutrition use biochemical markers as a component of

the diagnostic criteria. Explain the effect of inflammation on visceral proteins and
how that may impact the clinician’s ability to diagnose malnutrition. What laboratory
values may confirm the presence of inflammation?

The visceral protein refers to nonmacular or nonskeletal protein which is making up the
organs, structural components, erythrocytes, granulocytes, and lymphocytes, as well as other
protein found in the blood. The serum protein measurement will be affected by a change in the
amount of amino acid needed for protein synthesis by the liver, so the change in serum
protein levels would be consistent with changes in visceral protein status. However, the
synthesis rate of these transport protein can be affected by factors other than protein intake
or protein requirement. The transport protein synthesis will be inhibited when the acute-phase
protein synthesis rate is increased when response to inflammation. The acute-phase protein
are defined as plasma concentration increases positive acute-phase proteins or decreases
negative acute-phase proteins by at least 25%” during inflammation. Moreover, the C-reactive
protein and erythrocyte sedimentation rate are the common indicators for inflammation which
are correlated with visceral protein marks. Therefore, increasing levels of C-reactive protein and
erythrocyte sedimentation rate will indicate acute inflammation and they are consistent with
lower visceral protein markers.

(Nelms 2016, p.61,62)

II. Understanding the Nutrition Therapy

5. Mr. Campbell was ordered a mechanical soft diet when he was admitted to the
hospital. Describe how his meals will be modified with this diet order.

The mechanical soft diet is designed for people just like Mr. Campbell who have the trouble
chewing and swallowing, and this diet include chopped, ground and pureed foods as well as
foods that break apart without a knife. Mechanical soft food is easy to eat and don’t need a lot
of chewing to swallow safely. If the patient are missing teeth or have just had surgery which
cause cannot chew hard food, this diet will be very helpful for this patient. The mechanical soft
diet is described by the National Dysphagia Diet Guideline on an level system. For the level
1(Dysphagia Puree), it suggests that some smooth, pureed, homogenous, very cohesive,
pudding-like foods which also require little or no chewing ability and no whole foods should be
include, and this level include food like mashed potatoes, yogurt with no fruit added, pudding,
soups pureed smooth, pureed fruits and vegetables, and seeds etc. In the level 2( Dysphagia
Mechanically-Altered), it suggest cohesive moist, semisolid foods which require some chewing
ability, and this level include food like fork-mashable fruits, vegetable which is soft canned or
cooked fruits with vegetables in piece smaller than ½ inch, and meat that should be ground
and moist. In the level 3(Dysphagia Advanced), it suggest soft-solid foods include easy-to-cut
whole meats like tender meat cut into small piece, soft fruits and vegetable like banana,
peaches, and most of the food should be chopped and cut into small piece.

(Krause 2012, p.817)

https://www.uwhealth.org/healthfacts/trauma/363.pdf

6. What is the Ensure Complete supplement that was ordered? Determine additional
options for Mr. Campbell that would be appropriate for a high-calorie, high-protein
beverage supplement.

ENSURE® PLUS THERAPEUTIC NUTRITION provides concentrated calories and protein to help
patients (who have malnutrition, are at nutritional risk, or are experiencing involuntary weight
loss) gain or maintain healthy weight. Ensure plus (which about 350 Kcal/ 8 fl oz) have 40%
more calories than Ensure Original, and it also is a good source of vitamin D which can help
Mr. Campbell to support bone health. It is an excellent source of plant based omega-3 fatty
acid (650 mg/8 fl oz) and alpha-linolenic acid(40% of 1.6g DV) to help patient support heart
health. It is good source of fiber to maintain regularity and it’s gluten-free and suitable for
lactose intolerance.

https://abbottnutrition.com/ensure-plus-therapeutic-nutrition

Other option for Mr. Campbell that would be appropriate for a high-calorie, high-protein
beverage supplement are BOOST® High Protein and Carnation Breakfast Essentials®. Boost
High Protein have 240 calories, 20g protein, and 27 vitamins & Minerals. The Carnation
Breakfast Essential have 240 calories, 10g protein, and 21 vitamins & Minerals.

https://www.carnationbreakfastessentials.com/products/carnation-breakfast-essentials-
original-ready-drink

https://www.boost.com/products/high-protein
III. Nutrition Assessment

7. Assess Mr. Campbell’s height and weight. Calculate his BMI and % usual body
weight.

Height: 6’3” = 190 cm = 1.9m Weight: 156 lbs = 70.8kg

BMI= 70.8kg / (1.9m)2= 19.6 kg/m2

Since Mr. Campbell’s has lost over 60 pounds over past 1-2 years, he was mention that his
usual body weight is about 220 lbs.

% usual body weight = 156lbs. / 220 lbs. * 100%= 71%

8. After reading the physician’s history and physical, identify any signs or symptoms
that support the diagnosis of malnutrition using the proposed definitions of
malnutrition by AND/ASPEN malnutrition guidelines.

The consensus guideline identify six characteristics of malnutrition, and two or more of follow
characteristics are identified in patients is recommended for the diagnosis of adult
malnutrition: Weight loss, reduced energy intake, loss of body fat, loss of muscle, fluid
accumulation, and reduced grip strength. Base on Mr. Campbell’s medical report, he had
weight loss over 60 lbs. in past 1-2years, and he also complaint about that he feel weak all
over and don’t have the energy to do anything. This report also indicate that his strength is
reduced, and he have a decreasing muscle tone with normal ROM and loss of lean mass noted
quadriceps and gastrocnemius. In addition, his level of RBC, hemoglobin, and hematocrit are
lower than the reference range base on his laboratory result, and this also can support the
diagnosis of malnutrition.

(Krause 2012, p.117)

9. Evaluate Mr. Campbell’s initial nursing assessment. What important factors noted in
his nutrition assessment may support the diagnosis of malnutrition?

By evaluating Mr. Campbell’s initial nursing assessment, the important factors noted in his
nutrition assessment may support the diagnosis of malnutrition is weight loss over 60 lbs. in
past 1-2 years. Base on his % usual body weight which is about 71%, it indicates his current
weight is a lot less than his normal body weight. His BMI (19.6 kg/m 2) also is close to the side
of normal range and almost falls within the underweight range, so it also can support the
diagnosis of malnutrition. Secondly, the insufficient energy and fluid intake also are important
factors to support the diagnosis of malnutrition. Base on his Usual intake for past several
months, it obviously indicates that he is not consuming the adequate energy or calories to
meet his nutritional requirement. He only has 360 mL of fluid, and it doesn’t meet the fluid
requirement of 2000-2500mL/day. His intake % of meal is less than 5% with sips of liquids.

10. What is a Braden score? Assess Mr. Campbell’s score. How does this relate to his
nutritional status?

The Braden Scale is an evidenced-based tool which is developed by Nancy Braden and Barbara
Bergstrom, and it is used to predict the risk for developing the hospital or facility acquired
pressure ulcer. The Braden scale is using a scores from less than or equal to 9 to as high as
23., and the lower number indicate that patient have a higher risk for developing an acquired
ulcer. The Braden score is separated in six categories: special bed, sensory pressure,
moisture, activity, friction/shear (>18 = no risk, 15–16 = low risk, 13–14 = moderate risk, ≤
12 = high risk). Since Mr. Campbell’s score is 17, it means that he has a low risk for
developing pressure ulcer.
Understanding the Braden Scale: Focus on Sensory Perception (Part 1). (2020, May 06).
Retrieved October 06, 2020, from https://www.woundsource.com/blog/understanding-
braden-scale-focus-sensory-perception-part-1

11. Identify any signs (including laboratory values) or symptoms from the physician’s
history and physical and from the nursing assessment that are consistent with
dehydration.

Base on Mr. Campbell’s nursing assessment, the first sign of dehydration is that he does not
meet his fluid requirement of 2000-2500mL, and he only get 360 mL orally for the
requirement. Secondly, his Urine appearance are cloudy and amber, and this appearance
indicate that he has the dehydration or more waste product in his urine. Thirdly, based on his
laboratory values, he has an increasing of his sodium level to indicate he is consistent with
dehydration since the increasing sodium level will cause patient to loss fluid level.

12. Determine Mr. Campbell’s energy and protein requirements. Explain the rationale for
the method you used to calculate these requirements.

Current Energy requirement base on his current weight

Mifflin-St.Jeor EER= 10*70.8kg+6.25*190cm-5*68+5=1561 kcal/day

Choose PAL of 1.2 for him = 1561*1.2=1873 kcal/day

Since Mr. Campbell have problem of malnutrition and weight loss, we want to promote weight
gain for him. Therefore, we will use 30-35kcal/kg to calculate his energy need.

His recommended energy need for prompting weight gain is 2124kcal/day - 2478 kcal/day

(30 * 70.8 = 2124 kcal/day, 35 * 70.8 = 2478 kcal/day)

His protein need base on his current weight

0.8 g/kg * 70.8kg = 56.64g

Since Mr. Campbell have problem of malnutrition and weight loss, we want to promote weight
gain for him. Therefore, we will use 1.5-2.5 g/kg to calculate his protein need.

His recommended protein need is 106.2g/day – 177 g/day for prompting weight gain

(1.5 * 70.8 = 106.2 g/day, 2.5 * 70.8 = 177 g/day)

 13. Determine Mr. Campbell’s fluid requirements. Compare this with the information on
the intake/output report.

Mr. Campbell’s fluid requirements is 1770mL/day – 2478mL/day

70.8 * 25mL/kg=1770mL/day

70.8 * 35mL/kg=2478mL/day

Base on his intake/output report, he consumed 360mL orally when receiving 2160mL per day
through I.V. And his total output is 1444mL, resulting in a net I/O about +1076mL

14. From the nutrition history, assess Mr. Campbell’s usual dietary intake. How does this
compare to the requirements that you calculated for him? Can your evaluation of his
dietary intake contribute to the evidence for diagnosing malnutrition?

I use Myplate App to calculate his usual dietary intake, Mr. Campbell consumed a total of 865
calories , 44g of protein, 93g of carbohydrate, and 35g of fat.

He needs about at least 1008 more calories to meet his energy requirement base on his
current weight, and he need at least 1259 more calories to meet the recommend energy
requirement for prompting weight gain. In addition, he needs at least 62.2g protein to meet
his recommend protein intake.

IV. Nutrition Diagnosis

15. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses
and write at least two PES statements, with one focused on the clinical domain.

Malnutrition NI-5.2

Malnutrition related to chronic disease (primary tongue squamous cell carcinoma) as

evidenced by unintentional weight loss for 60lbs. in past 1-2years, decreasing muscle tone
with normal ROM, loss of lean mass noted quadriceps and gastrocnemius, and insufficient
energy intake base on his usual dietary intake.

Inadequate energy intake NI-1.5

Inadequate energy intake related to inability to consume adequate energy as evidenced by

unintentional weight loss for 60lbs. in past 1-2years, and insufficient energy intake base on his
usual dietary intake.
V. Nutrition Intervention

16. Determine the appropriate intervention for each nutrition diagnosis.

For the intervention for both Malnutrition and inadequate energy intake, he need to use
enteral nutrition since have problem to consume food orally. And our goal is helping him to
gain his weight back to 220lbs. I will choose Isosource HN 1.2kcal/mL at 75mL/hr for him
Total calorie= 75mL/hr*24hr*1.2kcal/mL=2160kcal
Protein= (2160kcal * 0.18) =97g
Then, he can keeping eat his mechanical soft diet and Ensure Plus to reach his recommend
energy requirement range 2142-2478kcal/day and his recommend protein intake range
106.2-177g/day.

https://www.vitalitymedical.com/novartis-isosource-hn-1-2-cal-tube-feeding-formula.html

VI. Nutrition Monitoring and Evaluation

17. Identify the steps you would take to monitor Mr. Campbell’s nutritional status while
he is hospitalized. How would this differ if you were providing follow-up care
through his physician’s office?
Since our main goal for Mr. Campbell is gaining weight back to his normal weight, and we will
monitor his weight change very frequently. If he weights gain is stop, we need to increase his
calories. In addition, since my intervention for him is using both enteral nutrition and
mechanical soft diet, I can lower his enteral nutrition feeding and increase his oral mechanical
soft feeding when he weights gain in a right tract or in progresses. Monitoring his weight gain
and muscle gain are important goals for Mr. Campbell currently.

18. Write your ADIME note for this initial nutrition assessment for Mr. Campbell.

A. Assessment

I. Patient diagnosed with squamous cell carcinoma of tongue five years ago, and
Patient previously treated with radiation therapy—no treatment x 3years.

II. Patient is a 68-year-old male admitted to acute care for possible dehydration,
weight loss, generalized weakness, and malnutrition. Patient have medication at
home for Lipitor 80 mg daily and Monopril 10 mg daily

III. Patient’s Hight is 6’3’’, weight 156lbs, and BMI 19.6kg/m^2

IV. Estimate Energy Requirement: 2124kcal/day - 2478 kcal/day,

Estimate Protein Requirement: 106.2g/day – 177 g/day

V. Patient have decreased muscle tone with normal ROM; loss of lean mass noted
quadriceps and gastrocnemius; 11 pedal edema; and strength reduced. Skin is
Warm and dry with ecchymoses.

B. Diagnosis
I. Malnutrition related to chronic disease (primary tongue squamous cell
carcinoma) as evidenced by unintentional weight loss for 60lbs. in past 1-
2years, decreasing muscle tone with normal ROM, loss of lean mass noted
quadriceps and gastrocnemius, and insufficient energy intake base on his
usual dietary intake.
 II. Inadequate energy intake related to inability to consume adequate energy
as evidenced by unintentional weight loss for 60lbs. in past 1-2years, and
insufficient energy intake base on his usual dietary intake.

C. Intervention
I. For the intervention for both Malnutrition and inadequate energy intake, he
need to use enteral nutrition since have problem to consume food orally.
And our goal is helping him to gain his weight back to 220lbs. I will choose
Isosource HN 1.2kcal/mL at 75mL/hr for him, since it can get 2160
carioles and 97g protein for this enteral nutrition formula. Then, he can
keeping eat his mechanical soft diet and Ensure Plus to reach his
recommend energy requirement range 2142-2478kcal/day and his
recommend protein intake range 106.2-177g/day for promoting weight
gain.

D. Monitoring/Evaluation
I. our main goal for Mr. Campbell is gaining weight back to his normal
weight, and we will monitor his weight change very frequently. If he
weights gain is stop, we need to increase his calories. In addition, since
my intervention for him is using both enteral nutrition and mechanical soft
diet, I can lower his enteral nutrition feeding and increase his oral
mechanical soft feeding when he weights gain in a right tract or in
progresses. Monitoring his weight gain and muscle gain are important
goals for Mr. Campbell currently.