Sage Nutrition Science Department - NCP Form

Patient: Ms. M

Case #24 Alicia Walker

e!erre" !or: Nutrition Assessment #$ "i!!icult% s#allo#ing

NUTRITION ASSESSMENT
Food and Nutrition Related History: Accor"ing to !amil%& increase" "i!!icult% eating. Pt complains o! !oo" getting stuck in 'er t'roat an" t'e !eeling o! c'oking& !rig'tens 'er to eat. Pt eats mostl% li(ui"s since "i!!icult% s#allo#ing 'as )egun. *e!ore "i!!icult%& lo# intake reporte". Anthropometric Measurements Age: -en"er +, %.o. F

.t: /0 1+234

Wt: ,2l)s 142., kg4 Wt .5: 662 l)s 1+ mont's pre7ious4 8 Wt c'ange: 698 Creat 6.6 Na > 64/ ?> 4.6 .g) 66./ C .ct B/ C

*M:: 6;.+ kg$m2 1un"er#eig't4

Biomedical ata! Medical Tests " #rocedures <a)s$Dat Al)umin -lucos .)A6 *=N e e C 2$6B B.2 C ;9 64

MC@ ;4 C

At'er

Calcium-9., C& C'olesterol- 62, C Protein- /.9 C& .D<- 42 C W*C- 66., D& *C- B., C Mean cell .g)- 2B C Mean cell .g) content- 29 C Erans!errin- B,2 D Ferritin- 66 C Medical ia$nosis%#MH%Rele&ant 'onditions: Parkinson0s "isease F 62 %rs 1=PD S: Stage B4& *ilateral salpingo-oop'orectom%. =ses alco'ol sociall%. Guit smoking o7er B2 %rs ago. Mot'er "iagnose" #it' AlH'eimer0s "isease an" Fat'er #it' CAD. Famil% reports B !alls #it'in last + mont's. Pen"ing C*C& C'em 2;& CF & -astroenterolog% consult !or M*S& an" S<P consult. #ertinent Medications at .ome: Sinemet: car)i"opa$le7o"opa& /2$222 mg controlle"-release ta)let t#ice "ail% 1s'akiness& sti!!ness& an" slo# mo7ement4I citalopram 22 mg "ail% 1anti"epressant4I esomepraHole 22 mg "ail%1'eart)urn& -J D4I omega-B-!att% aci"s 6222 mg "ail% 1Protection !rom 'eart "isease an" stroke4. :n 'ospital: aHit'rom%cin /22 mg :@ once "ail% 1anti)iotic4 S(in status:
skin turgor

F :ntact

Pressure =lcer$Non-'ealing #oun"I Comments: ecc'%mosis& angular stomatitis an" c'eilosis on lips& pale #it' poor

#hysical Assessment: E'in& Eemporal #asting& poor skin turgor& pale 1#it' ecc'%mosis4& angular stomatitis an" c'eilosis on lips Estimated Nutritional Needs Based on 'omparati&e Standards: Calories Protein Flui" W: M K 1,.,, 42.,4 > 1+.2/ 6/2.44 L 6.2 gm$kg 1el"erl%4 6 ml$kcal
14.,2 +,4 L 6+6

4/-+2 gm$"a% M K 9/9./46 5 AF 6./K aroun" 6B22 kcal$"a% 6&B22 > /22K 6922-2222 kcal$"a%ac'ie7e #eig't gain Diet Ar"er: Fee"ing A)ilit% :n"epen"ent NPA <imite" Assistance J5tensi7e$Eotal Assistance

Aroun" 6922-2222 ml$"a%

X No Nutritional Diagnosis at t'is time NUTRITION IA*NOSIS

N$A

Aral Pro)lems :ntake C'e#ing -oo" 1M ;/84 Pro)lem Fair 1appro5. /284 ) S#allo#ing Poor 1N/284 Pro)lem Minimal L 1N2/84 Mout' Pain X NPA None o! t'e A)o7e Procee" to Nutrition Diagnosis *elo# S 1Signs P S%mptoms4 patient currentl% )eing NPA& #eig'tloss o! more t'an 628 #it'in t'e last + mont's

P 1pro)lem4OO:na"e(uate Aral :ntake OOOOOOOOOOOOOOOOOOOOOOOOOOOOrelate " to:

J 1Jtiolog%4O"%sp'agia associate" #it' Parkinson0s Disease

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P 1pro)lem4OOMalnutritionOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOrelate " to:

OOOOOOOas e7i"ence" )%: J 1Jtiolog%4OC'ronic "isease an" s#allo#ing "i!!icultiesOOas e7i"ence" )%:

S 1Signs P S%mptoms4 *M: N22 1!or a"ults o7er +/416;.+ kg$m24 =nintentional #eig't loss o! M628 in + mont's 16984

INTER+ENTION
Nutrition Prescription: *ase" on S<P s#allo# e7aluation resultsI 5 Mec'anicall% altere" "%sp'agia "iet #it' nectar-t'ick li(ui"s to pro7i"e at least 6922kcal& /2gm protein& an" 6922m< !lui". Multi7itamin$mineral supplement "ail% #it' at least 6222 mg calcium. Foo" or Nutrient Deli7er%: Meals P Snacks: Ee5ture-mo"i!ie" "iet Supplement- ta)let )% mout' Nutrition Counseling: N$A Nutrition e"ucation: W'en rea"% !or "isc'arge& pro7i"e pt an" !amil% #it'J"ucation on NDD prescriptionI 'o# to t'icken li(ui"s or so!ten !oo"s to a consistenc% #ell tolerate". 5 use o! gelatin& puree" 7egeta)les& puree" !ruits or applesauce& )a)% rice cereal. Discuss commercial t'ickeners a7aila)le !or use. Coor"ination o! Care 1re!er to4: Continue !ollo# up #it' pen"ing consults an" tests.

-oal1s4: D%sp'agia "iet initiate" #it'in 24 'ours Pt meeting M$K;/8 o! est nee"s #it'in B "a%s o! )eginning oral "iet

MONITORIN* " E+A,UATION

:n"icators: Eotal energ% intake Eotal protein intake Eotal !lui" intake Weig't Criteria: 6922 kcal /2gm protein 6922 m< !lui" :ncrease in #eig't o! 6 l)$#eek

Case Stu"% Guestions

6.4 E'e pat'op'%siolog% o! Parkinson0s in7ol7es t'e marke" loss o! "opaminergic neurons in t'e su)stantia nigra 1area responsi)le !or "opamine pro"uction4& along #it' t%rosine '%"ro5%lase 1rate limiting enH%me !or "opamine4. Dopamine transmits messages )et#een t#o regions o! t'e )rain to coor"inate acti7it%. <oss o! t'is c'emical messenger lea"s to t'e ina)ilit% o! an in"i7i"ual to "irect an" control mo7ement. E'is is )elie7e" to )e cause" )ecause o! genetics an" en7ironmental !actors 1?rause& 226B& ,/24.

2.4 Signs an" s%mptoms !or Parkinson0s Disease inclu"e sti!!ness& slo#ness& muscle loss& s'aking& "epression& "i!!icult% sleeping& an" an5iet%. E'ese signs an" s%mptoms pla% into t'e pat'op'%siolog% )ecause t'e% relate #it' t'e loss o! coor"inating acti7it% in t'e )rain. Slo#ness& s'aking 1tremors4& an" "epression can contri)ute to nutritional risk. :n"i7i"ual #it' t'is "isease ma% take long amounts o! time to consume t'eir !oo". E'is can lea" to "ecrease" intake )ecause t'e% gro# tire" !rom eating "ue to #eakness an" t'e slo# rate. Also& t'e "isease usuall% causes t'e "e7elopment o! s#allo#ing "i!!iculties can e!!ect nutrient intake. E'e tremors also contri)ute )ecause it can make it "i!!icult !or t'e in"i7i"ual to actuall% )ring !oo" or "rinks to t'eir mout'. An in"i7i"ual ma% nee" assistance. Finall%& "epression can also contri)ute to nutritional risk. :t is "i!!erent !or QE%pe 'ereR

e7er% in"i7i"ual& )ut it can cause an in"i7i"ual to not #ant to eat& or o7er eat. Mrs. McCormick 'as "e7elope" s#allo#ing "i!!iculties& s'o#s muscle loss in (ua"riceps an" gastrocnemius #it' re"uce" strengt'& an" 'a" a )ilateral tremor 1?rause& 226B& ,/24.

4.4 <-"opa #as intro"uce" !or controlling s%mptoms 1a precursor !or "opamine4 an" is con7erte" to "opamine in t'e )rain. E'is treatment is usuall% use" once motor !unction is impaire" more se7erel% )ecause it can 'a7e negati7e long term e!!ects& suc' as cramps. J5elon #as appro7e" )% t'e FDA in 222+ !or use in mil"-mo"erate "ementia relate" to PD. J5elon is a c'olinesterase in'i)itor. :t pre7ents t'e )reak"o#n o! Acetoc'oline& #'ic' 'elps to prolong to "uration an" action o! t'e neurotransmitter. Surgical inter7entions an" p'%sical t'erap% are also possi)le use!ul a"Sunct treatments 1?rause& 226B& ,/24.

+.4 D%sp'agia re!ers to an in"i7i"ual 'a7ing "i!!icult% s#allo#ing. E'e National D%sp'agia Diet pro7i"es gui"elines !or intake "epen"ing on t'e le7el o! "i!!icult% to in"i7i"ual is !acing. D%sp'agia can e!!ect an in"i7i"ual0s a)ilit% to o)tain& prepare& an" ingest !oo". E'ere!ore& #eig't loss an" anore5ia )ecome pertinent concerns #it' "%sp'agia. D%p'agia increases an in"i7i"ual0s c'ance o! aspirating. Distractions s'oul" )e at a minimum an" t'ickene" li(ui"s can )e use" to "ecrease t'e c'ances. Jnteral nutrition ma% )e use" i! t'e case is se7ere 1?rause& 226B& ,B64.

9.4 M*S is a Mo"i!ie" *arium S#allo# test. :t is a special 5-ra% t'at can 7ie# s#allo#ing skills an" s'o# #'ic' consistencies are )est tolerate". :t is complete" )% t'e S<P or a ra"iologist. E'is test #ill pro7i"e in!ormation regar"ing #'ic' NDD an in"i7i"ual s'oul" )e prescri)e".

6B.4 E'e patient states t'at s'e is a!rai" to eat& "ue to t'e !eel o! t'ings getting stuck in 'er t'roat. E'e patient0s skin looks pale& #it' poor turgor. :n 'er nursing assessment& 'er urine #as clou"% an" am)er. Patient 'as also lost 698 o! 'er )o"% #eig't unintentionall% in t'e past + mont's. W'en looking at t'e patients usuall% "ietar% intake )e!ore s'e starte" e5periencing "i!!icult% s#allo#ing& 'er "air% intake it almost non-e5istent. .er protein an" !ruit intake is also lo#. A!ter plugging t'is past "iet recall into supertracker& : !oun" t'at s'e #as not QE%pe 'ereR

meeting recommen"ations #it' an% 7itamins& an" )arel% an% minerals. S'e is taking a supplement !or omegaB-!att% aci"s alrea"%& an" t'is "iet recall "i" not meet to recommen"ations !or t'at eit'er. :n 'er nursing assessment& 'er urine #as clou"% an" am)er. Eo !urt'er assess 'er risk !or malnutrition& : coul" ask 'er some (uestions a)out 'er usual intake since t'e s#allo#ing "i!!iculties )egan& is s'e 'as notice" an% particular !oo"s t'at gi7e 'er pro)lems& i! s'e is 'a7ing an% si"e e!!ects !rom 'er me"ications 1nausea& 7omiting4& i! t'ere is someone #'o 'elps 'er& or coul" 'elp 'er& to ingest 'er meals.

64.4 A)normal la) 7alues inclu"e Calcium-9.,mg$"< C& Protein& total- /.9g$"< C& Al)umin-B.2g$"< C& Preal)umin-6/ mg$"< C& W*C-66., 562B$mmB D& *C- B., 562B$mmB C& .g)- 66./g$"< C& .ct- B/8 C& MC@-

;4TmB C& Mean cell .g)- 29pg C& Mean cell .g) content- 29g$"< C& Erans!errin- B,2mg$"< D& an" Ferritin66mg$m< C. .er calcium an" all protein le7els are lo# "ue to ina"e(uate intake o! t'em. .er "iet #as lo# in protein& an" s'e consume" )arel% an% "air%. .er )loo" la)s coul" )e o!! "ue to an in!ection t'at 'er )o"% is tr%ing to !ig't o!!& e7i"ence" )% 'er !e7er an" increase" W*Cs. E'e 'ig' le7el o! trans!errin& lo# !erretin& an" lo# .g) le7els coul" in"icate an iron "e!icienc%. .er usual "iet recall #as lo# in iron intake.

6+.4 E'e "iet prior to Mrs. McCormick0s "e7elopment o! s#allo#ing "i!!iculties "i" meet 'er estimate" energ% nee"s. S'e #as lo# in 'er intake o! calories& an" t'ere!ore un"er in all 'er intakes o! !oo" groups. .er "air% intake #as almost non-e5istent. .er protein intake #as also lo#. .er "iet is also lo# in all 7itamin recommen"ations an" mostl% all mineral recommen"ations. E'is coul" cause 'er to )e$)ecome "e!icient in multiple 7itamins an" minerals.

6,.4 <e7el 6 o! t'e NDD consists o! puree" !oo" c'oices. E'is is !or in"i7i"uals #it' mo"erate-to-se7ere "%sp'agia #'o ac(uire a poor oral p'ase "uring s#allo#ing. E'e% s'oul" )e o)ser7e" #'ile eating an" nee" to a7oi" course te5tures& ra# !ruits or 7egeta)les& an" nuts an" see"s. <e7el 2 o! t'e NDD consists o! mec'anicall% altere" !oo" c'oices. E'is is recommen"e" !or in"i7i"uals #it' mil"-mo"erate "%sp'agia 1p'ar%ngeal "%sp'agia4. E'e !oo" is moist an" so!t te5ture" 1groun" )ee!4 an" some c'e#ing a)ilit% is re(uire". <e7el B o! t'e NDD consists o! a transition to regular !oo"s. :t is prescri)e" to in"i7i"uals QE%pe 'ereR

e5periencing mil" oral an"$or p'ar%ngeal "%sp'agia. A nearl% regular te5ture is !ollo#e"& #it' a7oi"ance o! crunc'%& 'ar"& an" stick% !oo"s. Foo" c'oices are moist an" )ite siHe. E'e !our le7els o! !lui" consistenc% inclu"e t'in& nectar-like& 'one%-like an" spoon-t'ick. E'in li(ui"s are more "i!!icult to s#allo# #it'out aspirating t'em into t'e lungs. Depen"ing on 'o# se7ere an" #'at p'ase1s4 o! s#allo#ing is a!!ecte"& "epen"s on #'ic' le7el is prescri)e". E'is is "i!!erent !or e7er% in"i7i"ual. E'e M*S coul" )e use" to "etermine #'ic' le7el o! t'e NDD an" #'at !lui" le7el s'oul" )e prescri)e" !or t'e patient.

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