JTSpiraling Out of Control?

JT, a retired computer company executive, eats out four times a week since his wife
died last year. Meals at home consist of microwave dinners or supreme pizza. He
belongs to a health club, which he visits three times a week, and where he has
many friends. Occasionally, JT and his friends go out for beers after their workout.
Shortly after his 69th birthday (2 years ago), he was diagnosed with type 2
diabetes. Last week, he visited the clinic for his annual check-up. He was measured
at 5 feet 9 inches (1.75 m) and weighed 235 pounds (106.8 kg). His doctor is
worried about JTs family history of heart disease.
Questions to assess, diagnose, intervene, monitor, and evaluate JTs
condition
1. What would you ask JT about his food and fitness routine?
2. Calculate JTs BMI. How does it compare to guidelines? He wants to know whether
BMI is an accurate measure of his body fat. How might you answer?
3. As his nutritionist, what nutrition remedies would you explore to help JT?
4. What fluid recommendation would you make?
5. What sort of monitoring and evaluation plan could you and JT devise to track his
weight management?
Case Study 19.1
Bridget Doyle Remembers Laura
Just because she lives at Lenoir Manor, a continuing-care retirement facility, Laura,
a petite
(4 ft. 8 in., 97 pounds) widow of the local college dean, does not consider herself as
old.
She is 87. She has had no major nutritional or health problems and her appetite is
good.
She had been a good cook and entertained graciously, but in the residential care
facility, meals are prepared for her. Because she has had slight fluid retention over
the past year, she no longer adds salt to her meals. She tells Bridget Doyle, her
nutritionist, that yes, occasionally she does not like her meals and misses cooking
for herself.
One Monday morning, Laura is found in bed with her left side paralyzed. The
diagnosis is a right-sided stroke, resulting in three weeks of hospitalization. Back at
the skilled-care wing of Lenoir, Laura needs a nasogastric tube for feeding. She is
alert and knows people but is limited in speech. Overnight, Lauras care has
changed from an individual needing routine nutritional monitoring to someone with
many interrelated problems:
Inability to communicate her overall medical and nutritional concerns clearly
Weight loss of 9 pounds during the three-week hospital stay
Intense dislike of the nasal tube, as demonstrated by repeated attempts to pull it
out, leading to restraint of her hands
Questions
Assessment
1. What nutritional parameters should be assessed and monitored now that Laura is
back at Lenoir Manor?
Diagnosis
2. What disciplines should be involved in Lauras care plan, and why?

3. The interdisciplinary care team wants to meet Lauras needs in a dignified and
respectful manner. How can the care team address both clinical and ethical
concerns?
4. What are strategies young adults can adopt to reduce their risk of stroke?
Monitoring and Evaluation
5. How could Bridget ensure that Lauras nutritional needs are met?
Exercise 4. Case Study: Nortey, Narku, and Kande
Part 1
Nortey is a 42-year-old man who is HIV-positive. He looks thin because he has been
losing weight for the past 3 months. Nortey is coughing a lot and has oral thrush,
diarrhoea, and skin problems. He looks pale. He decides to go to a health facility for
care and treatment. At the facility he has several tests done and gets his diarrhoea
and skin problems treated. His weight and height are also measured. He weighs 49
kg and is 168 cm tall. He is referred to a nearby ART clinic.
Part 2
Nortey goes to the ART clinic with his son Narku, who is now 4 years old. Nortey
says Narkus mother had to stay at home because she is pregnant and tired. He
tells the health care provider that his son is not eating well, has lost more weight in
the past 2 months, and has had diarrhoea and a cough. Narkus MUAC is 10.8 cm.
He looks thin (his ribs can be seen) and pale. He has oedema of both feet. No blood
has been seen in his stool, but he has had fever for almost a week. He is not on any
medications. His eyes are sunken, and there is a prolonged skin pinch. He is thirsty.
He has generalised lymphadenopathy, finger clubbing, and parotid enlargement. His
respiratory rate is 48/min (rapid). He has chest in-drawing, bronchial breath sounds,
and course crepitations in both lung fields. Narkus child health records show he had
all of his immunisations. His father says Narku was diagnosed with HIV during a
hospital admission last year. The health care provider makes an appointment for
him to come back in 2 weeks. Meanwhile, Nortey was also diagnosed with TB, so he
is put on TB drugs. He is asked to come to the facility every morning for his drugs
under the supervision of the health care provider. Nortey is asked to bring his
household and close friends to be tested.
Part 3
Nortey is feeling a bit better, but has lost more weight. He weighs 47 kg. His cough
and diarrhoea have disappeared, but he still has skin problems. At the ART clinic,
Nortey is put on ART while taking his TB drugs. He is given an appointment to return
to the ART clinic in 2 weeks, but before going home he is referred to the counsellor
in the same clinic. His worry is that some friends told him that once he is on ART he
will have to eat very well, but he does not know how he will buy enough good food.
Drinking alcohol has always been part of his life.
Part 4
Narku is now 50 months old and has been brought to the clinic by his mother,
Kande. She tells the health care provider that his weight has improved. His MUAC is
now 11.2 cm. Narku still looks thin (his ribs can be seen), but he has no oedema on
either foot. No blood has been seen in his stool, and he has not had a fever. He is on
no medications. He looks pale, and there is a prolonged skin pinch, although his
eyes are not sunken any more. He is not thirsty. His respiratory rate is 38/min
(slightly fast). He has generalised lymphadenopathy, finger clubbing, and parotid
enlargement. There is no in-drawing or bronchial breath