1. Initial Nutrition Assessment
Client Hx：85-year-old man admitted with acute symptoms related to his heart failure.
PMH: Long-standing history of CAD, HTN, and HF for 2 years.
Social Hx: Retired physician, live with wife, no tobacco/alcohol use.
Meds: Lanoxin, Lasix(K+depleting, Aldactonne, Lisinopril(K+ sparing), Lopressor(no n-3, low Na),
Zocor(no grapefruit juice), diuretics(K+depleting)
Temp: 98 BP: 90/70
Anthropometrics
Ht: 5’10’’ =177.8 cm Wt: 165 lbs = 75 kg IBW: 166 lbs +/-10% %IBW：99% (normal)
BMI: 23.7(normal) UBW: N/A Usual BMI: N/A
Biochemical
Elevated: BUN, creatinine, Glucose(pre-diabetic), LDL, LDL/HDL ratio, ApoB, WBC
Low: sodium, protein, albumin/pre-albumin(not accurate given elevated WBC), HDL, ApoA
NFPE
General: elderly male in acute distress
Head: temporal wasting Extremities: 4+ pedal edema, weak hand grip
Skin: Gray, moist, TENT, Braden score=15(low risk) Abdomen: distended, Ascites
GI:+BS, +BM Urine: clear/yellow
Overall NFPE indicates malnutrition.
ENN
Kcal: 2800-2900Kcal
Kcal/kg: 2750-2900Kcal/kg(30-35Kcal/kg+500 for wt gain)
MSJ: 2810-3184 (BMR1441*IF1.5-1.7*AF1.3)
Pro: 105-112g (1.4-1.5 malnutrition/mild infection) Fluid: minimum 1500 ml
DRI increased for vit D, Ca, B12
Diet Hx: poor appetite for 6 months w/ no real wt loss determined, difficulty eating(swallowing
difficulties given age?), recently soft food only(ice-cream), 2 cans Ensure Plus/day, monitor salt for 2
yrs, follow a low fat, low cholesterol diet for 10 yrs, centrum, calcium supplement
Current diet: 2g Na Intake % of meals: 5%
I&O’s: +1033 (25 PO), -625, net I/O: +408
Current intake meets % ENN: 39%
Nutrition Diagnosis: pt is at high nutrition risk
Malnutrition r/t poor PO secondary to chronic inflammation AEB PO<5%, current intake meets 39% of
ENN, temporal wasting, low protein and weak hand grip.
Inadequate parenteral nutrition infusion r/t increased needs with malnutrition secondary to moderate
infection AEB PN meets 43% of ENN, low protein, temporal wasting and weak hand grip.
Altered nutrition related labs (Glucose, LDL, HDL, Protein) r/t undesirable food choice secondary to
poor PO AEB high glucose, LDL, low Protein, HDL and PO < 5%.
Increased nutrient needs (vit D, Ca, supplemental B12) r/t advanced age AEB age of 85 and DRI for this
age group.
Nutrition Intervention

2. Goal: Meet calorie needs, meet nutrient needs for malnutrition/cardiac cachexia and aging, correct
edema, and prevent further muscle wasting and bedsore.
Food/Nutrient delivery:
• Remove non-nutritious fluid and keep fat-free milk, soup to meet strict fluid needs.
• Recommend NG tube then G-tube placement for permanent feeding. Rec EN meet 70%(2000kcal) of
needs and the other 30%(800kcal) via PO.
Concentrated(2 kcal/ml) low Na formula @ 84 ml/hr *12 hrs(nocturnal)=2016 Kcal, 706 ml water,
97g protein.
FWF 50 ml * 6 times during the day (1006 mL) to meet goal of 1500 mL, expect 500mL via PO.
• Offer SFM w/ favorite foods PO.
Nutrition Education:
• Educate on DASH diet: a DASH diet that includes 4 cups of fruits and vegetables daily; 2 cups of fat-
free milk daily, 2 times of 3.5 oz fish, encourages legumes, lean meat, non-tropical vegetable oils and
4 times of 1 oz nuts weekly; limits sweets and SSB.
• Continue on limiting salt intake to be less than 2300 mg( 1 tsp), use garlic salt,herbs and spice instead,
and avoid processed food.
• Food-drug interaction: avoid grapefruit; educate on fish oil might not be effective with beta-blockers;
educate on potassium rich food groups.
• Educate on fluid restrict diet and demonstrate fluid goals to decrease edema: anything liquid at room
temperature( ice-cream, pudding, gelatin, sherbet, etc) to pt and his wife.
• Given the pt has already taking Centrum, double check if the dose is adequate to meet micronutrient
needs, include B12, Mg, Zn, K, thiamine and at least 800 IU vit D, keep additional Ca supplement as
pt previously did.
Coordination of Care
• RN:Continue Calorie Count to better determine PO.
• MD: please check vit D, thiamine, plasma Zinc and replete prn.
• OT: Given advanced age, please evaluate potential causes for difficulty in eating, suggest diet
modification(minced meat, chopped fruit and vegetables) and assess the risk for aspiration.
• Referral to Skilled Nursing Facilities in assisting daily walking for 20min/ day to prevent bed sore and
diabetes.
Monitoring and Evaluation
Will f/u in 1-2 days to:
1. Check calorie count and protein intake to assess the need for EN.
2. Monitor I&O’s.
3. check the results for vit D, plasma zinc and thiamine.
4. Check MVI and Ca have been ordered.
5. If on EN, check for diarrhea. If diarrhea, consider partially hydrolyzed formula.
6. Monitor weight, if gain 3 lbs in 1 day or 5 lbs in 2 day, re-adjust build intake.
7. Monitor electrolyte(Mg, K, Ca, Zn, thiamine) and replete prn.
8. Check Na, Albumin, BNP, BUN and Lipids in 10 days.
Shuhan Zhan Date: 11/28/2016