For a Patient with Co-morbidities
Mr. Lee is a 79-year-old nursing home resident with CHF, CKD (stage 3), and DM. He also has a pressure injury on his coccyx. There are several things to consider when calculating his nutrition needs. The first is, what are Mr. Lee’s goals for nutrition, and how does he feel about maintaining his kidney function? A thorough look at the medical record and labs is the next step, followed by an interview with the individual. After speaking to Mr. Lee and conducting a Nutrition-Focused Physical Exam (NFPE), the following assessment what completed.
Results of Nutrition-Focused Physical Exam (NFPE):
- Slight indentations at the temporal region.
- No hollow area at the orbital region
- No pronounced clavicles or scapular bones
- 1-3+edema in BLE
- Denies decline in PO intake and weight
The resident has a stage 2 pressure injury on his coccyx. He is a medically complex patient with CHF, CKD (stage 3), and DM. He independently consumes 50-100% of his NAS Diabetic diet with a 1500 mL fluid Rx. Denies difficulty chewing or swallowing. Weight has fluctuated between 142-155 lbs. this past 6 months. He has 1-3+ edema, which varies at times. Will likely continue to see weight fluctuations r/t fluid. His IBW is 148+-15. His CBW is 148 lbs. Labs: Lytes WNL, BUN-30H, Cr-1.8H, and GFR-49L. Receives Lasix, Spironolactone, and Metformin, all of which may affect weights.
Needs: 2018 Kcals (Kg CBWx30***); 54-61 grams of protein (Kg CBWx.8-.9 r/t renal function and skin injury); Fluid needs are 1500 mL/d (per MD order). Meals provide approx. 1450-1550 Kcals and 47-52 grams of protein per day.
The resident agreed to conservative nutrition management to help preserve the remaining renal function. He will try to eat at least 75% of his meals, especially high-biological proteins. He agreed to have 8oz of Nepro carb steady if he eats less than 50% of any meal. Encouraged the avoidance of high-sodium foods. The resident agreed to reduce his sodium intake by not ordering bacon or soup.
Nutrition Diagnosis (PES Statement):
Nutrition diagnosis: Inadequate protein-energy intake related to increased nutrient needs as evidenced by a pressure injury complicated by Dx. DM, CHF, and CKD.
Recommend: Daily weights and notify MD of any 2 lb. change in one day or 5 lb. change in one week. Nepro carb steady (per above) and renal MVI. Will monitor nutrition parameters weekly.
***The National Pressure Ulcer Advisory Panel (NPUAP) suggests that we use 30-35 Kcals/Kg body weight for adults with pressure ulcers that are a malnutrition risk. Protein was kept low due to resident’s desire to preserve renal function.
National Pressure Ulcer Advisory Panel (NPUAP); Retrieved at: https://www.guidelinecentral.com/guideline/23835/ Published November 1, 2019. Accessed May 4, 2023.
All nutrition assessments should be individualized for each resident. Recommendations made here may not be suitable for others with the same conditions.
For information on creating a PES statement for unintended weight loss-click link below:
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