James D. is referred to your outpatient clinic following a recent admit for complications related to his DM type 2.  James is a 38 YOWM, 5'9" 210# with a L BKA.  He has had multiple admissions to the hospital due to PVD, peripheral neuropathy and dehydration.  His most recent admission was for treatment of a non-healing ankle wound that began as a blister and has progressed into a stage 3-pressure ulcer.  His foot is cyanotic and the admission was for the purpose of debridement.  The physician is quite concerned due to the advanced level of complications in such a young patient.  She has referred the patient to your clinic for aggressive outpatient intervention and education.

 

Lab values:

Albumin:  2.2 mg/dl

Prealbumin 8.9 mg/dl

BUN 52 mg/dl

Creatinine  3.1 mg/dl

Anion gap 12

H/H 10.8/32

Fasting Blood glucose:  210 mg/dl

K+ 4.2 mg/dl

Na +  136

Osmolality 289 mMol/dl

 

24 hour recall:

2 scrambled eggs

3 slices bacon

2 slices toast with butter

2 tsp jelly

8 ounces orange juice

1 cup whole milk

 

Large cheeseburger (McDonald's or Burger King)

Large fries

2-3 pkgs ketchup

apple pie

24 ounce coke

4 slices deep dish pepperoni pizza

3-12 ounce beers

6 oreo cookies

1. Develop a nutritional problem list (2 problems) for this patient in the order of highest to least priority. Be sure to choose nutritional problems not medical problems. Discuss the priority level.  
2. make a calorie count based on the 24 hour recall 
3. make a nutritional assessment on this patient.  This includes anthropometric, dietary and biochemical parameters.  Include estimates of Kcal, protein and fluid needs.  Assess the needs compared to the intakes.  Is his diet adequate? 
4. Determine a plan of care based on your problem list and assessment.  What would be the two most important topics for the patient's nutritional education?  Be Specific in your discussion. HINT: focus on the quality of his diet. 

Answer:

1. High blood sugar levels due to high carbohydrate consumption are considered a high priority level nutritional problem, while dehydration is considered as low priority level nutritional problem.

2. The person is consuming 4000 calories per day.

3. The patient is consuming a diet having high calories, high carbohydrates, and fats rich diet. He is also lying in the obese category and is having very reduced kidney function. He is also severely dehydrated and is consuming inadequate fluids daily.

4. Patients should avoid eating processed foods and food rich in saturated fats such as burgers and fries. He should also consume an ample amount of fluids through water and dairy products instead of beer and fizzy drinks. He should also incorporate PUFA containing nuts and food products that would reduce blood cholesterol and alleviate problems caused by atherosclerosis.

Step-by-step explanation

 

1.

• The patient is consuming a very high amount of carbohydrates in his daily diet resulting in the development of high blood sugar and the development of obesity in the patient. Obesity is indicated by the patient's heavyweight and high fasting blood glucose levels.
• The patient is also consuming a high amount of fats which has resulted in the development of peripheral vascular disease due to the deposition of high fatty content present in the diet onto the blood vessels.
• The patient's diet includes less than half of the daily fluid requirements resulting in dehydration and peripheral neuropathy in the patient.
• The consumption of a carbohydrate-rich diet has resulted in the development of high blood sugar and is considered as the root cause of ulcer formation in the legs and the non-healing of the wound. It is considered as a high priority level as it is the root cause of the other disease as well. Low fluid consumption is considered as a lower priority level.

2. 

3.

Provided information:

Age = 38

Sex = male

Height = 5'9"

= 60+9      (1 feet = 12 inches)

= 69 inches

= 69 x 2.54 (1 inch = 2.54 cm)

= 175 cm

Weight = 210 pounds

= 210 x 0.45  (1 pound = 0.45 kg)

= 94.5 kg

 

 

BMR (basal metabolic rate)= (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5

= (10 x 94.5) + (6.25x 175) - (5 x 38) + 5

=945 + 1094 -190 + 5

= 2044 - 190

= 1854 kcal

 

Considering the person is having left leg amputated, the activity level is considered as sedentary.

Total calorie needs = BMR x activity level

= 1854 x 1.2

= 2224.8 kcal

= 2225 kcal

 

Protein intake requirement:

Protein required per pound of body weight = 0.36 g

Total protein requirement = 0.36 x 210

= 75.6 grams

 

Total fluid volume per day requirement:

= 10 x 100 +[10 x 50] + [74.5x20]

= 1000 + 500 + 1499

= 2990 ml per day

= 3 Litre per day     (1 litre = 1000 ml)

 

Anthropometric measurement:

BMI = weight (in kg)/ height ²

= 94.5/ (1.75)²

= 94.5/3.06

= 30.9

 

Weight = 94.5 kg

Height = 1.75 meter

 

Biochemical parameters:

Normal albumin range is 3.4 to 5.4 g/dL

Prealbumin 15 to 36 milligrams per deciliter (mg/dL)

Normal BUN is 7 to 21 mg/dL

Creatine below 1.3 mg/dl

Anion Gap 8-12 mEq/L

Normal sodium level 136-145 mmol/L

Normal sodium level 3.6 to 5.2 mmol/L

Fasting blood glucose : below 100 mg/dl  (milligram per decilitre)

Normal osmolarity: 275 to 295 mmol/kg     (millimoles per kilogram)

 

Nutritional assessment:

DRI fat intake 20% to 35% of total calories;

= (20/100 x2225) to (35/100 x2225)

= 445 to 778.8

Energy obtained per gram of fat = 9

= 49 to 86.5 gram per day

 

DRI carbohydrates fat intake 45 to 65 % of total calories:

= (45/100 x2225) to (65/100 x2225)

 = 1001 to 1446 calories

Energy obtained per gram of carbohydrates = 4 kcal

= 250 to 361 g

 

Fluid consumption = 44 x 30

= 1320 ml

 

Comparative analysis:

• The patient is consuming more than 4000 calories per which is way high than the normal body requirements. The patient is also consuming a very high amount of fats, carbohydrates, protein, and cholesterol than the required per day.
• The daily fluid requirement per day is 3000 ml (milliliter) per day and is consuming 1320 ml per day which is way lesser than the required intake.
• The BUN (blood urea nitrogen) level, prealbumin, albumin, and creatinine are lying under abnormal ranges. The blood glucose levels are way higher than the normal range and indicative of diabetes.
• The BMI (body mass index) of the body is lying under the range of the obese category and the patient is considered as weighting the highly unhealthy category.

 

His current diet is composed of very high amounts of calories, fats, and carbohydrates in terms of intake.

 

 

4.

Plan of care:

• Reduction of body weight by modulating the diet of the patient.
• Treatment of the PVD by modulating the fatty content of the diet.
• Treatment of dehydration by increasing the fluid requirement.
• Reductional in the foods containing saturated and trans fats.

 

Patient education:

• He is currently consuming fast foods rich in saturated fats and simple processed sugars and is also rich in sodium and potassium content. High blood sugar is supported by the high carbohydrate content in the diet and is causing diabetes in the patient, which, in turn, results in the reduced ability of the body to heal even small blisters and wounds on the legs and other body parts. High fatty content is responsible for the development of the PVD and atherosclerosis in the body, resulting in the loss of sensation and tingling in the legs. Also, the calorie content is too high for his body characteristics and increasing the bodyweight of the patient. The patient should avoid eating processed foods and foods rich in saturated fats to reduce the fatty acid intake would improve the PVD condition and development of atherosclerosis. Patients should also avoid eating simple sugars and incorporate plant-based foods having a low glycemic index that would help in reducing the blood sugar levels.
• The patient is severely dehydrated and is having extensive kidney damage indicated by the high BUN levels and high creatinine levels. To improve kidney function, the patient should start consuming water instead of sugary and fizzy drinks such as cola and beer. They not only damage the kidney but affects the blood sugar level as well. Patients should consume at least 3 liters of water every day to improve bodily functions.
• Instead of consuming processed foods incorporate fresh fruits and fruit juices in the diet, along with polyunsaturated fatty acids by consuming foods such as walnuts, and almonds.

Reference:

Prealbumin (Blood) - Health Encyclopedia - University of Rochester Medical Center. (2020). Retrieved 1 August 2020, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=prealbumin

Pendick, D. (2020). How much protein do you need every day? - Harvard Health Blog. Retrieved 1 August 2020, from https://www.health.harvard.edu/blog/how-much-protein-do-you-need-every-day-201506188096

Harris-Benedict Calculator (Total Daily Energy Expenditure). (2020). Retrieved 1 August 2020, from https://www.omnicalculator.com/health/bmr-harris-benedict-equation

Albumin (Blood) - Health Encyclopedia - University of Rochester Medical Center. (2020). Retrieved 1 August 2020, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=albumin_blood

(2020). Retrieved 1 August 2020, from https://www.beckydorner.com/wp-content/uploads/2018/03/CheatSheetNutritionAssesment-3245.pdf

Prealbumin (Blood) - Health Encyclopedia - University of Rochester Medical Center. (2020). Retrieved 1 August 2020, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=prealbumin

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