230 ● ●

Part II Nutrition Assessment, Consequences, and Implications

clofibrate colestipol

CASE STUDIES

Case Study 1 An 89-year-old woman is admitted to an extended-care facility secondary to inability to care for herself any longer. She has a history of rheumatoid arthritis, consti- pation, and mild dementia. Her diet order is regular. Her medications include enteric-coated aspirin and milk of magnesia every 3 days. She provides a history of weight being stable at 140 lb until the last month. She has lost weight to her present 136 lb.

Current laboratory values include the following:

Na, 149 mEq/L K, 4 mEq/L BUN, 24 mg/dL Creat, 0.8 mg/dL Glu, 120 mg/dL Alb, 3.4 g/dL Hgb, 10.1 g/dL

Hct, 30.3% MCV, 90 μm3

serum Fe, 45 μg/dL TIBC, 198 μg/dL ferritin, 120 ng/dL Osm, 302 mOsm/kg water

Information generated from the laboratory test results for the RDN’s nutrition assessment includes mild dehydration. The client’s sodium, BUN, and osmolality are all elevated, consistent with dehydration. Physical examination will help to support this conclu- sion. Often the albumin level can be falsely high, depending on hydration status. This client’s albumin is borderline normal. With the recent weight loss and decline in the activities of daily living, including meal preparation, mild protein-calorie malnutrition may be the cause of her lower albumin level. The albumin will be falsely high until rehydration is achieved. Improved nutritional intake, including meal supervision, will help to replete albumin levels. The client has low hemoglo- bin, hematocrit, and serum iron levels, with normal MCV and ferritin levels. Anemia of chronic disease is the most likely rationale. The body stores of iron are normal; however, there is impaired release of these stores for heme synthesis. Providing iron supplementa- tion would be of little benefit for this client, either from a monetary standpoint or from a nutritional perspective, and could further aggravate her constipation.

Case Study 2 An 85-year-old man was transferred to an extended-care facility after hospitalization for rehabilitation after a frac- tured left hip. He has a history of congestive heart failure (CHF) and HTN. He has lost 8 lbs from prehospitalization to admission to the extended-care facility. His diet is no-added-salt. His current medications include

bumetanide, clonidine, warfarin, iron polysaccharide (Niferex), and famotidine. Values from his laboratory tests, taken before dis- charge from the hospital, include the following:

Na, 140 mEq/L K, 3.2 mEq/L BUN, 25 mg/dL Glu, 112 mg/dL Alb, 2.8 g/dL

Hgb, 11.3 g/dL Hct, 34% MCV, 78 μm3 ferritin, 11 ng/dL PAB, 15 mg/dL

This client has hypokalemia and depleted visceral proteins secondary to stress and surgery. He is on a diuretic, bumetanide, which is a potassium depleter. The RDN should review the menu for potassium content and evaluate the client’s actual intake. If dietary sources are inadequate, potassium supplemen- tation should be considered. The acute-phase reactants were preferentially produced in the liver, as opposed to nutritional proteins. If quick initial response to nutri- tion therapy is desired, serum prealbumin levels should be checked because of their more rapid repletion, sec- ondary to the shorter half-life. The client also has iron-deficiency anemia, most likely a result of blood loss from surgery. He is being treated with Niferex, and an adequate diet is also recommended. Repeat testing of hemoglobin and hematocrit should be recommended so that timely discontinuation of the iron supplement can be achieved.

Case Study 3 A 79-year-old man is admitted to an extended-care facility with chronic renal failure, type 2 diabetes, hypertension, and peripheral vascular disease. He lived with his wife until his disease progressed to the point where she could no longer manage his care. He has been eating fairly well, with no change in his dry weight of 152 lb. His medications at admission include calcium carbonate, epoetin alfa (Epogen) at dialysis, vitamin supplement (Nephrocaps), diltiazem HCl, and pentoxifylline. Values from his laboratory tests, sent from dialysis at admission, include the following:

Na, 142 mEq/L K, 5.2 mEq/L BUN, 75 mg/dL Creat, 6.8 mg/dL Glu, 155 mg/dL CO2,

19 mEq/L

Cl, 104 mEq/L Alb, 3.5 g/dL Hgb, 12.7 g/dL Hct, 38.1% Ca, 8.4 mg/dL PO4

, 6 mg/dL

This client’s end-stage renal disease (ESRD) and medication administration must be evaluated to accu- rately interpret the laboratory test results. His elevated BUN and creatinine are consistent with ESRD. The hyperkalemia is mild and should be addressed with diet so that it does not continue to increase and lead to