Description
ASSESSMENTCalculate patient’s BMI, %IBW, %UBW, and % weight loss. Calculate and evaluate the patient’s MCV, MCH, and MCHC. Thoroughly evaluate these and the other abnormal lab values. Investigate potential causes and discuss the causes that are applicable to this patient. (Limit the discussion of abnormal values to those which apply to this patient.)Discuss the issues that are contributing to patient’s problems.Evaluate patient’s intake. Estimate calorie and protein intake based upon her food recall. Consider her intake of vitamins and minerals. Discuss the adequacy of micronutrient and macronutrient intake.Determine patient’s kcal, protein and fluid requirements. Compare her current intake to her estimated needs (from question 5). What percent of her kcal and protein needs is she currently meeting? Is patient’s dietary intake of kcals, protein, and vitamins and minerals adequate? Why or why not? Explain in detail. MCV = Hct * 10/RBC. MCH = Hgb * 10/RBC.MCHC = Hgb * 100/Hct.
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Dietetic Practice Case Study
Objectives:
• Use current information technologies to locate and apply evidence-based guidelines and protocols, such as
the Evidence Analysis Library.
• Describe the governance of nutrition and dietetics practice, such as the Scope of Practice for the Registered
Dietitian Nutritionist and the Code of Ethics for the Profession of Nutrition and Dietetics. (KRDN 2.2)
• Utilize the Nutrition Care Process.
• Demonstrate documentation that follows professional guidelines.
Ms. Espinoza is a 26 YO Hispanic female. She is a graduate student at TCU and works as a graduate assistant in the
English Department. She presented to the Student Health Center after feeling weak and lethargic for the past few
months. Prior to the visit, patient reports fatigue for the past two or more months and worsening in the last two
weeks.
Ms. Espinoza is a vegan and has been for about one year. Her weight has been stable for the past year. Prior to
that time, her weight was approximately 152#. She initially chose a vegan lifestyle for environmental and animal
rights purposes. She has become more committed to the lifestyle for health reasons over the past two years. She
reports that her appetite is fine. She does not consume any meat, poultry, fish, milk or eggs. She consumes
legumes regularly, drinks plain soy milk, and eats soybeans and tofu regularly. She usually consumes legumes
meals and also tries to eat a whole grain at the same time. She does not take any medications or dietary
supplements. She has no food allergies or intolerances. She reports heavy menstrual periods.
Medical Hx: menarche age 14
Social Hx: Lives in an off-campus apartment alone; Denies tobacco or illicit drug use; Does not consume alcohol or
drugs; Sedentary lifestyle with infrequent exercise. She walks about one mile (round trip) from her off-campus
apartment to campus on weekdays. She takes the stairs to her four-story office on campus and her two-story
apartment off-campus. Otherwise, she rarely exercises.
Symptoms: Dizziness, Pallor, Pale gums, Fatigue, Easily fatigued upon physical activity
Medications/Supplement: none
Ht: 5’8”. Wt: 148#.
Patient’s lab values are as follows:
Test
Glucose
BUN
Cr
Ca
Serum Albumin
RBC
Result
85 mg/dL
12 mg/dL
0.7 mg/dL
8.8 mg/dL
3.7 g/dL
4.2
Reference Value
70-110 mg/dL
10-20 mg/dL
0.5-1.1 mg/dL
9.0-10.5 mg/dL
3.5-5.0 g/dL
4.2-5.4
WBC
76000/mm3
5000-10000/mm3
Test
Na
K
Cl
Hgb
Hct
Platelets
Result
142 mEq/L
4.0 mEq/L
102 mEq/L
10.0 g/dl
30%
270,000/mm3
Reference Value
136-145 mEq/L
3.5-5.0 mEq/L
98-106 mEq/L
12-16 g/dl
37%-47%
150.000400,000/mm3
You are an outpatient RD consulting at the student health care center. You received a consult to assess the patient
due to her reports of fatigue and to provide nutrition education regarding a general, healthy diet. She says that she
feels tired and finds it necessary to take a nap almost every evening after she leaves work before she begins
studying. She drinks 2-4 cups of black tea daily to try to stay awake and alert. She states that she has struggled
academically this semester and thinks that her fatigue is to blame.
You obtain a 24 hour recall from the patient. She reports that he usually eats alone. She does not take any dietary
supplements. This menu is fairly representative of her usual intake. Besides the beverages listed in her recall, Ms.
Espinoza drinks water throughout the day.
Breakfast:
2 6 oz cups of black tea
½ cup raw oats
1 T peanut butter
1 cup Silk Original Soymilk*
½ cup blueberries
1 T pumpkin seeds
Lunch:
3 cups of baby spinach
½ cup canned Kroger salted garbanzo beans
1 cup raw broccoli florets
8 Mezzetta pitted Greek Kalmata olives*
20 Wheat Thins* (crackers)
1 8 oz cup black tea
Snack:
½ large banana
1 oz Kroger dry roasted peanuts*
2 6 oz cups of black tea
Dinner:
Tofu tacos (2 Mission corn tortillas*, 3 oz Trader Joe’s Firm Tofu* cooked in 2 tsp olive oil)
2 tsp soy sauce
½ cup canned salted black beans
1 cup butter lettuce
4 Tablespoons of avocado
water
Snack:
1 cup Silk Original Soymilk*
¼ cup blueberries
water
* find precise information for these items rather than using estimates on the exchange list in your Nelms textbook.
ASSESSMENT
1. Calculate patient’s BMI, %IBW, %UBW, and % weight loss.
2. Calculate and evaluate the patient’s MCV, MCH, and MCHC. Thoroughly evaluate these and the other
abnormal lab values. Investigate potential causes and discuss the causes that are applicable to this
patient. (Limit the discussion of abnormal values to those which apply to this patient.)
MCV = Hct * 10/RBC.
MCH = Hgb * 10/RBC.
MCHC = Hgb * 100/Hct.
3. Discuss the issues that are contributing to patient’s problems.
4. Evaluate patient’s intake. Estimate calorie and protein intake based upon her food recall. Consider her
intake of vitamins and minerals. Discuss the adequacy of micronutrient and macronutrient intake.
5. Determine patient’s kcal, protein and fluid requirements.
6.
7.
Compare her current intake to her estimated needs (from question 5). What percent of her kcal and
protein needs is she currently meeting?
Is patient’s dietary intake of kcals, protein, and vitamins and minerals adequate? Why or why not?
Explain in detail.
DIAGNOSIS
8. List three pertinent nutrition diagnoses that apply to patient.
9. Prioritize the nutrition diagnoses from question 8. Write two PES statements for the most pertinent
diagnoses. Which of the two diagnoses is more important and why?
INTERVENTION
10. Brainstorm one or more intervention for each nutrition diagnosis. Use the NCP standardized language
and list your interventions under each nutrition diagnosis. List 1-2 specific goals for each nutrition
diagnosis.
11. Outline a nutrition education session for this patient. Individualize the education session based upon your
assessment.
12. What additional information do you need? Are there others with whom you should coordinate the
patient’s care? Explain and include in your interventions if applicable.
MONITORING/EVALUATION
13. Discuss how you will decide whether your interventions listed above are effective? Use the NCP
standardized language and list the Monitoring/Evaluation criteria that you will use to measure, monitor
and evaluate progress.
DOCUMENTATION
14. Write a chart note in the ADIME format.
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