Dietary and Nutritional Assessment - Case Study Example

?Clinical Nutrition Health Introduction The case discussion is about a 48 years old woman Anita who suffers from rheumatoid arthritis. Anita works ata local bakery and it is a part time job. Anita also suffers from depression, nausea and repeated mouth abscess for which she is receiving treatment. One significant recent change is loss of weight by 6 kgs in 4 months’ period. This loss is attributed to poor intake of adequate nutritious diet secondary to decreased appetite. Implications of poor nutrition and the impact of malnutrition on existing disease process needs to be evaluated to help Anita combat her current health issues. In this essay, dietary and nutritional assessment of the patient will be performed and the extent of malnutrition will be ascertained based on the evaluation. Interactions with other health care professionals and strategies to tackle malnutrition will be discussed. Dietary and Nutritional Assessment Dietary assessment has become an integral part of clinical evaluation and nursing assessment. Good nutrition is not only important for preventing disease, but also for comprehensive management of a patient (Beerman, 2009). Anita takes soft white bread and peppermint tea for her breakfast. Peppermint tea actually contributes towards weight loss (Wolinsky, 2010). For lunch she takes white bread, margarine and yogurt, but the yogurt is low-calorie one and will not contribute towards her calorie intake. For dinner, Anita takes mashed potato, baked white fish and baked beans. But she does not always finish her dinner because of her poor appetite, nausea, depression and mouth abscesses. Her evening diet consists of semi-skimmed milk, digestive biscuit and some horlicks, which have proteins and carbohydrates, but not to a good extent because in the milk, proteins are removed. From what we can see from Anita's’s 24 hour food recall, the total calorie intake is about 1000 kcal, shortcoming of her requirement. Based on the age, sex, height, weight and lifestyle, the calorie requirement of Anita is 1581 kcal per day. Her basal metabolic rate based on Harris-Benedict formula is 1318 kcal per day. The protein intake is about 20 grams when she needs about 45 grams (ICMR, 2010). Total fat is about 10% and mainly constituting saturated fat. Dietary fiber is only about 10% (when it should be 30%) (ICMR, 2010). Except for some iron and calcium in the breakfast and some vitamins in the snacks, her diet is poor in vitamins and minerals. The diet does not contain fresh fruits or vegetables or starchy staple foods. Nor does the diet contain adequate milk. Clinical Signs of Malnutrition Anita lost weight from 65 kgs to 49 kgs in just 4 months period. Malnutrition occurs when an individual's diet fails to provide nutrition that is required for growth, health and normal body function (NHS, 2012). Anita did not take diet that was sufficient to maintain health and normal functioning of her body. Malnutrition can affect any system in the body (NHS, 2012). The most significant symptoms of malnutrition are fatigue, weight loss and dizziness (NHS, 2012). Anita lost 6 kgs in 4 months. Anita also has anemia, depression and mouth abscess. One of the leading causes of weight loss in adults is depression. Anitha also has anemia. Her current hemoglobin is 10.4g/dl, much less than the normal range of 12- 14 g/dl. Anemia occurs due to deficiency in iron intake and also due to deficiency in the intake of some vitamins like B12. Another important sign of malnutrition in Anitha is repeated mouth abscesses. Malnutrition can cause depletion of important elements like zinc, calcium and magnesium which are very important to build a strong immunity (Beerman, 2009). Malnutrition makes the individual vulnerable to infection, causes delay in wound healing, impairs the function of lungs and heart, causes depression and decreases the strength of the muscles (NHS, 2012). Thus, Anita has a mouth abscess healing that with just antibiotics alone is difficult. In general, patients with malnutrition have higher mortality and morbidity rates. Persistence of poor eating and inability to properly feed for several weeks can cause death by itself (NICE, 2006). Interaction with other Health Care Professionals Malnutrition and depression occur hand in hand. Malnutrition can lead to depression and depression can lead to poor eating and further malnutrition. Depression is a common mental illness that falls into the category of mood disorders. Anita is on treatment for depression. The symptoms indicative of MDD are low mood, diurnal variation of mood, inability to experience pleasure in previously pleasurable activities, pessimistic thoughts about herself, the world and the future, excessive guilt, occasional suicidal ideation, loss of concentration and poor memory, loss of energy, loss of libido, hyperphagia and restricted physical and social activity. Anita has lost interest in cooking food for herself and in performing day to day activities. Her disability in the form of rheumatoid arthritis has contributed to this. The importance of MDD lies in the fact that it causes considerable impairment in social functioning, role functioning, employment and physical health of the afflicted person (Wells et al, 1989). Anita needs psychiatrist or occupational therapist intervention to treat depression. Other than the medication treatment, Anita will benefit from cognitive behavioural therapy. Cognitive Behavioral Therapy or CBT is a form of psychotherapy that mainly influences dysfunctional and problematic cognitions, emotions and behaviors through a 'goal- oriented' systematic approach. The main objective of the treatment in Anita is to identify thoughts, beliefs, assumptions and behaviors that are related to debilitating, dysfunctional, inaccurate and unhelpful negative emotions and then monitor them. The result expected out of such forms of therapy is to replace or transcend these emotions with more realistic and useful emotions. It is important to know that emotional dysfunction is maintained by metacognitive beliefs, inflexible self-focused attention, and perseverative thinking (Beck, 2008). Cognitive therapy will help Anita to understand and step out of automatic thoughts (Herkov, 2006). Anita suffers from Rheumatoid arthritis and needs rheumatologist intervention in this regard. Rheumatoid arthritis is also a chronic systemic inflammatory disease, but it mainly involves the synovial membranes and articular structures of the joints (King, 2008). The condition is mostly progressive in nature. The patient usually complains of pain, stiffness, and swelling of joints. Chronic involvement leads to joint destruction, deformity, and decline in functional status. About 80% of the patients develop anemia. The treatment for rheumatoid arthritis is instituted step-wise, starting with rest, salicylates, and ibuprofen and then gradually progressing to disease-modifying drugs like penicillamine (King, 2008). Anitha needs a physiotherapist to help her move around and to perform her day to day chores. Medications & any drug-nutrient Interactions Anita is consuming citalopram, 20 mg per day for treatment of her depression. It is not advisable to take alcohol when a patient is on citolapram because alcohol tends to exaggerate the side effects of citalopram (CIMS, 2011). She takes 250mg per day of penicillamine and 1000mg of ibuprofen per day, orally for rheumatoid arthritis. Penicillamine and ibuprofen do not have any dietary specifications and interactions, but they can cause gastritis and discomfort leading to anorexia (CIMS, 2011). Anitha also takes 750 mg of amoxycillin per day for 5 days to treat mouth abscesses (Maklan, 2000). Amoxycillin can alter the taste (CIMS, 2011). Overall Care Aim Aim is to improve calorie and protein intake of the patient to address malnutrition. Other than these, aim is also to improve intake of vitamins and minerals. The ultimate aim to improve overall health, decrease disability and improve lifestyle. Often, when unwell, provision of drink and food along with some physical feeding help as required, will suffice. However, when such feeding is not practical or is not safe, other measures to provide proper nutritional support to the patient is indicated. They are either one or a combination of these: extra intake of nutrition in the form of high nutrition and protein powder, foods and drinks orally; feeding the patient nutritious food through a tube inserted into the gastrointestinal tract and feeding the patients appropriate amino acids, minerals, vitamins, glucose and lipids through intravenous route, known as total parenteral nutrition. Such nutritional support is essential in those who are not in a position to meet the nutrient needs of the body to a large extent and for longer periods of time (De, 2001). Decision making becomes complex when the period of insufficient nutrition intake is uncertain and is associated with some risk. Dietary Targets for the Short-term and Long-term The dietary guidelines recommend that nutrition dense foods and beverages must be consumed with balance energy intake and sufficient amount of variety of fruits and vegetables, whole grains (50%), dairy products and fibre. Sodium intake, saturated fats, total fats and trans-fatty acids must be restricted while potassium rich foods must be taken. Alcohol must be consumed responsibly and last but not the least: food must be handled safely to prevent food-borne diseases (ICMR, 2010). Short term dietary targets in Anita would be to increase proteins, minerals and vitamins so that her depression and overall health is taken care. For this, Anita needs to be to provided with a menu for every week which has a well balanced diet. Long term targets would be to improve nutrition with a balanced diet without increasing the weight much. Conclusion From the nutritional assessment, it is clear that Anita's diet has decreased calories and proteins which has contributed to her weight loss. Specific attention is to be paid to this during diet counseling. Improving depression and treating painful conditions like mouth abscess and arthritis are pivotal in improving her appetite. References American Diabetes Association. (2004). Standards of Medical Care in Diabetes. Diabetes Care, 27, 1, S15-35. Beck, J.S. (2008). Questions and Answers about Cognitive Therapy. The Beck Institute for Cognitive Therapy and Research. Retrieved on 15th November, 2012 from http://beckinstitute.org/Library/InfoManage/Zoom.asp?InfoID=220&RedirectPath=Add1&FolderID=237&SessionID={30B583AB-3266-48ED-BC20-09A7829F5FA0}&InfoGroup=Main&InfoType=Article&SP=2 Beerman, A. (2009). Nutritional Sciences: From Fundamentals to Food, John Wiley and Sons, London. De B., Chapman, M., Fraser, R., Finnis, M., De Keulenaer, B., Liberalli, D., Satanek, M. (2001). Enteral nutrition in the critically ill: a prospective survey in an Australian intensive care unit. Anaesth Intensive Care, 29, 619-622. Hark L, Bowman M & Bellin L, Medical nutrition and disease: a case based approach, Ed.3, 2003, 3-24 Herkov, M. (2006). About Cognitive Psychotherapy. PsychCentral. Retrieved on 15th November, 2012 from http://psychcentral.com/lib/2006/about-cognitive-psychotherapy/ ICMR. (2010). Nutrient Requirements and recommended dietary allowances for Indians. Retrieved on 15th November, 2012 from http://icmr.nic.in/final/RDA-2010.pdf King, R. (2006). Arthritis, Rheumatoid. Emedicine from WebMD. Retrieved on 15th November, 2012 from Maklan, S. (2012). Medication and Drugs used in Treating Depression, Social Health, 5 (2), .28-30 NHS (2012). Physical Signs Suggestive of Malnutrition. Biochemical Investigations in Laboratory Medicine. Retrieved on 15th November, 2012 from http://www.pathology.leedsth.nhs.uk/dnn_bilm/Metabolic/Nutrition/PhysicalSignsofMalnutrition.aspx NICE. (2006). Nutrition support for adults oral nutrition support, enteral feeding and parenteral nutrition. London: National Collaborating Centre for Acute Care at the Royal College of Surgeons of England. Wells, K.B., Stewart, A., Hays, R.D., Burnam, M.A., Rogers, W., Daniels, M., Berry, S., Greenfield, S., Ware, J. (1989). The functioning and well being of depressed patients: results from the Medical Outcomes Study. The Journal of American Medical Association, 262, 914-919. Wolinsky, I 2010, Dietary and Nutrition Assessment, Oxford University Press, London. Read More