Clinical Health Nutrition - Case Study Example

Clinical Nutrition Health Introduction The case discussion is about a 48 years old woman Anitha who suffers from rheumatoid arthritis. Anitha also suffers from depression and 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 Anitha 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. Dietary assessment includes 24 hour recall of food intake, including the type and quantity, calories analysis, estimation of protein, fat and other important nutrients like vitamins and minerals and comparing with standard references for respective age, sex and physiological condition like pregnancy, lactation and adolescence. One day’s 24 hour recall of food may not be the best guide for nutrition assessment of a particular patient. However, it keeps matter simple for calorie calculation. From what we can see from Anitas’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 Anitha 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%). 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 Malnutrition occurs when an individuals diet fails to provide nutrition that is required for growth, health and normal body function. Malnutrition can affect any system in the body. The most significant symptoms of malnutrition are fatigue, weight loss and dizziness. Anitha lost 6 kgs in 4 months. Clinical signs of malnutrition include thin and sparse hair with lack of lustre, diffuse depigmentation on face, scaling and redness of nasolabial folds, conjunctival xerosis, pale conjunctiva, angular palpebritis, papilledema, intraocular hemorrhage, cheilosis, bilateral angular stomatitis, glossitis, raw tongue, spongy and bleeding gums, purpura and hyperpigmentation of skin, desquamatory dermatitis, dry skin, koilonychia, tachycardia and cardiomegaly, mental confusion and hepatomegaly (NHS, 2012). Anita also has anemia, depression and mouth abscess. 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. 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. 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. 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). Anitha needs psychiatrist intervention to treat depression. Other than the medication treatment, Anitha 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 Anitha 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 Anitha to understand and step out of automatic thoughts (Herkov, 2006). Anitha 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. The hallmark clinical feature of this condition is persistent symmetric polyarthritis affecting the hands and feet. Joint involvement includes edema, effusion of fluid into the joint, warmth and tenderness and presence of rheumatoid nodules. Systemic involvement manifests as weight loss, low-grade fever, and malaise. Individual organ involvement can manifest as carditis, pericarditis, pleuritis, interstitial fibrosis, vasculitis, skin nodules and ulcers. 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 NSAIDs and then gradually progressing to disease-modifying drugs like methotrexate, azathioprine and sulphasalazine (King, 2008). Medications & Any Drug-nutrient Interactions It is not advisable to take alcohol when a patient is on citolapram because alcohol tends to exaggerate the side effects of citalopram. Penicillamine and ibuprofen do not have any dietary specifications and interactions, but they can cause gastritis and discomfort leading to anorexia (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 Anitha would be to increase proteins, minerals and vitamins so that her depression and overall health is taken care. 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 Anithas 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 De B., Chapman, M., Fraser, R., Finnis, M., De Keulenaer, B., Liberalli, D., Satanek, M. 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 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). 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