Sodexo Distance Education Dietetic Internship

Name: ANGELA MISKO

Group: Shasta


Dietitian Dilemmas in Long-Term Care
(LTC Case Studies assignment and guidelines)

Dietitians must use critical thinking skills to determine the best course of
action in providing the nutrition care for residents in long-term care.

Complete this assignment after reading the Older Adult Articles, attending
the webinar with Phyllis Famularo, and after you had sufficient exposure working
with the elderly population.

The following are common situations that you may encounter. There is really no
completely correct answer to these questions, but using your critical thinking
skills and nutrition knowledge, suggest solutions to these questions. Keep in
mind that quality of life is very important to the residents, and that long-term care
facilities are considered their homes. Residents rights are very important in LTC
when it comes to food and preferences.

Include the nutrition problem and interventions you would use in your nutrition
care plan. Also include a possible PES statement for each situation.

Submit completed assignment to Sharon (PBJ & Shasta) within 2 weeks of
completing the LTC rotation.


1. A 84-year old male resident is admitted to the long-term care facility for
extended stay due to need for nursing care for a stage III wound on the
sacrum. When the RD reviews the residents labs, the following is noted:
Albumin- 3.0 mg/dL
BUN- 50 mg/dL
Creatinine- 2.1 mg/dL
Based on your knowledge, what would be your nutrition care plan?


Problems:
1. Resident has a stage III pressure ulcer to the sacrum
2. Albumin is depleted
3. BUN and Creatinine are elevated. This is an issue because BUN
increases as the kidneys function declines. Elevated creatinine levels may


be indicative of rapid muscle loss from trauma or surgery as well as
possible renal failure.

Possible PES statements:
1. Increased nutrient needs (protein) related to increased demands of wound
healing as evidenced by stage III pressure ulcer.
2. Nutrition-related altered lab values (albumin) related to increased age and
stage III wound as evidenced by albumin 3g/dl.
3. Nutrition-related altered lab values (BUN and Creatinine) related to
possible renal insufficiency as evidenced by BUN 50mg/dl and Creatinine
2.1mg/dl.

Plan:
1. Assess oral intake (interview staff, observation, 3 day calorie count)
2. Encourage PO intake (assuming no dysphagia or feeding issues)
3. Recommend Ensure TID (if po intake is poor)
4. Recommend Prostat AWC 30ml BID (if po intake good)
5. Monitor skin integrity
6. Encourage po fluids
7. If suboptimal oral intake- recommend MVI that includes vitamin C
8. Monitor renal and visceral protein labs
9. Request/review GFR, H&H, LYTES (assess hydration), total protein, and
prealbumin, and I&O report to better assess patients nutritional status.
10. Recommend 3-day calorie count


Goal:
1. PO intake to be at least 75% at most meals
2. Wound healing
3. Nutrition related labs wnl
















2. When conducting meal rounds, you observe a resident spitting out pieces
of food. What are the possible causes and what interventions could you
try to address this concern?


I would assess the patient to see if he is attempting to swallow or immediately
spitting out the food. Check patients dentition. If the resident is immediately
spitting out the food, this may be indicative of disliking the food or poor
dentitition. This issue can be solved by noting the residents food preferences
and honoring them within the boundaries of the patients diet order. If the
resident attempts to swallow and fails, this could be indicative of
oropharyngeal dysphagia (caused by Alzheimers, Parkinsons, MS), or
esophageal dysphagia (caused by cancer, tumors, strictures, achalasia). In
this case, it is critical to review the residents past medical history and order a
speech therapy evaluation.

Possible PES statements:

Inadequate oral intake related to spitting out food as evidenced by RD
observation

FH 5.4 Mealtime Behavior (Spitting) as related to possible difficulty
swallowing as evidenced by RD and staff observation.

FH 5.4 Mealtime Behavior (Spitting) as related to possible dentition
issues as evidenced by ill-fitting dentures

Interventions:
1. Recommend speech therapy consult to evaluate adequacy of diet
consistency
2. Recommend diet consistency change per speech therapy evaluation
3. Note food preferences, help resident fill out menus
4. Check when last dental consult was. If necessary, recommend dental
consult. Consider temporary diet change/food choice changes until dental
issues are resolved.
5. Consider need for recommending psych consult if warranted













3. A 73 year-old obese female resident with a BMI of 38 and a diagnosis of
diabetes enters your LTC community with a stage II pressure wound on
her heel. Her albumin level is 2.4 mg/dL. What interventions could be
part of your nutrition care plan?


Problems:
1. BMI=38 and obese
2. Resident has a stage II pressure ulcer
3. Albumin is depleted

PES: Increased nutrient needs (protein) related to increased demands of wound
healing as evidenced by stage II pressure ulcer

Plan:
1. Monitor po intake
2. Check if diet prescription is appropriate (NCS, CCD)
3. Monitor adherence to diet
4. Recommend Prostat AWC BID
5. If suboptimal oral intake- Consider glucerna or SF health shake
6. Recommend MVI with Vitamin C
7. Encourage po fluid intake
8. Recommend repeat albumin in 30 days. Monitor labs.

Goals:
1. Meet patient needs
2. Wound healing
3. All nutrition related labs to be wnl as able


















4. A resident with mild dysphagia is admitted to your LTC community. After
being seen by the speech therapist, the resident is placed on a pureed
diet with nectar thick liquids. You observe the resident eating poorly at
meals and sneaking thin liquids from the hydration cart (a cart on the
residents unit to get water, juice, etc.). What course of action should you
take?


Notify speech therapy and nursing. Request additional assistance with
monitoring patient behavior by communicating with nursing staff, aides, speech
therapy, occupational therapy, and dietary staff. If possible, educate the patient
on the importance of drinking nectar liquids and following the diet order. Ensure
that the employee who is in charge of the hydration cart does not leave it
unattended. Assess why patient has poor po intake. Address poor po intake by
encouraging po intake and noting resident food preferences. If po intake remains
poor, consider the need for a supplement. Family members can assist with food
preferences. Resident may need 1:1 Feeding assistance.

Possible PES Satements:

Inadequate oral food/beverage intake related to dislking modified consistency
diet (puree/nectar) as evidenced by observation and resident interview.






5. You have assessed a new resident with a poor appetite and weight loss
prior to admission. Your recommended interventions are to add fortified
foods (added protein and calories provided via fortified foods, such as
Super Cereal, enhanced mashed potatoes, etc.), a milkshake for a 2pm
snack as well as a multivitamin with minerals.
You leave a recommendation for the physician to add the multivitamin with
minerals; however, the physician refuses your recommendation. What
would you do?


Speak with physician directly to inquire why the recommendation was refused.
Explain the rationale behind recommending fortified foods, milkshake, and MVI
(poor appetite and weight loss). Recommend 3-day calorie count and present
results to MD for additional evidence behind recommendations. Review pre-
admission paperwork and speak with family to obtain weight history. Calculate
BMI and percentage of weight loss. Ask the physician for his recommendations.
Follow the MDs orders.





6. A family member of a resident informs you that a resident is to have a very
low sodium diet due to a history of hypertension. The resident is alert and
oriented and informs you during your visit that they love hot dogs. What
would be your course of action?



First check diet order and confirm if patient is placed on low sodium diet. If
patient is on low sodium diet, educate patient on importance of following
dietary orders. Speak with resident about alternative meal options in this
case and honor food preferences as possible (ie. Low sodium hot dog or
chicken dog). If patient is not on a low sodium restriction, explain to the
residents family members that the residents sodium intake is not
restricted and he is permitted to eat a hot dog if he wants. Depending on
severity of the residents condition, stick to diet order as much as possible
but allow for pleasure foods and figure healthier versions of preferred
foods. Allow a hot dog in moderation for quality of life purposes.






QUALITY ASSESSMENT CRITERIA
____ Answers to questions are expressed clearly, and thoughtfully
____Answers are based on evidence based nutrition practices
____ Summary paragraphs are clear and succinct
____Assignment is submitted on time, within 2 weeks of the completion of the
rotation

Put the FUN in Fungibility: Below are some skills you will learn
with this assignment that can be transferred to any area of practice:
Assessment *** Research *** Organization *** Cultural Competence
Writing *** Evaluation *** Critical Thinking