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ANSWERS TO CASE STUDIES

CHAPTER 1

CASE IN POINT—JAYDEN: COPING WITH MALNUTRITION

ASSESSMENT

1. List five characteristics of poor nutritional status.a. Any of the following are correct:• Apathy• Dull lifeless hair• Greasy blemished complexion with poor color• Dull, red-rimmed eyes• Red, puffy, receding gums and missing/cavity prone teeth• Swollen abdomen• Underdeveloped, flabby muscles• Bowed legs, “pigeon” chest• Overweight or underweight• Slumped posture• Easily irritated; depressed; poor attention span• Easily fatigued; frequently ill• Excessive or poor appetite• Insomnia at night; fatigued during the day• Constipation or diarrhea

2. Identify characteristics of malnutrition that Jayden is experiencing.a. Thin, pale, swollen abdomen, and painful lower limbs

3. Jayden needs to be provided with good nutrition and adequate calories. What would be important to consider in providing meals for Jayden?a. Jayden will need a diet that provides adequate protein for his growth. Jayden will need a variety of foods that he enjoys and that are healthy for him. His foods need to be nutrient dense to provide his body with the essential nutrients that he has been missing. He may need smaller, more frequent meals. His food preferences should be considered as well so that he is willing to eat the nutritious foods being offered. It may also be important for his foster parents to track what he is eating for a while. A dietitian could then assess the calories Jayden is consuming to ensure they are adequate to meet his needs.

4. Name five lab tests that the physician may order to help assess Jayden’s nutrition and hydration status.a. Serum albumin or prealbumin levelb. Serum transferring levelc. Blood urea nitrogend. Creatinine excretione. Serum creatinine

DIAGNOSIS

5. Write a nursing diagnosis for Jayden.a. Nursing Diagnosis: Nutrition, Imbalanced: less than body requirements. Related to parental neglect that has resulted in inadequate intake of calories, vitamins, and minerals. Manifested by swollen abdomen, sore limbs, underweight, and pale color.Interventions: Offer small frequent feedings, nutrient dense foods of his preference, educate caregiver on healthy diet for Jayden. Rationale: To achieve weight gain and sound nutrition.

PLAN/GOAL

6. What two changes can you predict will occur with the introduction of a good, nutritionally sound diet?a. Weight gain, decrease in abdominal swelling, return of healthy color

7. Whom can you refer to for assistance?a. Social worker, dietitian, caregivers, or other family members

IMPLEMENTATION

8. Name at least three nursing interventions that could be employed to improve Jayden’s nutrition.a. Offer small frequent meals, high in nutrient dense foodsb. Identify Jayden’s food preferences – likes and dislikesc. Prepare food in an appetizing way for Jaydend. Provide a pleasant and relaxed setting for Jayden’s meals.e. Sit with Jayden during meals if caregivers or family members are not with him. It would be best if he ate with others.

9. How might Jayden’s dental status impact his nutrition?a. Jayden may not have had adequate dental care at this point in his life. He may

benefit from a dental exam. If he has tooth caries or decay, it may impact his ability to eat without pain.

10. Would a home visit be beneficial for Jayden and a caregiver?a. Yes, to ensure that Jayden is thriving and progressing toward goals that are being

made.

EVALUATION/OUTCOME CRITERIA

11. What could the doctor assess at the next appointment to see if the plan is working?a. Weightb. Prealbumin or albumin levelsc. Overall appearanced. Abdomen girthe. Pain in lower limbs

12. What observations could the caregiver offer about the success of the plan?a. Change in Jayden’s appearanceb. Increase in energy/mental levelsc. Increase in nutrient dense food intaked. Jayden’s contentment

13. What could be an important piece of information from Jayden?a. Jayden states he feels better, has more energy to play, sleeps better, has less pain in his legs, and is gaining weight.

THINKING FURTHER

14. How could the Internet be of benefit to the caregiver?a. To research ways to help Jayden—how to adjust to new surroundings, how to adjust

to new caregivers, find recipes Jayden would like, snack ideas, etc.

RATE THIS PLATE

Jayden has been through a lot of heartache for a child his age. He is placed in a foster home, and his foster mother asks him what he would like to eat for his first dinner with them. He thought and thought and finally decided on the following plate. Rate this plate. Take into consideration that Jayden is malnourished, has not eaten much lately, and is lacking many nutrients.Fried chicken thigh½ cup mashed potatoes and 2 Tbsp gravy½ cup corn with butterBiscuit with butter2% milk—8 oz.Can Jayden eat all of this, and should he? Does this plate need to be changed, and how would you change it?

ANSWERS TO RATE THIS PLATE FOR JAYDEN

Jayden would probably not be able to eat the entire meal. Since he has not been eating large amounts of food, eating this entire meal may be too hard for his stomach. When feeding a child or adult that has been without food for a long period of time, it is important to start with small feedings with minimal calories.This meal lacks essential vitamins and minerals because there is no fruit option offered. Vitamins D, A, E, and C are lacking. He is getting B vitamins from the biscuit and the butter and fried chicken provide some protein and fat. The mashed potatoes are pure carbohydrate. Corn is a starchy vegetable and may be better substituted with green beans or broccoli. Milk provides calcium for growing bones and teeth and is a good option.An ideal meal would be a baked chicken thigh with a 6 oz. glass of milk and a mixed fruit cup. Vegetables can be included in the following meal (dinner).

CASE IN POINT—ASNAKU: VITAMIN A DEFICIENCY

ASSESSMENT

1. What are the symptoms of vitamin A deficiency?a. Night blindnessb. Bumpy “gooseflesh”

2. What is Asnaku experiencing that would suggest a vitamin A deficiency?a. Nearly exclusive grain-based dietb. Unable to find her way while going to the bathroom at nightc. Difficulty with tasks due to poor vision after daylight.

3. Make a list of foods that are high in vitamin A that should be incorporated in Asnaku’s diet.a. Any of the following foods are high in vitamin A:• Liver• Sweet potatoes• Carrots• Dark leafy greens• Butternut squash• Lettuce• Dried apricots• Cantaloupe• Spices such as Paprika, Red Pepper, Cayenne, Chili Powder• Herbs such as Parsley, Basil, Marjoram, Oregano

4. Think about Asnaku’s grain-based diet. What other vitamin or mineral deficiencies could she

have?a. Asnaku could also be deficient in any of the following:• Vitamin D • Vitamin C• Vitamin K• Vitamin E• Iron (if the grains are not fortified)• Niacin• Iodine• Thiamin

DIAGNOSIS

5. Write a nursing diagnosis for Asnaku.Nursing Diagnosis: Nutrition, Imbalanced: less than body requirements; Vitamin A. Related to inadequate consumption of food sources high in Vitamin A. Manifested by loss of night vision. Interventions: Offer foods nutrient dense in vitamin A. Offer vitamin supplement.

PLAN/GOAL

6. What change can you predict will occur with the introduction of vitamin A?a. Improvement in night vision or at least no worsening of the condition.

7. What can be done to ensure that Asnaku is able to get the vitamin A her body needs?a. Hopefully, the nurse who visits Asnaku’s village will be able to provide vitamin

supplements for Asnaku.b. It would be important to educate Asnaku and her family on what food sources are

high in vitamin A. If possible have them incorporate these foods into her meal plan on a regular basis.

IMPLEMENTATION

8. If Asnaku was hospitalized under your care, what interventions might you suggest for her care?a. Assess her food preference and provide her foods high in vitamin A and other

nutrient dense foods.b. Have the dietitian meet with Asnaku and her family for discussion about her diet and

sources of vitamin A.c. Calorie count/food log to assess how much of food rich in vitamin A she is eating.

9. In the United States, vitamin A deficiency is nearly unheard of, when compared to third

world countries. There are children in the United States who have diets that do not meet their caloric needs and have little nutritional quality. Why is vitamin A deficiency in the United States so much lower than in other countries?a. Many of the foods we consume have been fortified with vitamin A and other

vitamins and minerals to significantly reduce the incidence of deficiencies. Vitamin A is fortified into many foods, including milk, cereals, and grains.

10. Can you think of other examples of food sources that have been fortified to avoid deficiencies in vitamins or minerals?a. Could be many correct answers, some include:• Water fortified with fluoride• Salt fortified with iodine• Milk fortified with vitamins A and D• Cereals fortified with many vitamins and minerals• Orange juice fortified with calcium• Vitamin waters with many nutrients


11. What could the nurse assess at her next visit to Asnaku’s village to see if the plan is working?a. Visionb. Discussion of what foods Asnaku and her family have been eating c. Has Asnaku been taking a vitamin supplement daily?

THINKING FURTHER

12. Access the World Health Organization’s web page and read about the programs in place to provide vitamin A supplements to countries worldwide. Briefly discuss this program and the severity of this problem.

RATE THIS PLATE

Asnaku’s night-blindness sounds like a vitamin A deficiency. As the family does not eat anything grown, such as vegetables and fruit, nutrient deficiencies can result. Having access to biofortified rice can provide Asnaku and her family with nutrients, including vitamin A, iron, zinc, and iodine. Asnaku ate the following:

½ cup of fortified rice

¾ cup of vegetable stew

1 slice of flatbread

If Asnaku ate this meal three times a day, would the fortified rice be sufficient to provide her with 100% of her vitamin A and iron needs? What is the role of each nutrient within the biofortified rice?

ANSWERS TO RATE THIS PLATE FOR ASNAKU

No, the rice alone would not provide Asnaku with adequate iron and vitamin A. By eating vitamin A rich vegetables such as sweet potatoes, corn, cassava, and sorghum, Asnaku can decrease any further loss of vision.Vitamin A is an antioxidant that is commonly found in orange fruits and vegetables such as carrots, sweet potatoes, and pumpkin. Vitamin A deficiency can lead to total blindness.Iron is needed to fortify our blood and some should be stored for future needs especially among young girls and women. The best sources of iron include meat, beans, whole grain products, and nonheme iron sources (green leafy vegetables).Zinc promotes wound healing, boosts the immune system, and helps prevent further complications with night blindness and other eye problems.Iodine prevents goiters.

CHAPTER 2

CASE IN POINT—MARA: MAINTAINING A HEALTHY DIET WHILE GAINING INDEPENDENCE

ASSESSMENT

1. What factors will be influencing Mara as she attends college?a. Moneyb. How busy she becomesc. Ease of getting fast foodd. Different geographical areae. Being on her own

2. List the subjective information that can be obtained from Mara and her mother about her eating habits.a. Mara is used to eating a healthy meal of fruits and vegetables. Fresh meats and

seafood are her main protein sources. She has no preservatives in her food since she eats from the garden and from what her parents get from local meat and seafood markets.

3. What can you caution Mara regarding her introduction into the college world of nutrition?a. Fast foods contain high quantities of salts and preservatives.b. Fast foods are high in fat.c. Be aware of healthy choices where food is concerned.d. Preparing her own meals is an option.

4. How significant are these problems?

a. Highly significant to Mara’s well-being

5. Is Mara currently at a healthy weight for her height?a. Yes, her ideal body weight is 120 pounds ± 10%.

DIAGNOSIS

6. Write a nursing diagnosis for Mara.a. Nursing Diagnosis: Health maintenance possibly altered related to insufficient

knowledge of nutrition or of effects of poor nutrition on her body. Manifested by new surroundings and independent living.b. Interventions: Educate Mara on nutrition for healthy living. Discuss high fat, low

nutrient dense foods, label reading, and alcohol consumption. Discuss healthy meals Mara will be able to fix easily and independently.

PLAN/GOAL

7. What changes will Mara expect to see if she decides to eat less healthily?a. Loss of energyb. Change in appearancec. Increase in weightd. Acnee. Mental alertness altered

8. What situations will be most stressful to Mara?a. Initially the new surroundingb. Away from home for the first timec. Different geographical cultured. Examse. Meeting new people

9. What could Mara do to help keep her nutrition and food consumption on track?a. She could keep track of what she eats to make sure she is consuming the foods and

quantities she discussed with the dietitian.

10. What goals could Mara set to also help maintain her weight and her health?a. She could make a plan to exercise at least 3 days per week.b. She could monitor her weight every 1–2 weeks to make sure she is staying stable at

her healthy body weight.

IMPLEMENTATION

11. List some strategies Mara can use to help keep healthy.a. Keep a food diaryb. Limit the intake of fast foods to once a weekc. Be aware of how she is feeling physicallyd. Weigh herself weeklye. Exercise at least 3 times per week.

12. What substitutes could Mara make to be able to fit in with the crowd and still be eating well?a. Mara can carry her lunch and still eat with her friends on campus.b. Mara can encourage others to eat well.c. She can buy good vitamins.d. She can limit poor food choices by planning her meals and decreasing the

spontaneous food choices that are less healthy.

13. What would you caution Mara about in regard to stressful situations?a. Become aware of what she does to relieve her stressb. If food is a stress reliever, then make sure she has on hand lots of fresh vegetables

that she can eatc. Take a walk to relieve the stress


14. How will Mara be able to determine her success for healthy eating?a. Keeping her weight within normal limitsb. Keeping her energy level up

15. How well will Mara be able to associate body changes with poor food choices?a. After speaking with the nurse and dietitian, she should be able to identify body

changes and food choices extremely well.

16. How could the dietitian evaluate Mara’s progress?a. Mara could follow up with the dietitian at her semester break. She could discuss

with the dietitian how things have been going and any problems she has had staying on track with her nutritional goals.

b. Mara could discuss any pitfalls to healthy eating she has encountered and brainstorm with the dietitian on how to avoid them.

c. Mara could discuss her exercise routine. Has she been able to exercise or have there been obstacles to achieving that goal?

d. Dietitian could assess Mara’s weight since beginning college. Any significant changes or fluctuations?

THINKING FURTHER

17. Who else will benefit from Mara’s food choices?a. Her roommateb. Her friends

18. What resources could help Mara achieve her goals?a. Internet: she could look up nutrient content of foods on webpages such as

www.calorieking.com or webpages specific to restaurants.b. She could get a pocket guide for nutritional content of foods and fast foods.c. She could find healthy recipes that are quick and easy to prepare.d. If she has a smart phone, there are many nutritional apps that she could download

to track what she is eating or the calories in the food that she is consuming.

RATE THIS PLATE

Analyze the meal that Mara has prepared for dinner. Are the portions the right size for Mara? How would you change the portion sizes you feel are not correct? Rework this plate.

2 chicken tacos with lettuce, tomato, cheese, and onion

1 cup rice

¾ cup refried beans made with lard

12 oz. regular soda

ANSWERS TO RATE THIS PLATE FOR MARA

The 2 chicken tacos are fine.The cup of rice is too large of a serving. She only needs ½ cup of rice for a serving.Refried beans made with lard add extra calories and fat. The serving should be ½ cup made without lard to provide her with protein and some fat.If she is not lactose intolerant, she should be drinking a glass of milk instead of soda.

CASE IN POINT— THOMAS: CONSIDERING A VEGAN LIFESTYLE

ASSESSMENT

1. Thomas is 5 feet 9 inches tall. What is the ideal body weight for him?a. Ideal body weight for men is 106 pounds for being 5 feet tall and 6 extra pounds per

inch above 5 feet. Thomas’ ideal body weight is 160 pounds ± 10%.

2. Is Thomas at a healthy body weight for his height?a. No, he is above his ideal body weight range.

3. Using Table 2-6, what would you expect an appropriate calorie range for Thomas to be? a. 2400–3000. Toward the lower end if he desires weight loss.

4. What would be important to discuss with Thomas when considering a vegan diet plan?a. What alternate sources of protein Thomas could consume to ensure he is meeting

his nutritional needs.i. Beansii. Chickpeasiii. Meat analoguesiv. Tofuv. Nuts

b. How to read labels and nutrient lists for animal source products.c. Any vitamin or mineral supplements he may need to take to ensure he is meeting his

needs for all nutrients. Of particular concern may be B12, iron, omega-3, and calcium.

DIAGNOSIS

5. Write a nursing diagnosis for Thomas.a. Nursing Diagnosis: Risk for Nutrition, Imbalanced: Less than body requirements.

Related to new vegan lifestyle. Manifested by excluding animal source foods and learning to incorporate alternate sources of protein, B12, iron, omega-3, and calcium.

b. Interventions: Educate patient on how to follow a vegan lifestyle and continue to receive adequate nutrition for his body’s needs.

PLAN/GOAL

6. What could Thomas do to help ensure he is receiving adequate nutrition and meeting his macro- and micronutrient needs?a. Log the foods he is eating and review them to ensure he is receiving a variety of

foods and nutrients.b. Take a vitamin and mineral supplement.c. Monitor his weight and assess how he is feeling routinely.d. He may want his physician to check blood work for iron and B12 status to assure he

is meeting his needs.

IMPLEMENTATION

7. Name food sources Thomas could consume that are high in calcium.a. White beansb. Broccolic. Brussel sproutsd. Kalee. Kohlrabif. Mustard greensg. Orange juice (calcium fortified)h. Soy milki. Tofu (calcium set)j. Turnip greens

8. Name food sources Thomas could consume that are high in vitamin B12.a. Brewer’s yeastb. Sea vegetables such as dulse, kelp, and noric. Foods fortified in vitamin B12, including some plant milks, some soy products, and

some breakfast cereals.d. Thomas may also need a B12 supplement

9. Name food sources Thomas could consume that are high in iron.a. Green leafy vegetablesb. Whole grainsc. Almondsd. Avocadose. Beetsf. Blackstrap molassesg. Brewer’s yeasth. Datesi. Dulsej. Kelpk. Kidney and lima beansl. Milletm. Peachesn. Pearso. Dried fruits including raisinsp. Pumpkinsq. Rice and wheat branr. Sesame seedss. Soybeanst. Watercressu. Iron-rich herbs include alfalfa, catnip, cayenne, chamomile, chickweed, dandelion,

fennel seed, kelp, lemongrass, paprika, parsley, peppermint, plantain, and many more. The use of ironware when cooking foods also contributes to dietary intake. Tip: Be sure to eat organic blackstrap molasses so you know it does not contain lard as a foam-reducing agent, which may reduce its healthful effects.

10. Name food sources that Thomas could consume that are high in omega-3 fatty acids.a. Flaxseedsb. Hemp seedsc. Walnutsd. Soybeanse. Some leafy green vegetables and plant foodsf. Vegans typically will also need an omega-3 supplement.


11. How would you determine the success of Thomas’ transition to his new vegan lifestyle?a. He reports satisfaction with the foods.b. He reports feeling good with no fatigue or health issues.c. His iron and B12 blood work is within normal ranges

THINKING FURTHER

12. What other types of vegetarian lifestyles are options for Thomas if he would like to incorporate some animal food sources?a. Lacto–ovo vegetarians – use dairy products and eggs but no meats, poultry, or fishb. Lacto-vegetarians use dairy products but no meat, poultry, or eggs.c. There is even a new term known as flexitarian. A flexitarian is someone who follows

mainly a lacto–ovo vegetarian diet, but will occasionally incorporate fish or poultry. They usually do not incorporate red meat. The Mediterranean diet is a flexitarian type diet.

RATE THIS PLATE

Thomas is concerned about getting enough protein on a vegan diet. Will this meal provide Thomas with enough protein? What vegan protein sources could Thomas include in the meal or as a snack to meet his protein needs? Rate this plate.Tofu stir-fry with broccoli, snow peas, carrots, and onion½ cup brown rice of a cantaloupe, sliced Carbonated fruit beverage ANSWERS TO RATE THIS PLATE FOR THOMAS

The stir-fry is a healthy option. Four ounces of tofu will provide Thomas with 10 grams of protein. Including ½ cup of cooked beans will provide about 5–7 grams of protein and adding 2 tablespoons of nuts to the stir-fry will add 4–5 grams. The brown rice will provide carbohydrate for energy and a small amount of protein. Cantaloupe is a fruit and therefore provides more carbohydrate than protein to the meal. Since Thomas is physically active and a bodybuilder, he will need additional protein for muscle building. Consuming around 30–35 grams of protein per meal will meet his daily protein need. Thomas may also choose to eat a snack higher in protein such as ¼ cup of nuts, vegetables with hummus, or a peanut butter sandwich to assist in achieving the recommended intake.

CHAPTER 3

CASE IN POINT— JANEESHA: WEIGHT MAINTENANCE AFTER SMOKING CESSATION

ASSESSMENT

1. Identify the significant data in this case study.a. Janeesha has a 10-year history of smoking.b. Janeesha’s parents were both smokers also.c. Janeesha’s mother was diagnosed with lung cancer.d. Janeesha’s husband does not smoke and does not want her to smoke if she were to

get pregnant.e. She is ready to stop smoking and has spoken to her doctor about it.f. She is concerned about weight gain if she stops smoking.

2. Calculate Janeesha’s REE using the Harris-Benedict equation and account for the thermic effect of food (TEF).a. REE is 1436b. Thermal effect of food is 10% of REE (143.6)c. REE and thermal effect total 1579 calories per day

3. What does Janeesha need to discuss with her doctor to assist with her smoking cessation?a. How many cigarettes she can smoke per dayb. How much extra food she can consume if she quits smokingc. Medication options for smoking cessationd. Foods she can use to resist the urge to smoke

4. What questions or concerns might Janeesha want to discuss with the dietitian?a. How many calories she will need to maintain her weightb. How to work these calories into a healthy meal planc. How to estimate calories in her foodsd. How to handle difficult situations such as eating out or going to partiese. How to read a food labelf. Sample meal ideas

DIAGNOSIS

5. Write a nursing diagnosis for Janeesha.a. Family process altered, related to disruption of family life, fear of outcomes, and

uncertain future

PLAN/GOAL

6. What changes can Janeesha implement to help prevent weight gain?a. Eat more slowlyb. Consume less foodc. Eat fewer mealsd. Eat only at mealtimee. Identify stressful situations and avoid food at these timesf. Reduce her caloric intake

7. Set two measurable realistic goals for Janeesha during this process to prevent further weight gain.a. Eliminate snacking between mealsb. Exercise three times a week for 45 minutes each time8. How could information on exercise be helpful to Janeesha?a. Exercise during smoking cessation would be helpful for maintaining her weight. It

may also be helpful in reducing stress.

IMPLEMENTATION

9. What strategies can be used to help Janeesha become aware of her food consumption and the time it takes her to eat?a. Ask her to chew her food 32 times before swallowingb. Keep a food diaryc. Identify her activities when eatingd. Identify where she is eating

10. What actions would help Janeesha carry out these goals?a. Being accountable to one person that she respects

11. Who can help her?a. Her husbandb. Her familyc. Her friends


12. What will Janeesha be able to identify if the plan is successful?a. Weight lossb. Less nausea

13. What will she be able to measure as evidence of her success?a. Weight loss

THINKING FURTHER

14. Janeesha’s husband is concerned about her smoking. He would like her to quit not only for her own health, but also his (exposure to secondhand smoke) and for their potential children if Janeesha were to become pregnant. What are some of the risks associated with smoking and some of the added benefits of quitting?Risks might include:

a. Weight gainb. Short-term increase in stressc. Cravingsd. Withdrawal symptomse. Irritabilityf. Anxietyg. Decreased concentrationh. Increased appetitei. Relapse

Benefits might include:

a. Lower risk of lung and other cancersb. Decreased risk for premature deathc. Decreased risk for coronary heart disease, stroke, and perhaps vascular diseased. Decreased risk of COPD and respiratory diseasese. Decreased risk of infertility and low birth weight or premature infant

RATE THIS PLATE

With smoking cessation, Janeesha needs to realize that her hands are going to miss the smoking since it is such a habit. Most people will eat something to fill the temptation. Rate this plate to see if Janeesha will be able to maintain her current weight.

Cheeseburger with lettuce, tomato, and onion

Medium French fries

Side salad with low-fat ranch dressing

32 oz. regular soda

Calculate the calories that are in this meal and determine if it is one-third of the calories she needs in a day. What can be eliminated from this meal to reduce fat and calories?

ANSWERS TO RATE THIS PLATE FOR JANEESHA

This meal will provide Janeesha with approximately 1,300 calories and 48 grams of fat. You could eliminate the French fries from the meal and use vinaigrette salad dressing instead of low-fat ranch dressing. Instead of a regular soda, she could drink a diet soda or order water. She could have smaller meals and incorporate healthy snacks between meal times to distract from smoking. Healthy snacks could include apple slices, grapes, handful of nuts, peanut butter crackers, yogurt, and cottage cheese. Eat slowly.

CASE IN POINT— ED: CONTROLLING SYMPTOMS OF CROHN’S DISEASE

ASSESSMENT

1. What are the pertinent objective and subjective data related to Ed’s problem?a. Crohn’s disease of large intestineb. 6 feet 1 inch tall, 223 poundsc. Prone to flare-ups. Diarrhea for 2 weeks with weight lossd. Loss of fluide. Eating foods that have caused bowel irritation

2. Calculate Ed’s target caloric intake and weight range according to Tables 3-2 and 3-3.a. Target caloric intake: 2400−3000 kcals/dayb. Target weight: 159–205 pounds

DIAGNOSIS

3. Write a nursing diagnosis for Ed.a. Diarrhea: related to intestinal inflammatory process, Crohn’s, inflammatory bowel

disease. Manifested by loose stools for 2 weeks and weight loss of eight pounds. Interventions: Educate patient on low-lactose, low-fat, low-fiber, and high-protein diet.

4. What is the cause of Ed’s problem with elimination?a. Crohn’s disease, large intestine not able to reabsorb water, not able to synthesize

vitamin B and vitamin K

PLAN/GOAL

5. Write a measurable goal for controlling Ed’s diarrhea.a. Eliminate for 24 hours all known foods that cause diarrhea.b. Ensure adequate fluid intake to prevent dehydration.

6. Write a goal to help Ed adapt to his new diet. Incorporate Ed’s desire to lose weight.a. Keep a food diary noting bowel habit changes while following dietary

recommendations.

7. Where could the dietitian direct Ed to obtain information to increase his understanding of his disease and the related nutrition issues?a. Crohn’s disease website, focusing on the diet and nutrition section:

http://www.ccfa.org/info/about/crohns

IMPLEMENTATION

8. List at least one action to help Ed meet each goal.a. Keep a food diary and bring it with him to dietitian appointments.b. Consume at least 70 oz. of fluid daily.c. Follow up with Ed on the food diary he has been keeping and discuss with him any of

the new information he has used since reviewing the Crohn’s and Colitis webpage.

9. List two foods Ed should avoid.a. Caffeine in coffee, tea and other beverages, fresh fruits and uncooked vegetables,

high-fiber foods (such as fiber-rich breads, cereals, nuts, and leafy greens), high sugar foods, skins, seeds, popcorn, high-fat foods, spicy foods, raw foods, prunes, beans, large food portions, in some cases dairy products

10. List three things Ed needs to include in his diet.a. Fluidb. Small amount of food at any sittingc. Since there is no specific diet, Ed needs to identify what foods cause problems for

him and avoid them.

11. How could the website http://www.ccfa.org for Crohn’s and ulcerative colitis be helpful to Ed?a. To provide updated informative articles with input from specialists in this field and

lots of nutritional information and tips.


12. What will Ed report when your plan for his Crohn’s disease is effective?a. No diarrhea or loose stools

13. How will Ed know his new diet is successful?a. He will continue to lose his weight slowly while maintaining good bowel habits.

14. What can the doctor measure when all the goals are successful?a. His weight lossb. His electrolytes and hydration status

15. If the plan were not successful, what would Ed be experiencing?a. Weight gain or stable weight without loss; or if he continues to eat foods that irritate

his bowel, he may have return of diarrhea and therefore unhealthy weight loss.

16. What could be an unplanned, undesirable outcome of this diet change?a. Continuation of diarrhea and dehydrationb. Ed could feel deprived or not satisfied with his limited food choices.

THINKING FURTHER

17. What challenges does Ed face with chronic progressive disease?a. Maintaining a well-balanced, healthful dietb. Achieving a healthy weight lossc. Maintaining hydration statusd. Staying positive and motivated about following his diet and caring for his health.

RATE THIS PLATE

Ed’s doctor recommends a low-lactose, low-fat, low-fiber, and high-protein diet to begin treating his symptoms. Ed ate the following meal for dinner. Rate this plate.

10 oz. ribeye steak

Baked potato with sour cream, bacon bits, and butter

½ cup of lima beans

Whole wheat rolls with butter

10 oz. of whole milk

Whole wheat fruit crumble

What foods on this plate might give Ed continued symptoms of Crohn’s disease? How might you adjust this meal to fit the diet prescribed by the physician?

ANSWERS TO RATE THIS PLATE FOR ED

Ribeye steak is high in fat. He would be better off eating a sirloin steak or leaner choice of meat.The baked potato is fine, but Ed should not eat the potato skin since it is high in fiber. The toppings are high in fat; whipped butter is lower in fat and could be used in place of regular butter and sour cream. Lightly salting the potato for flavor would also be a healthy option. Lima beans are high in fiber and are not a good choice for Ed.The whole wheat rolls are also high in fiber; Ed would be better off eating enriched white flour rolls. He should not use the butter or lower it to ½ tsp. per roll.Milk is not allowed on a lactose-free diet. Plus, the fat content of the milk is higher in whole milk than in skim or 1% milk. He would be better to have water. The whole wheat fruit crumble is not a good desert choice for Ed because of the fat and whole wheat content. Ed should avoid eating desserts that have whole grains, raisins, nuts, coconut, or seeds. A better dessert option would be some banana, mango, papaya, or cantaloupe.

CHAPTER 4

CASE IN POINT— ANGELA: STEROIDS IMPACTING DIABETES CONTROL

ASSESSMENT

1. The dietitian can help Angela regulate her diet and in so doing lose weight. Calculate Angela’s ideal caloric intake and weight using Tables 3-2 and 3-3, the Harris–Benedict equation, and thermic effect of food (TEF).a. Table 3-2: 1600 caloriesb. Table 3-3: weight 130–167 poundsc. Harris–Benedict: 1540 caloriesd. With Thermal effect of food: 1386 calories

2. What does the dietitian need to know about Angela’s meal choices?a. When she eats, what she eats, and what size portions she eats

3. What does the dietitian need to know about Angela’s lifestyle?a. The dietitian needs to find out Angela’s lifestyle: Does she work outside the home?

What food does she like and dislike? How much activity does she get?

4. What information will be helpful once Angela is discharged and at home?a. Blood sugar log; portion sizes of food or food log; knowledge regarding high and low

blood sugar treatment.

5. What sources of carbohydrates would be most helpful in weight loss? a. Whole grains, Low-fat/fat-free dairy, Fruits and vegetables

DIAGNOSIS

6. Write a nursing diagnosis for Angela.a. High risk for ineffective management of therapeutic regimen related to insufficient

knowledge of diabetes, self-monitoring, ADA exchange diet, treatment of hypoglycemia, weight control, sick day care, exercise program, foot care, signs and risks of complications, and diabetes outpatient education. Manifested by elevated blood sugars and poor wound healing.

b. Interventions include educating patient on self-management of diabetes, including monitoring blood sugars, administering medication or insulin, following nutritional guidelines and the standards of care for patients with diabetes.

PLAN/GOAL

7. Write a goal related to weight loss that Angela should achieve at the end of diabetic classes.a. Weight loss should be no more than 2 pounds per week.b. She will follow her meal plan daily incorporating the correct number of

carbohydrates and calories.

8. State two goals for Angela related to her diet and blood sugar.a. Maintain blood sugar levels within normal rangeb. Maintain a daily food log to help control portion sizes and caloric intake.c. Maintain a blood sugar log to help physician determine where medication changes

need to be made. IMPLEMENTATION

9. List the topics that you would teach Angela to achieve her goals.a. Identify foods she likes and incorporate them into her dietb. Identify food portion sizesc. Identify healthy food choicesd. Identify the range of optimal blood sugar readings

10. What agencies or community resources can you provide to help Angela achieve her goals?a. Diabetes groups onlineb. Diabetic associationc. Local hospital dietitian or diabetes centerd. Insurance company for any assistance in follow-up in getting education classes,

testing supplies, and medications covered.


11. What can you expect from Angela to show she understands what you have taught?a. Maintaining blood sugars within normal limitsb. Weight loss of 1–2 pounds per week

12. What should Angela’s fasting blood sugar read?a. 70–100 mg/dl

13. How long do you think it would take Angela to learn a new diet plan, check her blood sugar, learn a new exercise plan, and demonstrate integration into her everyday life?a. Dependent upon her educational experience and understanding of information

presented. She would hopefully understand the information presented to her, however, it may take time and follow-up sessions to ensure she has changed her lifestyle and habits. Sometimes new plans are difficult to stick with long-term follow-up, and support groups can assist with this.

THINKING FURTHER

14. What blood test could the doctor order to see if Angela had maintained her blood sugar at a normal level over the past few months?a. A1c

15. What are some of the serious health consequences if Angela does not manage her diabetes well?a. Retinopathy – Loss of sightb. Nephropathy – Kidney failurec. Neuropathy – Leading to amputation of limbsd. High risk for cardiovascular disease

RATE THIS PLATE

While at the diabetes center, Angela was educated about the diabetic meal plan. She continues to learn about how medications, along with her eating habits, can affect her blood sugar levels. Rate this plate to see how she has done with planning a 1,600–1,800 calorie meal plan.

2 pieces of French toast

2 strips of bacon

1 cup of mixed fruit

Coffee with cream and sugar

ANSWERS TO RATE THIS PLATE FOR ANGELA

This meal contains too many carbohydrates for breakfast. Angela should start her morning with only 2 carbohydrate choices. She could eat 1 slice of French toast instead of two, or eat both slices and eliminate the cup of fruit. The two strips of bacon will provide some protein but 22 grams of fat. She could substitute turkey bacon or only eat 1 slice instead of 2. The coffee with cream is fine. If she is going to use sweetener for her coffee, she could use sugar-free substitutes such as Splenda.

CASE IN POINT— JEROME: COPING WITH GASTROPARESIS

ASSESSMENT

1. What has caused the gastroparesis that Jerome is now experiencing?a. Gastroparesis is caused by neuropathy or damage to the nervous system, in this case

the nerves surrounding the stomach. Neuropathy and gastroparesis are complications of uncontrolled diabetes.

2. What symptoms did Jerome have?a. Nausea and vomiting, tingling and burning sensations in his legs and feet, and

difficulty with his vision. All these symptoms are related to long-term complications of diabetes.

3. How will the disease alter his life?a. Jerome will be encouraged to consume smaller and more frequent meals. He will

need to avoid foods that are difficult for him to digest. He may also need to avoid gas forming foods as well.

4. How significant is this disease?a. Very significant; gastroparesis makes controlling blood sugars more difficult.

DIAGNOSIS

5. Write a diagnostic statement for Jerome’s potential alteration in nutrition.a. Nutrition altered related to dietary restrictions secondary to gastroparesis.

Manifested by nausea and vomiting.

6. Write a diagnosis for Jerome’s deficient knowledge related to the new diet.a. High risk for ineffective coping related to knowledge deficit related to complexity of

self-care and dietary limitations

PLAN/GOAL

7. What dietary goals are measurable and appropriate for Jerome?a. Eliminate foods that are not easily digested such as nuts, seeds, or gas forming

vegetables.b. Eliminate fried foods, foods high in fat and high in fiber

8. What education goals are specific and measurable for Jerome?a. Jerome will be able to identify foods to avoid with low-fat and low-fiber diets.b. Jerome will be able to identify other ways to decrease symptoms of gastroparesis (i.e., eating smaller, more frequent meals).

IMPLEMENTATION

9. What major topics about gastroparesis does Jerome need to understand to make necessary dietary changes?a. Gastroparesis can make timing of insulin doses and control of blood sugars

extremely difficult.b. Medications may need to be given to stimulate or regulate digestion.

c. If he does not follow the dietary restrictions he has been educated on, then he will continue to have nausea and vomiting with meals.

10. What dietary changes does Jerome need to learn to control the symptoms?a. Consume smaller, more frequent mealsb. Follow a low-fat, low-fiber dietc. Chew foods well at mealsd. Avoid broccoli and other gas forming foods, nuts, and seedse. Increase fluid consumption throughout mealsf. Sit up for at least 1 hour after meals.


11. At his follow-up doctor’s appointment, what is his doctor likely to ask to determine if the plan was successful?a. How many bouts of nausea and vomiting have Jerome experienced?b. How is his blood sugar control?c. How is his A1c?

THINKING FURTHER

12. Can gastroparesis be cured?a. No

13. What medications are typically used to help manage this disease?a. Oral diabetes medications to control blood sugarb. Prokinetic drugs such as Reglan to stimulate digestive tract

RATE THIS PLATE

Jerome has been instructed to consume a diet low in fat and fiber in order to make digestion easy and rest his gut. How did he do in planning the following meal according to the dietitian’s recommendations? Rate his plate:

4 oz. beef roast with cooked potatoes, carrots, celery, and onions¾ cup apple Waldorf salad1 whole-wheat roll

ANSWERS TO RATE THIS PLATE FOR JEROME

Jerome made some good and poor choices with his meal. The beef roast would be fine, but he would have to remember to chew it slowly in order to properly digest it. Skinning potatoes before cooking them will decrease the fiber content. Carrots may be tolerated since they do not have skin. The celery is high in cellulose and may be hard to digest. He may also be able to tolerate the onions. Since the apples are not peeled for the salad, it would not be ideal for Jerome. It also contains some celery and pecans that may be hard to digest. A regular dinner roll should be eaten instead of a whole-wheat roll since it is high in fiber.

CHAPTER 5

CASE IN POINT— MURALI: FAMILY HISTORY AND ELEVATED CHOLESTEROL

ASSESSMENT

1. What data do you have about Murali?a. Not paying attention to dietb. Family history of heart diseasec. New stress in his lifed. Eating out frequentlye. Smokes

2. As a nurse, what conclusion can you draw from Murali’s lab results?a. Murali is eating foods high in bad cholesterol.b. May also have elevated cholesterol related family historyc. He may not be getting much physical activity. His HDL is very low and would

normally be higher with routine exercise.

3. What do you need to know about his current eating habits? Could foods with unknown fat content have a bearing on his current diet? How could a 24-hour food diary help?a. You need to know what types of food Murali is consuming.b. Murali is eating foods prepared in restaurants, so he may not know the total fat

content.c. His food diary will help him identify the foods that are higher in fat and calories.

4. What about his health habits, like smoking and alcohol use?a. Smoking and excessive drinking add negatively to his health issues.

5. What is Murali doing that is healthy for his heart?a. Seeking help from his physician and following the recommendations to exercise and

eat rightb. Taking the prescribed medication as directed.

DIAGNOSIS

6. What is the cause of Murali’s imbalanced nutrition, more than body requirements?a. Murali’s busy lifestyle makes it difficult to follow a specific diet.b. Murali has a lack of knowledge about nutrition and is not making healthy choices.c. Murali is not getting regular physical activity.

7. Complete this statement: Murali’s change of lifestyle is related to a new career and the change in work hours and habits because of it.

PLAN/GOAL

8. What are two possible goals you have for Murali?a. Implement his exercise regime at least five times a week for 30–45 minutesb. Keep a food diary, begin to look at the sources of high-fat and high-calorie content in

the foods he is consuming.c. Enroll in a smoking cessation program.

IMPLEMENTATION

9. What topics do you need to cover related to dietary fats?a. Cover saturated and unsaturated fats and why this is importantb. Cover the amount of cholesterol Murali is consuming as well as how that compares

to the recommended guidelines.

10. Name three things Murali can do to help him recognize hidden fats in fast-food restaurants.a. Ask how foods are prepared; identify key words that could indicate a higher fat

contentb. Request foods to be prepared with less fat and for condiments to be on the side so

Murali can use them more sparingly.c. Eliminate fried foods

11. Who else should be in class with Murali?a. His wife

12. What agencies or resources could you provide to support Murali at home?a. American Heart Association

13. How could the information on the American Heart Association website (http://www.americanheart.org) be helpful to Murali?a. Introduce information in a nonthreatening manner


14. What can the physician measure to determine the effectiveness of the plan?a. Cholesterol levelsb. Murali’s weightc. Murali’s BMI

15. What can Murali provide to demonstrate his compliance with the plan?a. His food diary and exercise log

THINKING FURTHER

16. What is the worst consequence if Murali does not reduce his cholesterol?a. Death

17. What does family history have to do with Murali’s results?a. Family history plays a big part in how our bodies respond to lifestyle changes as well

as how much cholesterol our own bodies produce.

18. What are the challenges of maintaining a diet and exercise plan for life?a. Boredomb. Illnessc. Fatigued. Stressorse. Busy schedule

RATE THIS PLATE

Murali attended the nutrition class to learn how to choose healthy foods while eating out. He attended a dinner meeting with his clients and ordered the following meal. Rate this plate for foods that contain large amounts of cholesterol and fat.

4 oz. shrimp cocktail appetizer

2 cups chicken Caesar salad with 2 tbsp light vinaigrette dressing

2 hot dinner rolls with creamy butter

1 slice of cheesecake with strawberries

20 oz. iced tea

ANSWERS TO RATE THIS PLATE FOR MURALI

Shrimp is very high in fat, but low in cholesterol. The fat is not as detrimental in shrimp as it is in prime cuts of beef or meat. The chicken Caesar salad is not high in fat or cholesterol. The chicken does contain some cholesterol, but is considered a lean protein choice. The dinner rolls are fine, but it is the butter that will add additional calories and fat. The cheesecake is high in fat. Murali could ask for fresh fruit instead of eating a calorie and fat laden dessert. The iced tea is a good choice.

CASE IN POINT— CECELIA: ELEVATED CHOLESTEROL AND TRANS FATS

ASSESSMENT

1. Why were Cecelia’s parents concerned about her cholesterol levels?a. When Cecelia’s parents learned they both had elevated cholesterol, they were

concerned that she may also have elevated cholesterol due to genetics.

2. Cecelia’s doctor shares with her the results of her lipid panel. What are the recommendations for total cholesterol, LDL, and HDL levels for Cecelia.a. Total Cholesterol less than 200b. LDL less than 100c. HDL greater than 40

3. What is Ceceila’s ideal body weight range? Is her current weight within her ideal body weight range?a. 108–132 poundsb. Her current body weight of 173 pounds is above her ideal range.

4. What is trans fat and what are the impacts of trans fats on the body?a. Trans fats are produced when hydrogen atoms are added to unsaturated fats to

produce a semisolid product such as margarine.b. They are dangerous and will cause elevations in LDL and total cholesterol.

DIAGNOSIS

5. Write a nursing diagnosis for Cecelia.a. Risk for Ineffective Therapeutic Regimen Management: Related to knowledge deficit

of nutritional requirements to decrease LDL and total cholesterol.

PLAN/GOAL

6. Cecilia should be educated on what foods will elevate her cholesterol. What are some of these foods?a. Saturated fats such as the fats in any animal source products such as meats, milk,

butter, and egg yolks.b. Palm oil and coconut/coconut oil

7. Cecilia should understand that cholesterol comes not only from foods, but also from what other source?a. The body. The liver manufactures 800–1000 mg of cholesterol daily.

8. What goals would you set for Cecelia?a. Decrease the fat in her diet to no more than 30% and the saturated fats to less than

10% of total calories.b. Reduce consumption of high-fat meat.c. Begin consuming low-fat and fat-free dairy products.

IMPLEMENTATION

9. What is important for Cecelia to understand about trans fats?a. Trans fats can be just as harmful as saturated fats in cholesterol control.b. How to read food labels to find any trans fats the food containsc. She also needs to know the laws in New York City regarding trans fats in restaurants

and bakeries, so that she can run a successful business.10. How often should Cecelia have her cholesterol assessed?

a. Every 6 months. If her doctor puts her on cholesterol medication, her liver function needs to be assessed as well.


11. How will Cecelia and her doctor know if she has been successful with her goals?a. Total Cholesterol will be under 200b. LDL under 100c. HDL over 40d. She will adhere to her low-fat, low-cholesterol diete. Weight loss

THINKING FURTHER

12. Search guidelines on the National Cholesterol Education Program website (http://www.nhlbi.nih.gov) for cholesterol levels and take the 10-year risk assessment at the bottom of the page. Are you at risk for a cardiac event in the next 10 years? Are there changes in your diet that could help to decrease your risk?

RATE THIS PLATE

Cecelia would like to modify the following recipe for dark chocolate cake in order to make it healthier for her family and customers. What ingredient(s) needs to be eliminated and replaced with a trans-fat-free option? What can you substitute to eliminate trans-fat?2 cups boiling water1 cup unsweetened cocoa powder2 ¾ cups all-purpose flour2 teaspoons baking soda½ teaspoon baking powder½ teaspoon salt1 cup butter, softened2 ¼ cups white sugar4 eggs1 ½ teaspoons vanilla extract

ANSWERS TO RATE THIS PLATE FOR CECELIA

The main trans-fat ingredient in this recipe is the butter. One cup of applesauce can be used to replace the 1 cup of softened butter and yield a tasty product with less fat. Mashed bananas or ½ cup of fruit puree may also be used to replace the butter. Canola oil can replace butter in many baking recipes such as pie crusts, cakes, and muffins, yielding a moister and softer product with no cholesterol and less saturated fat.

CHAPTER 6

CASE IN POINT— ANNELIESE: HIGH-PROTEIN DIETS

ASSESSMENT

1. What data do you have about Anneliese’s eating habits?a. She has been eating large amounts of protein and fat.

2. What do you know about her ability to develop habits?a. Anneliese seems to be able and willing to adapt a new meal plan to meet her weight loss goals. She seems to miss the habit of eating many fruits and vegetables she had in Germany.

3. What is the cause of the current problem?a. Anneliese would like and needs fruits and vegetables in her diet. She would like to lose weight as well.

DIAGNOSIS

4. Complete the following diagnostic statement: Imbalanced nutrition, more than body requirements, as evidenced by weight gain or inability to lose desired weight.

5. Complete the following diagnostic statement: Deficient knowledge related to a lack of information about healthy diet options.

PLAN/GOAL

6. What are two possible measurable, reasonable goals for Anneliese?a. Introduce two fruits and two vegetables into her meals each dayb. Maintain a weight loss of 1–2 pounds per weekc. In addition to diet, have Anneliese begin thinking about how she could incorporate

exercise into her daily activities to help meet her weight loss goals as well.

IMPLEMENTATION

7. What foods need to be altered in Anneliese’s diet?a. Protein limitations according to body sizeb. Fat limitations according to body needs

8. What does Anneliese need to add to her diet?a. Fruits and vegetables

9. Using preferences, suggest some alternative menus that would help Anneliese lose weight.a. Include in each meal a fruit or vegetable and decrease the intake of protein and fatsb. Have smaller meals with fruit and vegetable snacks in between.


10. What criterion would a dietitian use to measure Anneliese's success?a. Amount of weight lossb. Food log that reports increase in fruits and vegetables and reduction of meats and

fats.

11. What diseases would Anneliese avoid by reducing her high-fat protein intake?a. Cardiac involvement, atherosclerosis, and obesity.

THINKING FURTHER

12. Which protein sources are most economical and are low in calories?a. Legumes and other vegetables such as peanut butter or nuts.

13. How could this information be useful in other situations?a. When dining out, helps to make the right choices

RATE THIS PLATE

Anneliese does not need a high amount of protein in order to lose weight. She only needs 5 ½ oz. of protein per day. By lowering the amount of protein in the diet, calories will decrease and weight will be lost. Rate what she ate on the Atkins diet before seeing the dietitian.

7 oz. deep fried chicken breast

Spinach salad with tomatoes, onions, egg, dried cranberries, and croutons

Vinaigrette dressing

¾ cup of broccoli

What changes can be made to this plate to encourage healthy choices and continued weight loss without the Atkins diet plan?

ANSWERS TO RATE THIS PLATE FOR ANNELIESE

This meal is too high in protein for her needs. Anneliese needs only 5 ½ oz. of protein per day, so she only needs about 2–3 per meal. The spinach salad is a great choice, rich in vitamins and minerals. Dressing should be used sparingly as it will provide additional calories and fat. Carbohydrates should be included in a healthy, weight loss diet. The Atkins diet restricts carbohydrates to only 20 grams in the first phase. Anneliese could eat a baked sweet potato with her meal to add carbohydrates for energy. The broccoli is a good choice and high in fiber. A serving size of broccoli is ½ cup. Anneliese would also have the option to include fruit in her diet. Fruit will provide her with carbohydrates, fiber, and natural sugars that will help with the constipation she is experiencing.

CASE IN POINT—TALIL: PROTEIN ENERGY MALNUTRITION

ASSESSMENT

1. What is deficient in Talil’s diet?a. Protein calorie foods

2. What causes kwashiorkor?a. Sudden or recent lack of protein-containing food

3. What caused Talil to develop kwashiorkor?a. He has recently been weaned because his mother has had another baby. Talil’s diet after weaning has consisted of mainly grains such as rice and berries.

4. If Talil’s kwashiorkor continues, what consequence could follow as a result?a. Mental retardation or death.

DIAGNOSIS

5. Write a nursing diagnosis for Talil.a. Nutrition Imbalance: Less than body requirements related to lack of available food

sources high in protein. Manifested by kwashiorkor.

PLAN/GOAL

6. What can Erin do as a dietitian to help Talil’s mother correct his kwashiorkor?a. Provide education on what causes the problem to help resolve the issue. Discuss

ways that his mother could find protein sources in their village.b. Provide lentils as a source of protein for Talil.

IMPLEMENTATION

7. What could Talil’s mom to do to help prevent further kwashiorkor in her children or other children in their village?a. Talil’s mom mentioned there is a stream nearby where they can fish. She may need

to help educate the men or others of the village as to what is causing this problem. The village may need to work together to fish or hunt for adequate protein sources for the children.

8. Explain what happens in kwashiorkor that causes edema, skin lesions, and changes in pigment of the skin?a. The disease causes fat to accumulate in the liver, and the lack of protein and

hormones results in edema, painful skin lesions, and changes in pigmentation of skin and hair.


9. How will Talil’s mom know that the strategies she has implemented have resolved the kwashiorkor?a. Talil’s health will return. He will have a reduction in edema, soars, and pigmentation

changes.b. He will consume the protein sources she offers to him.

c. The village will rally to help fish and hunt for protein sources for the children.d. There will be a decreased incidence of kwashiorkor and therefore a reduction of

mental retardation and death in their village.

THINKING FURTHER

10. Shown in Table 6-6, what are the key differences between kwashiorkor and marasmus?a. Kwashiorkor—lack of proteinb. Marasmus—lack of protein and total caloriesc. Refer to the table for additional differences

RATE THIS PLATE

Talil was diagnosed with kwashiorkor due to inadequate protein intake. His mother has asked the dietitian for good sources of protein and milk she would have in her area. Talil’s mother prepared the following meal. Rate this plate on protein content:

1 oz. cooked fish

⅓ cup rice

¼ cup of vegetables

4 oz. soy milk

ANSWERS TO RATE THIS PLATE FOR TALIL

Talil is only 2 years old and will not eat very much. Fish is an available protein in their area. Soy milk can be given to children above the age of 1 and contains adequate amounts of protein. He only needs approximately 2 tablespoons of each food given. This diet will be adequate, along with the berries and fruit they gather.

CHAPTER 7

CASE IN POINT— KRYSTYNA: DEEP VEIN THROMBOSIS

ASSESSMENT

1. What data do you have about Krystyna?a. Krystyna has just given birth to her first child. She was on bed rest for several weeks

before delivering her baby.

2. What factors put Krystyna at risk for developing a deep vein thrombosis?a. Pregnancyb. Giving birthc. Long periods of sitting or immobility.

3. As a dietitian, what would you find helpful in Krystyna’s history?a. What she usually has to eat and what her food preferences are.

DIAGNOSIS

4. Write a nursing diagnosis for Krystyna.a. Risk for Ineffective Therapeutic Regimen Management related to insufficient

knowledge of prevention of recurrence of deep vein thrombosis and signs and symptoms of complications.

b. Intervention: Educate patient on causes of Deep Vein Thrombosis. Discuss prevention, signs and symptoms, treatment, and complications.

PLAN/GOAL

5. What is a specific measurable goal for Krystyna in regard to her diet?a. Decrease sources of vitamin K to help prevent further clotting of blood.

IMPLEMENTATION

6. What food sources are high in vitamin K and should be avoided by Krystyna? a. Kaleb. Collardsc. Spinachd. Turnipse. Beetsf. Mustard greensg. Brussel sproutsh. Broccolii. Lettucej. Parsleyk. Okral. Cabbage


7. What criteria should Krystyna use to evaluate the success of her actions?a. Reduction in painb. Elimination of further clottingc. Successful elimination of DVT

THINKING FURTHER

8. Who else needs to be aware of Krystyna’s vitamin K restriction?a. Her husband and her familyb. Anyone who might bring her family meals to support them at this time.

RATE THIS PLATE

The dietitian educated Krystyna on high vitamin K vegetables to avoid until her thrombosis had healed. Rate the plate that Krystyna ordered for lunch.One 3 × 3 slice of spinach lasagna1 garlic breadstick½ cup steamed broccoli½ slice of apple pie12 oz. iced teaList the foods that are high in vitamin K and replace them with low sources of vitamin K.

ANSWERS TO RATE THIS PLATE FOR KRYSTYNA

Krystyna ordered items that contained high levels of vitamin K. The spinach in the lasagna contains vitamin K. She would have been better off choosing regular meat lasagna than one with vegetables. The broccoli is also high in vitamin K. Instead of broccoli she could order carrots or squash. The breadstick and apple pie is permitted while taking a blood thinner for thrombosis.

CASE IN POINT—TINA: RECOVERING FROM ALCOHOLISM

ASSESSMENT

1. What are some of the red flags that may indicate that Tina is an alcoholic?a. Drinking anytime day or nightb. Having periods where she blacks out and does not remember thingsc. Arrested for public intoxicationd. Decrease in appetitee. Weight loss

2. If Tina’s body cannot absorb thiamin as a result of excessive alcohol consumption, what are the consequences of this?a. Loss of appetiteb. Fatiguec. Nervous irritabilityd. Constipation

3. Tina was arrested with a blood alcohol level of 0.24. How does her level compare to the legal blood alcohol limit in most states?a. Blood alcohol level in most states is 0.08. When Tina was arrested, she had 3 times

the legal limit of alcohol in her blood

DIAGNOSIS

4. Write a nursing diagnosis for Tina related to her nutritional intake.a. Nutrition Imbalance: Less than body requirements related to anorexia secondary to

alcohol abuse. Manifested by weight loss and thiamin deficiency.

5. Write a nursing diagnosis for her alcohol abuse and rehabilitation.a. Ineffective Coping: Anger, dependence, or denial related to inability to manage

stressors constructively without alcohol.

PLAN/ GOAL

6. Tina needs to begin reintroducing foods into her body. What would be the best way to go about this?a. Tina will need the nutrient dense foods her body has been deprived of during her

excessive consumption of alcohol.b. She may need small frequent meals to help get her body reintroduced to foods.

IMPLEMENTATION

7. What must Tina understand about her nutrition and her recovery?a. Excessive alcohol consumption deprives her body of necessary nutrients. b. She may need vitamin and mineral supplements such as thiamin during her recovery

process.c. Recovering from alcoholism is a long process to which you will need to be dedicated

and surrounded by supportive people.


8. What would you expect from Tina in 6 months if her recovery plan is successful?a. She will no longer be consuming alcohol.b. She will be at a healthy body weight.c. She will be following a meal plan, including nutrient dense foods.d. She will be continuing rehab through a program such as Alcoholics Anonymous.

THINKING FURTHER

9. Look at the webpage for Alcoholics Anonymous. Read about this organization’s programs and what it offers clients. Note the historical timeline of AA at http://www.aa.org/aatimeline/.

RATE THIS PLATE

Rate this plate that the dietitian at the rehabilitation facility ordered for Tina.

3 oz. pulled pork on a whole-wheat bun2 oz. potato chips1 medium orangeOne 2x2 walnut brownie8 oz. milkDid the dietitian do a good job at planning a meal rich in thiamin for Tina? Where could improvements be made in this meal?

ANSWERS TO RATE THIS PLATE FOR TINA

This meal has sufficient thiamin for Tina. Pork is one of the richest sources of thiamin. Nuts in the brownie, milk, and oranges are also high in thiamin. The dietitian did a wonderful job developing a meal for Tina.

CHAPTER 8

CASE IN POINT— LIAN: BALANCING EDEMA AND POTASSIUM LEVELS

ASSESSMENT

1. How would you identify hidden sources of sodium in Lian’s diet?a. Ask her to relate a typical day’s menu, favorite foods, and how often she eats out.

Assess how often she is eating canned, boxed, or convenience food items.

2. What contributing factors would cause her to have swelling?a. Lack of exercise, sedentary lifestyle, excess sodium intake, and elevated blood

pressure

3. What questions about thirst would be helpful to pinpoint?a. How much fluid does she drink, and how often does she drink water?

4. What information from a 24-hour food diary could the doctor obtain?a. Frequency of meals, portion size, and types of food; vitamin and mineral content

and fluid intake

5. What information about no added -salt could be causing stress for Lian?a. Loss of taste in food

6. What information about Lian’s lack of physical activity could benefit her in the future?a. Increased activity levels decrease blood pressure and heart rate

DIAGNOSIS

7. Write a nursing diagnosis for Lian.a. Therapeutic Regimen Management, Ineffective related to insufficient knowledge

about potassium content of foods. Manifested by over consumption of foods high in potassium in conjunction with taking potassium supplement.

b. Interventions: Educate patient on foods high in both sodium and/or potassium.

PLAN/GOAL

8. What prepared foods can Lian have when starting to diet that would not interfere with her sodium restriction?a. Those marked low-sodium; monitor sodium content on package labelsb. Avoid prepackaged, convenience, and boxed foods.c. Avoid processed meats and cheese.

9. What foods are high in potassium that Lian may want to watch her consumption of?a. Apricotsb. Avocadosc. Bananasd. Beetse. Brussel sproutsf. Cantaloupeg. Datesh. Figs

i. Kiwij. Skim milkk. Nectarinesl. Orange juicem. Orangesn. Lima beanso. Honeydew melonp. Pearsq. Peanutsr. Potatoess. Prunes/prune juicet. Raisinsu. Spinachv. Tomatoes and tomato productsw. Winter squashx. Yogurt

10. What two goals would you set for Lian?a. Eliminate table salt and potassium-based salt substitutes and increase fluidsb. Increase exercise

IMPLEMENTATION

11. What are the main topics you would have Lian understand about a no-added-salt, low-fat diet?a. Increased salt intake causes high blood pressure and leads to edema, with stress

placed on the heart.b. Low-fat diets will help decrease weight.c. Potassium-based salt substitutes may not be better for her to use. She may need to

try something like Mrs. Dash for seasoning her food.

12. Explain the importance of drinking lots of water, even with edema.a. Increasing water consumption allows the body to rid itself of excessive fluids while

maintaining the electrolyte balance necessary for homeostasis.


13. How will Lian know if she is successful?a. Edema is gone, blood pressure is within the normal range, and heart rate decreases.

THINKING FURTHER

14. Look ahead to Chapter 18. What other factors could be influencing Lian’s hypertension?a. Arteriosclerosis and vascular disease

15. Why is it important for Lian to control her hypertension and what are some of the consequences if she does not?a. Maintain better healthb. Kidney failurec. Heart disease

RATE THIS PLATE

During her admission to the hospital, a registered dietitian educated Lian on a low-potassium, low-sodium diet. The dietitian regularly checked on the foods Lian ordered. Rate this plate.

Spaghetti and meatballs

1 breadstick

Side salad with Italian dressing

Are these food items permitted on a low-potassium, low-sodium diet? List some vegetables and fruits that are high in potassium.

ANSWERS TO RATE THIS PLATE FOR LIAN

Marinara sauce (spaghetti sauce) used to make spaghetti and meatballs contain tomatoes, which are a high potassium food. Tomato-based meals such as spaghetti and meatballs and pizza should be limited to once a week while on a low-potassium diet. Tomatoes, potatoes, asparagus, pumpkin, and Brussels sprouts are high potassium vegetables. Sauces may also contain large amounts of sodium.The salad containing iceberg lettuce is a low-potassium option. Having a salad on a low-potassium diet is fine, but make sure the vegetables included in the salad are low as well. Low-potassium vegetables include cucumbers, broccoli, cauliflower, and celery. The breadstick is a good choice for this meal plan. Fruit and vegetable intake needs to be monitored while on a low-potassium, low-sodium diet. High potassium fruits include avocado, banana, dried fruit, melons, and oranges.

CASE IN POINT— AISHA: IRON DEFICIENCY ANEMIA

ASSESSMENT

1. Would a 48-hour diet diary be helpful to you as a nurse?a. Yes, you could assess if Aisha is getting adequate iron sources in her diet.

2. What would you look for in the diet diary that would indicate a low iron store for Aisha?a. Lack of meat, fish, dried fruits, whole grains, dark leafy vegetables

3. What blood tests do you expect to see the doctor order for Aisha?a. TSAT, ferritin, HGB, HCT

4. How much iron is lost by women, per day, according to the NRC? a. 1.5 mg

5. What is the daily requirement for iron for women?a. 18 mg from ages 19–50, and 27 during pregnancy

DIAGNOSIS

6. Complete the following diagnostic statement: Activity intolerance related to impaired oxygen transport secondary to diminished red blood cell count related to anemia and iron deficiency.

7. Complete the following diagnostic statement: Health-seeking behaviors related to lack of understanding of iron deficiency anemia syndrome.

PLAN/GOAL

8. Name two reasonable goals for Aisha.a. In addition to the iron supplement, increase dietary intake of good iron sources

three times a week.b. Increase vitamin C intake daily for iron absorption.

IMPLEMENTATION

9. Which food categories are priorities to include in Aisha’s diet?a. Meat, fish, and poultry

10. What can Aisha include as part of daily living to assist in absorption of iron?a. Vitamin C

11. Would Aisha benefit from taking an iron supplement?a. Yes


12. In 4 months, when Aisha sees her doctor again, what could the doctor measure to evaluate the effectiveness of Aisha’s compliance?a. TSAT and ferritin levels

THINKING FURTHER

13. What changes could Aisha expect to see if she complies with her program?a. More energy, less agitation, and decreased pallor

RATE THIS PLATE

No wonder Aisha is tired. She does not have enough iron to keep her going. The dietitian helped her realize that she could eventually keep her iron levels up by taking an iron supplement and eating a healthy diet. Rate this plate for iron intake.

10 oz. medium-rare ribeye steak

¾ cup rice pilaf

Vegetable medley with cauliflower and broccoli

Whole-wheat dinner roll with butter

Slice of chocolate cream pie

Lemonade

What on this plate is high in iron?

ANSWERS TO RATE THIS PLATE FOR AISHA

Aisha did fairly well for her dinner. The ribeye steak will provide Aisha with heme iron, which is a complete protein source. The rice and whole-wheat roll are two incomplete proteins that equal one complete protein choice. The vegetable medley has other nutrients in it, other than iron. To further increase iron intake at this meal, Aisha could eat a spinach salad. Chocolate is high in iron as well.

CHAPTER 9

CASE IN POINT—ESHE: COPING WITH DEHYDRATION

ASSESSMENT

1. How can you explain to Eshe what is happening to her? a. Eshe is becoming dehydrated with the loss of fluid volume due to heavy perspiration

when in elevated temperatures.

2. What data support your conclusion? a. Increased perspiration, inability to rehydrate during working hours

3. What does Eshe’s increasing her physical exertion at work have to do with her condition?a. Increasing physical exertion increases metabolism, increasing workload on the cells

causes energy expenditure, and heat expenditure causes increase of perspiration.

4. What can be expected to occur if Eshe ignores the leg cramps? a. Dehydration, decreased blood pressure, death

DIAGNOSIS

5. Write a nursing diagnosis for Eshe.1. Deficient Fluid Volume related to insufficient oral fluid intake. Manifested by

extreme heat and insufficient fluids for temperature conditions and excessive perspiration. Resulting in dehydration and muscle cramps and pain.

2. Interventions: Educate patient on the volume of fluid needed by her body to avoid dehydration and fluid loss.

PLAN/GOAL

6. What would be your immediate concern for Eshe? a. Dehydration

7. What is your concern for her nursing shift? a. Electrolyte imbalance

IMPLEMENTATION

8. What fluid is most helpful to Eshe? Why? a. Water, because it makes up 50–60% of the body weight of a person. It is essential

for life.

9. How much fluid does she need to drink? a. At least 10% of her body weight

10. What else should Eshe’s nurse be aware of during her nursing shift?

a. Electrolyte imbalances, fatigue, confusion


11. What should Eshe look for when her plan is effective? a. Decrease in leg cramping

12. Who else could benefit from this information? a. Anyone working in a warm environment or in a job that creates profuse sweating.

THINKING FURTHER

13. At what point could Eshe have avoided her cramping problem? a. When Eshe noticed the increase in perspiration, she should have taken measures to

replace the excessive water loss.

RATE THIS PLATE

Eshe is becoming dehydrated due to not drinking enough fluids to replace the water lost through perspiration. How could Eshe’s food intake improve her hydration status? Rate the plate.

Ham sandwich on whole-wheat bun(the sandwich contains 3 oz. lean ham, tomato, and lettuce)

2 oz. corn chips

1 cup apple slices

8 oz. milk

Use Appendix D to look up the percentage of water in these foods. Which food ranked the highest in percent water and which one was the lowest? Would you change anything in this meal, and if so, what? ANSWERS TO RATE THIS PLATE FOR ESHE

Food WaterHam (extra lean) 71%Bun 34%Lettuce 96%Tomato 94%Corn chips 1%Apple 84%Milk 91%

To give Eshe more fluid, you could change the corn chips to a vegetable such as carrots or celery. She can replace any lost sodium by salting her food at dinner. Ham is very high in sodium which will help with fluid retention.

CASE IN POINT— BRANDON: CHRONIC RENAL FAILURE

ASSESSMENT

1. What do you know about Brandon that puts him at risk for this problem?a. Noncompliant with his blood pressure medications, hypertensive

2. How significant is his health problem?a. Very significant

3. How will dialysis alter his life?a. Dialysis will alter medications, diet, fluid restrictions; he will need to dialyze three

times a week at home or in the hospital.

DIAGNOSIS

4. Write a diagnostic statement about what Brandon needs to know about high blood pressure and renal failure.a. Noncompliance with blood pressure medication leading to chronic ESRD and need

for kidney dialysis

5. Write a statement about the risk of excess fluid in the body.a. Excessive fluid intake over 1–2 kg per day will cause CHF edema and shortness of

breath.

6. Write a statement about the risk of noncompliance for renal patients.a. ESRD patients who do not follow physician recommendations on diet, medication,

fluid management, and dialysis treatment run the risk of impairing renal function or poor clearances and in the long term will shorten their life span.

PLAN/GOAL

7. Brandon’s new renal diet is 3 grams of sodium, 3 grams of potassium, and 80 grams of protein. How could you as a nurse help improve Brandon’s knowledge of his new diet and encourage compliance?a. Include a dietitian in care plan meeting along with Brandon and a family member for

an understanding of the renal diet.

8. What goals are important for Brandon?a. Compliance with renal prescription

IMPLEMENTATION

9. What major topics would be important for the dietitian to discuss with Brandon?a. Fluid restrictions and salt restrictions, potassium restrictions, and supplemental

vitamins

10. Create a day’s menu for Brandon using the dietitian’s new diet. Spread the protein intake throughout the day.

a. 1 egg and a piece of whole-wheat toast, 4 oz. water for taking medicationsb. 3 oz. chicken salad with lemon juice dressingc. 4 oz. salmon, ½ cup potatoes, ½ cup canned peachesd. 1 small apple and 1 tablespoon of peanut butter for a snack

11. What teaching aids could the dietitian give Brandon to help him remember his new diet?a. Pamphlets on potassium and sodiumb. Sample sizes of foodsc. Prepared sample menu

12. How could the website http://www.choosemyplate.gov help with meal planning?a. SuperTracker can be used to help keep track of meals and foods eaten and their

nutritional value.b. Nutrition tips and educationc. Sample menusd. Recipese. Information on weight management and calorie controlf. Information on physical activityg. Many more answers are also possible.

13. What impact will his CRF have on his ability to be employed? What impact will it have on his physical and psychological status?a. After becoming stable on dialysis, Brandon should be able to be fully employed. By returning to work, he should feel productive and feel like he is contributing to his livelihood. Depression symptoms may be something to make Brandon and his family aware of so that he may seek early treatment if he is having difficulty. Give Brandon helpful hints on meal planning, food preparation, and what foods are high in potassium, salt, and hidden fluids


14. After discharge from the hospital, how will the physician know that Brandon has been compliant with his diet and medications?a. Brandon’s weight gains will be within prescribed limits. His lab work will indicate

compliance with taking his medications and his compliance in showing up for his dialysis treatments.

15. During the dialysis treatment, what is important for Brandon to do in order to have the appropriate clearances of his blood and ultrafiltration of his fluids?a. Commit to showing up for his treatments every day, on time, and staying the full

length of the treatment. Follow his diet, take his medications as prescribed, and limit his fluid intake.

THINKING FURTHER

16. Why is it important for clients with hypertension to control it?a. Hypertension unchecked can lead to kidney failure.

17. Why is it important for clients with diabetes to control it?

a. Uncontrolled diabetes can lead to kidney failure. Many people with diabetes also suffer from hypertension. If both our sugar and pressure are uncontrolled then the risk of kidney damage increases significantly.

RATE THIS PLATE

Now that Brandon is receiving dialysis, his protein, sodium, and potassium intake will have to be closely monitored. Before experiencing complications with his health, Brandon liked to prepare and eat the following meal. Rate the plate.

5 oz. fried catfish filet

1 cup sweet potato fries

¾ cup collard greens made with fatback

1 slice cornbread with butter

½ cup watermelon and cantaloupe 20 oz. sweet iced tea

In order to prevent further health complications, should Brandon continue to prepare this type of meal? How could this meal be changed to comply with his new meal plan?

ANSWERS TO RATE THIS PLATE FOR BRANDON

Brandon has been suffering from high blood pressure, so you will want to watch for sodium in his diet.He now has kidney failure, so he will need to watch his potassium and protein as well, according to the doctor.The breading on the catfish may be high in sodium. Frying fish, chicken, and other protein sources increase the fat and calorie content. Brandon may still eat the fish, but choosing to bake or grill the fish will save additional calories and added sodium.

Sweet potatoes and sweet potato fries are high in fat as well as potassium. Instead he could have corn or a salad made with romaine lettuce.Collard greens are a medium-potassium vegetable (see Table 19-1), and the fatback is high in sodium.Corn bread with butter is fine.Watermelon and cantaloupe are high-potassium fruits and should not be included. Brandon could eat a pear or peach instead, since they are both low-potassium fruits.

CHAPTER 10

CASE IN POINT — ALAMEDA: LISTERIA INFECTION DURING PREGNANCY

ASSESSMENT

1. What is Listeria?a. Listeria monocytogenes is a bacteria that can cause infection in humans

2. What food sources may contain Listeria?a. Milk (especially unpasteurized)b. Leafy vegetables (found in the soil they are grown in)c. Unpasteurized dairy foods including, soft cheeses and ice creamsd. Processed meats

3. What are the symptoms of Listeria?a. Fatigueb. Feverc. Chillsd. Headachee. Backachef. Abdominal paing. Diarrhea

4. How can Listeria infection be prevented?a. Meats and poultry should be cooked thoroughly before consumingb. Salad greens and other vegetables should be washed carefullyc. All dairy products should be pasteurized

DIAGNOSIS

5. Write a nursing diagnosis for Alameda.a. Risk for Infection; Listeria: Related to pregnancy and consumption of raw vegetables and lunchmeat. Manifested by flu-like symptoms and confirmation with blood test.

PLAN/GOAL

6. What should Alameda know about Listeria infections during pregnancy?a. Pregnant women have a 13 times greater risk of being infected.b. All meats should be cooked to correct temperatures.c. All dairy products should be pasteurized.d. All vegetables and fruits should be thoroughly washed before consuming.

7. Are there any medications that are recommended for Listeria infection?a. Typically no medications are used. In severe cases, antibiotics may be used.

IMPLEMENTATION

8. Why is it important for Alameda to follow the recommended guidelines for preventing Listeria?a. Infections during pregnancy can cause premature delivery, miscarriage, stillbirth, or

serious health problems for the newborn.


9. How will Alameda’s doctor know she is following the recommended guidelines?a. No further Listeria infections

THINKING FURTHER

10. Aside from pregnant women, who may also be at increased risk for Listeria infections?a. According to the CDC webpage, the following groups are at increased risk:• Pregnant women: Pregnant women are about 13 times more likely than the general population to get listeriosis. About one in six (17%) cases of listeriosis occurs during pregnancy.• Newborn babies: Newborn babies suffer the most serious effects of infection in pregnancy.• Persons with weakened immune systems from transplants or certain diseases, therapies, or medications.• Persons with cancer, diabetes, alcoholism, liver, or kidney disease.• Persons with AIDS: They are almost 300 times more likely to get listeriosis than people with normal immune systems.• Older adults• Healthy children and adults occasionally get infected with Listeria, but they rarely become seriously ill.

RATE THIS PLATE

Alameda takes the doctor’s advice and takes extra precaution when eating luncheon meats and fresh produce. Alameda’s family recently hosted a baby shower for her, where a lunch buffet was prepared by friends and family. The buffet consisted of the following items.

Cold cut tray consisting of turkey, ham, roast beef, and cheeses (served over ice)

Relish tray with pickles, olives, and condiments

Baked cheesy potato salad

Green salad with egg and tomato

Macaroni salad

Pretzels and potato chips

Cold cheese ball with crackers

Previously baked crab dip

Vegetable tray

Fruit salad

Cupcakes and cookies

Make a plate that would be safe for Alameda to eat, telling why you chose what you did.

ANSWERS TO RATE THIS PLATE FOR ALAMEDA

The following items would probably be safe for Alameda to eat:• Baked cheesy potato salad• Macaroni salad• Pretzels and potato chips• Previously baked crab dip• Cupcakes and cookiesThe following items would not be safe, unless Alameda took extra care in washing and preparing the food before eating:• Cold cut tray consisting of turkey, ham, roast beef, and cheeses (served over ice). The lunchmeat should be heated before eating.• Relish tray with pickles, olives, and condiments. Vegetables on a relish tray will need to be rinsed with water before consuming.• Cold cheese ball with crackers. Dairy products such as soft cheeses and milk can also have the potential for harboring Listeria.• Green salad with egg and tomato. Listeria can be spread through unwashed salad greens and vegetable.• Vegetable tray. Alameda should wash the vegetables before eating.• Fruit salad. Should be avoided or properly rinsed before eating.

This plate is subjective because we were not there to see how soon Alameda ate after the food was brought or if she even was there when the food was set out. We have no idea how far the food had been transported, whether its hot or cold status was preserved while being transported, or whether it was reheated to 165°F after arrival before consumption. Even if you know the people preparing the food, you have no idea about their food-handling expertise.

CASE IN POINT— CARSON: DISCOVERING A SHELLFISH ALLERGY

ASSESSMENT

1. What complaints did Carson have during the night?a. Severe stomach pains, dizziness, nausea, and difficulty breathing

2. What would you expect to be the problem?a. Allergy to shellfish

3. Which foods are most likely the cause of the problem?a. Oysters and clams

DIAGNOSIS

4. Carson’s abdominal pain and nausea could have been caused by allergy to shellfish. A nursing diagnosis for this could be: Knowledge deficit of food allergy related to shellfish. Manifested by abdominal pain, dizziness, nausea, and difficulty breathing.

5. What information should be gathered during his initial assessment?a. When he ate the food, where he ate, and what he ate; how difficult it was for him to

breathe

PLAN/GOAL

6. What is the immediate goal for Carson?a. Maintain proper airwayb. Maintain breathing and eliminate nausea and dizziness

7. What is the long-range goal? a. Teach Carson about his allergy and avoidance of shellfish. It may be necessary to

have Carson and his family trained on the use of an EpiPen for emergency situations.

IMPLEMENTATION

8. In the ER, what should Carson and his parents discuss with the physicians?a. Type of food eaten and when he ate it; first time he had these foods

9. Does it appear that Carson may have a food allergy?a. Yes

10. Is the doctor able to verify that this is an allergy?a. Yes

11. What is the most likely recommendation for Carson?a. Stay away from shellfish or foods that have shellfish listed as an ingredient.

12. What should Carson be cautioned about in the future about dining out?a. When in a restaurant, let the staff know that he has an allergy to shellfish


13. When the intervention is complete, how will Carson know it has been effective?a. Breathe easier and have no more symptoms of dizziness and nausea

THINKING FURTHER

14. What information could be obtained on the Internet?a. Signs and symptoms of allergies to foods and a list of foods most likely to cause

problems can be obtained online. Visit the Food Allergy Network, www.foodallergynetwork.com.

RATE THIS PLATE

Carson was so excited about his catch of the day and wanted to try everything for dinner. Is this a good idea? Rate this plate.

2 oz. lobster in butter sauce

3 oz. fried clams

1 oz. oysters on the half shell

1 small order of French fries

1 small Caesar salad made with homemade dressing containing a raw egg

12 oz. regular soda

Since Carson had not tried shellfish before should he have been given so many different choices to taste? Would it have been better for Carson to have been served only one shellfish item and no raw eggs?

ANSWERS TO RATE THIS PLATE FOR CARSON

Oysters on the half shell are raw. Raw oysters from the ocean are known to carry bacteria that can make one sick and even lead to death. Never eat raw oysters!Lobster and clams are fine because they have been cooked.The next food that could be suspect is the raw egg in the Caesar salad. The recommendation is not to eat raw eggs because of salmonella.Butter would not be a suspect because it could stay for hours unrefrigerated and never get spoilt.

CHAPTER 11

CASE IN POINT— JESSICA: TEENAGE PREGNANCY

ASSESSMENT

1. What objective data do you have about Jessica?a. Young, healthy, active, questionable nutritional status

2. What caused Jessica to eat the way she did?a. Age and deficient knowledge in pregnancy needs

3. What was the cause of Jessica’s noncompliance?a. Age, fear of telling her parents, fear of motherhood, fear of losing her boyfriend, and

stress at school

4. Which prenatal behaviors of Jessica were helpful? Which were not?a. Active youthb. Not eating or eating very little. Foods she was eating may not have been the

healthiest choices for her

DIAGNOSIS

5. Complete the following diagnosis statement: Jessica’s deficient knowledge about a healthy pregnancy and infant health is demonstrated by her lack of dietary intake.

6. Write a nursing diagnosis for Jessica that would be appropriate for her situation.a. Risk for Imbalanced Nutrition: Less than body requirements due to disturbed self-

concept related to pregnancy-associated body changes and conflict with adolescent and parenting roles.

PLAN/GOAL

7. What is your plan for Jessica’s health after the birth?a. Increase vitamin and mineral supplements and encourage healthy food intake

8. What is your goal for the baby’s health related to reducing the risk of SIDS and delayed development?a. Use breast milk to provide the best possible nutrition for baby’s health

IMPLEMENTATION

9. What topics does Jessica need to be taught about her baby’s health and development? What does she need to know about apnea and SIDS? What does she need to learn about normal infant growth and development?a. Jessica needs to know that her breast milk is the best to offer her baby for

protection and growth. She needs to know the signs and symptoms of apnea and SIDS and their consequences. Jessica needs to understand the importance of a well-balanced diet for her newborn to lessen the risks of health problems

10. Who else needs to be present for the teaching?

a. Jessica’s parents and possibly the baby’s father and his parents

11. As a teenage mother, Jessica needs what type of medical and nursing follow-up? Would home health care nursing visits help?a. Jessica needs dietary and psychosocial follow-up. Home health care nursing can

provide a means of reinforcing the information received.

12. What is your primary concern for the baby?a. Jessica to be a well-informed mother, who eats healthy for a successful pregnancy

outcome


13. At the next visit, what criteria will the nurse practitioner be using to see if Jessica is eating healthy and caring for herself?a. Weight gain, Jessica’s emotional status, and a log of Jessica’s foods.

THINKING FURTHER

14. What other issues make this situation more difficult for a teen mother to be successful?a. Need for returning to schoolb. Inadequate knowledgec. Unmarried to baby’s father, therefore possibly less support and assistance in caring

for herself or the baby

15. What other types of support may be helpful to a teenage mother?a. Her parents, other family and friendsb. Prenatal classesc. Breastfeeding class or support group

RATE THIS PLATE

Jessica and Ryan meet with a registered dietitian to learn about adequate nutrition during pregnancy and proper weight gain to support a healthy baby. The dietitian emphasized the importance of eating a nutrient-rich diet containing good sources of protein and iron. Rate the meal that Jessica purchased for her lunch while working at the coffee shop.

1 medium raisin bagel

2 Tbsp low-fat cream cheese

½ cup of mixed fruit

10 oz. regular coffee with cream and sugar

How many calories, grams of protein, and iron did Jessica consume in this meal? Is it enough for a pregnant teen? Why or why not?

ANSWERS TO RATE THIS PLATE FOR JESSICA

Jessica ate 831 calories, 10.3 grams of protein, and minimal non-heme iron. She needs 60 grams of protein and 30 grams of iron per day. There is doubt that she will get needed nutrients since she only has one meal and hopefully a snack or two left to eat for the day. She is not nourishing either herself or her baby.

CASE IN POINT— AH MAR MO: MANAGING GESTATIONAL DIABETES

ASSESSMENT

1. Why are elevated blood sugars during pregnancy a problem?a. Elevated blood sugars can cause complications for both mom and baby.

2. What are the consequences of high blood sugars during pregnancy on the baby?a. Large birth weight (>9 pounds)b. Jaundicec. Hypoglycemia post deliveryd. Breathing problemse. Stillbirth

3. What are the consequences of high blood sugars during pregnancy on mom?a. High blood pressureb. Higher risk of infectionsc. Greater need for cesarean section birthd. Higher risk of progression of diabetes complications (in type 1 or 2 diabetes)e. Recurrence of gestational diabetes in future pregnanciesf. Risk factor for type 2 diabetes in 10–20 years.

4. All pregnant women should be screened for gestational diabetes at what point during their pregnancy?a. 24–28 weeks

DIAGNOSIS

5. Write a nursing diagnosis for Ah Mar Mo related to her gestational diabetes.a. Risk for Ineffective Therapeutic Regimen Management: related to her gestational

diabetes. Manifested by her knowledge deficit and her language barrier.

6. Write a nursing diagnosis for Ah Mar Mo related to her nutrition.a. Risk for Nutrition Imbalance: related to knowledge deficit of nutrition guidelines and

consumption of high carbohydrate diet.

PLAN/GOAL

7. Ah Mar Mo needs to be educated regarding her gestational diabetes. What would be the two most important things to instruct Ah Mar Mo about?a. Nutritional guidelines for gestational diabetesb. Monitoring her blood sugar

8. How often may the nurse practitioner or educator need to see Ah Mar Mo?a. She may need to be seen every 1–2 weeks depending on her blood sugar levels.

IMPLEMENTATION

9. What steps might the dietitian take to insure that Ah Mar Mo is following the guidelines she was instructed on?a. Have her keep a routine food and blood sugar record.b. Keep in contact with the obstetrician to assure Ah Mar Mo’s baby is measuring on

target for size.c. Provide Ah Mar Mo with measuring cups or spoons if she does not have any in her

home to use.


10. How could the physician, nurse practitioner, and dietitian be assured their goals were met?a. Ah Mar Mo will deliver a healthy baby weighing less than 9 pounds via vaginal

delivery. The baby will have no complications such as jaundice or hypoglycemia. The baby does not have to be admitted to the NICU.

THINKING FURTHER

11. What are some of the considerations necessary when using a translator to speak to a patient?a. Is the translator familiar with medical terminology and able to translate it

accurately? When possible use a certified translator.b. Do you have any available materials in the patient’s native language?c. Can the translator take notes for the patient?d. Is the patient literate in their native language?e. Is the same translator available for follow-up visits?

RATE THIS PLATE

Rate the plate that Ah Mar Mo has chosen for lunch.

⅔ cup rice

1 cup pork stirfry made of bok choy, snow peas, and broccoli

8 oz. mango juice

½ cup tapioca pudding with coconut

Can you determine if her carbohydrates are correct for her meal? Yes or no and why? What changes if any should be made to lower her caloric intake?

ANSWERS FOR RATE THIS PLATE FOR AH MAR MO

This meal contains 5 carbohydrate servings. The diabetes educator encouraged Ah Mar Mo to monitor the portion sizes of rice and pasta she ate and to replace juice with water at meals and snacks. The serving size of rice is ⅓ cup. Eating ⅔ cup of rice will provide an estimated 30 grams of carbohydrate. The pork stir fry is a healthy option that is low in fat and rich in protein. Adding healthy vegetables such as the bok choy, snow peas, and broccoli will provide fiber to the meal and promote satiety.

Juice can easily increase blood sugar levels and should be limited when possible. Ah Mar Mo could drink 4 oz. of mango juice instead and begin incorporating more water into her meal plans. The tapioca pudding provides around 20 grams of carbohydrates per ½ cup serving.

CHAPTER 12

CASE IN POINT— DIEGO: OVERCOMING FAILURE TO THRIVE

ASSESSMENT

1. What data do you have about Bonita?a. Recently gave birth, but had to go immediately back to a busy work schedule. Has

not been able to spend the time with her child as she had planned and had to hire a neighbor girl to care for the baby.

2. What data do you have about Diego?a. Second child, very cranky with failure to thrive due to lack of maternal input

3. What factors contributed to Diego’s problem?a. Lack of maternal input to his needsb. Immature sitter

4. Using the growth charts in Figure 12-10, determine a baby’s normal weight and height at 4 months. What should Diego weigh, and how long should he be?a. Average at 4 months is 14 pounds 8 oz.b. Diego at only 10 pounds 14 oz. is well below the fifth percentile for his height and

weight.

5. What should Diego be doing developmentally at 4 months?a. Responding to mother’s voice with a smile, lifting his head, holding his head up

6. How severe is Diego’s failure to thrive?a. Very severe

DIAGNOSIS

Complete the following nursing diagnoses:

7. Diego’s failure to thrive is related to mother’s inability to stay with him initially after birth and lack of knowledgeable caregiver.

8. Diego’s imbalanced nutrition, less than body requirements, is secondary to lack of adequate nutrition required of a newborn. Manifested by lack of emotional and sensory stimulation and lack of knowledgeable caregiver.

9. Bonita’s ineffective feeding is a result of inability to nurse and be with Diego after birth.

PLAN/GOAL

10. What is your immediate goal for Diego?a. Increase weight

11. What is your long-term goal for Diego?a. Respond to mother’s love and bond with her while increasing weight gains for

appropriate age and length

12. What is your short-term goal for Bonita?a. Identify needs of Diego and respond to him

13. What is your long-term goal for Bonita?a. Make alternate plans as needed to ensure she can stay home and care for Diego or

that she has a caregiver who can better suit his needs.

IMPLEMENTATION

14. What changes need to occur for Diego to thrive?a. He needs to feel the love of his mother and eat to gain weight.

15. What does the NP need to teach Bonita?a. Mental and social skills for Diego may be affected by his failure to thrive. He may be

slow to develop.

16. How else can the NP help Bonita?a. Give her the information she needs to identify Diego’s ability to respond to her

successfully.

17. Who else needs to be involved in Diego’s care?a. Dietitian and physicianb. Husband


18. After the plan has been in place for 6 weeks, what changes should Bonita see in Diego?a. Building trust, gaining weight, and responding to her presence

19. What will the NP measure and observe in Diego and Bonita if the plan is successful?a. Ability to respond favorably to one another. Diego would be able to track objects

and will have gained weight. Bonita would show love to her baby.

THINKING FURTHER

20. Why is it important for infants to have a good start in life? Why is their nutrition so critical? What future complications can be avoided as a result?a. The first year of life is a period of most rapid growth. At 6 months the birth weight

should double. This is when the brain undergoes crucial development, which can affect the rest of the infant’s life. This explains why infants’ vitamin, mineral, and protein requirements are higher per unit of body weight than those of older children. During the first year the normal child needs about 100 kcal per kilogram of body weight each day. By getting a good nutritional start, failure to thrive syndrome can be prevented.

RATE THIS PLATE

Diego is now 6 months old and Bonita will have to experiment with different foods to get him back on track. He has only been getting formula, but now it is time to try solid foods. Rate this plate for lunch:5 oz. infant formula

2 Tbsp infant rice cereal2 Tbsp pureed green beans1 Tbsp pureed applesauceAre the servings correct for a 6-month-old infant? If not, what corrections should be made to this meal?

ANSWERS TO RATE THIS PLATE FOR DIEGO

Baby rice cereal is usually the first solid food that a baby is given. Two tablespoons is a good portion to start. Vegetables will be the next food offered. A parent should never offer more than one food at a time to begin because the baby could be allergic to a food, and that way you would know immediately which food triggered the allergic response.The only thing wrong with this meal is the applesauce. Fruit should not be offered until 7–9 months of age.Bonita needs to focus on Diego to give him a better start in life. She needs time to bond and relax with her baby.

CASE IN POINT— CADEN: INTRODUCING SOLID FOODS

ASSESSMENT

1. What are the benefits of breastfeeding?a. Immunity for baby from infectious diseasesb. Economicalc. Nutritionally perfectd. Sanitary and sterilee. Easily digestedf. Reduces strain on baby’s kidneysg. Promotes oral motor developmenth. Reduces risk of obesity and diabetesi. Promotes bonding of mother and baby

2. Use Figure 12-10 to assess Caden’s growth percentile for length and weight.a. 50th percentile for lengthb. 50th percentile for weight

3. How many ounces of breast milk or formula would you expect a baby Caden’s age to need? Use Table 12-1.a. 30–36 oz. per day.

4. What would you expect Caden’s calorie and protein needs to be at his age?a. Caden is 25 pounds. This is 11.4 kg. Infants Caden’s age (4 months) need 98–108

calories per kg. Caden would need 1,117–1,231 calories per day. b. Protein needs at his age are 2.2 grams per kg. Caden would need 25 grams of

protein daily.

DIAGNOSIS

5. Write a nursing diagnosis for Caden.a. Nutrition Imbalanced: Potential for more than body requirements related to

maternal knowledge deficit of infant feeding.

PLAN/GOAL

6. What is the immediate goal for Caden?a. Introduction and acceptance of cereals at 6 months of age.

7. What is your long-term goal for Caden?a. Caden will continue to gain weight and length appropriate for his age.

8. What is your short-term goal for Ann?a. To understand Caden’s needs and infant growth and reflexesb. To attend infant feeding and nutrition class offered by the dietitians

9. What is your long-term goal for Ann?a. Continue to grow in understanding of appropriate feedings and nutritional needs of

infants and children.

IMPLEMENTATION

10. What does Ann need to learn from the dietitian’s class?a. She needs to gain a firm grasp of how cereals and other foods should be introduced

into Caden’s diet. b. She needs to understand obstacles she may encounter such as “extrusion reflex.”c. Proper time to introduce a cupd. Foods that are potential choking hazardse. Signs and symptoms of allergic reaction to foods

11. Who else needs to be involved in Caden’s care?a. Father and other caregivers who may be feeding Caden


12. What might you expect of Caden by the time he is 1 year old?a. He will have tripled his birth weight.b. He will have had all food groups introduced. c. He has been weaned of breast (or nearly so).d. He is using a cup for other liquids and no bottle.

THINKING FURTHER

13. The American Dietetic Association has a new webpage for children. Check out http://www.eatright.org/kids and see the information offered. How would a website like this be helpful for Ann as Caden grows?

a. The website htpp://www.eatright.org/kids will be helpful for Ann as Caden grows because it offers information about nutrition for children of all ages. There is information for baby, toddler, preschooler, grade-schooler, and teen. Each section provides information on cooking healthy, eating right, and shopping smart. There are articles and tips on hot topics, videos, and recipes for healthy eating.

RATE THIS PLATE

Since Caden is not ready for solid foods, it would be recommended to wait and try again every week to see when his extrusion reflex disappears. At 10 months, Caden is now able to eat solid foods. Rate the meal that Bonita has prepared for his lunch.

6 oz. formula4 Tbsp infant cereal1 Tbsp baby chicken3 Tbsp pureed sweet potatoes4 Tbsp pureed pears

Does this meal meet the recommendations? If not, what can be changed?

ANSWERS TO RATE THIS PLATE FOR CADEN

Caden is not old enough to eat that much food. Babies do eat baby cereal a couple of times a day. Cereal should be offered for breakfast along with 5–6 oz. of formula or breast milk. He should be given 1–2 tablespoons of vegetables, according to Table 12-1. Fruits should not be introduced until 7–9 months. The serving of formula is correct for a 6-month-old infant. Mothers can be encouraged to follow the advice of their pediatrician, but often will listen to their own mothers, sisters, and friends.

CHAPTER 13

CASE IN POINT— ELIZABETH: IDENTIFYING ANOREXIA NERVOSA

ASSESSMENT

1. What objective information do you have about Elizabeth?a. Active, tall and thin, growing, eating very little for snacks after school, and no longer

eating dinner with her younger sister.

2. What subjective information do you have about Elizabeth?a. She is hungry, but will not let herself eat.b. She does not want to gain weight.

3. Which psychological issues are having an effect on Elizabeth’s understanding of proper nutrition?a. Need to be thin means not eatingb. Parents not present for supper meal most nightsc. She loves to look at fashion magazines and her idea of what is beautiful may be

incorrect based on what she is seeing.

4. What are the psychological needs of preteens?a. Acceptance by peers, need for independence, increased workload, extracurricular

demands

5. What would lead you to believe Elizabeth may be having appearance issues?a. She is hungry, but states she does not want to eat.b. Her after school snacks have decreased in portion size.

DIAGNOSIS

6. Complete the following statement: Elizabeth’s imbalanced nutrition is secondary to appearance issues and being self-conscious.

7. What signs of anorexia nervosa does Elizabeth exhibit?a. Not eating supper, only small snacks after school, isolating herself from others at

meal time, feeling tired, and sleeping a lot

PLAN/GOAL

8. What is the major nutritional goal for Elizabeth?a. Maintain good health for growth and development while maintaining good weight

status for her age

9. What is the priority for Elizabeth’s physical development?a. Offer good nutritious meals she will eat to provide adequate calories for growth and

development.

IMPLEMENTATION

10. What should Elizabeth and her mother be taught about good nutrition?a. Adolescents’ eating habits can be affected by busy schedules. They should be aware

of the available food choices and how they will benefit from good choices.

11. What needs to be taught about anorexia nervosa? Who else needs this information?a. Anorexia is a psychological disorder that can begin as early as late childhood. It

causes drastic decrease in kilo calories It disrupts metabolism and causes hair loss, low blood pressure, weakness, amenorrhea, brain damage, and death.

b. Siblings, parents, friends, neighbors—all preteen and teenage girls and boys

12. Would a counselor be of assistance to Elizabeth and her mother?a. If Elizabeth responds to her family’s intervention, then a counselor may not be

needed. However, Elizabeth’s parents need to be involved and aware of her activities and food consumption. If Elizabeth continues to display signs of anorexia, then it would be very important for her to seek counseling. Anorexia is a psychological disorder.

13. What can be done to prevent anorexia nervosa in her sister? Does anorexia nervosa have an age limit?a. Involve her sister in the discussions and teachings. Anorexia nervosa has no age

limit, but it usually develops in preteens and teens.


14. What criteria could be used to demonstrate that her anorexia nervosa was under control?a. Eating all her meals; healthy snacking and good self-esteem

15. Can anorexia nervosa be cured?a. Yes

THINKING FURTHER

16. How can parents, teachers, and coaches help young preteens who have eating disorders?a. Understand the need for acceptance and help increase self-esteem. Develop trusting

relationships with counselors. Learn what changes are normal, healthy body changes. Initiate diet therapy for all in the family.

17. Will Elizabeth’s younger sister be at risk for anorexia nervosa?a. Yes

RATE THIS PLATE

Elizabeth may be feeling pressured by the media she reads in her magazines to look a certain way and be a particular weight. As she continues to grow throughout her teen years, her calorie and nutrient needs will increase. Elizabeth needs nutrient-dense foods. Rate the plate she ate for dinner:

2 chicken nuggets¼ cup of instant mashed potatoes

½ cup of diced pineapple8 oz. fruit punch drink

Are any of these foods nutrient dense? Are any of these foods calorie dense? If so, which one(s)? How could this meal be improved to provide Elizabeth with adequate calories and nutrients to support growth throughout her teenage years?

ANSWERS TO RATE THIS PLATE FOR ELIZABETH

The chicken nuggets are a good source of protein in a small amount. Two chicken nuggets are calorie dense. Elizabeth would need to eat about 4 chicken nuggets to provide her with the correct serving and calories for a meal.The instant mashed potatoes can be cooked in milk to add additional nutrients and calories. Instant mashed potatoes contain the same vitamins as whole potatoes, but have smaller amounts of protein, dietary fiber, and vitamin C. If Elizabeth was able to prepare a baked potato for herself and sister, that would provide her with additional nutrients and fiber. Also, her serving size is small. She can have a ½ cup to 1 cup of potatoes for her meal.The pineapple is nutrient dense—good choice.Also, add a glass of milk to the meal instead of fruit punch.

CASE IN POINT— JORDAN: CHILDHOOD OBESITY

ASSESSMENT

1. What objective data do you have about Jordan?a. She is 45 inches tall and weighs 61 pounds. She is not physically active for her age.

2. Using Figure 13-5, what percentile weight and height is Jordan in for a 6-year-old girl?a. Jordan is greater than the 95 percentile for weight and about 50 percentile for

height

3. How do diet, activity, heredity, and family lifestyle impact her current weight?a. Her mom is aware of foods that cause problems. However, since the divorce and the

change in their family schedule, their lifestyle and eating habits now include more fast foods and convenience items and less activity. Hereditary issues play an important part in health, eating, and lifestyle.

4. How significant is this problem?a. Jordan could easily slip into obesity. She could also develop bad habits with her

eating such as using foods as comfort or snacking out of boredom.

DIAGNOSIS

Complete the following diagnostic statements:

5. Imbalanced nutrition; more than body requirements related to excessive body weight. Manifested by consuming foods high in calories and fat and a decrease in activity level.

6. Deficient knowledge related to healthy eating and energy expenditure.

PLAN/GOAL

7. State two reasonable and measurable goals for Jordan.a. Jordan will increase her physical activities to 30–60 minutes each day after school.b. Jordan will consume healthier snack options provided by her parents.

8. At Jordan’s checkup, the doctor agreed with her mom and referred them to a dietitian. As a dietitian, what personal goals are appropriate for Jordan and her parents, including their activities and foods?a. Appropriate personal goals for Jordan could include but would not be limited to the

following:• Increasing activity to at least 60 minutes daily• Becoming involved in an exercise program at the local YMCA, Parks/Rec Program, or

community center• Eliminating eating at fast food restaurants• Replacing high calorie/low fat snacks and desserts with fruits, vegetables, or other

higher nutrient/fiber snacks• Discussing healthy foods that Jordan likes and trying to incorporate those in at meal

time

• Limiting “screen time” to 1–2 hours daily; this would include TV, computer, video games, etc.

• As much as possible the emphasis should be on the entire family eating healthy and not just Jordan

• In addition, emphasis should be on increasing activity

IMPLEMENTATION

9. What information does the dietitian need to know to help Jordan?a. Jordan’s lifestyle, including activity, and typical foods and meals

10. Who needs to be involved in the plan for it to be successful?a. All family members

11. What are the two big changes that need to occur to help Jordan stop gaining weight?a. Activity level increasesb. Healthy snack options

12. What strategies could you suggest so Jordan would be successful but have fun in the process?a. Accompany her in exercisingb. Have her choose her favorite type of exercisec. Vary the exercises

13. How can playing outdoors with friends be helpful?a. Take her mind off food and help her to get exercise

14. How can her family help?a. Exercise with her, eat nutritiously, and learn correct portions of food


15. How often should Jordan be weighed?a. Monthly

16. What outcome is reasonable in 3 months? In 6 months?a. Since Jordan is in the age range of 2–7 years old and not suffering from any

additional complications, the goal for 3 months is weight maintenance. It would be appropriate for her parents to be providing healthier foods for her to choose from. It would also be helpful if they would begin finding inexpensive ways for her to become more active. At 6 months, it would be reasonable for the healthier eating to become more routine as well as the activity. In addition, weight maintenance would still be a goal. Her weight for height may begin to see a decrease on the growth curve as she continues to grow, but her weight stays the same.

THINKING FURTHER

17. Why is it important to intervene with Jordan’s weight now? What are the future consequences of a lifetime of being overweight? Why is this a community health issue in America now?

a. Prevent obesity, health issues (along with teasing), and low self-esteem. The risk for many comorbidities increases significantly with obesity.

18. What would the Internet be able to provide?a. Healthy diet information, online support groups or blogs, sample meal ideas and

recipes, as well as the nutrient content of many foods and restaurant choices.

19. In March of 2012, the National Nutrition Standards for school lunches were revised. You can read the current guidelines by visiting http://www.fns.usda.gov/cnd/governance/regulations.htm.

RATE THIS PLATE

Jordan still enjoys the occasional treats from a fast-food restaurant when she visits her father on Wednesday nights. Rate the meal that her father ordered for her.

1 kids-size cheeseburger1 small order French fries4 oz. vanilla yogurt ½ cup apple slices12 oz. orange juice drink

Check a fast food menu online to determine total calories. Is this too much food? If so, where can calories be decreased in this meal?

ANSWERS TO RATE THIS PLATE FOR JORDAN

This meal has some healthy options for Jordan, but also some poor choices that could be improved. This meal may also be too large for 6-year-old Jordan to eat.The cheeseburger contains an additional 100 extra calories because of the added cheese. It would be better to order a regular hamburger.The small order of French fries is fine on occasion, but for this meal Jordan could not order the French fries and eat the yogurt or apple slices instead.Vanilla yogurt is a good choice and can be substituted for the small French fries. Apple slices are also a good choice. If she is unable to eat them for her meal, they would make for a good snack.Instead of ordering the orange juice drink, Jordan’s dad could offer her milk. Most fast food restaurants offer milk with their children’s meals instead of sugary beverages.

CHAPTER 14

CASE IN POINT— NIKOLAI: CHANGING BEHAVIORS TO ACHIEVE WEIGHT LOSS

ASSESSMENT

1. What do you know about Nikolai?a. Nikolai has had years of physical activity with his job. He is a hard worker, he has

been working to finish his college degree, and he has eaten many meals at his bakery due to lack of time between work and classes. He has gained 25 pounds over the past 4 years and is currently overweight.

2. What value has he acted on for several years?a. His physical activity at work will be enough activity and that the foods at his bakery

will be sufficient to meet his needs within his time constraints.

3. What values does he want to act on in the future?a. Maintain good eating habits for life, exercise, and lose weight.

4. What do you suspect Nikolai had been eating?a. Easily accessible foods; foods high in calories and fat. He is eating foods found in his

bakery, but may be doing numerous other convenience and fast food items as well due to the demands of his schedule.

DIAGNOSIS

5. What are possible causes of Nikolai’s weight problem?a. Decrease in exercise, increase in schoolwork after work along with an increase in

poor food choices

6. What education is needed to help Nikolai lose weight?a. Calorie requirements for his height and desired weight with information on

increasing activity. He may need to keep a food and exercise log to ensure he is eating adequate calories and getting enough exercise.

PLAN/GOAL

7. What is a reasonable goal for weight loss for Nikolai once he graduates? Assume a loss of 1–2 pounds per week.a. He is 6 feet 1 inch tall. He currently weighs 235 pounds. His ideal body weight for his

height is 184 pounds, ±10%. So his ideal range is 165–202 pounds. To get to the top of this range he would need to lose 33 pounds. At the recommended weight loss of 1–2 pounds per week, it should take Nikolai 16–33 weeks to lose the weight.

IMPLEMENTATION

8. What are the two most important changes that Nikolai needs to make to lose weight?a. Eliminate fast foods and high fat bakery itemsb. Monitor portions of mealsc. Increase activity level

9. How could a 24-hour food diary help?a. Identify what and how much he is consuming. This will show him where his extra

calories are coming from and he can then discern which calories he would like to eliminate.

10. What does he need to do about exercise?a. Even though Nikolai is active on the job, he should increase his energy expenditure

to at least 3–5 times a week for 45 minutes to an hour.

11. How can his family help?a. Exercise with himb. Prepare good, healthy mealsc. Not eat fast foods or junk foods around him or keep them around the house

12. How can strategies like packing his lunch help?a. By packing his lunch he can be in control of what he eats and have food readily

available.

13. Would he be more successful losing weight alone or in a group?a. Many people are more successful with the support of a group. Nikolai’s group could

be his family.


14. One month after starting the new plan, what changes will be in place?a. Nikolai would have lost 4–8 pounds. He would be carrying his lunch and exercising as

planned.b. He will have eliminated many of the fast foods and empty calories in his diet.

15. If the plan is successful, what changes will Nikolai report in 3 months?a. Successful weight loss of 12–24 pounds and increase in energy and well-being

THINKING FURTHER

16. Even though Nikolai’s short-term goal is to lose weight, how could he maintain his new habits so he will not regain the weight?a. Continue to bring lunch to school and exercise; continue to be aware of the need for

a healthy, well-balanced dietb. Have smaller portions of sweets and treats, eat out less often, and be more aware of

portion sizes

17. Why is it important to control excess weight in middle age?a. To counteract decreased metabolism and decrease in physical activities

RATE THIS PLATE

Nikolai has begun making healthy decisions in an effort to lose weight. He knows that eating baked goods for his meals is not the best choice. Nikolai decides to pack a lunch that he can eat between school and work. Rate the plate that he prepared:6 inch Italian sub sandwich on white bread including:

2 oz. salami, 2 oz. ham, 2 oz. pepperoni, 1 oz. cheddar cheese, red onion, tomatoes, lettuce, black olives, and mayonnaise sauce

1 medium apple

1 cup raw baby carrots

1 chocolate chip cookie

32 oz. regular sodaWhat ingredients need to be changed? Is white bread his best choice for good nutrition? What would be a better option instead of a soft drink? Could he really eat just one chocolate chip cookie? Is this a good choice for dessert?

ANSWERS TO RATE THIS PLATE FOR NIKOLAI

The Italian sub sandwich could be improved. This sandwich has over 7 oz. of protein. Nikolai only needs about 3–4 oz. of protein per meal. Both salami and pepperoni are high in sodium and fat. The toppings on sandwich are good, but the mayonnaise dressing is not the best choice since it is high in fat. Nikolai could make a turkey and ham sandwich instead and include different vegetables with a light dressing such as olive oil and vinegar. He could also make the sandwich using whole wheat or whole grain bread to increase his fiber intake. The apple and baby carrots are a great choice! The chocolate chip cookie will provide him with additional calories and fat and could be excluded from the meal.If he really enjoys drinking soda, a diet beverage or water would be a better option.

CASE IN POINT—ALAINA: PREPARING FOR HER BIG DAY

ASSESSMENT

1. Identify changes in Alaina that suggest she was getting into trouble.a. Less energetic, lost her “shine”b. Oily, pale skin; dull hairc. Fatigue and Irritabilityd. Looks thin

2. What information would be important to share with the physician?a. Alaina’s diet history; weight lossb. Her irritability and fatiguec. Her complexion changes

3. In which category of nutritional assessment would you list Lillie’s observations?a. Anthropometric and clinical examination/observation

4. Which observation would you consider significant to cause concern?a. Irritability b. Lack of energy; fatiguec. Complexion changesd. Weight loss; not eating

5. Is there any other information that would be helpful in identifying Alaina’s condition?a. Is she showing signs of bulimia or anorexia?b. Lab tests – prealbumin, albumin, kidney function, and electrolytes.

DIAGNOSIS

6. Write a nursing diagnosis that most likely applies to Alaina’s problem.Altered nutrition: Less than body requirements related to inadequate intake of sufficient calories, balanced diet, and water-soluble vitamins. Manifested by weight loss, irritability, oily skin, and dull hair. Possibly related to Anorexia or Bulimia

7. What contributed to the development of the problems?a. Lack of confidence in her appearance; she was worried she had gained weight over

the holidays and that her wedding dress would not fit.b. Desire to be thin for her wedding dayc. National obsession with weight and thin = beautiful

PLAN/GOAL

8. Who can help with the plan?a. Fiancéb. Parentsc. Friends; Lillied. Dietitiane. Physician

9. What two changes are most significant for Alaina?a. Change in attitudeb. Change in appearance

IMPLEMENTATION

10. Name three methods that could be used to improve Alaina’s nutrition.a. Add good, nutritious foods that do not allow for high calorie intake; discuss with

Alaina how many calories she needs for weight maintenance and review the portion sizes she needs from different foods she likes to eat.

b. Ensure lean proteins are incorporatedc. Prepare meals that Alaina enjoys. Show her how to incorporate her favorite foods without going over her calorie limits for the day.

11. How could friends and family help?a. Provide encouragement that Alaina is working toward better healthb. Invite Alaina to dinner at her favorite restaurantc. Support Alaina’s efforts

12. How could a food diary help?a. Identify quantity of foods, frequency of intake, and types of foods eaten; the

dietitian could review the food log with Alaina and assure her that she is staying within her recommended calories for the day.


13. What can the doctor assess at the next appointment to see if the plan is working?a. Alaina’s physical appearanceb. Alaina’s weightc. Alaina’s attitude toward her weight and her satisfaction with her meal planning

14. What observations could Alaina’s friend Lillie offer about the success of the plan?a. Alaina’s attitude toward family and friendsb. Alaina’s willingness to eat when they are togetherc. Alaina’s physical appearanced. Alaina’s satisfaction and happiness with her meal plan and her wedding plans

15. What information from Alaina would benefit the success of the plan?a. How she feels about her appearanceb. How she feels about herselfc. How she cooperates with the plan

THINKING FURTHER

16. Who else could be at risk for a similar problem?a. Teenage girlsb. Young girlsc. All women with low self-esteemd. People in need of being accepted

17. How could information from the Internet be useful?a. To identify early signs and symptoms of anorexia and bulimiab. To give information on where to get helpc. To identify the need for recognition of types of people who may fall under the

category of bulimia or anorexia

RATE THIS PLATE

Like all brides, Alaina would like to look her best on her wedding day. Rate this plate. For lunch Alaina has fixed herself:1 small side salad with tomatoes, cucumbers, broccoli, and carrots

2 Tbsp Italian dressing

1 cup tomato soup

1 cup tea with 1 tsp of sugar

What macronutrients are lacking in this meal? Was the amount of dressing on her salad sufficient? Are there any foods that you would like to add to this meal? What would they be, and why?

ANSWERS TO RATE THIS PLATE FOR ALAINA

Although her meal is nutrient rich, containing various vegetables, it is lacking in adequate protein and carbohydrates. To provide her with protein, grilled chicken could be added to the salad. Three ounces of grilled chicken would be the correct serving of protein for this meal.The Italian dressing for her salad is fine and 2 Tbsp is the correct serving for salad dressing.The tomato soup is a good choice as well. Fixing the soup with milk instead of water will provide her with calcium and additional calories and nutrients.The tea with sugar will provide little to no additional calories. If Alaina is still hungry, she could eat a piece of fruit that will provide her with little calories but plenty of essential vitamins and nutrients.

CHAPTER 15

CASE IN POINT— MARY: DISCOVERING OSTEOPOROSIS

ASSESSMENT

1. What do you know about Mary’s health? a. Good health, regular exercise, possible calcium deficiency or bone loss

2. What did the doctor suspect about Mary? a. Bone loss due to age; possibly osteoporosis

3. How significant is this problem? a. If caught early, fair significance

4. How common is this problem in the elderly? a. Fairly common; 50% of elderly have some form of osteoporosis

DIAGNOSIS

5. Write a diagnosis for Mary’s alteration in health maintenance and its cause. a. Alteration in health maintenance due to lack of sufficient dietary calcium or calcium

supplements. Manifested by bone fracture due to possible osteoporosis.

6. Write a diagnosis for Mary’s deficient knowledge and the type of education she needs. a. Knowledge deficit due to lack of nutritional knowledge associated with bone

depletion and calcium loss.

PLAN/GOAL

7. What must change in Mary’s diet? a. Mary needs to take a calcium supplement or other medication used to treat bone

loss.

IMPLEMENTATION

8. What additions or alterations in Mary’s diet would prevent further osteoporosis? What are the best sources of calcium? a. Introduction of calcium. Milk and milk products are the best sources. Additional

source of calcium may include:• White beans• Broccoli• Brussel sprouts• Kale• Kohlrabi• Mustard greens• Orange juice (calcium fortified)• Soy milk• Tofu (calcium set)• Turnip greens

9. What information does Mary need to make this change? a. Bone density results will prove that she has bone loss. This may help to motivate

Mary to take her calcium supplement as well as incorporate foods higher in calcium in her diet routine. Information about incorporating calcium into her meals will come from the dietitian.

10. Who can help her learn? a. The dietitian. Her husband can assist and encourage her efforts as well.

11. How can regular exercise help? a. Regular exercise can increase feelings of well-being and help strengthen bones.

12. How could information from the National Osteoporosis Foundation (http://www.nof.org) help Mary? a. Updated information received in a nonthreatening manner


13. At her next office visit with the doctor what will Mary report? a. Increase in strength and healed wrist with no further fractures b. She will report that she has been taking her calcium supplement and any other

osteoporosis medication that was ordered.c. She will report an increase in foods high in calcium in her diet.

14. How long will it take before the doctor can measure an improvement in a DEXA scan? a. Treatment of osteoporosis occurs over a long time. Most insurance companies will

pay for a DEXA scan once every 2 years.

THINKING FURTHER

15. From your review of the National Osteoporosis Foundation website (http://www.nof.org), what kind of information is available there?a. Information on osteoporosis for men and women; facts and statistics presented in a

nonthreatening manner

16. Aside from calcium, how could other medications for osteoporosis help? a. Biphosphonates such as Fosamax, Actonel, and Boniva suppress osteoclast activity

so they will not breakdown bones. b. Selective Estrogen Receptor Modulators or SERMS are the class of medications that

contains Evista. Evista works by creating estrogen receptors on the body’s tissues. The estrogen improves the strength of bones and helps prevent fractures.

c. Calcitonin is also used in the treatment of osteoporosis. It is a chemical messenger that can help normalize blood calcium levels and reduce bone loss.

17. Why is it important to intervene with a person at any age who suffers from osteoporosis? a. Prevent further demineralization of bones and help prevent fractures

18. How can you use this lesson in other situations? a. Awareness of bone loss due to diet and illness

http://www.nof.org/

http://www.nof.org/

RATE THIS PLATE

Mary’s problem was first noticed when she injured her wrist on the tennis court. She will need further testing to properly diagnose osteoporosis. Even though Mary has tried to eat healthy and live an active life, adequate calcium and vitamin D may not have been eaten to develop dense bones. Rate this plate on calcium content:

1 cup clam chowder

6 whole-wheat crackers

1 medium peach

½ cup tapioca pudding

Water with lemon

Will this meal give Mary a serving of calcium? How many milligrams of calcium is considered a serving? List foods that are good sources of calcium.

ANSWERS TO RATE THIS PLATE FOR MARY

Yes, this meal will most likely supply Mary with adequate calcium.The chowder is made with cream and will provide her with 200 mg of calcium per cup. The tapioca pudding will provide about 115 mg per ½ cup serving. This meal will provide her with a total of 315 mg of calcium.A serving of calcium is about 300 mg. Good sources of calcium include oranges, dried prunes, cottage cheese, yogurt, milk, creamed soups, almonds, and beans.

CASE IN POINT— MAX: DECREASING APPETITE

ASSESSMENT

1. What do you know about Max and his health?a. Good physical health most of his life. Lately he has become less involved and more

malnourished. Max seems to be losing interest in his health and well-being.

2. What do you know is a barrier in Max’s life to maintaining health?a. Lack of interest and desire, old age

3. What nutrients are missing from Max’s diet, and why?a. Max is not getting enough calories in general. It is possible that he is deficient in all

macro nutrients.b. Vitamins and minerals are missing as well because Max is not eating adequate

calories to meet his needs.

4. How significant is the problem? What are the long-term consequences of the problem?a. Very significant. If Max continues this way, he will die.

DIAGNOSIS

5. Complete the following statement: Imbalanced nutrition; less than body requirements related to loneliness, lack of interest in activities, and old age.

6. What nutrition education does Avery need, to help Max?a. If Max consumes less than 1,500 kcal a day, a multivitamin and supplement are

recommended. Older persons’ needs vary according to their conditions. So each person should be examined by a physician to determine the needs. It is important to prevent dehydration, maintain urinary volume, and prevent constipation.

PLAN/GOAL

7. What are your goals for Max’s diet?a. Monitor fluid intake and take daily multivitamin.b. Keep a food log of what Max is eating to ensure he is consuming adequate calories.

IMPLEMENTATION

8. Identify how each of the following resources can help Max solve this problem and prevent further problems: his daughter, Avery; his grandchildren; his church; and local agencies.a. His daughter Avery—Offer fluid frequently, offer supplements as ordered by the

doctor, invent a means by which she can remind her dad to eat when she is at work, phone calls, having a neighbor stop by; continue to offer and provide his favorite meals and snacks.

b. His grandchildren—Support their grandfather and offer encouragement and help when needed; visit routinely to provide him with company and encouragement.

c. His church—Have parishioners visit when Avery is at work.d. Local agencies—Provide Meals on Wheels.


9. At Max’s next NP appointment, what changes would the NP expect to note? What would the NP expect Avery to report?a. Max is alert and oriented.b. Max is eating well, with assistance from family friends and church members. c. Weight is stable and Max has less weakness.d. Max is more motivated to dress and bathe himself.

THINKING FURTHER

10. Why it is so important in older persons to ensure there is a balance between nutrition, medication, and chronic illness?a. Even though nutritional requirements are less for the elderly, having a good

balanced diet helps with absorption of medications and helps eliminate illness. Chronic illness may not be affected by what we eat, but by how medications react. Drug−drug interactions as well as food−drug interactions can contribute to decreased nutritional status.

11. What would be the benefits of an assisted living setting for Max?a. He would have routine interaction with other people, which was an important part

of his life.b. He would have frequent activities offered for enjoyment and mental stimulation.c. He would have routine meals provided and professional staff to ensure he was

consuming his foods.d. Insurance that medications are administered properlye. Assistance for Max with grooming and housekeeping needs.

12. How can you use this lesson in other situations?a. Awareness of elderly needs and changes in medication in hospital settings is crucial

to maintain optimal health and healing.

RATE THIS PLATE

Max’s lack of energy and weakness could be directly related to his poor appetite. Avery brought Max a warm meal to encourage her father to eat. This is the plate she brought for Max:

4 oz. meatloaf

1 small baked potato with butter and sour cream

½ cup of green beans and corn

1 dinner roll

½ cup custard

Coffee

Are these choices good or does any food need to be changed or added? Will this meal provide enough calories and nutrients for Max?

ANSWERS TO RATE THIS PLATE FOR MAX

Four ounces of meatloaf may be too much for him to eat. If Max would eat just half of the meatloaf he would get 2 oz. of protein.The baked potato is fine. Small servings are best for elderly people. The baked potato will have some protein as well and the butter and sour cream will offer additional calories and protein.Corn is a starchy vegetable and is a good choice. The green beans are a good choice as well.Custard would provide a serving of milk which has 7 grams of protein. Max is getting enough protein in this meal. He is also getting 4 servings of carbohydrates.This would be an excellent meal if he chooses to eat it.

CHAPTER 16

CASE IN POINT— RIDA: GAINING WEIGHT IN RETIREMENT

ASSESSMENT

1. What information do you have about Rida’s activity and eating habits before her retirement?a. Rida had an active life and ate healthy meals.

2. How did Rida’s habits change after she retired?a. Rida had a change in activity when she retired. She has been cooking “fancier”

meals, preparing desserts, and eating out with friends. She was also no longer working and therefore her activity was decreased.

3. How has the change affected her?a. Weight gain

4. How long should Rida expect to take to lose the 16 pounds she gained?a. Approximately 2–4 months

DIAGNOSIS

5. Write a diagnosis for Rida’s alteration in nutrition.a. Nutrition Imbalanced: More than body requirements related to change in nutritional

habits; Manifested by 16-pound weight gain since retirement.

6. Write a diagnosis for Rida’s activity level change.a. Nutrition Imbalanced: More than body requirements related to sedentary activity

level; Manifested by change in work status resulting in 16-pound weight gain.

PLAN/GOAL

7. What is a reasonable, measurable goal for Rida’s weight loss?a. Lose 1–2 pounds per week

IMPLEMENTATION

8. List some strategies that match Rida’s new priorities.a. Take time to take care of herself, adjusting kcal to energy expenditure

b. Invite friends to lunch in lieu of eating out at a restaurant or being more mindful of the choices she is making at restaurants.

c. Making time to exercise routinelyd. Keeping a food log to review where her extra calories may be coming from.

9. What can her husband and friends do to help her lose weight?a. Encouragementb. Her husband could exercise or walk with her.c. He could also begin to establish better eating habits as well.d. Maybe she and her friends could meet for walks or coffee instead of eating out each

time.

10. How can she enjoy her new routine without gaining weight?a. Fix nutritious meals and desserts that fit her kcal needb. Incorporate routine activity in her lifestyle


11. What criteria would Rida use to determine the success of the plan?a. Weight lossb. Improvement in energy levels and self-satisfaction.

THINKING FURTHER

12. How can she maintain weight control for the rest of her life?a. Decrease kcal as she ages and increase exercise

13. How can websites such as SparkPeople.com be helpful to Rida?a. Allow her to track foods and activityb. Provide accurate nutritional information and recipes

RATE THIS PLATE

Rida has been enjoying retirement by visiting with friends over lunch a few times a week. Since her recent weight gain, Rida has decided to pay closer attention to the meals she orders while out with her friends. Rate this plate:

2 cups orange chicken stir-fry with broccoli, snow peas, and carrots

1 cup steamed white rice

1 garlic breadstick

12 oz. sweet iced tea

What questions could Rida ask the server before ordering the meal? What decisions could Rida make to improve the nutritional quality of her meal? What suggestions would you give Rida when choosing to eat out with friends?

ANSWERS TO RATE THIS PLATE FOR RIDA

The questions should be:Is the chicken grilled or fried? Would it be possible to get the orange sauce on the side instead of cooking it with the stir-fry?Are the vegetables cooked in butter or oil?Can a smaller, lunch-sized portion be offered?Are the breadsticks heated plain, are they dipped in butter and garlic, or are they deep fried?Also, she could ask the management for the nutrition information on the entrées.When eating out with friends while trying to lose or maintain a healthy weight, it may be helpful to ask for the nutrition information of the menu items. Knowing the nutrition information will make ordering easier and guilt free. Restaurants can prepare your meal to order, taking any special requests into consideration.CASE IN POINT— BELLA: STAYING HEALTHY FOLLOWING GASTRIC BYPASS SURGERY

ASSESSMENT

1. What do you know about Bella?a. Bella used foods for comfort. Her age is a deterrent to weight loss, and her

sedentary lifestyle also factors into her weight.

2. What was her new priority?a. Weight loss to improve her health

3. What is her ideal weight?a. 115 pounds ±10%, 100–130 pounds

4. How many pounds does she need to lose to be at the high end of her ideal body weight?a. 157 pounds

5. How long should it take to be done safely without the assistance of gastric bypass?a. 20 months to 3 years and 3 months; with gastric bypass surgery she will lose weight

faster

6. What is her current BMI and what are her risks for health problems on the basis of her BMI?a. High risk for stroke, diabetes, cardiac involvement, and with a BMI of 50 she would

be at risk for many chronic illnesses

7. What are her known health problems?a. Hypertension, obesity, hypercholesterolemia

8. At what weight will her health risk be reasonable?a. 169 pounds. This weight would put her BMI in the overweight category instead of

obese

9. How long will it take to reach that reasonable health-risk weight?a. 15 months to 2 ½ years without gastric bypass intervention

DIAGNOSIS

10. Write a complete nursing diagnostic statement for Bella’s nutrition problem.a. Altered nutrition: More than body requirements related to intake of high fat, high

carbohydrate, and high calorie foods, ineffective coping and knowledge deficit of nutrition; Manifested by excess body weight resulting in obesity, high blood pressure, and hypercholesterolemia.

11. Write a diagnosis for her activity intolerance.a. Altered Nutrition: More than body requirements related to Activity intolerance;

Manifested by limited mobility and weakness secondary to poor nutrition and weight gain.

PLAN/GOAL

12. Write at least three goals for Bella that are reasonable and measurable.a. Increase activity• Bella will walk 3 times a week for 20 minutes each time.• Bella will increase her walking regime after 3 weeks to walking 5 times a week for 20

minutes each time.• Bella will increase her walking regime after 5 weeks to walking daily with an increase

of time up to 1 hour a day.b. Improve nutrition• Increase fruits and vegetables to at least 5 servings daily• Decrease use of saturated fats and high fat toppings• Incorporate more whole grains in her diet• Eliminate sweets and desserts on a routine basis• Measure portion sizes to ensure accurate calorie consumption• Keep food log for review by dietitian

IMPLEMENTATION

13. What class of obesity was Bella in when she weighed 287 pounds?

Bella’s BMI was 50.8 when she weighed 287 pounds. This put her in the category of Class III obesity.

14. How much weight would Bella need to lose to move from category III obesity to the overweight category?Bella would need to drop her BMI less than 30 to move into the overweight category. This would mean that for her height of 63 inches, she would need to drop her weight to at least 225 pounds. This means Bella would need to lose 62 pounds.

15. What topics are essential in Bella’s nutrition classes?a. Recognize why she eats and how to cope with the reasons in a different wayb. Portion sizes of foodsc. Reading food labels for nutrient content.

16. Use the food items Bella liked to eat and list low-calorie, low-fat alternatives.a. Low-fat substitutes; light trans-fat free margarinesb. Wheat pastasc. Low-fat dairy

17. What are some behavior modification hints or tips related to where and when she eats that would help her?a. Eat slowlyb. Chew her food wellc. Use a smaller plated. Decrease portion sizee. Eat at the same times each dayf. Once finished with her meal, she needs to do the dishes and get out of the house g. Get a hobby

18. Bella was instructed to turn in her home scale to the doctor’s office and to see him every Friday morning to weigh in and have her blood pressure checked. What is the rationale for these directions?a. Keeps her focused and accountable to the doctor

b. Avoids discrepancies between scales and provides a weight at a consistent time and on a consistent scale

19. How would the information on the National Heart Lung and Blood Institute’s website (http://www.nhlbi.nih.gov) be helpful to Bella?a. Help her realize that she is not alone, give her updated information on food substitutes, and allow her to ask questions

EVALUATION/OUTCOME

20. What changes should the doctor see, hear, and be able to measure that are indicative of success?a. Weight lossb. Increase in stamina and less fatiguec. Enthusiasm about lifed. Reduction in cholesterole. Reduction in blood sugarf. Reduction in blood pressure

THINKING FURTHER

21. Why is it important for Bella to persevere at weight reduction?a. She is at a very high risk for health complications.

22. What are some of the serious potential complications of this surgery?a. Death, ulcers, infection

RATE THIS PLATE

After surgery, Bella allowed her stomach to start to heal by only consuming liquids and semisolid foods. She transitioned from semisolids to soft solid foods after a few weeks and by 8 weeks was ready to try solid foods. Four months after gastric bypass surgery, Bella returns to a normal, healthy diet following the advice of her health care team. She continues to meet with a registered dietitian to assist in planning her meals. Rate this plate:

2 oz. pork tenderloin

¼ cup sweet potatoes

¼ cup pears

¼ cup cottage cheese

6 oz. water

Does this meal meet the recommendations for diet after gastric bypass surgery? If not, what can be improved?

ANSWERS TO RATE THIS PLATE FOR BELLA

This plate is correct except for the water with her meal. Liquids should be consumed between meals since drinking with meals can lead to nausea, cramping, and dumping syndrome. The cottage cheese and pork are good sources of protein and will assist in healing. Meals following gastric bypass surgery should be kept small, starting with six small meals throughout the day. Each meal should include about a half cup to a cup of food. Paying attention to her full and hunger cues will help as well. It is also important to eat slowly and limit foods that are high in fat and sugar as they may be harder to digest.

CHAPTER 17

CASE IN POINT—SIMONE: TYPE 2 DIABETES AND HEART HEALTH

ASSESSMENT

1. Why did not Simone think she had diabetes?a. She had no symptoms, no family history, and she came from a country with very

little incidence of diabetes.

2. Simone is 5 feet 5 inches and 134 pounds. Is she within her ideal body weight range?a. Yes. Her ideal body weight range is 113–137.

3. Simone’s A1C is 12.3%. What is the normal range and the recommendation for someone with diabetes?a. Normal range is 4–6%b. Acceptable with diabetes is less than 7% according to the American Diabetes

Association.

4. Why does the doctor think the diabetes has caused damage to Simone’s heart?a. Diabetes is a risk factor for heart disease. Damage to blood vessels is a

macrovascular complication of diabetes.

DIAGNOSIS

5. Write a nursing diagnosis for Simone.a. Therapeutic Regimen Management, Ineffective: Mistrust of regimen and of health

care personnel secondary to diabetes. Manifested by denial of diagnosis and development of diabetes complications; heart attack.

PLAN/GOAL

6. What resources do you think Simone’s doctor should refer her to?a. Simone needs self-management classes on diabetes.b. She needs education on nutrition by a registered dietitian.c. Simone’s family needs to understand the severity of the situation and be supportive

of her efforts.

7. Simone’s family needs to understand the severity of the situation and be supportive of her efforts. What could they do to support her efforts in gaining control of her diabetes and her health?a. Support her in a healthier lifestyle by improving their health habitsb. Encouraging and reminder her to take her medicine and test her blood sugarc. Encouraging her to exercise by offering to exercise with herd. Reminding her to schedule and attend doctor’s appointmentse. Attending an updated diabetes education class with her

8. What is a primary goal in Simone’s care?a. Acceptance of diagnosis of diabetes so it is no longer an obstacle to her care

IMPLEMENTATION

9. What could Simone begin doing to show she is beginning to accept her diagnosis and move toward a healthier lifestyle?a. Schedule meetings with diabetes educator and dietitianb. Begin following the nutrition guidelines that are presented to herc. Taking her medications correctly and as directed by the physician


10. How would you determine the effectiveness of the plan and the goals?a. Acceptance of diagnosis and attendance at classes to which she was referredb. Reduction in A1cc. Taking medication correctlyd. Monitoring blood sugars and keeping a record of the same.

THINKING FURTHER

11. Go to the website for the American Diabetes Association (http://www.diabetes.org) and look particularly at the food and fitness tab. What are some of the recommendations and resources they have available to clients? What information did you find useful?

a. Answers will vary.

RATE THIS PLATE

Simone has met with a diabetes educator to learn about the importance of monitoring her blood sugar levels and eating healthy. Simone decides that carbohydrate counting would be the easiest way to plan her meals. The diabetes educator recommends a 1,500–1,600 calorie meal plan, which allows 2–3 carbohydrate choices per meal. Rate the plate that Simone plans for her breakfast:

1 toasted whole-grain English muffin

1 tsp margarine

1 tsp grape jelly

1 egg cooked over-easy

1 medium banana

8 oz. low-fat milkDoes Simone have the correct number of carbohydrates for this meal? What should be added or subtracted from this plate?

ANSWERS FOR RATE THIS PLATE FOR SIMONE

Although Simone made healthy choices for her breakfast, her plate consists of 4 carbohydrate servings instead of the recommended 2–3 servings.The whole-grain English muffin is high in fiber and will help maintain her glucose levels. It will count as 2 carbohydrate choices.The margarine gives her a serving of fat and the jelly is known as a “free food” and would not count in her total carbohydrate intake.The egg will provide her with protein that will help maintain satiety and balance blood sugar levels.Eating both the banana and the milk will add an additional 2 carbohydrate choices. Simone could eat the whole-English muffin and leave out the milk and banana, or she could eat half of the muffin and include either the banana or milk to make 2 carbohydrate choices for breakfast.

CASE IN POINT—MICHAEL: MANAGING NEW-ONSET TYPE 1 DIABETES

ASSESSMENT

1. List all the subjective information you have about Michael related to diabetes.a. Had to go to the bathroom a lot especially at night, but voided in small amountsb. Increased thirstc. Fatigued. Weight loss

2. What objective data do you have about Michael?a. Eating without weight gain; in fact, looking thinner

3. What tests are necessary to confirm the diagnosis of diabetes?a. Glucose tolerance, fasting blood sugars, random blood sugar or A1C. The same test

must be repeated to affirm diagnosis.

DIAGNOSIS

4. What education will be needed for Michael’s diagnosis?a. Food exchanges or carbohydrate counting, insulin administration, blood sugar

monitoring, signs and symptoms of hyper and hypoglycemia. He will also need other survival skills such as standards of care and foot care. He will also need to be educated on what to do if he were to get sick.

5. What nursing diagnoses apply to Michael?a. Nutrition Imbalance Altered: Less than body requirementsb. Knowledge Deficit: Needs education on diabetes self-management practices and

standards of care.

PLAN/GOAL

6. Complete the following goal statement: Michael will verbalize and demonstrate his self-care measures related to monitoring his blood sugar and insulin administration.

7. Complete the following goal statement: Michael will verbalize and demonstrate survival skills for persons with diabetes and information by identifying the signs and symptoms of early ketoacidosis, sick-day management, standards of care, foot care, and nutritional management.

IMPLEMENTATION

The doctor has prescribed a long-acting insulin injection for Michael at bedtime and a dose of rapid-acting insulin at meals based on the amount of carbohydrate Michael will consume and his current pre-meal blood sugar level.

8. What topics are essential for Michael to learn?a. Hyper and hypoglycemia signs and symptoms as well as treatment when testing

blood sugarb. How to count grams of carbohydrate and calculate the dose that is correct for his

needs.9. What skills does he need to master before he goes home?

a. Self-injections, drawing up appropriate dose of insulin and calculating the correct dose based on his carbohydrate consumption and his blood sugars

b. Monitoring blood sugars

10. Who else needs to be in class with Michael?a. Mother and any other family members who live with Michael

11. What information does Michael’s mother need to know about emergency situations?a. Hyper and hypoglycemia signs and symptoms as well as treatment

12. What does Michael need to know about exercise?a. Possibly need to increase food consumption and monitor sugars more closelyb. Drink plenty of water


13. What should Michael’s fasting blood sugar be at his 2-week follow-up appointment?a. Within normal limits or much closer to it

14. What should he be able to verbalize and demonstrate?a. Insulin dosage and regimen prescribed; insulin injectionsb. Monitoring blood sugarsc. Calculating the correct number of carbohydrates and the insulin necessary for what

he will consume

15. What should happen to his weight?a. Return to near normal

THINKING FURTHER

16. Why is it essential for Michael to manage his diabetes?a. To prevent complications, both short term and long term

17. What challenges does Michael face in balancing between being a carefree teenager and managing a serious chronic disease?a. Peer pressure to eat the wrong foods; alcohol consumption

18. What information will need to be provided to Michael’s school, including his teachers and his coach?a. They will need to be aware of his diabetes and where his meter and emergency

supplies are. They will also need to be aware of the symptoms of hyper and hypoglycemia and the treatment of each.

RATE THIS PLATE

During his stay at the hospital, Michael receives a visit by a registered dietitian. The dietitian provides education on carbohydrate counting and how carbohydrates will affect his blood sugar levels. She also explains to Michael that exercise will have an effect on his blood sugar levels and that it is important to check his blood sugar regularly when engaging in basketball practice and games. Since Michael is an active, growing teenager, the dietitian recommends a 2,800 calorie diabetic meal plan. This meal plan allows for 5–6 carbohydrate choices per meal and 2–3

carbohydrate choices for snacks between meals. Rate the snack that Michael plans to eat before basketball practice.

2 mozzarella string cheese sticks

1 medium apple

1 oz. cookie snack pack

8 oz. low-fat milk

Will this snack provide him with enough carbohydrate servings to maintain his blood sugar levels through basketball practice? Does the mozzarella cheese contain carbohydrates? Why is it recommended to consume a protein source with a carbohydrate choice as a snack for the diabetic meal plan?

ANSWERS TO RATE THIS PLATE FOR MICHAEL

Yes, this meal will provide Michael with enough carbohydrate to maintain a normal blood sugar range during basketball practice. Michael may still wish to check his blood sugar during practice to see how his levels are doing while exercising. If his blood sugar becomes too low during practice, he could drink fruit juice or eat a couple glucose tablets to get his blood sugar back to a normal range.

The mozzarella cheese does not contain carbohydrate. It is a great protein and fat source. It is recommended to consume protein with a carbohydrate serving for a snack to help balance blood sugar levels. The carbohydrate will provide immediate energy and sugar, while the protein is slower to digest and will cause the blood sugar to remain constant instead of dramatically increasing.

This snack provides approximately 51 grams of carbohydrate or 3.5 carbohydrate servings (or choices).

CHAPTER 18

CASE IN POINT—AYVION: CONGESTIVE HEART FAILURE

ASSESSMENT

1. What subjective data do you have about Ayvion and his health?a. Ayvion knew that his family history was against him.

2. What objective data do you have?a. Chest pain, young, active, stressful lifestyle, elevated blood pressure

3. How significant is his problem?a. Very significant

4. What are the potential consequences if Ayvion ignores his doctor’s advice?a. Death

DIAGNOSIS

5. Write a diagnostic statement about Ayvion’s lack of knowledge regarding his cardiac condition and his new diet.a. Ayvion is deficient in knowledge regarding nutritional status and post-cardiac

symptoms due to lack of involvement in health.

6. What education is needed to help achieve improvement in his health?a. Foods high in fat, cholesterol, and salt, reasons for avoiding and limiting their

consumptionb. Importance of the medications prescribed and how to take them correctlyc. Ways to decrease stress and increase a safe amount of activity

PLAN/GOAL

7. What are several reasonable goals for Ayvion?a. Incorporate recommended exercise regime daily while staying free of chest pain and shortness of breathb. Take medication as directedc. Follow meal plan as instructed

IMPLEMENTATION

8. What issues must Ayvion begin to comply with regarding his new diet?a. Incorporate more fruit and vegetables, eliminate salt use, especially watch fast foods

and pre-prepared foods (canned, boxed, and convenient items)

9. What cardiac topics does Ayvion need to learn to understand his new diet?a. Signs and symptoms of cardiac involvementb. Ways to decrease stress levelsc. Ways to incorporate exercise

10. What two food categories can Ayvion use that have almost no restriction in his new diet?

a. Fruits and vegetables

11. What other problems may Ayvion be at risk for?a. Hypertension, kidney failure, diabetes, and of heart disease

12. How could the information at the American Heart Association website (http://www.americanheart.org) be helpful to Ayvion?a. Provide updated information and local resources available to him


13. If diet and exercise are successful, what changes will be measurable in 3–6 months?a. Decreased stress level and blood pressure within normal limitsb. No fluid retention or weight gainc. Decrease in cholesterol

14. What will the dietitian be able to assess in an interview with Ayvion?a. Types of food that he eats and his likes and dislikes regarding foodsb. Show Ayvion how to incorporate correct portions of his favorite foodsc. Types of foods that are high in cholesterol, saturated fats, and sodium

FURTHER THINKING

15. What are the possible consequences of noncompliance for Ayvion?a. Early death

RATE THIS PLATE

Ayvion attended the cardiac rehabilitation program with support from his wife, to learn about the importance of regular exercise, maintaining a healthy weight, and consuming meals that are low in cholesterol and sodium. Ayvion has decided to plan his meals on a weekly basis and to try and include meat, vegetables, fruits, and milk at every meal. Here is one of the meals he prepared for dinner:

7 oz. baked chicken breast in cream of broccoli soup

1 cup white rice with juices from the broccoli soup as dressing

1 cup of green beans with bacon bits

2 biscuits with butter

½ cup peaches and pears

8 oz. 2%-milk

What foods are high in cholesterol and/or sodium if any? Has Ayvion chosen the right portions and calories for weight loss? If not what should be changed?

ANSWERS TO RATE THIS PLATE FOR AYVION

Ayvion certainly did plan a meal that included a meat, vegetables, fruit, and milk, but he made unnecessary additions that added unneeded calories and fat. First was the cream of broccoli soup on the chicken breast. The soup is high in sodium and higher in fat since it has a cream base. The chicken, since it is an animal protein, contains cholesterol. Keep the serving of chicken to 4–5 oz. instead of 7 oz.White rice is fine, but adding the drippings used from the chicken as gravy, contain mostly fat—gravy should be eliminated. The serving size for rice should be 1/3 cup instead of 1 cup.Green beans are great, but no bacon bits should be allowed.The biscuits are higher in fat compared to regular dinner rolls. A better choice would be to eat a whole-wheat dinner roll with no butter.Ayvion made a good decision when choosing to eat the peaches and pears.Ayvion tried and should continue to try. He could check out the low-cholesterol recipes on the Internet, or if he is a great cook, he could easily modify his current recipes.

CASE IN POINT— NANCY: ADHERING TO A CARDIAC DIET

ASSESSMENT

1. What do you know about Nancy’s health?a. Nancy’s health is in jeopardy due to her poor eating habits. She has already had a

heart attack and quadruple bypass. She was a former smoker, but stopped smoking already.

2. How significant is her health problem?a. Extremely significant

3. What would the consequences be if Nancy decided to ignore the doctor’s advice?a. Nancy will have another heart attack. The next heart attack could be severe enough

to result in death.

4. What do you know about Nancy’s willingness to comply?a. Nancy seems to try to abide by her doctor’s orders; however, she has not made

them a lifestyle change.

5. List all the foods Nancy ate that contained sodium or are usually restricted on a low-sodium diet.a. Diet sodas, potato chips, canned vegetables, gravy butter, sausage, bacon, and salad

dressings

6. List the foods Nancy likes to eat that are high in fat?a. Eggs, bacon, potato chips, gravy, sausage, salad dressing, cheese, chicken salad, and

croissants. Possibly she likes meat, depending on the type and the cut.

DIAGNOSIS

7. Write a diagnostic statement based on Nancy’s condition.a. Nutrition Imbalanced; More than body requirements related to increased intake of

calories, sodium, and saturated fats in excess of body needs. Manifested by lack of knowledge, ineffective coping resulting in heart attack and bypass surgery.

8. What does Nancy need to understand about CHF and low-sodium diets?a. Salt holds water. Excessive fluid means more work for the heart.

9. Why does Nancy continue to retain fluid?a. Excessive salt intake and damage to her heart

PLAN/GOAL

10. What are reasonable, measurable goals for Nancy?a. Omit all sodas by the end of the weekb. Eliminate processed meats by the end of the week

c. Increase exercise regime to walking three times a week for 10 minutes at a time unless she becomes short of breath

d. Substitute snack foods that are high in fat and sodium with snack foods that are in line with Nancy’s dietary guidelines

IMPLEMENTATION

11. What are the main topics to teach Nancy about her diet?a. Hidden salts and fatsb. Balance to her nutritionc. How to obtain the data she needs to control her diet by reading the food label

12. Modify Nancy’s food choices to reflect a low-sodium diet.a. Try to eliminate processed foods, increase consumption of fresh fruits and

vegetables, and be aware of salt content when purchasing foods. Canned foods contain high-sodium content.

b. For breakfast, instead of sausage, bacon, and cheesy eggs, she could try egg whites, whole-wheat English muffin with peanut butter, and fresh fruit. For lunch, she could try a grilled chicken sandwich on whole-grain bread with lettuce and tomato. She could have a cup of yogurt and fresh fruit with carrot sticks and light ranch dressing. For supper, instead of meat, potatoes, and gravy; she could have baked fish, green beans (frozen or fresh), and salad with light dressing, fruit and a glass of skim milk. She could substitute her diet sodas for water or skim milk.

13. What food categories can Nancy eat without restrictions?a. Fruits and vegetables

14. What else does Nancy need in order to control the edema?a. Exerciseb. Medication


15. At her 2-week doctor’s appointment, what changes can the doctor observe and measure as evidence of the effectiveness of the diet?a. Decrease in 4+ edema, breathing easier, decrease in blood pressure, and weight loss

THINKING FURTHER

16. Can this disease be cured?a. No, but it can be controlled with attention to nutrition and other aspects of lifestyle management.

17. Why is managing the disease a constant challenge?a. Lifelong commitment

RATE THIS PLATE

Nancy enjoys preparing meals at home. She is trying to decrease her sodium and fat intake as the registered dietitian instructed. Nancy used a slow-cooker to make the following meal. Rate this plate:

4 oz. beef roast made with cream of mushroom soup and dry onion soup mix

3 oz. cooked potatoes and carrots

1 cup of salad greens with diced tomatoes, cucumbers, cheese, and croutons

2 Tbsp low-fat salad dressing

1 dinner roll with butter

12 oz. diet soda

What changes would you make to her meal, if any? Is she eating according to her sodium restrictions? What do you think about her portion control?

ANSWERS TO RATE THIS PLATE FOR NANCY

Nancy did well with choosing the correct portion sizes for her meal. The 4 oz. of beef roast was an adequate serving size; however, the mushroom soup and dry onion soup mix is high in sodium and fat. Nancy could shop for a low-fat or low-sodium version of the soup instead.The 3 oz. of cooked potatoes and carrots from the roast are a good option, but have also been cooking in the soup mix and would be high in sodium. The cup of salad with low-fat salad dressing is a good choice.Nancy can eat the dinner roll, but added fat should be limited.Diet soda, although it may be low in calories, provides additional sodium. Nancy could try drinking more milk or water instead of drinking soda with her meals.

CHAPTER 19

CASE IN POINT— CHARLES: MANAGING DIET AFTER A KIDNEY STONE

ASSESSMENT

1. What do you know about Charles that put him at risk for kidney stones?a. Eating mainly from the land he lives on, consuming large amounts of animal

products, including organ meatsb. Charles consumes many foods that are high in calcium.

2. What were Charles’ symptoms?a. Stabbing pain in side that radiates down his leg

3. How will this condition affect Charles for the rest of his life?a. Charles will always need to be careful about the foods he is consuming.

4. How significant is this dietary change?a. Significant enough that Charles will need to continue to monitor his diet for specific

foods and will continually need to follow this diet.b. This may be difficult for Charles to adhere to given that many of the foods he

consumes are raised on his farm.

DIAGNOSIS

5. What is the cause of calcium oxalate stones?a. Dietary intake of excessive animal protein has been shown to be a risk factor for

developing stones as well as a diet high in oxalate such as beets, wheat bran, chocolate, tea, rhubarb, strawberries, and spinach.

6. Complete the following diagnostic statement: Charles’ deficient knowledge is related to kidney stones and possible nutritional causes.

PLAN/GOAL

7. What are reasonable, measurable goals for Charles’ change in health?a. Eliminate organ meats from diet for 3 weeks, then incorporate them into his diet no

more than twice a monthb. Become aware of foods that are high in oxalate and consume them less often

IMPLEMENTATION

8. What changes does Charles need to make in his diet?a. Follow the dietitian’s recommendations and eliminate the organ meats and monitor

consumption of foods high in oxalate.

9. What would the consequences be if Charles ignored the doctor’s advice?a. Continue to develop kidney stones and possibly block kidney function

10. Could Charles have another stone?a. Yes, if he does not comply with his diet


11. How will the doctor know if the plan is effective?a. Signs and symptoms will diminish and disappear

THINKING FURTHER

12. What could someone else learn from Charles’ experience?a. Importance of limiting food products high in animal proteins and oxalate

RATE THIS PLATE

During his stay at the hospital, Charles spoke with a registered dietitian about his meal planning concerns. The dietitian told Charles that a diet rich in oxalates can lead to the formation of oxalate kidney stones. Charles provided the dietitian with a 24-hour recall of what he typically ate for lunch. Rate this plate:

5 oz. grilled chicken sandwich on whole-grain bun

2 cups fresh spinach salad with strawberries, pecans, and cheese

2 Tbsp light vinaigrette salad dressing

1 medium orange

1 small slice of rhubarb pie

2 cups hot tea

What foods, if any, are high in oxalates? What nutrient deficiencies are common in clients who experience the formation of oxalate kidney stones? What can Charles include in his diet to hopefully prevent the formation of future kidney stones?

ANSWERS TO RATE THIS PLATE FOR CHARLES

NOTE: Most patients with kidney stones are given a drug that controls the problem, with minor restrictions such as no alcohol or organ meats. On the Internet you can find many different sites, and they have varied restrictions. Following your doctor’s advice is first and foremost.Protein is restricted to about 5–6 oz. per day. The spinach salad is rich in oxalates as well as the strawberries included in it. Instead of eating a spinach salad, Charles could eat a romaine lettuce salad with a variety of vegetables. The light vinaigrette dressing and orange are good choices.Rhubarb pie, although it is a favorite of Charles’, should be limited since it is high in oxalates.Drinking hot tea throughout the day will also increase his intake of oxalates. Charles should consider switching to milk or water.Common nutrient deficiencies associated with oxalate stones include pyridoxine, thiamine, and magnesium. To increase the intake of these nutrients, Charles could consume more whole-grain products, nuts and seeds, and beans. Increasing the amount of calcium in his diet may also prove beneficial in reducing the occurrence of kidney stones.

CASE IN POINT— LENA: DISCOVERING GLOMERULONEPHRITIS

ASSESSMENT

1. What is the subjective data you have on Lena?a. She has never felt healthyb. People refer to her as sicklyc. She reports feeling run downd. She has frequent urinatione. Her urine is darker and appears “foamy”f. Stomachache and no appetite

2. What is the objective data you have on Lena?a. Blood pressure is 148/98b. She is 5 feet 7 inches tall and 133 pounds. This puts her in her ideal body weight

range.c. Blood work indicated glomerulonephritis

3. How will this condition affect Lena?a. Lena will need to be careful about the foods and fluids she is consuming. b. She will need a blood pressure medication and an anti-inflammatory medication

such as a steroid.c. If the disease progresses it can lead to serious kidney damage.

DIAGNOSIS

4. What is the cause of glomerulonephritis?a. It is an inflammation affecting the capillaries in the glomeruli. It may occur acutely in

conjunction with another infection and be self-limiting, or it may lead to serious renal deterioration.

5. Write a nursing diagnosis for Lena.a. Anxiety related to present status and unknown prognosis related to complications

from glomerulonephritis.

PLAN/GOAL

6. What are reasonable, measurable goals for Lena?a. Lena will begin taking her blood pressure medication daily as directed.b. Lena will become aware of foods that are high in sodium and the appropriate

amount of protein and fluids that her physician has given her.

IMPLEMENTATION

7. What changes does Lena need to make in her diet?a. Follow the dietitian’s recommendations and eliminate the high-sodium foods in her

diet. b. She needs to begin to read food labels so that she may find foods that have hidden

sources of sodium in them.

8. What would the consequences be if Lena did not follow doctor’s advice?a. Her condition could progress and cause permanent kidney failure and need for

dialysis.


9. How will the doctor know if the plan is effective?a. Signs and symptoms will diminish and disappear

THINKING FURTHER

10. What are some of the most effective ways to prevent infections?a. Wash your hands frequently

• The CDC recommends washing thoroughly and vigorously with soap and water for at least 20 seconds, followed by hand-drying with a paper towel.

b. Do not share personal itemsc. Cover your mouth when you cough or sneezed. Get vaccinatede. Use safe cooking practicesf. Be a smart traveler

• Use a safe water source (e.g., bottled water) for drinking and brushing your teeth; eat foods that have been cooked (no raw vegetables and fruits); update all immunizations advised or required for travel destination

g. Practice safe sexh. Do not pick your nose (or your mouth or eyes either)i. Exercise caution with animals

• Zoonotic diseases—infections that can spread from animals to people. Wild animals can carry diseases (rabies, bird flu), and fleas/ticks; pets need regular checkups and vaccinations; clean litter boxes frequently—unless you are pregnant; keep small children away from animal feces

j. Watch the news

RATE THIS PLATE

Lena met with a registered dietitian to discuss her concerns about preparing a healthy meal. The dietitian told Lena not to consume more than 48 oz. of fluid per day in order to help control her blood pressure and lessen the workload on her kidneys. Sodium and potassium intake would be limited to improve blood pressure control and prevent fluid retention. Protein is also restricted to decrease the workload on the kidneys and prevent waste from building up in the blood. Lena’s diet should be rich in complex carbohydrates and “good” fats until her body recovers. Rate the plate prepared for dinner.

4 oz. breaded cod fillet

¾ cup brown rice

½ cup broccoli

½ cup fruit salad containing apples, oranges, and grapes

1 cup chocolate ice cream

20 oz. regular soda

Does this meal meet the recommendations advised by the registered dietitian? If not, what can be improved?

ANSWERS TO RATE THIS PLATE FOR LENA

High-quality protein should be consumed while receiving treatment for glomerulonephritis. High-quality protein includes lean meats, fish, chicken, and eggs. Most calories will be supplied by complex carbohydrates such as whole-wheat products, brown rice, whole-grain breads and cereals, and fruits and vegetables. Calories from fat should be supplied by monounsaturated sources such as peanut butter and olive oil.The 4 oz. of cod is a good choice. The breading on the cod may be high in sodium and fat. A better option would be to grill a plain fillet of fish lightly seasoned with herbs and spices with no added salt.The brown rice and broccoli are good options as well.The fruit salad, although a healthy choice, is high in water content and should be included in her fluid count for the day. The ice cream also has high water content and should be included in her fluid intake.Soda will count towards her fluid intake as well as potassium and sodium intake. Water or tea would be a better option.

CHAPTER 20

CASE IN POINT— CHARLOTTE: COPING WITH CELIAC DISEASE

ASSESSMENT

1. What do you know about Charlotte that puts her at risk for celiac disease?a. She has type 1 diabetes.

2. What symptoms did Charlotte have?a. Gassy and bloated, stomach pain, diarrhea, feeling run down, and weight loss.

3. How will the disease alter her life?a. Charlotte will need to be aware of the foods that contain gluten and be able to read

the ingredient list on packages so she will know what sources of gluten they may contain.

4. How significant is this disease?a. Very significant, yet very controllable

DIAGNOSIS

5. Write a diagnostic statement for Charlotte’s potential alteration in nutrition.a. Nutrition Altered: potential for less than body requirements related to gluten

restrictions. Manifested by stomach pain, diarrhea, and weight loss associated with celiac disease.

6. Write a diagnosis for Charlotte’s deficient knowledge related to the new diet.a. Therapeutic Regimen Management ineffective: Related to difficulty in following and

adhering to regimen of gluten-free diet or gluten-free products unavailable.

PLAN/GOAL

7. What dietary goals are measurable and appropriate for Charlotte?a. Begin reading ingredients list on packages and determining if gluten sources are in

the productb. Eliminate fried foods, whole-grain breads and cereals that contain barley, oats, rye,

and wheatc. Reduction in stomach pain, diarrhea, and weight loss

8. What education goals are specific and measurable for Charlotte?a. Charlotte will be able to identify foods to avoid with gluten-free diet.b. Charlotte will be able to identify which foods are safe for her to consume.

IMPLEMENTATION

9. What information about celiac disease does Charlotte need to understand, to make necessary dietary changes?a. It can be difficult to identify foods that contain hidden sources of gluten. She will

need to be very conscientious in reading ingredient labels of the foods she eats. She will also need to be very careful when eating out or away from home.

10. What foods are going to be a problem for Charlotte?a. Gluten-containing grains like barley (including malt extract, beer, and ale), rye,

wheat (all types of wheat flour and products made with wheat, bran, germ, starch), spelt, triticale, and farro


11. At her follow-up doctor’s appointment, what is her doctor likely to ask to determine if the plan was successful?a. Is Charlotte pain-free, and has she had any more bouts with diarrhea, stomach pain,

or fatigue?

THINKING FURTHER

12. Can celiac disease be cured?a. No

13. What medications are typically used to help manage this disease?a. Not typically, anti-inflammatories such as corticosteroids may be used if necessary.

RATE THIS PLATE

Charlotte is overwhelmed by her new diagnosis of gluten sensitivity. As a diabetic, she has learned to control her blood sugar through counting carbohydrates, but following a gluten-free diet seems like a challenge. After receiving education from a registered dietitian, Charlotte feels more confident in preparing a healthy meal. Rate the plate she made for dinner:

2 slices gluten-free pepperoni pizza

1 cup Caesar side salad with croutons

20 oz. iced tea

What types of food contain gluten? Is there anything in this plate that should be eliminated?

ANSWERS TO RATE THIS PLATE FOR CHARLOTTE

Gluten is found in wheat, rye, and barley products. Common foods that contain gluten are bagels, bread, breakfast cereals, crackers, pizza, and pasta. Beer products also contain gluten, as well as ice cream, salad dressings, candy, and canned or frozen soups and vegetables, and processed foods. Paying close attention to food labels and ingredients is important when eating a gluten-free diet.The gluten-free pizza is a good option. The crust for the pizza would have to be gluten-free and if Charlotte made this pizza at home, she would need to read the labels on the tomato sauce jar and pepperoni package to make sure they did not contain gluten.The Caesar salad is also a good option. Salad dressings and croutons may also contain gluten, so reading the labels will come in handy. Iced tea does not contain gluten and therefore is a good choice. Charlotte’s symptoms should decrease within 2–3 weeks of adapting to the gluten-free diet. Following both a gluten-free diet and diabetic diet is possible. It may be challenging at first, but

Charlotte will be able to manage both meal plans with practice.

CASE IN POINT— ALEK: MANAGING AN ULCER THROUGH DIET

ASSESSMENT

1. What put Alek at risk for his ulcer to bleed?a. Stress, aspirin, and spicy food consumption

2. What symptoms did he have?a. Burning pain in his chest and abdomen

3. What could have been done to prevent this problem?a. Proper diet, stress-relieving techniques, and different treatment of headaches (no aspirin)

4. What impact did this health problem have on Alek?a. Dietary changes that included no spicy foods, increased fear and stress, loss of work

DIAGNOSIS

5. Write two diagnoses for Alek’s problems of diet and lack of knowledge.a. Risk for Ineffective Therapeutic Regimen Management related to insufficient

knowledge of disease process and not adhering to dietary restrictions.b. Nutrition Imbalanced: Risk for less than body requirements related to altered

nutrition due to dietary restrictions. Manifested by diarrhea and abdominal cramping associated with painful ulcers.

PLAN/GOAL

6. What goals would be appropriate for Alek’s education and nutrition?a. Understand the consequences of taking aspirinb. Use an antibiotic to kill the bacteria causing the ulcerc. Identify, as early as possible, signs and symptoms of flare-upsd. Know the importance of rest and counseling to deal with stress

e. Consume low-fat proteins and take vitamin and mineral supplements, especially iron because of bleeding

f. Avoid anything that causes increase of gastric secretionsg. Avoid spicy foods that irritate the lining of the stomach

IMPLEMENTATION

7. What does Alek need to learn about his new diet?a. Foods that cause distress

8. What does he need to learn about his ulcer and his new medications?a. Frequency of taking his medications, early signs of stress, and elimination of

stressors. Alcohol and aspirin irritate the mucous membrane of the stomach.

9. What challenges will he face in complying with the diet while at work?a. Difficulty finding the right foods to eat

10. Construct a meal that Alek would be likely to find at work.a. Chicken sandwich, fruit, and yogurt (many options available)

11. Instead of aspirin, what can Alek use to treat his headaches that will not irritate his ulcer?a. Acetaminophen (Tylenol)b. Motrin, Advil, Ibuprofen


12. How will Alek’s doctor know this plan is effective?a. Alek’s pain will be relieved.b. He will have no new bouts of pain.

THINKING FURTHER

13. Diet, stress, and medications can contribute to ulcers and prevent them from healing. Can you list some of the other causes and treatments for ulcers?a. Other possible causes include genetic predisposition, high secretion of hydrochloric

acid by the stomach, and in some cases a bacterium called Helicobacter pylori may contribute to their development. They are treated with drugs such as antibiotics and cimetidine. Antacids containing calcium carbonate can neutralize excess acid. Management of stress can also be helpful.

RATE THIS PLATE

Following a low-residue diet will allow Alek’s ulcer to heal. Rate the plate that Alek ate while working late at the office:

3 Cajun chicken and steak fajitas with onions and peppers

¾ cup of Spanish rice

½ cup of refried beans

12 oz. caffeine-free lemon-lime soda

How did Alek do with preparing his meal from what was catered in at the office? Can he eat everything? If not, what needs to be changed?

ANSWERS TO RATE THIS PLATE FOR ALEK

Cajun seasoning is a spicy seasoning and should be changed to a grilled chicken or steak. The onions and peppers are spicy and may cause him some discomfort. Instead of having them on this fajita, he would choose lettuce or cheese instead.He may be able to tolerate the Spanish rice if it is not too spicy. Eating plain, white, or brown rice would be a better option.Refried beans are high in fiber and fat and should be avoided on a low-residue diet.The caffeine-free soda is a better choice than a caffeinated soda choice, since caffeine can cause stomach upset and irritate ulcers.

CHAPTER 21

CASE IN POINT— KATE: ADJUSTING TO LIFE WITH A COLOSTOMY

ASSESSMENT

1. What do you know about Kate?a. Kate is 50 years old. She has a family history of colon cancer. She put off her routine

colonoscopy and by the time she had it done, the doctor found cancerous cells.

2. What barriers does she have to balance nutrition?a. She has had much difficulty with diarrhea and has not been feeling well. She may

have loss of appetite due to depression over diagnosis.

3. What resources does she have to overcome these barriers?a. Make meals appealingb. Use small portions more frequentlyc. Take food supplements as neededd. Eat soft foods that may be easier to digeste. Follow a low-residue diet if diarrhea is a problem

4. How important is her nutrition to her current health? How about to her future treatments?a. Kate could easily become weak or anorexic if she is unable to eat a balanced diet. If

she is unable to get the proper nutrition, healing will be difficult or impossible.

DIAGNOSIS

5. Write a diagnosis about potential alteration in nutrition.a. Imbalanced Nutrition: Less than body requirements related to diarrhea and loss of

appetite secondary to disease process and treatment.

6. Write a diagnosis about her deficient knowledge.a. Risk for Ineffective Therapeutic Regimen Management related to insufficient

knowledge of colostomy and stoma care.

PLAN/GOAL

7. What is the immediate goal for Kate’s nutrition?a. Increase protein and kcal intake in order to rebuild damaged tissue

8. What is the long-term goal?a. Maintain weight without weight loss throughout any needed procedures such as

chemotherapy and radiation.

IMPLEMENTATION

9. What does Kate needs to learn?a. Kate needs to learn that patients who can maintain their weight or minimize its loss

increase their chances of responding to treatment and survival.

10. List strategies to increase what Kate eats at home.a. Present foods she likes to eat in a pleasing manner in small portionsb. Present nutritious foods in a pleasing mannerc. Eat soft foods if chewing is a problemd. Provide supplements or snacks as needed

11. How important is nutrition to her healing?a. Her nutrition is vital to healing.

12. What can a home health care nurse do to enhance Kate’s nutrition? What can a dietitian do?a. The home health nurse can eliminate any unpleasant odors, offer praise for eating,

and teach the importance of a balanced nutritional diet and healing. The dietitian can identify Kate’s likes and dislikes and make suggestions for balanced nutrition.


13. What can the home health nurse observe and measure as evidence of the success of the plan?a. Kate’s symptoms are diminishing, she is no longer losing weight and she is becoming

stronger.

THINKING FURTHER

14. Why is it important to use nutrition to reduce your risk of cancer?a. Although not totally proven, it is thought that by eating the proper foods in a well-

balanced diet, you can avoid or help protect against many forms of cancer.

RATE THIS PLATE

The dietitian meets with Kate to discuss protein sources and foods she can include in her diet to help decrease bowel irritation. Everyone’s body acts different to various types of food, so Kate would have to experiment to see what her intestines could tolerate. In order to prevent additional weight loss, the dietitian recommends a protein supplement drink for Kate if she is unable to obtain sufficient protein from her meals and snacks. Rate the plate she plans to eat for lunch, taking into consideration any possible irritants and protein sources:

2 cups spinach salad with mandarin oranges and pecans

3 oz. crispy chicken on top of the salad

¾ cup tomato soup made with water, not milk

½ cup cottage cheese

½ cup sliced peaches

Are there any parts to this meal that may cause Kate some intestinal discomfort? What foods in this meal are rich in protein? Will Kate need to drink the supplement with this meal or does it provide enough protein alone?

ANSWERS TO RATE THIS PLATE FOR KATE

The spinach salad is high in fiber. A low-fiber diet is commonly recommended for people with colon cancer to decrease the stress of the gut and allow for healing. Kate may try the salad and see how her body tolerates it. The mandarin oranges in the salad are fine, while the pecans are also high in fiber. The crispy chicken included in the salad is a great protein source, but is also high in fat. Fat is limited on low-residue or low-irritant diets. Therefore, trying grilled chicken strips instead of one with a coating would be a better option. The 3 oz. of chicken will provide about 21 grams of protein.Soups are easily tolerated on a low-irritant diet. Since it was made with water and not milk, the protein and fat content will be lower than if it was made with milk. To increase calorie and protein intake, the soup could be made with skim milk, which will still add nutrients without the added fat.The cottage cheese is a great choice! It is a good source of protein and fat. If the whole cottage cheese bothers her stomach, a low-fat option may be better tolerated. The peaches are fine to eat with it as well.If Kate can eat this entire meal, it will provide her with 45 grams of protein. She will not need to drink the protein supplement with this meal. This is a great meal, rich in protein to promote healing.

CASE IN POINT— DAVE: APPETITE AND WEIGHT LOSS DURING CHEMOTHERAPY

ASSESSMENT

1. What has Dave’s response to the chemotherapy been so far?a. Fear, anxiety, and apprehension

2. What does the doctor suspect will happen to Dave’s nutrition during round 4 of chemotherapy?a. Dave may experience typical side effects of chemotherapy—nausea and vomiting

and an increased aversion to foods and smells.

3. What can the dietitian assess to measure how Dave is eating?a. Weight lossb. Food log

DIAGNOSIS

4. Write a diagnostic statement describing the nutrition problems Dave could have with chemotherapy.a. Imbalanced Nutrition: Less than body requirements related to taste changes,

persistent nausea and vomiting, and increased metabolic rate in chemotherapy

PLAN/GOAL

5. What is the major nutrition goal for Dave?a. Maintain weight or minimize weight loss

6. What is the rationale for aggressive proactive nutrition between rounds of chemotherapy?a. Those clients who maintain their weight or minimize its loss increase their likelihood

of responding to treatment and increase their chances of survival.

7. What does Dave need to know related to the nutritional demands of ongoing chemotherapy?a. Nutritional demands will increase due to the increase in metabolic rate.

IMPLEMENTATION

8. List four strategies the dietitian can use to encourage Dave to eat.a. Prepare foods Dave likes to eatb. Eat richer foods earlier in the dayc. Offer small portions frequently, and use high-caloric supplementsd. Follow a low-residue diet if diarrhea occurs

9. List three strategies that his family can use to help him eat.a. Eat meals together, provide encouragementb. Eat slowlyc. Prepare flavorful meals that Dave enjoys

10. If Dave eats only 5–10% of his normal food volume, what foods should be a priority? How are fluids important?a. High-protein foods a priority

b. Prevent dehydration if nausea and vomiting are frequent, but do not use if consumption reduces the client’s appetite at mealtime

11. In preparation for round 5 of chemotherapy, what could Dave do to enhance his nutrition once his appetite returns?a. Take in high-caloric supplements, including high-protein foods

12. How can other cancer clients undergoing chemotherapy and their families help Dave?a. They can listen and truly understand what he is going through. They can offer

suggestions that worked for them, and they can support him and his family.

13. How can the Internet be of help? Check out the American Cancer Society at http://www.cancer.org.a. Provide community resources


14. How would the doctor evaluate the success of the diet plan?a. Dave is maintaining his weight, or the weight loss is minimal.

THINKING FURTHER

15. Why is nutrition so important in the successful treatment of cancer?a. Nutrition supplies the body with the calories, proteins, fats, and vitamins and

minerals required to meet the needs of the body during a higher metabolic rate of healing.

RATE THIS PLATE

Dave has done a good job at eating healthy and maintaining his weight while receiving chemotherapy treatments. Dave will be seeing the dietitian a few times a month to review his food intake and weight status. Using the meal he made for lunch as an example, will Dave be able to maintain his weight? Rate the plate:

4 oz. salmon fillet

1 cup mashed potatoes

¾ cup sautéed vegetables, including red peppers, broccoli, and zucchini

1 cup romaine salad with dried cranberries and cherries

2 Tbsp light poppy seed dressing

1 toffee nut cookie

Cancer patients need additional protein because cancer tends to deplete protein stores. Has Dave planned enough protein for this meal? If not, how could he adjust this meal to include more protein?

ANSWERS TO RATE THIS PLATE FOR DAVE

Dave could use more protein.Additions to the menu might include:

Add 3 more oz. of fish.Add cream cheese and sour cream when mashing the potatoes.Add 1 scoop of protein powder to the mashed potatoes.Use regular salad dressing instead of light dressings for additional calories.Add walnuts, blue cheese, or feta cheese to the salad.Add ice cream to the cookie.Add a glass of milk as the beverage.

That will add quite a bit of protein. How much? Plug it into MyPlate to find out both what the original meal contained, and what the additions contain.

CHAPTER 22

CASE IN POINT— DEMETRIOS: SURVIVING SEVERE BURNS

ASSESSMENT

1. What do you know about Demetrios’ need for fluids?a. Fluid needs will increase due to loss of body fluids

2. What do you know about Demetrios’ need for electrolyte balance?a. Electrolytes will be imbalanced due to fluid loss.

3. What would help you identify Demetrios’ health before his accident?a. Nursing assessment information taken from family members

DIAGNOSIS

4. Write a diagnostic statement describing the problems Demetrios could have with his severe burns.a. Anxiety; Related to sudden injury, treatments, uncertainty of outcome, and painb. Pain; Related to thermal injury treatments and immobilityc. High risk for altered nutrition: Less than body requirements related to increased

protein calorie and vitamin requirements for wound healing and decreased intake secondary to pain, decreased mobility, and activity, and possibly nausea and vomiting

5. Write a diagnostic statement about the risk of infection for Demetrios.a. High risk of infection related to loss of protective layer secondary to thermal injury

PLAN/GOAL

6. What is the overall nutritional goal for Demetrios?a. Increased caloric and protein intake (protein sparing), increase in B-complex

vitamins (metabolism), vitamin C for wound healing

IMPLEMENTATION

7. What strategies can the dietitian use to assure proper nutritional balance for Demetrios?a. Determine the client’s food preferences and eating habits, collaborate with the

client to establish a mutually acceptable nutrition plan if appropriate, and identify anorexia and nausea as well as fatigue and pain issues. Offer frequent small meals, and restrict fluids 1 hour before and after meals. Arrange to have food with the highest protein content served at the times when the client usually feels most like eating.

8. If Demetrios would require tube feedings, what can the dietitian expect to happen?a. Increased calorie count if tolerable, frequent small feeding flushed with water, or

continuous feedings depending on the client’s needsb. Possible problems of high osmolar feeding detracting or pulling fluid from the blood

to the tissues; aspiration of formula causing pneumoniac. Diarrhea

9. What strategies can the dietitian use to prevent side effects of tube feedings?a. Prepare the proper formula and monitor labs for osmolality changes

b. Investigate the cause of diarrheac. Check with the physician if the formula is too high in osmolality

10. What categories of food are priorities for Demetrios right now?a. High protein, calories, and vitamins


11. What criteria could be used to evaluate the plan?a. Demetrios’ lab values are within normal range.b. Demetrios’ electrolytes are balanced and his fluid output is normal.

THINKING FURTHER

12. Why is nutrition so critical in the treatment of the client with burns?a. The hyperbolic state after a serious burn continues until the skin is largely healed, so there is an enormous increase in energy needed for the healing process.

RATE THIS PLATE

Demetrios was transported to the burn unit within the hospital and was immediately hooked up to an IV to receive fluids. Since Demetrios is unable to receive nutrition orally at this time, a feeding tube was inserted for nutrition. The physician started the following tube feeding: A 1-calorie/ml product such as Nutren 1.0 or Jevity 1.0

Is this the best product for a severely burned client? What nutrient would this client need for building and repairing burned tissue? Search the Internet for Nestle and Ross nutritional products to determine which product would be best for Demetrios.

ANSWERS TO RATE THIS PLATE FOR DEMETRIOS

Demetrios will need a high-protein and high-calorie tube feeding until he is able to eat. Crucial is the Nestle product. Crucial is a 2-calorie/ml tube feeding (the highest-caloric-dense product available) and is also high in protein.Ross has a HiCal product that is also a 2-calorie product and is high in protein. Either one of these would be appropriate.

CASE IN POINT— BETTY: TRANSITIONING FROM PARENTERAL NUTRITION

ASSESSMENT

1. What information do you have about Betty and her nutrition?a. Betty is not eating all of her food, and she is sacrificing nourishment that would help heal her injuries and give her energy.

2. What deficit does the dietitian suspect?a. Protein

3. What does the physician suspect?a. Possibility of diabetes and low-protein intake; failure to thrive

4. How significant is the problem?a. Very significant

5. If Betty were 5 feet 2 inches tall and weighed 110 pounds before the accident, what would be her daily protein requirements?a. 40 grams (protein needs are 0.8grams per kg of body weight)

6. What two benefits of protein is Betty missing?a. Cell/tissue repair for wound healingb. Energy production

DIAGNOSIS

7. What is the cause of Betty’s nutritional problem?a. Lack of exercise, boredom, difficult mobility, possibly depression

8. Complete the following nursing diagnosis statement: Betty’s imbalanced nutrition less than body requirements, related to decreased appetite resulting in poor wound healing and lack of vitamins required for healing.

PLAN/GOAL

9. What is your goal for Betty?a. Increase intake especially protein consumption

IMPLEMENTATION

10. What will the calorie count reveal?a. Amount of food consumed

11. What do you need to know about Betty’s food preferences?a. What she likes to eat and how she likes her foods prepared. You also need to know any food allergies Betty has.

12. What could Kenny do to help during meals?a. Help prepare the food at homeb. Help feed Betty as necessaryc. Keep Betty occupied while ensuring that she eats

13. What should be the size and frequency of Betty’s meals?a. Small meals several times a day

14. Should appetite stimulants be used?a. Yes, if appetite and healing do not improve.

15. Should liquid nutritional supplements be used?a. Yes

16. Which proteins could provide the highest quality per bite?a. Animal proteins


17. What criteria would the doctor, physical therapist, and dietitian use to evaluate the effectiveness of the plan?a. The doctor would see wound healing, the physical therapist would see an increase in

energy level, and the dietitian would see an increase in appetite.

18. Would weight gain be an effective criterion? If not, why?a. No. Proteins build and repair body tissue, play a major role in regulating various

body functions, and provide energy if there is insufficient carbohydrate and fat in the diet. Betty could see weight gain from fat or carbohydrate sources or simply from fluid imbalance and this would not be adequate for her needs.

THINKING FURTHER

19. How could the lessons from this case be used in other situations?a. The elderly usually have a difficult time with long-term hospital stays. With attention

to the details of proper nutrition, we can help the healing process, and with attention to each individual, we can help with depression and lack of motivation.

RATE THIS PLATE

Along with offering a protein supplement between meals, the dietitian encouraged Betty to include protein sources in her meals and snacks. Increased protein intake will provide her with additional energy and assist in healing her fractures. Rate the plate she ate for breakfast:

½ cup oatmeal

¼ cup blueberries

1 slice whole-wheat toast with butter

4 oz. yogurt

4 oz. orange juice

Sips of coffee

How many calories and grams of protein did Betty receive from this meal? Was this meal sufficient in calories and protein? What foods can be added to this meal, if any, to increase protein? What can be done to encourage Betty to eat more than 50% of her plate at meal time?

ANSWERS TO RATE THIS PLATE FOR BETTY

This meal provided approximately 389 calories and 10 grams of protein. This meal provides Betty with enough calories for breakfast, but not enough protein.Ways to incorporate more protein into this meal:

1½ tablespoons of protein powder will provide 22 grams of protein. Adding this amount or less to the oatmeal will increase the protein content.

Betty could put peanut butter on her toast instead of butterSubstituting Greek yogurt for regular yogurt would provide her with additional protein. Six

ounces of Greek yogurt contains 15–20 grams of protein.If eating three, regular-sized meals per day is too overwhelming to Betty, 5–6 small meals a day may be better accepted. Eating smaller meals throughout the day will hopefully encourage a higher intake at meal time. Once her appetite improves, she may be able to return to 3 regular meals a day.

CHAPTER 23

CASE IN POINT— LOUIS: SUFFERING FROM WEIGHT LOSS AND SKIN BREAKDOWN

ASSESSMENT

1. What do you know about Louis and his nutrition?a. Louis is a widower of about 6 months with very poor nutritional habits related to

family circumstances. He does not desire to prepare meals and his brother has been trying to assist him.

2. Did he eat a balanced diet?a. No

3. What barriers were there to his healing?a. Lack of good nutrition, immobility

4. What foods are priorities for healing?a. Proteins, vitamins, and a high-kcal diet

5. How significant is nutrition to this problem?a. Increased energy and protein is needed for healing

DIAGNOSIS

6. Write at least two diagnoses that apply to Louis’ problem.a. Anxiety related to anticipated surgery, unfamiliarity with pre- and postoperative

routines, and postoperative sensations of skin flap surgery.b. Altered health maintenance related to imbalance between caloric intake and energy

expenditure related to major change in lifestyle after the death of his spouse.

PLAN/GOAL

7. What is the priority goal for Louis?a. Learn dietary needs and reasons for a well-balanced diet, and institute the new diet

plan upon discharge from the hospital.

IMPLEMENTATION

8. What does the dietitian need to know about Louis to help?a. The dietitian should find out what foods Louis likes and dislikes, where he eats, and

how often he eats. The dietitian also needs to determine what motivates him to eat and who prepares the meals for him.

9. What is the dietitian likely to recommend?a. High-protein, low-fat, high-fiber meals with nutrient-dense foods

10. How could vitamin supplements help?a. Vitamins can help with tissue repair, clotting factors, and general well-being.

11. Who else can help?a. All family members, but particularly his brother who is living at home with Louis

12. What strategies could be helpful to get Louis to eat?

a. Offer foods he likesb. Offer meals at a time when he is likely to be the most hungryc. Offer a well-balanced diet in a pleasing mannerd. Offer smaller, more frequent meals

13. What could a home health nurse do?a. Monitor the home situation and compliance with diet and food preparationb. Ensure that Louis is getting some activity and staying off his wound to promote

healing

14. What does Louis need to do to help himself?a. Embrace the changes and understand the need for the changes

15. If Louis is unable to eat enough food to maintain his weight, what alternatives does the doctor have?a. Food supplements and tube feedings


16. What needs to happen for Louis to avoid having a feeding tube?a. Louis needs to maintain his current weight.b. His wound needs to show signs of healing.

17. What criteria will the doctor use to determine if the plan is effective?a. Healing and weight maintenance

THINKING FURTHER

18. How are Louis’ needs similar to those of any other surgical client?a. Louis needs to have good nutrition to help the healing process.

19. What are the most serious consequences if Louis is unable to heal, even with tube feedings?a. Infection and sepsis

RATE THIS PLATE

Lenny made the following meal for Louis. Rate the plate on protein quality:

6 oz. baked meatloaf

1 medium baked potato with shredded cheese and butter

¾ cup mixed vegetables

1 dinner roll with butter

4 oz. custard cup

How many grams of protein are in this meal? Is it enough to support the healing of Louis’ ulcer?

ANSWERS TO RATE THIS PLATE FOR LOUIS

Lenny did an excellent job of planning a high-protein meal.6 oz. of meatloaf has approximately 44 grams of protein.A baked potato has 5 grams of protein.Cheddar cheese has 7 grams of protein.Mixed vegetables have 2 grams of protein.A hard roll has 5 grams of protein.A 1-cup serving of custard has 14 grams of protein. Louis ate 4 oz. of custard equaling 7 grams of protein.Total protein equals 70 grams.

CASE IN POINT— DUMISANI: ADJUSTING TO LIFE IN ASSISTED LIVING

ASSESSMENT

1. What has happened to Dumisani?a. Water loss due to the diarrhea and no replacement of water and electrolytes

2. What data do you have to support your findings?a. Increased stools, elevated temperature, and confusion

3. What conditions will occur if Dumisani’s diarrhea and temperature are not treated?a. Kidney failure, heart failure, death

4. Because of his age, what do you know about Dumisani’s total body water content?a. Content of body water decreases with age due to loss of muscle tissue

DIAGNOSIS

5. Complete the following nursing diagnosis statement: Dumisani’s deficient fluid volume is related to diarrhea and fever as evidenced by his behavior of confusion.

PLAN/GOAL

6. What is your immediate concern for Dumisani?a. Fluid replacement

7. What is your concern for the next 24 hours?a. Electrolyte balance

IMPLEMENTATION

8. What fluid would be most helpful to Dumisani and why?a. Normal saline IV provides volume for hydration and sodium, a source for electrolyte

balancing.

9. How much fluid should he have?a. 10% of body weight in volume

10. What else should be done to treat Dumisani?a. Identify the source of his diarrhea

11. What should Dumisani do the next time he starts to have diarrhea?a. Notify the nurses immediately


12. What changes will you expect to see if your plan is effective?a. Diarrhea stops, confusion clears, temperature returns to normal

THINKING FURTHER

13. At what point could Dumisani have avoided this problem?a. The first time he had diarrhea and he felt he was ill

14. How could you use this lesson in your future experiences as a nurse?a. Being aware of the elderly's needs and complaints and observing behaviors

RATE THIS PLATE

Chronic diarrhea can lead to dehydration so it is important for Dumisani to be drinking fluids regularly. It is also important to replenish lost electrolytes and sodium. Rate this plate that Dumisani received for lunch:

1 cup chicken noodle soup

1 small baked potato with butter

½ cup fruited orange gelatin

½ cup chocolate pudding

8 oz. apple juice

Use Appendix D to list the water and sodium content of these foods. Will this meal provide Dumisani with adequate fluids?

ANSWERS TO RATE THIS PLATE FOR DUMISANI

1 cup chicken noodle soup 1,106 milligrams sodium, 92% water8 oz. apple juice7 milligrams sodium, 88% water½ cup fruited gelatin 57 milligrams sodium, 85 % water½ cup chocolate pudding 146 milligrams sodium, 69% water1 small baked potato 16 milligrams sodium, 71% water

Yes, this meal will provide Dumisani with enough fluids. The chicken noodle soup is high in sodium, but may be included at this time to allow for water retention.

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