Outline steps you would take to assist Mrs. Maney as she prepares for discharge. Include the ...

Answer to #1

 Assess readiness/motivation for change
 Educate the importance of sodium and fluid restriction and their implications on the clinical manifestations and exacerbations of her cachexic state (increased work of breathing due to pulmonary congestion, anorexia, etc.)
 Educate Mrs. Maney on nutrient density  steps to add both kcal and protein to her diet. Suggest that Mrs, Maney have assistance with meal preparation and grocery shopping. Attempt to get at least 1/3 of her kcal at the meal where she is hungriest. Could also suggest spreading meals over 5-6 small feedings rather than only three. Discuss the use of high calore and high protein supplements. Every bite of food should provide both kcal and protein discourage consumption of empty calorie foods.
 Educate Mrs. Maney on fluids:
- See question 5 . for examples
- How to optimize/reduce intake (e.g. avoid salty foods, drink only when thirsty, etc.)
 Educate on low-sodium and avoidance of high-sodium options:
- Low sodium: fresh or frozen vegetables, fruits, unprocessed meats, noodles, rice, English muffins, etc.
- High-sodium: processed foods, salty snack foods, soups, sauces, fast foods, pickles, etc.

Answer to #2

 Intake by mouth with modified diet via diet recall
Whether or not she is following recommendations/strategies
 Protein modifications with medication use
 Weight changes, GI motility/output, GERD
 Functional capacity with UPDRS
 Labs (albumin, iron status, hydration)
 The need for alternative nutrition support (compliance with use/care of feeding tube)

Answer to #3

 If she is able to eat, provide her with foods that she likes with increased nutrient density.
 Small, frequent feedings work well to minimize the volume of food consumed and stress on both the cardiac and respiratory systems.
 Within her fluid allowance, use of a nutrient-dense liquid supplement may be easier than attempting to consume solid food.
 Consume fluids between meals to prevent their contribution to fullness during mealtime

Answer to #4

 Iron
 B vitamins (limit vitamin B6 supplementation to less than 15 mg)
 Calcium/vitamin D

Answer to #5

 The formula could be changed to one with added fiber (such as Jevity) or fiber could be added to Mrs. Maney's medications.
 It is important to remember that fiber supplements should not be added separately to the enteral formula or placed down the feeding tube. It may cause interactions with the formula and could result in a tube blockage.
 Additionally, an antidiarrheal agent such as loperamide could be used.
 Depending the osmolality of the formula, it may be advisable to have a lower initiation rate to lower the water-pulling effect that the higher osmolar formula may have in the intestinal tract.

Answer to #6

 Based on this assessment and using the DOSS, recommend a modified diet of Level 4  moderate dysphagia: intermittent supervision/curing, one or two consistencies restricted
This patient has no noted problems chewing, but stated that she feels food gets stuck in her throat  would benefit from a softer diet
 Level 3 (advanced) for most liberal diet
Only need to restrict liquid consistency to be thicker
 Pt had penetration into the larynx with some aspiration
Pt may need cueing, but with some tips, can learn to initiate on her own
 Recommend: Level 3 advanced diet and nectar-thick liquids
The thickness of the liquids/diet consistency depends on what the SLP recommends

Answer to #7

 Inadequate oral food/beverage intake related to poor appetite as evidenced by few sips of liquids, soft foods, and trying to take Ensure.
 Inadequate intake from enteral nutrition related to intolerance secondary to uncontrolled diarrhea as evidenced by ___ (more data would be needed regarding the specific amount that was either provided or withheld during this period of time, e.g. only X mL of formula compared to goal rate).
 Malnutrition related to anorexia and SOB as evidenced by consumption of <75 of estimated energy
needs, moderate temporal wasting and reduced handgrip strength.