Question

Case Study 19.1

Bridget Doyle Remembers Laura

Just because she lives at Lenoir Manor, a continuing-care retirement facility, Laura, a petite

(4 ft. 8 in., 97 pounds) widow of the local college dean, does not consider herself as old.

She is 87. She has had no major nutritional or health problems and her appetite is good.

She had been a good cook and entertained graciously, but in the residential care facility, meals

are prepared for her. Because she has had slight fluid retention over the past year, she no

longer adds salt to her meals. She tells Bridget Doyle, her nutritionist, that yes, occasionally she

does not like her meals and misses cooking for herself.

One Monday morning, Laura is found in bed with her left side paralyzed. The diagnosis is a

right-sided stroke, resulting in three weeks of hospitalization. Back at the skilled-care wing of

Lenoir, Laura needs a nasogastric tube for feeding. She is alert and knows people but is limited

in speech. Overnight, Laura’s care has changed from an individual needing routine nutritional

monitoring to someone with many interrelated problems:

● Inability to communicate her overall medical and nutritional concerns clearly

● Weight loss of 9 pounds during the three-week hospital stay

● Intense dislike of the nasal tube, as demonstrated by repeated attempts to pull it out, leading

to restraint of her hands

Questions

Assessment

1. What nutritional parameters should be assessed and monitored now that Laura is back at

Lenoir Manor?

Diagnosis

2. What disciplines should be involved in Laura’s care plan, and why?

3. The interdisciplinary care team wants to meet Laura’s needs in a dignified and respectful

manner. How can the care team address both clinical and ethical concerns?

4. What are strategies young adults can adopt to reduce their risk of stroke?

Monitoring and Evaluation

5. How could Bridget ensure that Laura’s nutritional needs are met?

Answer 1

1. In this scenario, Laura has lost 9 pounds during her stay in the hospital. The parameters used to check the nutritional status are: Anthropometric assessment, biochemical assessment, clinical assessment and dietary evaluation. The parameters to be assessed under the anthropometric measurements are height, weight, mid-arm circumference, skin fold thickness, waist circumference, hip circumference and body mass index (BMI). The parameters to be assessed under biochemical assessment are stool examination, urine test, urine creatinine, serum retinol, iron, urinary iodine, analysis of hair, nails and skin. The parameters under clinical assessment are seeing for signs of malnourishment or over nourishment, clinical examination of organs like hair, mouth, gums, nails, skin, eyes, tongue, muscles, bones and thyroid gland. The parameters under dietary assessment are24 hours dietary recall, food questionnaire, dietary history and observation of food consumption. All the above parameters should be checked and monitored.
2. The various disciplines to be included in Laura’s care are physical therapist, nutritionist, speech therapist, psychiatric counsellor and social worker. The physical therapist can provide her some passive exercises and regain her body functions that she has lost due to stroke. As it is evident that she has lost several pounds of weight and dislikes having the nasogastric tube she needs the help of the nutritionist and counsellor because she isn’t ready to keep her tubes in. As she is having altered speech, the speech therapist can help her. The social worker can provide her care and regain her back to the society.
3. As an interdisciplinary care team is required to provide care for Laura, it is important for Laura to accept them. They need to explain to her regarding the benefits of the care they give them. But before starting with the care, an informed consent should be obtained from Laura and she should be explained regarding the care and the outcomes.
4. The strategies that young aged population should take in order to prevent stroke are:
   • Lower blood pressure and keep within normal
   • Lose weight
   • Indulge in more exercise
   • Keep alcohol intake limited
   • Treat any cardiac problems
   • Treat diabetes
   • Quit smoking
5. Bridget, her nutritionist should assess and monitor the nutritional parameters as mentioned above. As Laura states that she sometimes doesn’t like to eat and skips her food, she has to keenly monitor her nutritional status and provide alternate methods to overcome this. As Laura previously had fluid restriction, she can be checked on it and salt quantity can be added accordingly. This will increase the appetite of Laura and help to maintain good nutritional status.