Nutrition Care Plan

Amanda Lee
Professor McCrief
4/16/15

SOCIAL HISTORY: Mrs. Barnes is a 73 year old white female who resides with her
husband in La Verne, CA. They own a one story fixed location trailer with no handicap
access. Community has non-busy streets, tennis courts, and pool access. Mrs. Barnes is a
housewife and her husband is a retired maintenance worker/painter. According to the
client they live on a fixed income but have adequate funds to purchase food. Mrs. Barnes
is ambulatory but walks with a cane because of her Sacroiliac dysfunction. She does not
require home care, has access to and can drive a car. She has no history of tobacco use
and is a mild social drinker (avg. 1 drink per gathering).
Nutritional Implications: Both Mrs. Barnes and her husband are able bodied and
can cook at home. Mr. Barnes appears to be very supportive of Mrs. Barnes
limitations and symptoms. He assists in meal preparations, shopping, and is
encouraging toward her in terms of exercise and symptom management.
MEDICAL HISTORY: Mrs. Barnes has had many surgeries and currently suffers from
Sacroiliac joint dysfunction which limits her ambulatory ability and her ability/desire to
exercise but is scheduled for a corrective Sacroiliac fusion with the hope of improving
her comfort and mobility. Her cognition is excellent with no signs of dementia. She has
impaired digestion with diagnosed Irritable Bowel Syndrome with either diarrhea or
constipation and nausea/vomiting. Mrs. Barnes also has Coronary Artery Disease and has
undergone Angioplasty, 2 stent placements, and 2 taxus stent placements in 2005. Mrs.
Barnes received a 3 shot series between October 2012 and November 2012 for Lumbar
Nerve block to release low back/hip pain. Client underwent a colonoscopy and
endoscopy in 2010 related to her IBS. She had a full thyroidectomy in 1976 and a full
Hysterectomy in 1988. She was prescribed and did take hormone replacement post
hysterectomy for 10 years until age 56. Client suffers from shortness of breath when
walking/exercising. Her BMI status is overweight/obese at 31.6 BMI.
Nutritional Implications: Mrs. Barnes current medical problems negatively affect
her nutrition status. The client indicated that she is afraid to try foods or eat
regularly because of the extreme discomfort she experiences from her IBS.
Because of her hip injury she does not exercise which may affect her overweight
status which may exacerbate her heart condition. She is currently scheduled for
corrective surgery of her Sacroiliac dysfunction which should improve her
ambulatory ability. She meticulously keeps a food diary daily and is currently
attempting to recognize triggers. She avoids trigger foods and is educated in her
condition maintaining a binder of information and research on possible trigger
foods and substances. Because she is ambulatory and can eat outside of the home
she does but does not always make correct choices regarding her IBS. She is at
risk for developing anorexia due to her fear associated with eating which could
lead to malnutrition.
DIET HISTORY: Mrs. Barnes kCal consumption is erratic due to her IBS symptoms
which conflict with her desire to eat but she consistently consumes around 40g of fiber
daily which is above the recommendation of 21grams/day for elderly women and
consistently drinks 2100mL of water with the occasional soft drink or coffee. Because of

her IBS the client avoids most dairy, egg yolks, peanut butter, and tomatoes. The client
has fear associated with eating which adversely affects her appetite though she tries to eat
consistently. When she is experiencing an attack her kCal consumption drops
dramatically and she only consumes mashed potatoes, white rice, or plain toast from one
to a few days.
Nutrition Implications: Because the IBS causes the client extreme discomfort and
food avoidance she may not be getting all of her necessary calories despite her
overweight/obese status. Her protein consumption appears adequate. Her fiber
intake is above average and her fluid intake appears adequate at 2100mL/day. Her
fat consumption varies greatly from day to day.
MEDICATIONS: Mrs. Barnes takes 27 different medications, 19 of which she takes
either 1x or 2x daily. The remaining are either as needed or rescue. Of the 27 listed
below are those that may affect IBS adversely.
Lisinopril- ACE inhibitor used to treat high blood pressure and heart failure
Nutritional Implications: This medication can cause nausea, vomiting, diarrhea,
and upset stomach and may exacerbate the clients IBS.
Crestor- lowers high-cholesterol and triglycerides
Nutritional Implications: Upper Abdominal and Stomach pain, which is less
common, but can occur. Pain in the stomach may add to the clients avoidance.
Pantoprazole- Treatment for GERD
Nutritional Implications: Severe GI distress is a common side effect, urinating
either less or more frequently depending on the clients reaction and either weight
gain or weight loss. Diarrhea, vomiting, and frequent or less frequent urination
may contribute to the clients avoidance and IBS episodes.
Vesicare- Treats an overactive bladder
Nutritional Implications: An overactive bladder indicates the Pantoprazole causes
frequent urination. Frequent urination could cause an avoidance of drinking but in
this particular client it does not appear to be an issue as she consumes at least
2100mL of water.
Fluticason- Treatment for allergy symptoms such as runny nose and itchy/watery eyes
Nutritional Implications: This medications side effects also include nausea,
vomiting, and diarrhea. This medication, as all the others, is taken daily and may
contribute to the clients symptoms and attacks.

Docusate Sodium- Stool softener

Nutritional Implication: With the side effects of the clients other medications it is
surprising this medication is necessary. This medication is taken twice daily
which would indicate severe constipation.
Polyeth GlYC- Laxative
Nutritional Implication: This medication is also take daily and would indicate
severe constipation as there is not one but there are two laxative/softening aids
utilized by this client despite the numerous medications whose side effects include
diarrhea.
Baclofen- Muscle relaxer
Nutritional Implications: This medication causes constipation and nausea in users.
This may have an adverse affect on the clients IBS symptoms.
PATHOPHYSIOLOGY:
Mrs. Barnes problems consist of IBS symptoms and attacks. It is this authors opinion
that the majority of the clients IBS symptoms and attacks are due to her poly-pharmacy
and lack of exercise due to her Sacroiliac dysfunction. Due to her mixed IBS diagnosis
(Kraus, 2012) and the differing symptoms among the clients medications with both
diarrhea and constipation being side effects is it likely a contributor along with her
sedentary life style. Below will be discussed the pathophysiology of Irritable Bowel
Syndrome.
Irritable Bowel Syndrome is a syndrome affecting approximately 15% of females and
10% of males and can be either diarrhea-predominant, constipation-predominant, or
mixed. The diagnosis of IBS is based upon an international consensus (Rome consensus)
and algorithms to help separate other diagnoses and post-operative complications that can
present with similar symptoms. The criteria states there must have been 3 days in each of
the previous 3 consecutive months where the patient experienced 2 of 3 features;
1) discomfort relieved by defecation
2) onset associated with a change in frequency of stool
3) onset associated with change in the form of stool
(Krause, 2012).
IBS is considered a functional disorder because it is only diagnosed by exclusion. It is
commonly described as a gut brain disorder because it is associated with serotonin.
Sufferers of IBS have increased sensitivity to internal intestinal stimuli. Excessive use of
laxatives and other medications are known to cause flairs and IBS symptoms along with
stress, trouble sleeping, and antibiotics (Krause, 2012).

Treatments for IBS can be complex and vary patient to patient due to differing symptoms
and attributed causes. Reduction in stress is often advised and techniques discussed. The
patient may be prescribed medications to help with motility such as osmotic laxatives in
those with constipation or pain reduction medications (Krause, 2012).
Regarding medical nutrition therapy the goal is to ensure the client is receiving adequate
calories, adequate nutrient intake, monitor and tailor the diet for the clients specific
symptoms and needs and identify trigger foods that may be avoided (Krause, 2012). Mrs.
Barnes diet is occasionally adequate in calories but her nutrient intake is poor as
evidenced by a low consumption of fruit and vegetables in her diet which can also
contribute soluble and insoluble fiber. It is advisable that a light exercise regimen that
does not exacerbate the clients current Sacroiliac injury be started.
ASSESSMENT:
Mrs. Barnes has many health problems that can affect her nutrition status. Specifically the
clients lack of exercise puts her at risk for continued and debilitating IBS attacks and
symptoms. The client has indicated that when she was able to walk her IBS symptoms
abated to a level which was comfortable and manageable. Activities Mrs. Barnes can
perform should be started as soon as she is comfortable to do so such as swimming and
seated yoga.
Mrs. Barnes is currently 136% her IBW and 100% her UBW. Her weight status may be a
contributing factor to discomfort while exercising alongside her Sacroiliac dysfunction
diagnosis. This theory was confirmed by the patient who stated that exercise was easier
when she weighed less.
Mrs. Barnes estimated energy needs (based on Mifflin St. Jeor) are 1,300kCal
1,500kCal per day and her estimated protein needs (based upon her IBW of 130lbs x
0.8g/kg) are 47 grams per day. Currently on days when she is not having an attack she is
minorly exceeding or meeting her needs. On days when she is experiencing an attack she
is far below her requirements. With her IBS symptoms affecting her intake and a lack of
exercise being attributed to the worsening and debilitating nature of her symptoms,
exercise is needed. Client may need to be educated on the side effects of her medicine
and the benefits of daily exercise. PES statement is:
INTERVENTION:
Discuss a low impact exercise regimen 1-2x weekly for IBS symptom relief to improve
nutrition status. Obtain information from client regarding ability to access community
pool and ability to utilize in-home exercise techniques.
Collaboration with client: Monitor the number of, consistency of, and comfort with bowel
movements and vomiting/nausea.

MONITORING:
Short-term Goals
1. Monitor compliance with exercise routine of 1-2x for 1 month via exercise log.
2. Monitor number of, consistency of, and comfort with bowel movements/
vomiting/nausea via tracking and journaling by client.
Long-term Goals
1. Promote regularity in clients bowel movements i.e. consistent solid stools 2 -3x
weekly
2. Compliance with exercise regimen of 1-2x weekly and increase in frequency to 4x
weekly in 6 months.

REFERENCES
Mahan, Kathleen L., Escott-Stump, Sylvia, Raymond, Janice L., (2012). Irritable Bowel
Syndrome. Krauses food and the nutrition care process. St. Louis, Missouri.
Author unknown, (2015). Lisinopril. Drugs.com. Sourced from www.drugs.com
Also:
Crestor
Pantoprazole
Vesicare
Fluticason
Docusate-Sodium
Polyeth GlYC
Baclofen