Better understand how to mange real-life patients as a registered dietitian in clinical nutrition with this straightforward CHF case study.
CHF Case Study - The MNT
This is part one of a simple and very short CHF case study review.
It’s very close to a real life patient who doesn’t have a lot of complexities with their current conditions. But as with all your patients, it does require you to consider multiple angles before finally deciding on an acute nutritional issue — and then writing the nutrition assessment.
In this post, we’ll look at the patient and talk through the medical nutrition therapy you have available.
In the next post we’ll review how to write the note and PES statement using this case study as the example.
Need to know what the abbreviations mean? Pick up this free download for quick reference as you walk through this case study.
Let’s get our CHF case study started with a look at our patient.
CHF Case Study Introduction: Meet your patient
Your patient is a 47 yo man admitted last night to the CCU (cardiac care unit) with CHF exacerbation and SOB. You’ve gotten a referral to see him for weight management and dietary support.
*This is not a lot of information. But when you’re assigned a new referral, this is usually the only the information you’ll get. As you start learning more about them, take note of when a piece of information is missing. Then, as you continue the assessment make sure you find the answer to that question.
Gathering more information: What’s in the chart
After reviewing the EMR, you note that your patient has a PMH of HTN and DM.
Labs pulled on his admission show an A1C: 7.3%, Glu: 102, with all other pertinent labs WNL. His height is noted to be 5’10” with a wt on admit of 343 lb.
There’s both a cardiology and endocrinology referral pending. At this time, you’re the first provider to start charting on this patient.
*Reviewing the chart before you see your patient is essential. It gives you a good sense of who they are, what their most acute issues possibly are, and where you’re likely going to focus your nutritional assessment. Here is where you’ll begin to see the bigger picture beyond their admitting diagnosis, and start to identify some of the more chronic or ongoing issues your patient is having.
What else you notice: A previous admission
In the EMR, you realize the chart goes back almost 8 month.
This is because your patient was admitted 7 months ago for SOB and +3 pitting B/L LE edema with a then weight of 278 lb. This was when he was also diagnosed with CHF, which means it’s a pretty new condition for your patient. And when you take a look at his old labs, you notice that at that time his A1C was 5.6%.
Since then your patient has had meds in place that include a diuretic, metformin, two blood pressure meds, and a 81 mg aspirin.
The RD note from his last admission states this patient had steady weight gain of 53 lbs during the 3 months leading up to that hospitalization. They had discussed lifestyle changes to address edema and weight gain, heart health, and how to better manage his fairly well controlled diabetes.
The assessment summary also notes your patient was not ready to make any nutritional changes and the reporting RD was concerned he might be non-compliant with his meds.
The PES statement used was:
Excessive nutrient intake (energy, sodium) related to CHF with SOB as evidenced by B/L LE +3 pitting edema, 53 lb / 23.6% wt gain x 3 months and pt with fast food intake 4-5 x/week.
*If your patient has had a past admission, review it! You’ll not only get a look at what’s happening with your patient right now as your read the EMR, but the past assessment will give you a clear idea what was happening with them before you came on the case. Use this information to get a better idea of where they previously struggled, and what kind of conversation you might want to have with them down the line.
First, identify the most acute nutritional issue.
What is an acute issue?
The most acute issue is the one thing that needs to be managed right now, in order to make sure your patient improves quickly and gets discharged fast.
This can get confusing. How do you know what IS most important in the first place?
Think of it like this:
ACUTE is something extreme, serious, immediate
CHRONIC is persistent, long-term, possibly incurable
These can be a medical problem (like acute kidney failure), something long term (like chronic kidney disease), or it can be something else entirely (dehydration that leads to altered renal labs).
A dietitian working in an acute care setting (usually a hospital) is going to focus on those issues that have the ability to be resolved to the point where your patient is able to be discharged.
For those RDs working in long-term care with patients who primarily have chronic conditions, you’re going to be looking for the most acute item that you can help to normalize into a chronic condition.
Make sense? Sort of…? How about this:
The most acute nutritional issue is a significant problem your patient is having which has both direct implications on their nutritional well-being and most importantly, what you as a dietitian can impact through your scope of practice.
Knowing what you know about this patient, the most acute nutritional issue might take on a couple of forms.
And in this case, depending on how you’re planning to manage your patient, you might consider it to be:
- CHF exacerbation
- The significant changes in weight
- DM
All of these are acceptable places to start both your evaluation and your interventions. As long as you ALWAYS do one thing: justify your recommendation.
If you can justify your reasoning and validate every argument you choose to make, you can choose any problem you consider to be most acute and run with it.
*None of these are wrong answers, and the all have the potential to be considered the most acute nutritional issue. More important than which is the best answer to choose is how you can justify the issue you consider the most significant. Here are some examples:
- CHF with a likely high sodium intake and possibly non-compliance with prescribed meds
- The significant changes in weight, likely related to ongoing edema 2/2 CHF and possibly also related to intake and previously reported h/o fast food
- DM with elevated A1C and glu labs possible 2/2 poor knowledge/understanding of how to manage blood sugar
Next, what will you do about the most acute issue.
This is where your interventions — or how you plant to solve that acute problem — come in.
The interventions you choose should be completely aligned with the most significant nutritional issue you choose to focus on.
Examples of interventions you’ll be working on include things like:
- The diet order you assign
- Any supplements you consider relevant
- The nutrition education you provide
- Next steps or recommendations for your patient when discharged
- Any follow up support you’ll do or referrals you’ll make while your patient remains admitted
Each of these will ultimately become part of the way you both justify your recommendations and how you formulate your PES statement.
And just like choosing the most acute nutritional issue, the only requirement is that you’re able to say exactly why you’re doing what you’re doing.
For example:
If the most acute nutritional issue is CHF, then your intervention will revolve around managing things like sodium intake, managing fluid and improving edema.
If you decide the most acute nutritional issue is the significant weight changes your patient has gone through, you’ll focus the interventions on an improved weight status. Maybe that’s simply weight stability. Maybe it’s improved intake or better food choices.
If you believe that diabetes is the most acute nutritional issue, you must illustrate the significance in your patient’s change in A1C and identify interventions that will support improved glucose control.
*The most acute nutritional issue is also what you’ll be writing your PES statement about. So as long as you can give concrete reasons for every problem you choose to focus on, you’ll have a strong ability to justify every decision you make for your patient.
Finally, is there any information you’re missing?
We’ve talked about everything you can find on paper.
But as you’re reviewing the information available in the chart, look for gaps.
Gaps in what you know and gaps in what you can explain about your patient or their medical history.
Most of the time, there’s a good chance you’re missing some information.
Information that will stop you from making really strong justifications for your recommendations.
Maybe you didn’t see something in the chart, that’s possible. But a lot of times the information you’re missing has nothing to do with you or a mistake you made.
A lot of times, it’s simply about what isn’t available in the chart. Or even more likely, what your patient hasn’t told anyone yet.
How to know what you’re missing
Make a list of things that would make justifying your recommendations stronger or something that might make identifying the most acute nutritional issue easier to do.
Think about things like:
- Usual body weight over the last 6 months to a year
- What a typical day of eating looks like (including what they drink, eat between meals, or portion sizes they might not share)
- Any other medications, herbs, or other supplements they take (especially the ones they don’t think “count”), and any meds they’ve opted out of taking
- Knowledge of what they should be doing (or anything they think they’re doing correctly)
- Any lab work that might be relevant or missing
Many times you’ll find this kind of information in one place: hearing it directly from your patient.
What we haven’t covered is the conversation you’re going to have when you visit your patient and do their in-person evaluation.
Part of this will be the NFPE (nutrition focused physical exam).
But an arguably bigger part of visiting your patient is what you’ll learn by asking him some specific questions to help you fill in some of the gaps you’ve probably noticed as you’ve looked at his chart.
Things like:
- What his current diet is like?
- Does his take his medications regularly?
- What kind of things does he want to know or feel he needs help with
These are the kinds of things you as the dietitian will ask, which very likely, no one else will ask.
But the answers you get will also help you structure and focus your assessment interventions and possibly even the PES statement.
Ready to talk about how to do some charting on this patient?
This is the first part of a two part CHF case study. Check out part 2 of this series where we’ll be looking at how to pull all of this information we’ve collected into a nutrition assessment note and get you thinking about some possible PES statements.
Looking for more support?
- Clinical Evaluation Power Pack: A complete downloadable set of tips, tricks and templates to help you write perfect assessments every time
- Nutrition Quick Chats: And introduction to doing motivational interviewing in a clinical setting
- Case Study Library: Full access to all past case study replays and each monthly live case study review sessions
Want even more to help in clinical?
Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.
