Nutrition Assessment: Medical Diagnosis Osteomyelitis R elbow, Hypotension, Hypoxia, R hip pain, Generalized Weakness Age: 78 yo Labs: Gender:
: WM 3/18 3/19 Weight: 60.3 kg (133 lb) Na 145 (H) Usual body wt: 182 lb (Pt wife reports -50lb K+ 3.6 unintentional weight loss over past 8 months) BUN 17 12 Height: 172.7 cm (68 in.) Cl 106 BMI: 20.3 Cr 0.83 (L) 0.74 (L) Glucose 130 (H) PMH POC 85-103 CVA (8-9 months ago with R-sided deficit) glucose HTN RBC 4.06 (L) Hypercholesterolemia HGB 12.8 (L) h/o Fracture of right shoulder HCT 39.3 (L) COPD WBC 6.9 CAD Albumin 3.5 MI h/o CABG (triple bypass) Blood Pressure MRSA positive carrier Admission: 123/78 Former Smoker (quit in 2006) Lowest BP during admission: 109/55 h/o asbestosis Femoral fracture s/p Intramedullary nailing Facility-Administered Medications: (5/3/13) Aspirin [Link] Lipitor Reported fall 3-4 months ago Prevacid Toprol-Xl Symptoms Remeron (possible appetite stimulation) Increased weakness (x weeks) worsening (x3 d) Zosyn R hip pain Senokot Spiriva Diet History Vancocin (vancomycin) Wife reports pt consumed regular diet PTA but Vitamin C not eating well PTA (<50% of meals). Pt had Zinc difficulty self-feeding after fracturing R MVI shoulder 3-4 months ago (pt is R-handed). NS @ 50mL/hr Skin Status Stage III Coccyx Pressure Ulcer Burn to right leg Infected (osteomyelitis) Right Elbow
Current Diet Cardiac, 4 gm sodium, no caffeine
Nutrition Diagnosis utilize PES Statements 1. Inadequate oral intake related to generalized weakness and decreased appetite as evidenced by pts wife reporting unintentional weight loss of 50 lb over 8 months (27% wt loss). 2. Biting/chewing difficulty related to lack of dentition as evidenced by wifes report of pt consuming mostly soft foods and chopped meats PTA. Nutrition Intervention Nutrition prescription, Interventions with goals Nutrition Prescription Intervention with goals
Continue current diet order Cardiac diet, 4 gm sodium, no caffeine. No hard fruits and vegetables. Assistance at meals as needed. Ensure Plus TID.
1. Food & Nutrient Delivery Order cardiac diet, with normal fluids. Will add Ensure Plus TID (1050 kcal, 39 gm protein) for adequate energy and protein intake. 2. Coordination of care Nursing to document intake of food and fluids at meals. Nursing to also monitor skin integrity for wound healing. Nursing to assist with meals as needed.
Nutrition Monitoring and Evaluation Indicator 1. Energy Intake 2. Weight
Criteria 1. Consumes >50% of meals and supplements. 2. Pt maintains current wt or increases .5-1lb/week.
Source Facility standards
Kcal requirements Mifflin-St. Jeor: 1297-1687 kcal (stress factor = 1-1.3) N/A 1303 kcal
Protein requirements 72-90 gm protein (1.21.5 gm/kg)
Fluid requirements 1507 mL (25 mL/kg)
EAL Online nutrition care manual
N/A N/A
N/A N/A
References: Escott-Stump S. 1998. Nutrition and Diagnosis Related Care. Lippincott Williams & Wilkins: New York. Jones, S., Gilligan, M., Childers, A., Coleman, A., Copes, E. Dorner, B., et al. (2013) International Dietetics & Nutrition Terminology Reference Manual (Fourth ed.). Chicago: Academy of Nutrition and Dietetics. Mahan LK. & S. Escott-Stump. 2000. Krauses Food, Nutrition & Diet Therapy. W.B. Saunders Co.: New York.
