Question

Part 1

C.M. is an 89-year-old female who presents with her daughter to the provider’s office. The daughter is concerned because her mother has not been eating well.

Subjective Data

PMH: HTN, Hypothyroid

24-hour diet recall reveals approximately 1,100-calorie intake

Lives alone, daughter nearby

Does not drive

Daughter shops

Patient cooks light meals

Objective Data

Vital signs: T 37 P 72 R 12 BP 104/64

Weight: 105 lb

Weight last visit, 3 months ago: 115 lb

HT: 5 feet, 1 inch

Medications: Metoprolol 12.5 mg per day, Synthroid 0.75 mg per day

Oral mucosa dry, gums bleeding, dentures loose

Poor skin turgor

Questions

1. Develop a problems list. Differentiate from the objective and subjective data.

a. What two (2) nursing diagnoses can be derived from the problems list?

b. What should be included in the plan of care?

Calculate the patient’s body mass index.

c.How many calories a day does this patient need to maintain her current weight? Explain your answer.

d. Discuss three (3) laboratory studies that would help determine the patient’s nutritional status. Explain your answer.

Answer 1

1. Problem list

Objective data.

• weight loss.
• dryness of mouth.
• Gum bleeding.
• poor skin turger.
• dehydration.
• poor nutritionl status.

Subjective data

• Hypertension
• Hyerthyroidsm
• Poor intake of food

2.Nursing diagnosis

1. Imbalanced nutritonal status less than body requirements related to inadequate intake of food.
2. Fluid volume deficit related to less than body requirement related to poor intake od food.

3.Body ,mass index.

Weight -105 lb,in kg 47.14 kg

Height -5 feet 1 inch

in centimeter 154.94 cm

BMI is 19.7

18.4- 24.9 is normal body weight.

This indicate she has normal body weight now.

Plan of care include

• maintain adequate nutritional status and fluid balance of the body.
• Encourage the patient take adequate food and fluid
• Provide small and frequent diet.

4.Now the women taks 1100 calorie per day.

Women needs to take 2000 calories per day to maintain the present body weight.

If take 1500 calories lose body weight one pound in a week.

5.Labortaory test to identify nutritional status are

• Serum protein
• Serum albumin.
• Retinol binding protein
• transferin

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