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64


Part I Introduction to Nutrition Care in Older Adults


Additionally, the following indicators are documented to monitor and evaluate how AC responds to the nutri- tion interventions for her second nutrition diagnosis (excessive fluid intake):


●


Oral fluids (FH-1.2.1.1): Criteria: Intake record: Exceeds 500 mL per meal


●


Feeding tube flush (FH-1.3.1.2): Criteria: Nursing notes: Tolerates tube feeding flushes


● Part 2: Reassessment


AC is pleased with the meals served and happy to report that she is usually consuming more than 50% of her meal. She has had only one extra feeding in the past week. She wants to keep the evening feeding so her weight does not go down. She currently weighs 146.5 lbs. Her surgical wound is improving. She had a follow-up visit with her surgeon, and he plans to reverse her ileostomy soon. She is reported to be con- suming 65% to 100% of her meals and drinks 500 to 600 mL of fluid at meals. She also drinks water between meals. Her son brought in her favorite meal (shrimp scampi, pasta, and broccoli). She consumed 75% of that meal. She is doing well in physical therapy and spends more time in her wheelchair during the day (as opposed to being in bed). She feeds herself after tray setup by staff. In recent testing, the following lab values were recorded: Hb 12.3 g/dL; Hct 36%; Na 136 mmol/L; K 3.8 mmol/L; glu 89 mg/dL; BUN 23; creat- inine 0.61 mg/dL; calcium 9 mg/dL; and Mg 2.1 mg/dL.


The reassessment focuses on the two previously established nutrition diagnoses:


●


excessive enteral infusion related to increased oral intake as evidenced by reported intake greater than 75% and complaints of being too full and


●


excessive fluid intake related to intake greater than calculated needs as evidenced by oral and enteral fluids consumed.


Note: The NCP Codes are listed only for reference and are not included in the documentation.


Nutrition Assessment Food/Nutrition-Related History:


● Food intake (FH-1.2.2) ➤


Types of food/meals (FH-1.2.2.2): Regular mechanical soft diet (standard diet offers 2,200 kcal, 92 g protein, and 900 mL water per day, plus 1,500 mL fluids on trays and extra water at bedside throughout the day)


➤


Amount of food (FH-1.2.2.1): Intake of 65% to 100% per meal reported


● ● Enteral nutrition intake (FH-1.3.1): ➤


Enteral nutrition formula/solution (FH-1.3.1.1): Enteral formula 1.5 one-can bolus (provides 355 kcal, 15.1 g protein, and 180 mL water) at bedtime and if less than 50% eaten per meal.


➤


Feeding tube flush (FH-1.3.1.2): 100 mL water before and after feedings (providing 200 mL per feeding). Total fluid from feeding and flushes is 380 mL/d per feeding.


Fluid/beverage intake (FH-1.2.1): Oral fluids (FH- 1.2.1.1): 500 to 600 mL per meal reported


Medications (FH-3.1): Prescription medication use (FH-3.1.1): Protonix, Coumadin, Xanax, mul- tivitamin with minerals, Lomotil, Lopressor, and Remeron


● Physical activity (FH-7.3): ➤


Frequency (FH-7.3.3): She is doing well in physical therapy three times per week.


➤


Duration (FH-7.3.4): She spends more time sitting up in her wheelchair during the day.


Anthropometric Measurements: ●


➤ ➤


Body composition/growth/weight history (AD-1.1):


Height/length (AD-1.1.1): 63 inches (160 cm)


Weight (AD-1.1.2): Admission weight was 145.2 lbs (66 kg); UBW 145 lbs (65.9 kg)


➤


Weight change (AD-1.1.4): Current weight is 146.5 lbs (65.59 kg), indicating a 1.3 lb (0.59 kg) weight gain since admission.


➤ BMI (AD-1.1.5): 25.6 (overweight)


Biochemical Data, Medical Tests, and Procedures: ●


●


Nutritional anemia profile (BD-1.10): Hemoglobin (BD-1.10.1): Hb 12.3 g/dL Hematocrit (BD-1.10.2): Hct 36%


➤ ➤ ●


Electrolyte and renal profile (BD-1.2): Sodium (BD-1.2.5): Na 136 mmol/L Potassium (BD-1.2.7): K 3.8 mmol/L BUN (BD-1.2.1): BUN 23


➤ ➤ ➤ ➤ ➤ ➤


Creatinine (BD-1.2.2): Creatinine 0.61 mg/dL Calcium, serum (BD-1.2.9): Calcium 9 mg/dL Magnesium (BD-1.2.8): Mg 2.1 mg/dL


Nutrition-Focused Physical Findings: ●


Overall appearance (specify) (PD-1.1.1): She is alert and oriented. She wants to keep her weight stable.


●


Digestive system (mouth to rectum) (specify) (PD-1.1.5): She has an ileostomy and PEG tube.


Glucose/endocrine profile (BD-1.5): Glucose, fasting (BD-1.5.1): 89 mg/dL


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