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Case Study
C.M. is an 89-year-old woman who presents with her daughter to the provider's office. The daughter is concerned because her mother has not been eating well. She has been having bleeding gums. Her past medical history includes HTN and Hypothyroidism. A, 24-hour diet recall reveals an intake of approximately 1100-calorie. The patient lives alone and the daughter lives nearby. Since she doesn't drive, her daughter shops for her. The patient usually likes to cook and eat light meals. Her Vital signs shows T: 37 ° C , P: 72 bpm/min, R:12 breaths / min, BP 104/64 mmHg Weight: 104 lb. Her weight at the time of her last visit 3 months ago was 115 lb. Her height is 5 feet 1 inch. Her oral mucosa is dry. Her dentures seem loose. Poor skin turgor noted.
Writing Prompts
Question 1: Develop a problems list from the objective and subjective data.
Question 2: What nursing diagnoses can be derived from the problems list?
Question 3: What should be included in the plan of care?
Question 4: Calculate the patient's body mass index.
Question 5: How many calories a day does this patient need to maintain her current weight?
Question 6: What laboratory studies would help determine the patient's nutritional status?
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