Marlene is an 86-year-old white female resident in a skilled nursing facility with unintentional weight loss. She was admitted 3 months ago from the hospital after a hip fracture. She had been residing in an independent living facility for several years. She reports she has been eating poorly because of difficulty moving around, being generally uncomfortable, and states, “If I am not active, I don’t need to eat so much.”
Intake is less than 50% of regular diet. No problems chewing or swallowing are noted after a speech language pathologist’s evaluation. Admission weight was 112 pounds; current weight is 95 pounds. Self-reported height is 5’ 3”; Hgb/Hct is normal; total cholesterol is 135; and Mini Nutrition Assessment score is 5.
Hip scans show slow fracture healing and no improvement in bone density; currently she is being supplemented with calcium 1000 mg/day and vitamin D 600 IU/day. Blood pressure is 128/80 with furosemide (Lasix); other medications are lorazepam (Ativan), fentanyl transdermal patch (Duragesic), senna (Senokot-S), docusate (Colace), and mirtazapine (Remeron)
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Formulate responses to the two topics below. Write in the language and tone appropriate for either Marlene or the nursing staff to easily understand.
What three questions would you like to ask Marlene?
What three requests do you have for the nursing staff of the facility?
Lastly, create the nutrition diagnostic statement for this patient using the PES format. [Refer to Chapter 9, p.148 of your text for a description of documentation using the PES format.]
What is the nutrition Problem….?
As related to/caused by (Etiology)….
As evidenced by (Signs/Symptoms) ….
