NUTR 415 (Use this information and transfer to nutritional assessment form)
Nutritional Assessment
82 y/o female, thin and frail, adm s/p syncope episode. Neighbor found pt on floor of kitchen and called EMS.
EMS Assessment: B/P: 110/50, Pulse: 120, HEENT-WNL, skin-dry, multiple abrasions, Stage I on hip flexor, L elbow and L side of head. Upon arousal pt not a&o, language unintelligible, L side flaccid.
Upon hospital arrival, pt found to have a mild R CVA with L side hemiparesis. Follows verbal commands, but continues with garbled speech.
GI:BS+ x4, ND, NG, Æ BM x3 days
Ht: 5’3”, Adm. Wt: 120#, UBW: 140#
U/L loose fitting. Dt hx obtained from pts. neighbor reveals eats typically 1-2 meals/day. 1 meal may be 1 can of Ensure or canned soup. Pt lives alone, but neighbors check in with her 1-2x/day.
PMH: TIA x4 over the last 4 years, Osteoporosis, DJD, h/o CAD
Sign Labs:
147 111 25
3.7 32 1.0 108
Cholesterol: 250
Albumin 3.1
