In-Depth Assessment Form

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

 

Meds: Plavix, Fosamax

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