Etta Rose

Assessment:
Overview Information: 83-year-old African American female admitted to the hospital for acute
exacerbation stage III COPD (r/o pneumonia). Fall risk and full code, stable.

Client History (CH):

Medical hx: essential hypertension, stage III COPD and acute generalized weakness.
Past Surgeries: N/A
Allergies: NKA, environmental sensitivity to dust, mold, and animal dander
Current Medications/supplements: Albuterol 0.21 ml/ml PRN Q2H, infusion meds in
sodium chloride 0.9% continuous, acetaminophen 500 mg oral capsule 2 PRN, tiotropium
0.018 mg/actuat inhalant powder 1 puff daily, Omeprazole 40 mg PO daily, nifedipine 30 mg
PO daily, a-methapred 62.5 mg/ml injectible solution (125 mg), 1 ml morphine sulfate 2
mg/ml prefilled syringe PRN.
Physical Activity: ADLs until recently when weakness began, was independent and cared
for herself. Is afraid that her diagnosis is going to affect her normal lifestyle.

Anthropometric Measurements (AD):

Ht.: 163 cm
Wt.: 55 kg
BMI: 20.7 normal

Biochemical Data, Medical Test and Procedures (BD):

Temp 38C, pulse 112, respiration 22, BP 166/80, low pH 7.33 (ref 7.38 7.42), low
serum chloride 96 mEq/L (ref 98 107), high PaCO2 55 mmHg (ref 38 42), low SaO2 93%
(ref 94 100), high BUN 29 mg/dL (ref 7 20), high CO2 40 (ref 22 29), high creatine 2.3 (ref
0.6 1.5), high WBC 15000 cells/ml (ref 4,500 10,000)

Nutrition-Focused Physical Findings (PD):

Physical appearance: generalized weakness, edema in lower extremities, occasional
reflux, chronic cough, wheezing, SOB, Chest hurts when coughing, LOC WNL
Appetite: at moderate nutritonal risk, does not appear to be malnourished at this time

Food/Nutrition Related History (FH):

Food and Nutrient Intake: regular diet as tolerated. Track I & O daily.
Smoked 1-2 ppd for 30 years. Denies alcohol.
Patient lives alone and can care for herself.
24-hour recall: 877 kcal, 32.5 g protein

Comparative Standards/Calculated Needs:

Estimated calorie needs using Mifflin St. Jeor with injury factor of 1.4
- 1,290 kcal

Protein - 1.2 g/kg x 55 = 66 g/day

1
Nutrition Diagnosis:

P: Inadequate energy intake (NI-4.1)

E: related to: decreased appetite, difficulty breathing, COPD diagnosis
S: as evidenced by: 24-hour recall, energy deficit of ~500 calories per day, weakness

Nutrition Intervention:
Prescription: consume ~1,300 kcal per day and 66g protein per day within 5 small meals
(with the biggest meals in the morning), increase water intake
Recommend: eat protein rich foods such as nut butters, whole grains, legumes and
protein shakes, incorporate water with each meal. Ensure between each meal.
Goals: increased energy intake, increased protein intake, increased fluid intake

Nutrition Monitoring and Evaluation:

Improved nutrition intake
Have client keep a food log that will be evaluated during follow up appointment in one month.

Maintain body weight

Will keep track of patients body weight by daily weighing while in hospital, and weighing by
monthly follow up appointment after discharge.