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Current Date:
12/10/15
NUTRITION ASSESSMENT
Food and Nutrition Related History:
Resident reports eating healthy and cooking meals at home. Daily selective menus reviewed; she self-selects menu.
Current issues with decreased appetite due to constipation.
Current Inpatient Diet
Order:
Regular; thin liquids
Feeding Ability
Independent
Limited Assistance
Extensive/Total Assistance
N/A
Explain:
Resident is able to feed herself
independently without set up
help.
Oral Problems
Chewing Problem
Swallowing Problem
Mouth Pain
None of the Above
Explain:
Resident has no difficulty
chewing/swallowing or mouth pain at this
time. None observed during meal rounds.
Physical Assessment:
Resident is alert and oriented x3, and is able to make needs known. She is ambulatory and needs assistance getting
up, walking, toileting, etc. due to recent fracture. Skin is intact.
Anthropometric Measurements
Age:
Gender
Ht:
Current Wt: 151# (12/7/15)
BMI:
Admit Wt: N/A
80
Female
63
IBW: 121-147#
26.7
Wt Hx (specify time frame):
resident reports UBW 150#; BMI Classification:
unknown time frame
% Wt change: No significant
Overweight
change
Biomedical Data (list only pertinent nutrition-related labs)
Labs
BUN
Date
23
12/7/1
5
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
HX of GERD, anxiety, hypothyroidism, HTN, breast cancer.
PMH:
HX of breast cancer, GERD, anxiety, hypothyroidism, HTN. Resident admitted with vertebral fracture due to recent fall.
Pertinent Medications & Dosage
Senna, Ducosate Sodium, Amlodipine, Losartan, Levothyroxine
Skin status:
Intact Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): _______________
Comments:
2014
SGS DI
INTERVENTION
Plan of care is for adequate oral intake and stable weight:
Adequate oral intakes by next review (12/24/15)
Weight will remain +/- 4# of 151# by next review (12/24/15)
Assist with oral intake as needed: set up help
Meet food preferences as able and offer available alternates if resident is not satisfied with meal;
offer snacks between meals if needed
Monitor and encourage intake of food, fluids and snacks during meal rounds and with follow-up;
offer fluids between meals and with medication pass
Monitor for complaints of constipation with meal rounds and follow-up
Monitor nutrition-related lab work as available with follow-up for improvement: BUN
Monitor weight as required for significant change and to meet established goal
Offer resident appropriate bedtime snack daily
Provide medically appropriate diet per MD order: regular diet with thin liquids
Provide nutrition education as needed with meal rounds and follow-up: adequate fluid intakes and
increased fiber to promote bowel regulation
Follow bi-monthly
_______________________________________________________________________________________________
Interns Signature
Date
Date
Preceptors Signature
2014
SGS DI