According to CMs subjective and objective data, she significantly reduces her weight from her last visit.
According to CMs subjective and objective data, she significantly reduces her weight from her last visit.
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According to C.M.’s subjective and objective data, she significantly reduces her weight from her last visit. This could signify a problem in her nutritional intake due to drastic weight changes. C.M. faces a high risk of suffering from under nutrition due to poor physical and mental health. Leaving alone sets in a feeling of social isolation, and depression may follow hence unable to feed well. Given her age (89) years old, she is experiencing physiological and physical changes that affect her nutritional status, such as loose dentures, decreased G.I. absorption, and decreased salivary production. This may contribute to her inadequate dietary intake. From her past medical history, C.M. is a known client for hypothyroidism. Hence, this makes her vulnerable to fatigue and dry skin due to a reduced metabolic rate.
Nursing Diagnoses
C.M. presents with weight loss, poor calorie intake, poor skin turgor, loose dentures, dry oral mucosa, and bleeding gums. Looking at this information from the objective data, then the following are the likely nursing diagnoses: Imbalanced nutrition less than body requirements related to inadequate nutritional intake as evidenced by a weight loss from 115Ib to 105Ib, intake of only light meals, and poor skin turgor. Impaired skin integrity related to nutritional imbalances as evidenced by dry skin and poor skin turgor. Fluid volume deficit related to reduced metabolic rate secondary to hypothyroidism as evidenced by dry oral mucosa, bleeding gums, and poor skin turgor. Plan of Care
Since C.M. is diagnosed with hypothyroidism, it is essential to monitor the adverse outcomes related to severe cases of this condition, such as dehydration. Hence, in the plan of care, adequate intake of fluids should be included. It is vital to measure and assess the skin to identify malnutrition signs such as skin breakdown, skin turgor, and muscle tone.
It is also vital to include mouth and throat care in this patient. She reports having loose dentures, which could be associated with edema effects due to hypothyroidism. Hence, it is essential to ensure that the dentures are correctly fit in her mouth to avoid the bleeding of gums.
It is also vital to monitor the patient’s sense of smell. According to Jarvis et al. (2020), as individual ages, they have a high risk of losing their sense of smell, hence are predisposed to under nutrition. One of the most common physiological changes that occur as an individual age is saliva reduction that causes dry oral mucosa and decreased taste. Hence, it is essential to monitor for these signs to provide necessary interventions to prevent nutritional imbalances. Body Mass Index Body Mass Index = Weight (in pounds)/ Height (in inches) 2 x 703105/ (61)2 x 703= 19.84According to Jarvis et al. (2020), a body mass index of 19.84 among adults is classified as average weight. Amount of Calories a Day
Having recorded a weight loss of 15Ib since her last visit, C.M. needs to take the correct amount of calories a day to maintain her current weight of 105Ib. With her sedentary lifestyle, as evidence by the subjective data that she does not go to the shop and stays alone, C.M. should take about 1800 calories a day (Jarvis et al., 2020).Laboratory Studies
It is essential to determine the nutritional status of elderly patients such as C.M. as malnutrition is often underdiagnosed among these populations. It aids in the accurate diagnosis and development of effective treatment plans. Various laboratory studies or markers can be used to evaluate the nutritional status of patients, including but not limited to, albumin, transferrin, and retinol-binding protein. A decrease in these laboratory markers indicates poor nutritional status. Blood tests can also be performed to evaluate the level of the thyroid-stimulating hormone (TSH), a reduction in this hormone is a primary indicator of poor nutritional status (Hanif et al., 2018).
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