Question

C.M. is an 89-year-old female who presents with her daughter to the provider’s office. The daughter is

concerned because her mother has not been eating well.

Subjective Data

PMH: HTN, Hypothyroid

24-hour diet recall reveals approximately 1,100-calorie intake

Lives alone, daughter nearby

Does not drive

Daughter shops

Patient cooks light meals

Objective Data

Vital signs: T 37 P 72 R 12 BP 104/64

Weight: 105 lb

Weight last visit, 3 months ago: 115 lb

HT: 5 feet, 1 inch

Medications: Metoprolol 12.5 mg per day, Synthroid 0.75 mg per day

Oral mucosa dry, gums bleeding, dentures loose

Poor skin turgor

Questions

1.   Develop a problems list from the objective and subjective data.

2.   What nursing diagnoses can be derived from the problems list?

3.   What should be included in the plan of care?

4.   Calculate the patient’s body mass index.

5.   How many calories a day does this patient need to maintain her current weight?

6.   What laboratory studies would help determine the patient’s nutritional status?

Annotations

Answer 1

1) FRom subjective data and objective data it is seen that patient is having hypothyroidism with hypotension , so less blood pressure is low and dry oral mucose and poor appetite and poor skin texture etc these are the signs of the hypothyrodism. 2)The nursing diagnosis for this patient is decreased cardiac output / decreased metabolism and constipation /decreased peristalsis and risk for noncompliance and risk for distrubed body image /altered physical appearance(goiter). 3)plan of carre for this patient:a) assss the clients weight , b) assess the clients appetite, 3) provide a food diary to the client, d)eduacate the client and family regarding body weight changes inhypothrroidim e)collaborate with a dietician to detician to determine clients caloric needs f)encourage the client to eat six small meals throughout the day , g)provide assistance and encouragement as needed during mealtime, h)encourage theclient to follow a low cholesterol , lowcalories and low saturated fat diet,etc. care plan for hypotension is assess and monitor BP , fluid restiriction , promote rest, decrease stress etc. 4)patient blody mass index: 19.8 5)1,650 calories a day to maintain weight, 6)Laboratory examines to determine the patients nutritional status is serum proteins like albumin, prealbumin, transferrin and retinol binding protein to ,measure malnutrition, c reactive protein, totla lymphocyte count and serrum total cholesterol etc.