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Adime 2 Final

Etta Rose is an 82-year-old woman diagnosed with stage III COPD who was recently hospitalized for shortness of breath. She has a history of smoking for 30 years but quit 33 years ago. Her medical history also includes hypertension, asthma, and bronchitis. A nutritional assessment found she was only consuming about 900 calories per day and needed over 1,200 calories. She has lost 14% of her body weight recently. The nutrition diagnosis is inadequate energy intake related to decreased appetite. The intervention is to recommend adding two Ensure drinks per day to increase her calorie and protein intake to meet her needs.

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173 views

Adime 2 Final

Etta Rose is an 82-year-old woman diagnosed with stage III COPD who was recently hospitalized for shortness of breath. She has a history of smoking for 30 years but quit 33 years ago. Her medical history also includes hypertension, asthma, and bronchitis. A nutritional assessment found she was only consuming about 900 calories per day and needed over 1,200 calories. She has lost 14% of her body weight recently. The nutrition diagnosis is inadequate energy intake related to decreased appetite. The intervention is to recommend adding two Ensure drinks per day to increase her calorie and protein intake to meet her needs.

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api-437596453
Copyright
© © All Rights Reserved
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ADIME #2 Etta Rose

Assessment:
Overview Information:
Etta Rose is an 82 year old Female. She was recently diagnosed with stage III COPD. She was with a friend
and was having shortness of breath and trouble breathing and was unable to carry a conversation. Her
friend called and was told to bring Etta to the hospital. Oxygen and normal saline has been administered.

Client History (CH):


Medical hx: Stage III COPD, hypertension since early 60s, asthma, bronchitis, cough
Past Surgeries: N/A
Allergies: NKDA, allergies to dust, animal dander, and mold.

Etta had smoked 1-2 packs per day for about 30 years but quit when she was 49 but does not drink
alcohol. Her husband died from cardiovascular complications so she now lives alone. She has two sons
but one mainly takes care of her since the other lives farther away and wants her to move into assisted
living which she does not want to do. She used to work as a relator and was very independent but since
COPD she is too weak and is afraid this is going to take away her independence.

Current Medications/supplements:
1. Albuterol PRN Q2H
2. Sodium Chloride- continuous
3. Pnuemococcal vaccine polyvalent 0.5 ML injectable
4. Acetaminophen 500 MG oral capsule
5. Tiotropium- non-verified
6. Omerprazole- non-verified
7. 24 HR Nifedipine- non-verified
8. A-MethaPred- Non-verified
9. 1 ML Morphine Sulfate- non-verified
10. Advair Diskus- Not filled
11. Symbicort- Not filled

At home
1. Albuterol Inhaler, 2 puffs every 4 hours PRN
2. Nifedipine XL 30 mg PO daily
3. Tiotropium inh 18 mcg daily
4. Fluticasone inh 2 sprays in each nostril once daily
5. Prilosec OTC 1 tab daily

Physical Activity: Not physically active, was more independent and moving around before being in
hospital and diagnosis of COPD a few weeks ago. Can not be very physically active now due to
shortness of breath

Anthropometric Measurements (AD):


Ht.: 163 cm
Wt.: 64 kg 3 months ago but now 55 kg, 14% weight loss
BMI: 20.7 (Normal)

1
Biochemical Data, Medical Test and Procedures (BD):
High PaO2 (55), low pH (7.33), low SaO2 (91%), Low serum chloride (96), high BUN (29), high CO2 (40), high
creatinine (2.3), High WBC (15000)
Physical therapy assessment

Nutrition-Focused Physical Findings (PD):


Appetite: poor appetite
Physical Findings: Per nursing assessment edema in extremeties and moderate temporal and clavicle
muscle watsing, soft nondistended abdomen.

Food/Nutrition Related History (FH):


Food and Nutrient Intake: eating 50% of her usual intake, regular diet
24 Hour Recall
Morning- 1 Cup coffee, 1 teaspoon creamer, ½ cup orange juice, 1 small poached egg, ½ piece of
white toast bread
Noon- 1 cup cream of tomato soup, ½ piece of white bread toast, ½ banana, 1 cup Pepsi,
Evening- 1 KFC chicken leg, ½ cup KFC mashed potatoes, 2 Tbsp. gravy, ½ cup orange juice
Late Evening- ½ cup applesauce

Estimated calories: 901


Protein: 22.5 grams

Comparative Standards/Calculated Needs:


Mifflin x 1.2 = 1,205 Calories

Protein requirements
1.2(55 kg) = 66 grams protein

Nutrition Diagnosis:
P: Inadequate energy intake (NI-1.2)
E: related to: Decreased appetite
S: as evidenced by: Only eating about 900 calories and 22 grams of protein as shown by 24 hour recall and
needing about 1,205 calories per day and 66 grams of protein.

Nutrition Intervention:
 Prescription: 1,205 calories/d, 66 grams of protein/d
 Recommend: Add in 2 Ensure a day between meals to give patient an extra 440 calories and 18
grams of protein per day.
 Goals: Patient gets adequate amount of calories and protein from added supplement in order to get
adequate amount of calories and protein

Nutrition Monitoring and Evaluation:


 Indicator: Increased caloric intake
 Criteria: Patient will have 2 Ensure per day and be getting adequate energy and protein needs

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