Uploaded by gingersammi13


FMT-BSNA 21 F4 S1C2-RN-200A-21F4S1C2
Nutrition Assessment Case Study
1. Problem list: (A) Subjective data: Poor eating pattern, bleeding gums, poor alignment
of dentures. (B) Objective data: Oral mucosa dryness, poor skin turgor, Vitals signs:
Height and weight (decreased), low blood pressure, 1100 calorie intake.
2. Nursing diagnoses: Alteration in nutrition less than body requirements, deficit in fluid
volume , impaired skin integrity
3. Plan of care:
Regarding about the problems in dentures : Consultation or make an appointment to
a dentist for oral problems (concerning dentures)
Nutritional status: Make time to talk to the daughter directly about meal prepartion
and shopping, fluid intake monitoring, and skin turgor breakdown prevention such as
mobility activities. Also seek help towards a nutritionist or dietitian on what foods are
appropriate at to eat and avoid to lessen more deficits.
4. body mass index: weight / (height)2 = 47 kg / (1.5m)2 = 20.8 (NORMAL RANGE)
5. Since the patient is 89 years old already, it is advised that females ages 51 years old
and up should have 1600 calorie intake /day to
maintain her current weight.
6. Laboratory studies: Body fluids laboratory in serum retinol (vitamin A deficiency),
serum iron(iron deficiency), urinary iodine (iodine intake) and vitamin D (bone conditions).
Blood test (CBC) should also be performed for checking of general health and level of TSH.
Urinary creatinine is done to check if the patient is dehydrated or has low blood volume.