Answered step-by-stepNutrition Assessment Note Client History Age: 64 y/o Sex: ...
Nutrition Assessment Note
Client History
Age: 64 y/o
Sex: Male
Date of admission: 3/15/2022
PMHx: Stage IIIa colon cancer (dx 1/2022), COPD, Chronic constipation, Anemia, GERD
RFA: SOB, night sweats, fevers
Anthropometric Data
Height: 67 in (3/15/2022)
Most recent weight: 121.1 lb. (55 kg) (3/19/2022)
BMI: Body Mass Index is 19
Weight: Measurement DT Weight LB
3/19/2022 121.1#
2/22/2022 132.4#
1/31/2022 134.8#
12/19/2021 135.7#
11/15/2021 136.1#
9/10/2021 135.8#
8/6/2021 139.5#
5/17/2021 142.2#
4/2/2021 141.3#
3/27/2021 140.9#
-BMI places a patient in the normal weight range, concern for patients disease state
-Weight 135.7 three months ago reflects significant weight loss of 14.6# (10.8%)
Biochemical Data (3/15/2021)
Cr: 0.52mg/dL (L)
Calcium: 9.0 mg/dL
Albumin: 2.9 g/dL (L)
-low albumin (most likely related to cancer diagnosis), corrected calcium 9.9 mg/dL (normal), low CR (lower muscle mass, low protein diet (inadequate PO), muscle dystrophy caused by disease)
*please check
Nutrition-Focused Physician Exam
-Edema not reported
-Moderate subcutaneous fat wasting (triceps, buccal fat pads, orbital fat pads)
-Moderate LBM wasting (temples, clavicles, thigh, interosseous muscle, calves).
Malnutrition Screen Tool: MST 3 - has lost weight recently without trying (6-10 kg) and is eating poorly due to decreased appetite
Braden and Skin Assessment
Braden score: 19
Nutrition sub score: 2
Wounds present: No
Food and Nutrition History
Current Diet Ordered: No diet restriction
Food allergies: Peanuts
Appetite/Intake
- Decreased appetite
- 24-hour recall:
B: I skipped breakfast yesterday. Will sometimes eat a frozen Jimmy Dean's breakfast sandwich
L: 1 over easy egg, ½ cup rice, ½ cup beans, 1 cup water
D: ½ grilled chicken sandwich on a bun, ¼ cup green beans, ¼ cup potato wedges, 1 cup apple juice
Snacks: Orange in the evening; Oikos Greek yogurt cup after lunch
Additional beverages: Will typically drink an additional 1-2 cups of water throughout the day
-Alcohol use: 2-3 glasses of wine per week
Gastrointestinal Symptoms: Reports constipation, last BM x 5 days ago, nausea/abdominal pain w/o vomiting
Chewing/Swallowing: Denies any chewing/swallowing issues.
Nutritionally - Pertinent Medications and Supplements:
Ferrous sulfate, Omeprazole, Ondansetron, Polyethylene glycol, Sennosides
*please check
Estimated nutrient needs using previous body weight 135 lbs (61.4 kg)
Energy needs: 1842 - 2149 kcal (30 -35 kcal/kg) (average 1996 kcal)
Protein needs: 92.1g (1.5 g/kg body weight per day)
Fluid needs: 1842 - 2149 mL (1mL/1 kcal)
*Please check
Malnutrition Assessment
Patient meets the criteria for severe malnutrition in the context of - chorionic illness or disease.
As evidenced by the following:
1. Reduced dietary intake per ASPEN/AND Criteria for Malnutrition
2. Unintended weight loss per ASPEN/AND Criteria for Malnutrition
3. Subcutaneous fat loss per ASPEN/AND Criteria for Malnutrition
4. Lean body mass loss per ASPEN/AND Criteria for Malnutrition
Nutrition Diagnosis
Severe chronic disease-related malnutrition related to physiologic demand of cancer and (potentially add decrease in appetite along w/ xerostomia + metallic flavor and/or nausea/abdominal pain) evidenced by significant weight loss of 14.6# x 3 months (10.8%), moderate LBM wasting noted (temples, clavicles, thigh, interosseous muscle, calves), and moderate subcutaneous fat wasting (triceps, buccal fat pads, orbital fat pads)
What would you recommend for the intervention, nutrition education, collaboration of nutrition care and monitoring and evaluation?
Nutrition Intervention
Nutrition prescription:
Food and/or Nutrient Delivery
Nutrition Education
Collaboration of Nutrition Care
Monitoring and Evaluation
Answer & Explanation
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