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Assessment:

Overview Information: Patient admitted to the hospital after falling in the bathtub. Was found to
be unresponsive. Suffered trauma to the head. Has PEG tube in place. Recent weight loss since
hospitalization.

Client History (CH):


Medical hx: kidney stones, HTN, osteoporosis, resolved aneurysm, flaccid hemiplegia, deep
vein thrombosis, intracerebral hemorrhage, benign neoplasm of colon, elevated PSA, DMII
Past Surgeries: resolved aneurysm
Allergies: NKA/NKDA
Current Medications/supplements:
Physical Activity: enjoys fishing, minimal physical activity since hospitalization

Medications:
1. Zantac 150 mg per PEG tube twice daily
2. Ritalin 5 mg at 0700 and 1300 per PEG tube
3. Trazodone 50 mg per PEG tube at bedtime
4. Tylenol per rectum or per tube 650 mg every 4 hours PRN

Trazodone Hydrochloride 50mg PO, Methylphenidate Hydrochloride 10 mg PO, Amantadine


Hydrochloride 100 mg PO, heparin sodium porcine 5000 UNT/0.5ml prefilled syringe,
Docustate Sodium 100 mg PO, Miralax 17 g/4oz soln PO, Senna Lax 8.6 mg PO

Anthropometric Measurements (AD):


Ht.: 69in/59
Wt.: 145lb
BMI: 21.4 indicating normal weight

Biochemical Data, Medical Test and Procedures (BD):


Temperature 98.7 F - WNL
Abnormal LOC does not know time/place/purpose
Abnormal mental health low score (18) on MMS exam
Abnormal appetite since hospitalization
Low hemoglobin see below
High WBC see below
Low Bilirubin see below

From day of discharge: WBC 13,500(ref 4,500 10,000); hemoglobin 10.4 (ref 13.5-16.5);
hematocrit 30.3; platelets 285,000; MCV 91.2; sodium 138; potassium 4.1; chloride 102; CO2
24; BUN 13; urobilirubin 0.4 (ref 0.5-1); creatinine 0.7; glucose 108; calcium 8.4; magnesium
1.7; phosphorus 2.8.

Nutrition-Focused Physical Findings (PD):


Physical appearance: lethargic, weak, high fall risk, needs help to get up, weight loss with
recent hospitalization

1
Appetite: abnormal as indicated on general vital assessment.
High risk for malnutrition
High braden scale score indicating high risk for ulcer
GI problems occasional constipation, last BM yesterday

Food/Nutrition Related History (FH):

Food and Nutrient Intake: the patient is at high risk for malnutrition. Has PEG tube in place.
Does not drink alcohol.
Infuse Replete via PEG tube at 80 ml/hr. 250 ml of water bolus every 6 hours
Check gastric residuals every 8 hours. Hold tube feeding if residual greater is than or equal to
400 ml.

Comparative Standards/Calculated Needs:


Using the Harris Benedict equation. I determined that the patients needs are 1,344 kcal/day
With an injury factor of 1.1, the calorie needs come out to 1,478 kcal/day

Nutrition Diagnosis:

P: inadequate oral intake (NI-2.1)


E: related to: post stroke complications and dysphagia
S: as evidenced by: recent weight loss, wasted appearance, reduced appetite and need of PEG
tube

P: swallowing difficulty
E: related to: post stroke complications
S: as evidenced by: results of swallowing tests

Nutrition Intervention:
Prescription: meet daily energy and protein needs
Recommend: enteral nutrition daily (1,546 kcal per day and 98 g protein per day via PEG
tube until patient is able to eat comfortably) Replete via PEG tube at 80ml/hr nutrition
education and counseling centered around post stroke nutrition and dysphasia once a
month
Goals: to be able to meet calorie and protein requirements

Nutrition Monitoring and Evaluation:


Indicator: Enteral nutrition order
Criteria: monitoring patients EN intake, laboratory results and physical examinations

Indicator: Weight change


Criteria: Patient will weight within 10% of goal body weight

Type of food/meals
Patient will receive nutrition therapy to fully be able to eat PO on own within 1 month