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    The patient, a 68-year-old male with a history of glossectomy, hypertension, and hyperlipidemia, was diagnosed with malnutrition based on a BMI of 20.6 kg/m2, moderate weight loss of 29%, and meeting less than 50% of his estimated calorie needs for two years due to his partial glossectomy and decreased appetite. His nutrition intervention plan includes a mechanically soft diet with supplements, medication management, a referral to speech pathology, and increasing his calorie intake. The goals are for him to meet at least 75% of his estimated needs, normalize lab values and fluid balance, and gain 1-2 pounds per month. Enteral nutrition should be considered.

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    The patient, a 68-year-old male with a history of glossectomy, hypertension, and hyperlipidemia, was diagnosed with malnutrition based on a BMI of 20.6 kg/m2, moderate weight loss of 29%, and meeting less than 50% of his estimated calorie needs for two years due to his partial glossectomy and decreased appetite. His nutrition intervention plan includes a mechanically soft diet with supplements, medication management, a referral to speech pathology, and increasing his calorie intake. The goals are for him to meet at least 75% of his estimated needs, normalize lab values and fluid balance, and gain 1-2 pounds per month. Enteral nutrition should be considered.

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    582 views2 pages

    Malnutrition Adime

    Uploaded by

    api-508953960
    The patient, a 68-year-old male with a history of glossectomy, hypertension, and hyperlipidemia, was diagnosed with malnutrition based on a BMI of 20.6 kg/m2, moderate weight loss of 29%, and meeting less than 50% of his estimated calorie needs for two years due to his partial glossectomy and decreased appetite. His nutrition intervention plan includes a mechanically soft diet with supplements, medication management, a referral to speech pathology, and increasing his calorie intake. The goals are for him to meet at least 75% of his estimated needs, normalize lab values and fluid balance, and gain 1-2 pounds per month. Enteral nutrition should be considered.

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    © All Rights Reserved
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    of 2

    Recorder: Pedro Guzman

    Date:25 Sep 2019


    Nutrition Care Process (NCP): Malnutrition

    Nutrition Assessment
    Diagnosis: Diagnosed with Malnutrition.
    Nutrition-related PMH, treatments, surgeries: Glossectomy, History of hypertension,
    hyperlipidemia, family history of lung cancer, Peripheral vascular disease.
    Age, gender: 68y/o male
    Dietary intake: %PO intake, typical diet, appetite-mechanical soft, IV
    Food preferences, allergies, intolerances: n/a
    Exercise habits: none
    Functional/behavioral factors: glossectomy/mastication
    Resources for obtaining, preparing food: spouse.
    Symptoms: fatigued/lack of energy to accomplish tasks.
    Anthropometric measurements
    Ht/wt: Ht: 185.42cm. Wt:70.9kg
    BMI= 20.6kg/m2
    IBW= 184#/83.6kg, %IBW:84% mild Malnutrition. %UBW: 70.9% moderate
    malnutrition
    % Weight change—29% weight change which is indicated as severe weight
    change.

    Energy, protein and fluid needs --- use equations specified for each case study
    o Total Energy= 2283 calories based on the Mifflin-st.-Jeor formula.
    o Protein=1.25-1.5g/kg=88g-106g of protein.
    o Fluid=1,950ml/day needed.

    Medications/supplements: Lipitor 80mg daily, Monopril 10mg daily.


    Skin integrity: pale/dry skin.
    Fluid intake/output (I/O) Intake: 2,520ml, Output: 1,444ml.

    Nutrition Diagnosis

    Inadequate calorie intake (N1–1.2) R/T partial glossectomy and decreased appetite AEB
    meeting less than 50% of estimated needs for the last two years

    Swallowing difficulty (NC-1.1) R/T partial glossectomy AEB meeting less than 50% of
    estimated needs for the last two years.

    Nutrition Intervention
    1. Meals and snacks
    a. Texture modified diet.
    b. Oatmeal with sliced bananas and blueberries
    c. Greek yogurt with sliced fruit

    2. Nutrition-related medication management

    Prescription-2 times a day supplements in breakfast and dinner. 4oz supplement twice a
    day
    3. Referral to another provider- Speech pathologist.

    4. Increase calories

    Goals
    1. Meeting greater than 75% of estimated needs
    2. Normalizing lab values, normalizing fluid balance, stabilize weight gain 1-2
    pounds a month
    3. Increase appetite

    Nutrition Monitoring and Evaluation

    • Check and monitor blood sugar levels, or electrolytes.


    • Check and monitor weight
    • Monitor modified diet
    • Evaluate total energy intake

    Summary: Consider Enteral Nutrition.

    Pedro Guzman 25 Sep 2019

    Signature Date

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