In-depth Assessment Form

NUTR 415 (Use this information and transfer to nutritional assessment form)

Nutritional Assessment

82 y/o female, thin and frail, adm s/p syncope episode. Neighbor found pt on floor of kitchen and called EMS.

EMS Assessment: B/P: 110/50, Pulse: 120, HEENT-WNL, skin-dry, multiple abrasions, Stage I on hip flexor, L elbow and L side of head. Upon arousal pt not a&o, language unintelligible, L side flaccid.

Upon hospital arrival, pt found to have a mild R CVA with L side hemiparesis. Follows verbal commands, but continues with garbled speech.

GI:BS+ x4, ND, NG, ( BM x3 days

Ht: 5’3”, Adm. Wt: 120#, UBW: 140#

U/L loose fitting. Dt hx obtained from pts. neighbor reveals eats typically 1-2 meals/day. 1 meal may be 1 can of Ensure or canned soup. Pt lives alone, but neighbors check in with her 1-2x/day.

PMH: TIA x4 over the last 4 years, Osteoporosis, DJD, h/o CAD

Sign Labs:

147 111 25

3.7 32 1.0 108

Cholesterol: 250

Albumin 3.1

Meds: Plavix, Fosamax