-Ostomy/Wound nurse noted no pressure ulcers on sacrum/coccyx or elsewhere, only some issues on buttocks that appeared to be related to moisture. -Foley catheter in place Excretory -500 mL output over 5 on furosemide Using the Subjective Global Assessment upon initial visit on 6/22/16, I was able to conclude that the Veteran was at moderate risk for malnutrition. The table below conveys my findings. SGA Findings Nutrition Potential Component Implication1 Intervention1 -Per Veteran’s -At that -Determine Veteran’s family, UBW was in time weight dry weight and base 160 lb and last per CPRS estimated energy weight per CPRS likely needs off of that was 159 lb inaccurate due weight. Weight History -Veteran presents to volume -With elderly patients weight stable = 0 overload. on dialysis, the risk points for malnutrition is high. Goal is to maintain weight status. -Per Veteran’s -Poor appetite -A patient on dialysis family, Veteran has indicates requires higher a poor appetite. overall energy needs than a -Significant inadequate healthy person. appetite/intake oral intake. -If needs are not Appetite/Intake changes = 2 points -Veteran’s being met, an -Nutrition needs appetite individual is at an would likely be met changes likely increased risk for by diet + oral due to uremia malnutrition. supplements either and fluid -Potential in the form of dense overload. interventions involve
-Ostomy/Wound nurse noted no pressure ulcers on sacrum/coccyx or elsewhere, only some issues on buttocks that appeared to be related to moisture. Excretory -Foley catheter in place -500 mL output over 5 on furosemide Using the Subjective Global Assessment upon initial visit on 6/22/16, I was able to conclude that the Veteran was at moderate risk for malnutrition. The table below conveys my findings. SGA Component Findings Nutrition Implication1 Potential Intervention1 Weight History -Per Veteran’s family, UBW was 160 lb and last weight per CPRS was 159 lb -Veteran presents weight stable = 0 points -At that in time weight per CPRS likely inaccurate due to volume overload. -Determine Veteran’s dry weight and base estimated energy needs off of that weight. -With elderly patients on dialysis, the risk for malnutrition is high. Goal is to maintain weight status. Appetite/Intake -Per Veteran’s family, Veteran has a poor appetite. -Significant appetite/intake changes = 2 points -Nutrition needs would likely be met by diet + oral supplements either in the form of dense -Poor appetite indicates overall inadequate oral intake. -Veteran’s appetite changes likely due to uremia and fluid overload. -A patient on dialysis requires higher energy needs than a healthy person. -If needs are not being met, an individual is at an increased risk for malnutrition. -Potential interventions involve
allison_k_fassler_clinical_case_study.docx