77, male, married; living independently with his wife. Suffers from type 2 diabetes. Medications include: NovoLOG insulin injections 3 X daily and glimepiride tablets once a day.
No current allergies; great group of friends; has been living in the same home for over 20 years; goal of care is to live the best possible life. Other important information to note is his wife primarily cooks all of the meals.
-“It’s really hard to turn down the last brownie.”
-“I am just not as hungry as I use to be.”
-“I use to live to eat, now I eat to live.”
-“My favorite food is bread, pasta, and hamburgers.”
-“I usually take my blood sugar and give myself insulin 3 times a day, but sometimes I forget.”
-“I feel like I might be losing weight.”
-“I have had …show more content…
• Nutritional assessment: individual suffers from type 2 diabetes, has difficulty maintaining weight, and a lack of a healthy appetite.
• Findings of tool – patient scored a 19/30.
• What the findings mean to OA? The individual is at risk for malnutrion.
• Is this what you thought you would find? Yes, the individual was aware of weight loss and lack of appetite due to pants fitting larger. The nutritional assessment was completed, based off of the subjective and objective data.
• What additional assessments to consider: A depression assessment and functional assessment because a lack of appetite could be a sign of depression and the patient may be having difficulties with feeding himself.
Assessment
Individual scored a 19/30, therefore, he is at risk for malnutrition and uncontrolled diabetes.
Plan/ Response
1) Refer individual to a Dietitian for education for himself and wife on healthy eating; do this within 1 week.
2) Instruct individual to document food intake for 1 week; do this within a month.
3) Harmon center or any meals on wheel’s program to assist individual and his
No current allergies; great group of friends; has been living in the same home for over 20 years; goal of care is to live the best possible life. Other important information to note is his wife primarily cooks all of the meals.
-“It’s really hard to turn down the last brownie.”
-“I am just not as hungry as I use to be.”
-“I use to live to eat, now I eat to live.”
-“My favorite food is bread, pasta, and hamburgers.”
-“I usually take my blood sugar and give myself insulin 3 times a day, but sometimes I forget.”
-“I feel like I might be losing weight.”
-“I have had …show more content…
• Nutritional assessment: individual suffers from type 2 diabetes, has difficulty maintaining weight, and a lack of a healthy appetite.
• Findings of tool – patient scored a 19/30.
• What the findings mean to OA? The individual is at risk for malnutrion.
• Is this what you thought you would find? Yes, the individual was aware of weight loss and lack of appetite due to pants fitting larger. The nutritional assessment was completed, based off of the subjective and objective data.
• What additional assessments to consider: A depression assessment and functional assessment because a lack of appetite could be a sign of depression and the patient may be having difficulties with feeding himself.
Assessment
Individual scored a 19/30, therefore, he is at risk for malnutrition and uncontrolled diabetes.
Plan/ Response
1) Refer individual to a Dietitian for education for himself and wife on healthy eating; do this within 1 week.
2) Instruct individual to document food intake for 1 week; do this within a month.
3) Harmon center or any meals on wheel’s program to assist individual and his