Problem, Etiology, Signs and Symptoms=Nutrition diagnosis
1) Inadequate protein and energy intake related to increased nutrient needs as evidenced by impaired skin integrity
2) At risk for weight loss and malnutrition related to frequent COPD exacerbations as evidenced by PO intake <50% of estimated nutrient needs
3) Inadequate oral intake related to intakes less than 50% of estimated nutrient needs as evidenced by dislike of a prescribed mechanically altered diet
4) Moderate malnutrition related to intakes meeting <50% of estimated nutrient needs x >7 days as evidenced by weight loss > 5% in 30 days, functional decline, and visual appearance of loss of subcutaneous fat and muscle wasting at temple and orbital regions
5) Mild malnutrition related to a recent decline in PO intakes and difficulty swallowing as evidenced by 5.7% weight loss in 30 days, functional decline, and slight indentation at the temples
6) Fluctuating blood sugars related to excessive carbohydrate intake as evidenced by inconsistent timing of meals and increased snacking
7) Severe malnutrition related to intakes < 75% EEE for > 1 month as evidenced by 17% weight loss in 7 months, functional decline, and severe fat/muscle wasting at: temples, orbitals, triceps, and buccal fat pads
8) Swallowing difficulty related to recent CVA as evidenced by a diagnosis of aspiration pneumonia
9) Inadequate protein intake related to the increased need for high quality-protein as evidenced by CKD 4 diagnoses
10) At risk for weight loss and malnutrition related to altered GI function as evidenced by frequent diarrhea and IBS diagnosis
11) Excessive energy intake related to increased snacking as evidenced by weight gain of 12% in 180 days
12) Unintended weight loss related to infection as evidenced by weight loss of >5% in 30 days
(Numbers 2 and 10 are “at risk” PES Statements)
References
Michigan Academy of Nutrition and Dietetics. (2016). Retrieved from: https://eatrightmich.org/wp-content/uploads/2016/04/3.-Trepasso.pdf Accessed August 9, 2019.
Academy of Nutrition and Dietetics (AND). (2017). Retrieved from: https://www.andeal.org/vault/2440/web/files/EAL/NCP_EAL_201711.pdf Accessed August 9, 2019.