Case Study – Nutrition
C.M. is an 89-year-old female who presents with her daughter to the provider’s office. The daughter is
concerned because her mother has not been eating well.
Subjective Data
PMH: HTN, Hypothyroid
24- hour diet recall reveals approximately 1,100-calorie intake (insufficient calorie intake)
Lives alone, daughter nearby
Does not drive
Daughter shops
Patient cooks light meals
Objective Data
Vital signs: T 37 P 72 R 12 BP 104/64
Weight: 105 lb (10lb wt loss)
Weight last visit, 3 months ago: 115 lb
HT: 5 feet, 1 inch
Medications: Metoprolol 12.5 mg per day, Synthroid 0.75 mg per day
Oral mucosa dry, gums bleeding, dentures loose
Poor skin turgor
Stage I pressure ulcer on sacrum
Questions
1. Develop a problems list from the objective and subjective data.
❖ Looking at the subjective information, knowing she has hypothyroidism, which is the
deficiency of thyroid hormone means that the thyroid furnace is cold. This reduces the
metabolic rate and if a severe case, it causes a non-pitting edema or myxedema.
Systems include fatigue and cold intolerance. Signs include puffy, edematous face,
especially around eyes- periorbital edema; puffy hands and feet; facial features; cool, dry
skin; and dry, coarse hair and eyebrows.
❖ Older adults have an increased risk for either undernutrition or over nutrition. Poor
physical or mental health, social isolation, alcoholism, limited functional ability, poverty,
and polypharmacy are the major risk for malnutrition in older adults.
❖ Normal physiologic changes in aging adults that directly affect their nutritional status
include poor dentition, decreased visual acuity, decreased salivary production, slowed GI
motility, decreased GI absorption, and diminished olfactory and taste sensitivity.
❖ Socioeconomic conditions can frequently affect nutritional status of an aging adult.
Medications must also be considered because aging adults frequently take multiple
medications that have a potential for interaction with nutrients and with one another.
❖ The 24-hour recall is the easiest and most popular method for obtaining information
about the patient’s dietary intake. It is a questionnaire or either an interview where the
C.M. is an 89-year-old female who presents with her daughter to the provider’s office. The daughter is
concerned because her mother has not been eating well.
Subjective Data
PMH: HTN, Hypothyroid
24- hour diet recall reveals approximately 1,100-calorie intake (insufficient calorie intake)
Lives alone, daughter nearby
Does not drive
Daughter shops
Patient cooks light meals
Objective Data
Vital signs: T 37 P 72 R 12 BP 104/64
Weight: 105 lb (10lb wt loss)
Weight last visit, 3 months ago: 115 lb
HT: 5 feet, 1 inch
Medications: Metoprolol 12.5 mg per day, Synthroid 0.75 mg per day
Oral mucosa dry, gums bleeding, dentures loose
Poor skin turgor
Stage I pressure ulcer on sacrum
Questions
1. Develop a problems list from the objective and subjective data.
❖ Looking at the subjective information, knowing she has hypothyroidism, which is the
deficiency of thyroid hormone means that the thyroid furnace is cold. This reduces the
metabolic rate and if a severe case, it causes a non-pitting edema or myxedema.
Systems include fatigue and cold intolerance. Signs include puffy, edematous face,
especially around eyes- periorbital edema; puffy hands and feet; facial features; cool, dry
skin; and dry, coarse hair and eyebrows.
❖ Older adults have an increased risk for either undernutrition or over nutrition. Poor
physical or mental health, social isolation, alcoholism, limited functional ability, poverty,
and polypharmacy are the major risk for malnutrition in older adults.
❖ Normal physiologic changes in aging adults that directly affect their nutritional status
include poor dentition, decreased visual acuity, decreased salivary production, slowed GI
motility, decreased GI absorption, and diminished olfactory and taste sensitivity.
❖ Socioeconomic conditions can frequently affect nutritional status of an aging adult.
Medications must also be considered because aging adults frequently take multiple
medications that have a potential for interaction with nutrients and with one another.
❖ The 24-hour recall is the easiest and most popular method for obtaining information
about the patient’s dietary intake. It is a questionnaire or either an interview where the
