Problems with eating and nutrition: geriatric self-learning module

MedSurg Nursing, Dec, 2004 by Virginia K. Lee

Inpatient Case Study

Ms. T.E. is an 88-year-old white female admitted to your unit from the ED. She was admitted because of increased confusion and lethargy. She lives with her 86-year-old sister and was brought into the ED by a concerned niece. T.E. has no known health problems and does not take any medications. Your findings on admission assessment: frail older woman who is oriented to self only. IV fluid is infusing in her left forearm. She is weak and needs maximum assistance to move from the stretcher to the bed. Her hair is thin and sparse, and mucus membranes are pale and dry. Vital signs T 97, P 122, R 22, BP 86/60, and weight 102 lbs (50.9 kg).

Additional significant physical findings are

* moderate kyphosis,

* diminished size and tone of the muscles of her extremities,

* poor skin turgor, and

* 1 to 2 edema bilaterally in lower extremities.

Significant laboratory data include the following:

* red blood cells (RBC) 3.1 (3.6 - 5 x [10.sup.6])

* hemoglobin 10.5 (12-16 g/dL)

* hematocrit 35% (36% - 48%)

* sodium 148 (136 - 145 mEq/l)

* blood urea nitrogen (BUN) 50 (8-23 mg/dL)

* creatinine 1.0 (0.6 - 1.1 mg/dL)

* albumin 3.1 (3.5 - 4.8 g/dL) What data give cues that nutrition and dehydration are significant areas of concern? List these and then compare to the discussion of the case study.

Vital signs. Her elevated pulse rate and her decreased BP likely are related to dehydration. At 102 pounds, she is thin. Given her dehydration, you would expect a weight loss. However, it is important also to consider her nutritional status. She may have been thin all her life, but it is important to get information about her usual weight and any significant recent weight loss. Significant weight loss is considered 5% or more of body weight in 1 month, 10% or more of body weight in 6 months, and/or involuntary weight loss of 10 pounds in 6 months.

Physical exam findings

* The niece reports that T.E.'s weakness, lethargy, and confusion recently have increased. There may be other causes, but dehydration is a contributing factor. Malnutrition would be a factor as well in her baseline lethargy. Possible nutritional causes of her confusion are vitamin B and folate deficiencies.

* Dry mucous membranes and poor skin turgor are signs of dehydration. Loss of subcutaneous tissue that occurs with normal aging makes checking skin turgor of questionable usefulness as a sign of dehydration in elders. In this age group, skin turgot is best assessed over the sternum.

* Pale mucous membranes are indicative of anemia, and thin sparse hair can be a sign of malnutrition. There is some thinning of hair with normal aging, but you would not expect the hair to be sparse.

* Some loss in the size and tone of muscles is expected with aging; however, this would be more pronounced in someone who is malnourished. Skeletal muscle is metabolized for energy if food intake chronically is inadequate.

* Bilateral edema in the extremities indicates that her malnutrition may be significant. Fluids migrate into the tissues because of inadequate serum proteins.