Assessment of an 84-Year-Old Client Admitted with Malnutrition and Weakness

QUESTION

Scenario: An 84 year-old client has been admitted from home to the acute medicine unit due to malnutrition and weakness. The client is awaiting a placement in long-term care. Review the client’s chart prior to answering the first question. Client Data: Name: Laksmi Agarwal Diagnosis: Malnutrition and weakness Allergies: none Age: 84 years old PMHx: asthma, hypertension, presbycusis Nurse’s Notes: 0800: Client admitted from home due to malnutrition and weakness. The client is awaiting a placement in long-term care. Client is alert and oriented to person, place, and time. Denies pain. All lung lobes clear with good air entry throughout. Pulses 3 and equal bilaterally in all limbs. Bowel sounds present but hypoactive in all 4 quadrants. 4cm x 4 cm dark non-blanchable area noted on client’s sacrum. Active, full range of motion in all limbs. Diagnostic Tests Lab Test Result Normal Range Hemoglobin (HGB) 115 g/L 115-155 g/L White blood cells (WBC) 9 × 109/L 3.5-10.5 × 109/L Hematocrit (HCT) 0.38 0.37-0.46 Platelets (PLT) 286 X 109/L 130 – 400 X 109/L Sodium (Na) 140 mmol/L 135-145 mmol/L Chloride (Cl) 100 mmol/L 98-106 mmol/L Potassium (K) 3.1 mmol/L 3.5-5 mmol/L Creatinine (Creat) 60 μmol/L 50-90 μmol/L Albumin (Alb) 32

ANSWER

Assessment of an 84-Year-Old Client Admitted with Malnutrition and Weakness

Introduction

This case study focuses on Laksmi Agarwal, an 84-year-old client who has been admitted to the acute medicine unit due to malnutrition and weakness. By reviewing Laksmi’s chart and analyzing the provided data, we can gain insights into her current health status and develop a comprehensive understanding of her condition. This assessment will include an overview of her medical history, presenting symptoms, and results of diagnostic tests.

Client Data and Medical History

Laksmi Agarwal, aged 84, has been diagnosed with malnutrition and weakness. Her medical history includes asthma, hypertension, and presbycusis. No known allergies have been documented. She was admitted from home and is currently awaiting placement in long-term care. According to the nurse’s notes, Laksmi is alert and oriented to person, place, and time. She denies pain and exhibits clear lung lobes with good air entry. Peripheral pulses are palpable and equal bilaterally in all limbs. Bowel sounds are present but hypoactive in all four quadrants. A non-blanchable 4cm x 4cm dark area is noted on her sacrum. Laksmi demonstrates active, full range of motion in all limbs.

Diagnostic Test Results

Several diagnostic tests have been performed, and their results are as follows:

Hemoglobin (HGB): Laksmi’s hemoglobin level is 115 g/L, falling within the range of 115-155 g/L. Hemoglobin measures the oxygen-carrying capacity of red blood cells and can indicate the presence of anemia or other blood disorders.

White Blood Cells (WBC): Laksmi’s white blood cell count is 9 × 109/L, within the normal range of 3.5-10.5 × 109/L. This test measures the body’s immune response and can indicate the presence of infection or inflammation.

Hematocrit (HCT): Laksmi’s hematocrit level is 0.38, falling within the normal range of 0.37-0.46. Hematocrit measures the volume of red blood cells in relation to the total blood volume and can indicate anemia or dehydration.

Platelets (PLT): Laksmi’s platelet count is 286 X 109/L, within the normal range of 130-400 X 109/L. Platelets are essential for blood clotting, and abnormal levels can indicate bleeding disorders or certain diseases.

Sodium (Na), Chloride (Cl), and Potassium (K): Laksmi’s sodium, chloride, and potassium levels are within normal ranges. These electrolytes play a vital role in maintaining fluid balance, nerve function, and muscle contractions.

Creatinine (Creat): Laksmi’s creatinine level is 60 μmol/L, within the normal range of 50-90 μmol/L. Creatinine is a waste product produced by muscles and is used to evaluate kidney function.

Albumin (Alb): Laksmi’s albumin level is 32, with no provided normal range. Albumin is a protein produced by the liver and serves as a marker of nutritional status. A lower albumin level can indicate malnutrition or liver disease.

Conclusion

Based on the information provided, Laksmi Agarwal, an 84-year-old client, has been admitted with malnutrition and weakness. Reviewing her chart and diagnostic test results provides insights into her current health status. The results of the tests, including hemoglobin, white blood cells, hematocrit, platelets, electrolytes, creatinine, and albumin, help evaluate her blood profile and nutritional status. This comprehensive assessment provides a foundation for formulating an appropriate care plan to address Laksmi’s malnutrition and weakness, improve her overall health, and prepare her for long-term care placement.