Case Study 2

C.M. is an 89-year-old man who presents with his daughter to the provider’s office. The daughter is concerned because her father has not been eating well.

Subjective Data

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PMH: HTN, Hypothyroid
24-hour diet recall reveals approximately 1100-calorie intake
Lives alone, daughter nearby
Does not drive
Daughter shops
Patient cooks light meals
Objective Data

VS: T 37 / P 72 / R 12 / BP 104/64
Weight: 135 lb
Weight last visit, 3 months ago: 150 lb
Height: 5 feet, 7 inch
Medications: metoprolol 12.5 mg per day, Synthroid 0.75 mg per day
Oral mucosa dry, gums bleeding, dentures loose
Poor skin turgor

CS #2 Questions:
Create a list of 2 problems from the objective and subjective data.
Create a nursing diagnosis, derived from your problems list?

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