Clinical Nutrition Assessment Explained for Students (Easy Guide)

This question focuses on applying theory to practical scenarios.

What This Question Is About

This question relates to clinical nutrition assessment and requires a structured academic response.

How to Approach This Question

Focus on explaining concepts clearly and supporting them with examples.

Key Explanation

This topic involves clinical nutrition assessment. A strong answer should include explanation, application, and examples.

Original Question

DIE6248 Clinical Nutrition and Assessment 1 Module 1 Assignment: Nutrition Screening 1. Mr. Black, Mr. Blue and Mr. Rojas were admitted to your general medicine team. The NDTR normally screens all new admits but he is out sick so you are completing the nutrition screening today. The admission screening for each patient follows and includes nutrition questions to assist you. Screen each patient using two different screening tools. For example, you may use SGA and MUST for patient #1 and MNA and MST for patient #2. Providing the results of the screening for each patient in the table below Screening Tool Used, Score, what (if any) factors increased their risk Screening Tool Used, Score, what (if any) factors increased their risk Mr. Black Mr. Blue Mr. Rojas 2. Reflect on any differences you saw between tools and the tools’ specificity. DIE6248 Clinical Nutrition and Assessment 2 Mr. Black STANDARD TITLE: NURSING ADMISSION EVALUATION NOTE DATE OF NOTE: JUN 15, 2022@20:34 ENTRY DATE: JUN 15, 2022@20:34:53 URGENCY: STATUS: COMPLETED ============================================================ MEDICATION REVIEW (MRR1) ============================================================ Did patient bring medication(s) from home? No ============================================================ GENERAL INFORMATION ============================================================ Admission information given by: Patient Preferred Language for Discussing Healthcare: English Preferred mode of communication: Verbal Items at bedside: Dentures: Upper and lower dentures ============================================================= INFECTIOUS DISEASE RISK SCREEN ============================================================= Travel Screen: Have you traveled within the United States within the last 21 days? No Have you traveled outside the United States within the last 21 days? No Within the last 14 days, have you had: No known exposure Other Exposure to Infectious Disease: No known exposure Patient reported the following symptoms: No Symptoms Present DIE6248 Clinical Nutrition and Assessment 3 History of Multiple Drug Resistant Organism (MDRO): No Methicillin-resistant Staphylococcus aureus (MRSA) Swabbing: Education Provided Informed verbal consent obtained MRSA swab obtained ============================================================= NUTRITION SCREENING ============================================================= ============ Malnutrition Screening ============ Measurement DT WEIGHT LB(KG)[BMI] 05/23/2022 12:53 331.8(150.50)[42*] 04/21/2022 11:08 322(146.06)[40*] Lost weight recently without trying: No (0 points) Eating poorly due to decreased appetite: No (0 points) Total Score: 0 ============ Additional Nutrition Screening ============ Patient requiring tube feedings/TPN/PPN? No Do you have any food intolerances, special dietary needs, ethnic, cultural or religious preferences affecting dietary needs? No In the past 3 months, did you ever run out of food and were not able to access more food or money to buy more food? No ============================================================ RISK SCREENINGS ============================================================ Alcohol Screen: Screen to be completed by: DIE6248 Clinical Nutrition and Assessment 4 Nurse SCREEN FOR ALCOHOL (AUDIT-C) An alcohol screening test (AUDIT-C) was negative (score=1). 1. How often did you have a drink containing alcohol in the past year? Monthly or less 2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? One or two drinks 3. How often did you have six or more drinks on one occasion in the past year? Never Have you consumed alcohol within the last 72 hours? No Tobacco or Nicotine Use: Substance Use Assessment: Have you used any recreational drugs or narcotics in the last 72 hours? No ============================================================= RISK OF WANDERING ============================================================= History of wandering or elopement: No Patient expressing a desire/plan to leave immediately: No =========================================================== SUICIDE SCREEN =========================================================== *** The Columbia Suicide Severity Rating Scale (C-SSRS) has been completed within the past 24 hours *** Result of C-SSRS screener done today was NEGATIVE. ============================================================ EXPOSURE TO VIOLENCE AND ABUSE PRE-SCREEN ============================================================ Are you worried for your safety, that you will be hurt or harmed? No Has anyone tried to force you to sign papers or use your money against your will? No ============================================================ DIE6248 Clinical Nutrition and Assessment 5 POST TRAUMATIC STRESS/MILITARY SEXUAL TRAUMA CARE CONSIDERATIONS ============================================================ To minimize a startle response, what is your preference on how best to awaken you? No preference ============================================================= SEXUAL HEALTH ============================================================= Do you have any concerns or health questions regarding your sexual health that you would like to discuss with your provider? No ============================================================ ADVANCE DIRECTIVE ============================================================ Notification of Rights Related to Advance Directives: Written notification provided. The patient wishes to receive information about or assistance with Advance Care Planning and/or Advance Directive: No =========================================================== SPIRITUAL ASSESSMENT =========================================================== Are there religious practices or spiritual concerns you want the chaplain, your provider, and other health care team members to know? No ============================================================ ANTICIPATED DISCHARGE NEEDS ============================================================ Where do you live? Housing owned/rented by Veteran Do you have a legal guardian/conservator? No Method of transportation: Private Vehicle =========================================================== EDUCATIONAL NEEDS/LEARNING STYLE =========================================================== Barriers to learning: None evident DIE6248 Clinical Nutrition and Assessment 6 Patient learning style preferences: Demonstration Printed materials Verbal explanation Video/education TV ============================================================ VISITOR INFORMATION ============================================================ Will you have a primary support person while in the hospital? Yes: Relationship to patient: Spouse Patient’s Visitor Restriction preferences: No Privacy Review: Discussed with patient who may receive health information and the need for that identified person to provide a passcode for the staff to discuss. Passcode provided to patient ============================================================== MORSE FALL SCALE & TIPS PROGRAM ============================================================== Morse Fall Scale: The Morse Fall scale was performed and score was 85. This is indicative of high risk for falls. History of falling in past 3 months? Yes Secondary diagnosis: Yes Ambulatory aid: Crutches/cane(s)/walker Intravenous therapy/Heparin lock: Yes Gait/Transferring: Weakness Mental Status: Oriented to own ability/knows own limitations ============================================================= ASPIRATION RISK ASSESSMENT AND SWALLOW SCREEN DIE6248 Clinical Nutrition and Assessment 7 ============================================================= Cough/frequent throat clearing with oral intake, per patient and wife. They report that at times patient will cough until he passes out. However, patient did pass bedside swallow screen. Speech Language Pathology consult ordered. BEDSIDE SWALLOW SCREEN 1. 5 mL via a cup: A. Cough after swallowing: No B. Audible throat clear after swallowing: No C. Wet voice with “AHHH”: No 2. 5 mL via a cup: A. Cough after swallowing: No B. Audible throat clearing after swallowing: No C. Wet voice with “AHHH”: No 3. 90 mL via a cup: A. Cough after swallowing: No B. Audible throat clear after swallowing: No C. Wet voice with “AHHH”: No D. Unable to continuously drink: No E. Wet voice with “AHHH” after 1 minute: No Bedside Swallow Screen Results: Pass ============================================================== PAIN ASSESSMENT ============================================================== Are you currently experiencing pain? Yes – DVPRS scale used to assess Location: Bilateral Knees, back Defense and Veterans Pain Rating Scale (DVPRS): 5 Interrupts some activities Pain Score: 5 Patient’s acceptable pain goal: 0 No pain DIE6248 Clinical Nutrition and Assessment 8 Mr. Blue STANDARD TITLE: NURSING ADMISSION EVALUATION NOTE DATE OF NOTE: JUN 09, 2022@15:13 ENTRY DATE: JUN 09, 2022@15:13:28 AUTHOR: EDWARDS,HAYLEY N EXP COSIGNER: URGENCY: STATUS: COMPLETED ============================================================= ALLERGY/ADVERSE DRUG REACTION (ADR) REVIEW (MRT5) ============================================================= **Review JLV for more accurate data on ALL/ADR/Med Recon** FACILITY ALLERGY/ADR ——– ———– AUGUSTA VAMC MILK OLIN E. TEAGUE VET CENTER NO KNOWN ALLERGIES TAMPA FL VAMC LACTOSE TAMPA FL VAMC PENICILLIN Allergy/Adverse Drug Reaction Review to be conducted by: Nurse Results of Allergy/ADR Review: Allergy/Adverse Drug Reaction list confirmed ============================================================ MEDICATION REVIEW (MRR1) ============================================================ Did patient bring medication(s) from home? No Medication Review conducted by Nurse Results of Medication Review: Active Medication List: INCLUDED IN THIS LIST: Alphabetical list of active outpatient prescriptions dispensed from this VA (local) and dispensed from another VA or DoD facility (remote) as well as inpatient orders (local pending and active), local clinic medications, locally documented non-VA medications, and local prescriptions that have expired or been discontinued in the past 90 days. Non-VA Meds Last Documented On: May 17, 2022 ************************************************************************ ***NOTE*** The display of VA prescriptions dispensed from another VA or DIE6248 Clinical Nutrition and Assessment 9 DoD facility (remote) is limited to active outpatient prescription entries matched to National Drug File at the originating site and may not include some items such as investigational drugs, compounds, etc. NOT INCLUDED IN THIS LIST: Medications self-entered by the patient into personal health records (i.e. My HealtheVet) are NOT included in this list. Non-VA medications documented outside this VA, remote inpatient orders (regardless of status) and remote clinic medications are NOT included in this list. The patient and provider must always discuss medications the patient is taking, regardless of where the medication was dispensed or obtained. ———————————————————————— INPT ACETAMINOPHEN 325MG UD (Status=Active) 325MG BY MOUTH EVERY FOUR HOURS AS NEEDED For pain or fever. Do not exceed 4000mg of acetaminophen from all sources in 24hrs. OUTPT CALCIUM CARBONATE 1.25GM (CA 500MG) TAB (Status = Active) TAKE TWO TABLETS BY MOUTH EVERY DAY (CALCIUM REPLACEMENT) Rx# 8485455 Last Released: 4/8/22 Qty/Days Supply: 100/50 Rx Expiration Date: 4/8/23 Refills Remaining: 3 INPT CALCIUM CARB 1.25GM (CA 500MG) TAB UD (Status=Active) 1000MG BY MOUTH QDAILY OUTPT CAPECITABINE 500MG TAB (Status = Active) TAKE FOUR TABLETS BY MOUTH TWICE A DAY FOR 14 DAYS, OFF FOR 7 DAYS. TAKE 30 MINUTES AFTER A MEAL (1000MG/M2) Rx# 43982377 Last Released: 6/6/22 Qty/Days Supply: 112/21 Rx Expiration Date: 5/13/23 Refills Remaining: 2 OUTPT CHOLECALCIF 50MCG (D3-2,000UNIT) TAB (Status = Active) TAKE 1 TABLET (2000 UNITS) BY MOUTH EVERY DAY VITAMIN SUPPLEMENT Rx# 43883637 Last Released: 3/4/22 Qty/Days Supply: 100/90 Rx Expiration Date: 3/5/23 Refills Remaining: 3 INPT CHOLECALCIF 50MCG (D3-2,000UNIT) TAB UD (Status=Active) 2000 UNITS BY MOUTH QDAILY OUTPT DEXAMETHASONE 4MG TAB (Status = Active) TAKE ONE TABLET BY MOUTH TWICE A DAY BEGINNING THE DAY AFTER CHEMOTHERAPY TO PREVENT NAUSEA/VOMITING Rx# 43980519 Last Released: 5/17/22 Qty/Days Supply: 4/2 Rx Expiration Date: 5/13/23 Refills Remaining: 3 CLIN DEXAMETHASONE PHOSPHATE 4MG/ML 1ML INJ (Status=Discontinued) 12MG/3ML IV Q3WK AS NEEDED 30min prior to chemotherapy on Day 1 BCMA ORDER LAST ACTION: 05/17/22 11:31 GIVEN DIE6248 Clinical Nutrition and Assessment 10 INPT SENNOSIDE 8.6MG/DOCUSATE NA 50MG TAB UD (Status=Active) 8.6/50MG TABLET AS DIRECTED BY MOUTH TWICE A DAY Hold for diarrhea INPT ENOXAPARIN 40MG/0.4ML INJ SYRINGE 0.4ML (Status=Active) 40MG/0.4ML ON SCALP QDAILY Indication: Prophylaxis for Hospitalization. Optional: stop date & time .POST-OP:GIVE AT 7 AM OUTPT FOLIC ACID 1MG TAB (Status = Discontinued) TAKE ONE TABLET BY MOUTH EVERY DAY (VITAMIN SUPPLEMENT) Rx# 43932865 Last Released: 4/8/22 Qty/Days Supply: 100/90 Rx Expiration Date: 4/8/23 Refills Remaining: 2 OUTPT LACTOBACILLUS ACIDOPHILUS TAB (Status = Active) TAKE 1 TABLET BY MOUTH EVERY DAY Rx# 43880549 Last Released: 3/9/22 Qty/Days Supply: 100/90 Rx Expiration Date: 3/3/23 Refills Remaining: 3 INPT LACTOBACILLUS ACIDOPHILUS TAB UD (Status=Active) ONE TABLET BY MOUTH QDAILY OUTPT LOPERAMIDE HCL 2MG CAP (Status = Active) TAKE TWO CAPSULES BY MOUTH ONCE AND TAKE ONE CAPSULE AS DIRECTED AFTER EACH LOOSE STOOL (MAXIMUM OF 8 CAPSULES PER DAY). IF DIARRHEA PERSISTS FOR MORE THAN 24 HRS CONTACT ONCOLOGIST Rx# 43980520 Last Released: 5/17/22 Qty/Days Supply: 56/7 Rx Expiration Date: 5/13/23 Refills Remaining: 2 Non-VA NO NON-VA DRUGS, HERBALS OR OTC’S TAB TAKE OUTPT NUTRITION SUPL PLUS/VANILLA LIQ (Status = Active) TAKE 1 CAN BY MOUTH TWICE A DAY FOR NUTRITION Rx# 43990287 Last Released: 5/20/22 Qty/Days Supply: 72/30 Rx Expiration Date: 5/18/23 Refills Remaining: 3 OUTPT OMEPRAZOLE 20MG EC CAP (Status = Discontinued) TAKE ONE CAPSULE BY MOUTH EVERY DAY FOR STOMACH Rx# 43880300 Last Released: 3/2/22 Qty/Days Supply: 90/90 Rx Expiration Date: 3/3/23 Refills Remaining: 3 OUTPT ONDANSETRON HCL 8MG TAB (Status = EXPIRED) TAKE ONE TABLET BY MOUTH EVERY DAY AS NEEDED TO PREVENT NAUSEA AND VOMITING Rx# 43912238 Last Released: 3/24/22 Qty/Days Supply: 30/30 Rx Expiration Date: 4/23/22 Refills Remaining: 0 CLIN ONDANSETRON 8MG TAB UD (Status=Discontinued) 16MG BY MOUTH Q3WK AS NEEDED 30 MIN PRIOR TO CHEMOTHERAPY. DIE6248 Clinical Nutrition and Assessment 11 BCMA ORDER LAST ACTION: 05/17/22 12:10 GIVEN CLIN OXALIPLATIN INJ,LYPHL (Status=Discontinued) OXALIPLATIN INJ,LYPHL 260 MG in DEXTROSE 5% INJ,SOLN 250 ml IV INFUSE OVER 120 Minutes Q3WK AS NEEDED In 250ml D5W over 2 hours. Day 1 (Standard: 130MG/m2) BSA=1.99 m2 BCMA ORDER LAST ACTION: 05/17/22 12:44 GIVEN CLIN POTASSIUM CHLORIDE 20MEQ BAG INJ,SOLN (Status=Discontinued) POTASSIUM CHLORIDE 40MEQ BAG INJ,SOLN 40MEQ IV ONE TIME BCMA ORDER LAST ACTION: 06/09/22 12:58 GIVEN CLIN POTASSIUM CL 20MEQ SA TAB (DISPERS) UD (Status=EXPIRED) 40MEQ BY MOUTH ONE TIME ASAP BCMA ORDER LAST ACTION: 06/09/22 13:40 GIVEN OUTPT POTASSIUM CL 20MEQ SA TAB (DISPERSIBLE) (Status = Discontinued) TAKE ONE TABLET BY MOUTH EVERY DAY (POTASSIUM REPLACEMENT) Rx# 43883638 Last Released: 3/4/22 Qty/Days Supply: 90/90 Rx Expiration Date: 6/2/22 Refills Remaining: 0 OUTPT POTASSIUM CL 20MEQ SA TAB (DISPERSIBLE) (Status = Discontinued) TAKE ONE TABLET BY MOUTH EVERY DAY (POTASSIUM REPLACEMENT) FOR 3 WEEKS Rx# 43912243 Last Released: 3/24/22 Qty/Days Supply: 21/21 Rx Expiration Date: 4/23/22 Refills Remaining: 0 OUTPT POTASSIUM CL 20MEQ SA TAB (DISPERSIBLE) (Status = Active) TAKE ONE TABLET BY MOUTH TWICE A DAY (POTASSIUM REPLACEMENT) Rx# 43933072 Last Released: 4/11/22 Qty/Days Supply: 180/90 Rx Expiration Date: 4/8/23 Refills Remaining: 3 OUTPT PROCHLORPERAZINE MALEATE 10MG TAB (Status = Active) TAKE ONE TABLET BY MOUTH 4 TIMES A DAY AS NEEDED FOR NAUSEA AND VOMITING. Rx# 43980522 Last Released: 5/17/22 Qty/Days Supply: 60/15 Rx Expiration Date: 5/13/23 Refills Remaining: 2 INPT PROCHLORPERAZINE MALEATE 10MG TAB UD (Status=Active) 10MG BY MOUTH FOUR TIMES A DAY AS NEEDED nausea and/or vomiting OUTPT PSYLLIUM ORAL PWD (Status = Active) DISSOLVE 1 TABLESPOONFUL IN LIQUID & DRINK BY MOUTH AT BEDTIME AS DIRECTED FOR CONSTIPATION,SHAKE,LEAVE FOR 3 MINUTES. Rx# 43880552 Last Released: 3/5/22 Qty/Days Supply: 390/90 Rx Expiration Date: 3/3/23 Refills Remaining: 3 OUTPT SENNOSIDES 8.6MG TAB (Status = Active) DIE6248 Clinical Nutrition and Assessment 12 TAKE ONE TABLET BY MOUTH TWICE A DAY AS NEEDED FOR CONSTIPATION Rx# 43931776 Last Released: 4/8/22 Qty/Days Supply: 100/90 Rx Expiration Date: 4/8/23 Refills Remaining: 3 CLIN SODIUM CHLORIDE 0.9% INJ (Status=Discontinued) SODIUM CHLORIDE 0.9% BY INJECTION 1000 ml IV 500 ml/hr BCMA ORDER LAST ACTION: 06/09/22 10:37 INFUSING OUTPT UREA 10% CREAM (Status = Active) APPLY TO AFFECTED AREA ON SKIN THREE TIMES A DAY (APPLY TO HANDS AND FEET) Rx# 43985495 Last Released: 5/18/22 Qty/Days Supply: 180/30 Rx Expiration Date: 5/18/23 Refills Remaining: 3 ———————————————————————— SUPPLIES ———————————————————————— =============================================================== MEDICATION REVIEW =============================================================== 4. Patient/Family/Caregiver report TAKING AS WRITTEN all other medications ============================================================ GENERAL INFORMATION ============================================================ Admission information given by: Patient Preferred Language for Discussing Healthcare: English Preferred mode of communication: Verbal Items at bedside: None ============================================================= INFECTIOUS DISEASE RISK SCREEN ============================================================= Travel Screen: Have you traveled within the United States within the last 21 days? No Have you traveled outside the United States within the last 21 days? No DIE6248 Clinical Nutrition and Assessment 13 Within the last 14 days, have you had: No known exposure Other Exposure to Infectious Disease: No known exposure Patient reported the following symptoms: Fatigue History of Multiple Drug Resistant Organism (MDRO): No ============================================================= NUTRITION SCREENING ============================================================= ============ Malnutrition Screening ============ Measurement DT WEIGHT LB(KG)[BMI] 06/09/2022 08:26 151(68.49)[21] 05/17/2022 09:43 171(77.56)[23] 05/12/2022 10:44 172.1(78.06)[23] 04/07/2022 08:17 175.2(79.47)[24] 03/21/2022 02:12 183.2(83.10)[24] 03/02/2022 09:17 193.6(87.82)[25] Lost weight recently without trying: Yes Amount weight lost: 6-10 kg (12-22 lbs) (2 points) Eating poorly due to decreased appetite: No (0 points) Total Score: 2 ============ Additional Nutrition Screening ============ Patient requiring tube feedings/TPN/PPN? No Do you have any food intolerances, special dietary needs, ethnic, cultural or religious preferences affecting dietary needs? Yes: DIE6248 Clinical Nutrition and Assessment 14 Specify: lactose allergy Nutrition Consult ordered. In the past 3 months, did you ever run out of food and were not able to access more food or money to buy more food? No ============================================================ RISK SCREENINGS ============================================================ Alcohol Screen: Screen to be completed by: Nurse SCREEN FOR ALCOHOL (AUDIT-C) An alcohol screening test (AUDIT-C) was negative (score=0). 1. How often did you have a drink containing alcohol in the past year? Never 2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? Response not required due to responses to other questions. 3. How often did you have six or more drinks on one occasion in the past year? Response not required due to responses to other questions. Have you consumed alcohol within the last 72 hours? No Tobacco or Nicotine Use: Substance Use Assessment: Have you used any recreational drugs or narcotics in the last 72 hours? No ============================================================= RISK OF WANDERING ============================================================= History of wandering or elopement: No Patient expressing a desire/plan to leave immediately: No =========================================================== SUICIDE SCREEN =========================================================== Columbia Suicide Severity Rating Scale (C-SSRS) 1. Over the past month, have you wished you were dead or wished you could DIE6248 Clinical Nutrition and Assessment 15 go to sleep and not wake up? No 2. Over the past month, have you had any actual thoughts of killing yourself? No 3. Over the past month, have you been thinking about how you might do this? Response not required due to responses to other questions. 4. Over the past month, have you had these thoughts and had some intention of acting on them? Response not required due to responses to other questions. 5. Over the past month, have you started to work out or worked out the details of how to kill yourself? Response not required due to responses to other questions. 6. If yes, at any time in the past month did you intend to carry out this plan? Response not required due to responses to other questions. 7. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills, obtained a gun, gave away valuables, went to the roof but didn’t jump)? No 8. If YES, was this within the past 3 months? Response not required due to responses to other questions. C-SSRS Screen is Negative ============================================================ EXPOSURE TO VIOLENCE AND ABUSE PRE-SCREEN ============================================================ Are you worried for your safety, that you will be hurt or harmed? No Has anyone tried to force you to sign papers or use your money against your will? No ============================================================ POST TRAUMATIC STRESS/MILITARY SEXUAL TRAUMA CARE CONSIDERATIONS ============================================================ To minimize a startle response, what is your preference on how best to awaken you? No preference ============================================================= DIE6248 Clinical Nutrition and Assessment 16 SEXUAL HEALTH ============================================================ have any concerns or health questions regarding your sexual health that you would like to discuss with your provider? No ============================================================ ADVANCE DIRECTIVE ============================================================ Notification of Rights Related to Advance Directives: Written notification provided. The patient wishes to receive information about or assistance with Advance Care Planning and/or Advance Directive: No =========================================================== SPIRITUAL ASSESSMENT =========================================================== Are there religious practices or spiritual concerns you want the chaplain, your provider, and other health care team members to know? No ============================================================ ANTICIPATED DISCHARGE NEEDS ============================================================ Where do you live? Housing owned/rented by Veteran Do you have a legal guardian/conservator? No Method of transportation: Private Vehicle =========================================================== EDUCATIONAL NEEDS/LEARNING STYLE =========================================================== Barriers to learning: None evident Patient learning style preferences: Printed materials Caregiver/family present ============================================================ VISITOR INFORMATION ============================================================ Will you have a primary support person while in the hospital? DIE6248 Clinical Nutrition and Assessment 17 Yes: Patient’s Visitor Restriction preferences: No Privacy Review: Discussed with patient who may receive health information and the need for that identified person to provide a passcode for the staff to discuss. Passcode provided to patient ============================================================== MORSE FALL SCALE & TIPS PROGRAM ============================================================== Morse Fall Scale: The Morse Fall scale was performed and score was 35. This is indicative of moderate risk for falls. History of falling in past 3 months? No Secondary diagnosis: Yes Ambulatory aid: None/bedrest/nurse assist Intravenous therapy/Heparin lock: Yes Gait/Transferring: Normal/bed rest/immobile Mental Status: Oriented to own ability/knows own limitations Fall Tailoring Interventions for Patient Safety (TIPS) Fall TIPS initiated with patient: Yes Fall TIPS reviewed with patient: Yes ============================================================= ASPIRATION RISK ASSESSMENT AND SWALLOW SCREEN ============================================================= None ============================================================== PAIN ASSESSMENT ============================================================== Are you currently experiencing pain? NoDIE6248 Clinical Nutrition and Assessment 17 Yes: Patient’s Visitor Restriction preferences: No Privacy Review: Discussed with patient who may receive health information and the need for that identified person to provide a passcode for the staff to discuss. Passcode provided to patient ============================================================== MORSE FALL SCALE & TIPS PROGRAM ============================================================== Morse Fall Scale: The Morse Fall scale was performed and score was 35. This is indicative of moderate risk for falls. History of falling in past 3 months? No Secondary diagnosis: Yes Ambulatory aid: None/bedrest/nurse assist Intravenous therapy/Heparin lock: Yes Gait/Transferring: Normal/bed rest/immobile Mental Status: Oriented to own ability/knows own limitations Fall Tailoring Interventions for Patient Safety (TIPS) Fall TIPS initiated with patient: Yes Fall TIPS reviewed with patient: Yes ============================================================= ASPIRATION RISK ASSESSMENT AND SWALLOW SCREEN ============================================================= None ============================================================== PAIN ASSESSMENT ============================================================== Are you currently experiencing pain? No DIE6248 Clinical Nutrition and Assessment 18 DIE6248 Clinical Nutrition and Assessment 19 Mr. Roja DATE OF NOTE: MAY 23, 2022@00:21 ENTRY DATE: MAY 23, 2022@00:22:13 URGENCY: STATUS: COMPLETED ============================================================= ALLERGY/ADVERSE DRUG REACTION (ADR) REVIEW (MRT5) ============================================================= **Review JLV for more accurate data on ALL/ADR/Med Recon** FACILITY ALLERGY/ADR ——– ———– No Remote Allergy/ADR Data available for this patient TAMPA FL VAMC SIMVASTATIN Allergy/Adverse Drug Reaction Review to be conducted by: Pharmacist Provider ============================================================ MEDICATION REVIEW (MRR1) ============================================================ Did patient bring medication(s) from home? No Medication Review to be conducted by Pharmacist Medication Review to be conducted by Provider ============================================================ GENERAL INFORMATION ============================================================ Admission information given by: Patient Preferred Language for Discussing Healthcare: English Preferred mode of communication: Verbal Items at bedside: None ============================================================= INFECTIOUS DISEASE RISK SCREEN ============================================================= DIE6248 Clinical Nutrition and Assessment 20 Travel Screen: Have you traveled within the United States within the last 21 days? No Have you traveled outside the United States within the last 21 days? No Within the last 14 days, have you had: No known exposure Other Exposure to Infectious Disease: No known exposure Patient reported the following symptoms: Fatigue History of Multiple Drug Resistant Organism (MDRO): No ============================================================= NUTRITION SCREENING ============================================================= ============ Malnutrition Screening ============ Measurement DT WEIGHT LB(KG)[BMI] 05/22/2022 23:37 171.1(77.61)[25] 05/22/2022 23:37 171.1(77.61)[25] 03/22/2022 11:15 187(84.82)[27] 12/10/2021 09:30 195.4(88.63)[28*] 12/09/2021 10:13 199(90.26)[29*] Lost weight recently without trying: Yes Amount weight lost: 1-5 kg (2-11 lbs) (1 point) Eating poorly due to decreased appetite: Yes (1 point) Total Score: 2 ============ Additional Nutrition Screening ============ Patient requiring tube feedings/TPN/PPN? No DIE6248 Clinical Nutrition and Assessment 21 Do you have any food intolerances, special dietary needs, ethnic, cultural or religious preferences affecting dietary needs? No Nutrition Consult ordered. In the past 3 months, did you ever run out of food and were not able to access more food or money to buy more food? No ============================================================ RISK SCREENINGS ============================================================ Alcohol Screen: Screen to be completed by: Nurse SCREEN FOR ALCOHOL (AUDIT-C) An alcohol screening test (AUDIT-C) was negative (score=0). 1. How often did you have a drink containing alcohol in the past year? Never 2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? Response not required due to responses to other questions. 3. How often did you have six or more drinks on one occasion in the past year? Response not required due to responses to other questions. Have you consumed alcohol within the last 72 hours? No Tobacco or Nicotine Use: Substance Use Assessment: Have you used any recreational drugs or narcotics in the last 72 hours? No ============================================================= RISK OF WANDERING ============================================================= History of wandering or elopement: No Patient expressing a desire/plan to leave immediately: No =========================================================== SUICIDE SCREEN =========================================================== DIE6248 Clinical Nutrition and Assessment 22 *** The Columbia Suicide Severity Rating Scale (C-SSRS) has been completed within the past 24 hours *** Result of C-SSRS screener done today was NEGATIVE. ============================================================ EXPOSURE TO VIOLENCE AND ABUSE PRE-SCREEN ============================================================ Are you worried for your safety, that you will be hurt or harmed? No Has anyone tried to force you to sign papers or use your money against your will? No ============================================================ POST TRAUMATIC STRESS/MILITARY SEXUAL TRAUMA CARE CONSIDERATIONS ============================================================ To minimize a startle response, what is your preference on how best to awaken you? No preference ============================================================= SEXUAL HEALTH ============================================================= Do you have any concerns or health questions regarding your sexual health that you would like to discuss with your provider? No ============================================================ ADVANCE DIRECTIVE ============================================================ Notification of Rights Related to Advance Directives: Written n

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."