Exacerbation of confusion postoperatively

Millicent, an 82-year-old female is 4 days status-post successful hip replacement surgery following a hip fracture that occurred when she fell off her sofa. She will require prolonged rehabilitation in a hospital setting. The patient has a history of mild dementia and is presently unable to feed herself due to an exacerbation of confusion postoperatively. According to family members, the patient lives alone, does her own shopping, and prepares her own meals. She generally stays in

the house with limited physical activity. She is on NHIF support as her sole source of income. The patient cannot give a medical history.

Current body weight is 80% of ideal body weight. PE reveals normal vital signs and an operative skin incision that appears to be healing well.

There is moderate skeletal muscle and fat wasting. Her tongue is reddish and the papillae are flattened. A skin exam reveals numerous petechiae and her hair is very easily pluckable. The patient has been receiving intravenous hydration fluids with electrolytes since the operation. Lab tests are within normal limits except for low concentrations of blood urea nitrogen (4 mg/dL, normal range 10 – 20), creatinine (0.2 mg/dl, normal < 1.5), and albumin (2.2 g/dL, normal range 3.5 – 5.5). Serum calcium and phosphorus are in the low-normal range.

1. What are the potential causes of malnutrition in this patient?

2. Her physical examination findings suggest depletion of what specific micronutrients (check symptoms against literature)?

3. Why may her serum urea nitrogen, creatinine, and albumin levels

be decreased? What non-nutritional factors cause a decrease in serum albumin concentrations?

4. Discuss in detail the best option for specialized feeding in this