The Nutrition Care Process: Developing a Nutrition Care Plan

NFSC 370 - Clinical Nutrition McCafferty

Illness: any medical condition that alters nutrient needs; not necessarily a disease.

• Analyzing Assessment Data – Study accumulated data – Generate Nutrition Problem List – Nutrition Solutions • • •

Energy Needs

Long’s Method: BEE x AF x IF

• BEE = Harris-Benedict Equation Women: 655+ (9.6 x W) + (1.8 x H) - (4.7 x A) Men: 66.5 + (13.8 x W) + (5 x H) - (6.8 x A) –

W

= –

H

= –

A

=

• AF = Activity Factor Bedrest 1.2

Ambulatory 1.3

• IF = Injury Factor Minor Surgery Skeletal Trauma Major Sepsis Severe Burns 1.2

1.35

1.6

2.1 (depends on %BSA burned)

Practice Example:

• Mrs. H is a 64 y/o female ht: 5’4”, wt: 146# • Admitted for minor surgery, after which she’ll be on temporary bed rest. Calculate her energy needs using Long’s method.

Energy Needs Based on Body Weight Alone

• 25-35 kcal/kg body wt or adjusted body wt. (maintenance) • 35-40 kcal/kg body wt or adjusted body wt. (anabolism) • Try this with Mrs. H (146 lbs.)

Using Adjusted Weight for Obesity

• If patient is >130% IBW • [(ABW - IBW) X0.25] +RBW = adjusted weight – ABW = – IBW = – 0.25 = • Controversial!!!!

Example: Mrs. J. is 5’7” tall and weighs 185 pounds. She is lightly to moderately active. Calculate her protein needs.

1. Find her appropriate weight 2. Is her weight  appropriate weight >130%? 3.

4. Use this adjusted weight to calculate protein needs:

• Other methods: • Enloe: – If pt. is <200% IBW, use IBW + 10% for adjusted weight – If pt. is >200% IBW, use IBW + 25% for adjusted wt.

• OR, average of actual/ideal weights • OR actual wt if BMI < 40, IBW if BMI > 40 • OR 21 kcal/kg if obese

Protein Needs

• Based on present nutr. status and stress level: Normal Mild Moderate Severe (critically ill) 0.5 - 0.8 g/kg/day 0.8 - 1.0 g/kg/day 1.0 - 1.5 g/kg/day 1.5 - 2.0 g/kg/day

Nutrition Education Needs

• Best way to present material – Oral, written, how much time do you have, etc.

• Amount. of info pt. can handle – level of fear – literacy level – level if interest – level of control over own nutritional intake – … be flexible!!

• Motivation to practice info…

The Nutrition Care Plan

Plan to meet nutrient and nutrition education needs (MNT) • Objectives – • Content of counseling sessions • Time frame

Example Problem: Goal: Plan/Intervention:

• Implementing Care Plan • Evaluating Care Plan – – –

Medical Nutrition Therapy

• The provision of appropriate amounts of energy, protein, carbohydrate, fat, vitamins, minerals, trace elements, and water in whatever form best meets the client’s needs.

The Diet Order

• Physician’s written statement in the medical record of what diet a client should receive.

– Physician writes the order – Dietary dept. receives order and provides regular or modified diet – R.D. suggests diet Rx or makes recommendations for changes if necessary.

The Diet Manual

• Contains all hospital’s diets – Describes the diet, rationale for use, foods allowed/ not allowed, nutritional adequacy and sample menu – Approved by hospital administration, physician, nursing, clinical dietitian – Different facilities have different diet manuals

Routinely Ordered Diets

• NPO - (nil per os) – – Pt. is put on this diet prior to surgery or test so that nothing is in the GI tract –

• Clear Liquid Diet- usually used day prior to and following surgery.

– Transparent to light in color liquids… – E.g. – Mostly CHO, low prot, low fat = no residue left in GI tract – 600 - 900 kcals/day and 5-10g protein – Provides fluid/lytes to prevent dehydration – Should not be used for more than _____ days

Full Liquid Diet

• • Used for pts unable to chew, swallow, or digest solid foods  nutr. adequate than cl. liq., but low in niacin, folacin, and iron • All foods on clear diet allowed, plus milk and milk products: – e.g., cream soups, milk, cream of wheat, plain yogurt, pudding, custards, eggnog, ice cream, all juices, sherbet, coffee • ~1000-1500 kcals, ~45-50g protein, fiber free

Dysphagia Diets

• Further modifications in consistency for patients who have limited chewing or swallowing ability • See Appendix 55 pp. 1272-1277

Soft Diet

• More solid than liquid or puree diet but consists of food that is easily digested, bland, and low in fiber – Tender, soft meats (or mechanically ground),canned fruits (no raw fruits), well-cooked vegetables, white bread (no whole grains).

– No gassy vegetables such as broccoli, cabbage, or cauliflower – Used for:

Mechanical Soft Diet

• • Intended for pts w/ difficulty chewing

Regular Diet

Also called House Diet, General Diet, or Routine Diet. No restrictions.

• ADAT— • DAT – • DOC –

Other Terms

Special Diets

• Diets used in treatment of specific ds. states • We’ll discuss w/ each ds. state • e.g. low residue, diabetic, cardiac, renal.

Test Diets

• Fecal Fat Test Diet: provides a means of measuring fecal fat for the diagnosis of ____________________.

– • Glucose Tolerance Test (GTT) – used for diagnosis of diabetes and impaired glucose tolerance

• • •

Increasing Patient Intake

   Frequency of feedings number and size of servings nutrient density: Add nutr supplements, e.g. Ensure, Boost • Encourage eating at mealtime – Have nurse (or other staff) set up meal tray and assist pt.

The Medical Record

• Medical record = legal document – Communication among members of health care team.

– Confidentiality – POMR • Computer or black ink • Chronological order • Institution’s accepted abbreviations • Signature, date and time • Professionalism • Corrections/addendums

Confidentiality Issues

• Discussing current or former patients or any confidential information (except for the authorized professional exchange of info) • Information stored on computers • Documents with confidential info • Breach of confidentiality - penalties

Writing a SOAP Note

• Subjective – Information pt. or caregiver/family tells you, what you observe but haven’t measured.

– Significant nutritional history • Appetite, home diet practices, chewing and swallowing ability, N/V/D, etc.

– Pertinent socioeconomic, cultural info – Level of physical activity

• Objective – Factual, reproducible observations (anthropometric and lab data) – Dx. And pertinent medical history – Age, gender, height, weight, %IBW, etc.

– Desirable weight/weight goal – Labs (pertinent) – Diet order/nutrition support (current diet provides…) – Meds (pertinent) – Calculated nutrient needs (may also go under “A”

• Assessment – Your assessment of pt. nutritional status based on S & O data •

If you make an assessment statement in “A,” the information has to be under “S” or “O.”

Example: pt. w/mod. depleted visc. prot. stores per alb level (must be listed under ‘O’). – Do not repeat lab values in assessment (“alb. Of 3.0 indicates…” No-no)

– Evaluation of pertinent nutritional history – Assessment of labs – Assessment of patient’s comprehension and motivation, if appropriate – Assessment of the diet order and/or feeding modality – Anticipated problems and/or difficulties for patient compliance or adherence

• Plan – Diagnostic studies needed – Suggestions for gaining further pertinent data – MNT goals – Recommendations for nutrition care

and nutrition education

– Recommendations for other health care providers – Specific parameters you will monitor – Plan for follow-up (time frame)

This is

your plan

to improve nutritional status or make recommendations to the doctor examples: 1. Educate pt. on 1500 kcal diabetic diet 2. Provide Ensure w/meals TID 3. Recommend MVI q day 4. Provide food preferences (list specific changes) 5. Recommend increased TF rate to 75cc/hr.

6. Monitor ______ (labs) 7. Follow-up in 2 days

Other documentation styles:

• DAR – diagnosis, assessment, recommendations • PIE – problem, intervention, evaluation • PGIE – problem, goal, intervention, eval.

• (content is the same regardless of recording style) • Others…

JCAHO

• What is it?

• New guidelines for charting abbreviations See Handout: JCAHO Do Not Use List