The Nutrition Care Process: Developing a Nutrition Care Plan

1. The Nutrition Care Process: Developing a Nutrition Care Plan NFSC 370 - Clinical Nutrition McCafferty

2. Illness: any medical condition that alters nutrient needs; not necessarily a disease. • Analyzing Assessment Data • Study accumulated data • Generate Nutrition Problem List • Nutrition Solutions

3. 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 =

4. AF = Activity Factor Bedrest 1.2 Ambulatory 1.3 • IF = Injury Factor Minor Surgery 1.2 Skeletal Trauma 1.35 Major Sepsis 1.6 Severe Burns 2.1 (depends on %BSA burned)

5. 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.

7. 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.)

8. Using Adjusted Weight for Obesity • If patient is >130% IBW • [(ABW - IBW) X0.25] +RBW = adjusted weight • ABW = • IBW = • 0.25 = • Controversial!!!!

9. Example: Mrs. J. is 5’7” tall and weighs 185 pounds. She is lightly to moderately active. Calculate her protein needs. • Find her appropriate weight • Is her weight  appropriate weight >130%? • Use this adjusted weight to calculate protein needs:

10. 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

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

12. 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…

13. The Nutrition Care Plan Plan to meet nutrient and nutrition education needs (MNT) • Objectives • Content of counseling sessions • Time frame

14. Example Problem: Goal: Plan/Intervention:

15. Implementing Care Plan • Evaluating Care Plan

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. 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

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

23. 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:

24. Mechanical Soft Diet • Intended for pts w/ difficulty chewing

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

26. Other Terms • ADAT— • DAT – • DOC –

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

28. 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

29. 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.

30. 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

31. 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

32. 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

33. 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”

34. 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)

35. 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

36. 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)

37. 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

38. 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…

39. JCAHO • What is it? • New guidelines for charting abbreviations See Handout: JCAHO Do Not Use List