Chapter 15

1. Chapter 15 The Nutrition Care Process in the Health Care Setting

2. Learning Objectives • Discuss the differences in acute care versus long-term care settings. • Describe patient risk factors for poor nutritional status. • Identify risk factors for skin breakdown. • Discuss institutional meal service concerns.

3. Learning Objectives (continued) Discuss different types, methods, and uses of nutritional support. Identify common drug and food interactions. Describe differences in nutrition care between palliative and curative care. • 3

4. The Nutrition Care Planning Process in Health Care Settings Assessment needs to be undertaken within 24 to 72 hours of admittance to the facility (based on written protocol of specific facility) Includes the following areas: Medical diagnoses or conditions Lab values Anthropometric data: height, weight, BMI Diet history Interview to assess food intolerances/preferences

5. Sample of an Eating Skills Screening Form

6. Care Plans Developed to Coordinate Total Team Approach Goals need to be achievable and measurable objectives; time frame dictated by level of care Long-term care facilities review and update care plans at least quarterly (every 3 months), for example: Resident will achieve albumin >3.5 by next lab order Resident will maintain weight between 150 and 160 lb through observation period

7. Plan of Care Specific strategies are stated in Care Plans aimedat achieving stated goals, along with relevant health care disciplines, for example: Monitor labs as ordered (RD, RN, MD) Monitor monthly weights (RD, CNA, MD) Provide fortified food and supplements (RD, CNA) Provide adaptive feeding equipment (CNA) Evaluation is done at least quarterly in long-term care; plan of care (POC) is revised as needed to meet stated health goals

8. Basic Hospital Diets Basic hospital diets—designed to treat medical conditions within health organizations (e.g., clear liquid, full liquid, soft diet) Alterations in macronutrient content—consistent carbohydrate for persons with diabetes, or low protein, low potassium for renal failure Alterations in consistency—solids: whole, ground/mechanical soft, puree; liquids: thin, nectar thick, honey thick, pudding thick Nutritional support—use of tube feeding or parenteral nutrition (bypass of the GI tract)

9. Assistive Devices for Eating Problems

10. CNA Care Card Includes Individual Meal Strategies

11. Weight Measurements Are an Important Part of Nutritional Assessment Monitoring patient weight. (From Jarvis C: Physical examination and health assessment, ed 4, Philadelphia, 2004, Saunders.)

12. Weight Goals For children, based on growth charts (see Appendix 12, Evolve) For adults, may use gerontology standards or the following for determination of IBW: Women: 100 lb for first 5 feet, 5 lb for each additional inch; subtract ½ lb for each inch under 5 feet Men: 106 lb for first 5 feet, 6 lb for each additional inch BMI increasingly serving as the standard for IBW

13. Adjusted Body Weight Calculation used for obese individuals to avoid providing excess kilocalories, protein, and fluids: Adjusted BW = Actual BW – IBW × 0.25 + IBW

14. Critical Illness Critical illness related to hypermetabolic state Includes concerns such as burns, AIDS, cancer Increased need for kilocalories Increased risk for muscle breakdown due tostress hormones Metabolic cart can help prevent overfeeding and reduce need for respiratory therapy Excess kilocalorie intake results in increased production of carbon dioxide

15. Diabetes in Acute Illness Keeping blood glucose normalized lowers risk of morbidity and mortality Insulin use is generally required for diabetes that otherwise may be treated with diet and exercise alone IV insulin algorithms advised in ICU settings to promote normal BG with lowered risk of hypoglycemia Consistent Carbohydrate diet increasingly being used rather than use of a No Concentrated Sweets diet

16. Nutritional Support The provision of nutrients that are in excess of usual needs through food (milkshakes or snacks) or special liquid supplements or through alternate sites (e.g., tube feeding through the nose to the stomach or intestinal tract or through an incision into the stomach or intestinal tract [enteral nutrition] or directly into veins or large arteries [parenteral nutrition]) “When the gut works, use it” Used in conditions of physiologic stress, such as burns, surgery, infections found with AIDS, or other catabolic states when a high-kilocalorie intake is needed to prevent weight loss and promote healing (an anabolic state)

17. Tube-Feeding Routes

18. Nutritional Support Issues Kilocalorie needs can increase from 20 kcal/kg BW to 45 to 50 kcal/kg; difficult to achieve this through oral intake alone Refeeding syndrome—nutritional support that is too aggressive can lead to low levels of blood potassium, elevated blood glucose levels, or fluid overload Monitoring of lab values and body weight is essential onat least a daily basis while nutritional support is being initiated Reducing the rate or type of feeding or decreasing fluid delivery may be warranted

19. Food and Drug Interactions Health care professionals should be aware of potential interactions and encourage review of medications and nutritional status issues with pharmacists Common issues Potassium-depleting diuretics Coumadin and need for stable vitamin K intake Anticonvulsants and folic acid deficiency Antidepressants and appetite changes

20. Long-Term Care MDS forms: multiple data systems; form used by members of the health care team for optimal documentation of resident needs Mealtimes have to be pleasant to ensure adequate nutritional intake. Some strategies include: Clearing bedside table Providing resident with clean dentures Focus on positive conversation Meal assistance with cutting of foods or openingcontainers, arranging for assistive feeding devices,helping with positioning for meals Describing foods for visually impaired residents

21. Pressure Ulcers Stage I: a nonblanchable area on the skin Stage II: an open sore or blister involving the epidermis or dermis layer Stage III: damage to the subcutaneous region and a crater is formed Stage IV: damage down to the muscle, bone, or tendons Suspected deep tissue injury: discolored intact skin or blood-filled blister (treated as Stage IV until otherwise staged) Unstageable: full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed (treated as Stage IV until otherwise staged)

22. Risk Factors for Pressure Ulcers Elderly population Immobility Malnourishment (albumin <3.5, anemia, or low BW) Dehydration (signs and symptoms or <1500 mL fluids) Incontinence Fragile skin Altered cognition Sensory loss Polypharmacy

23. Nutritional Treatment of Pressure Ulcers Stage I: no change required if calculated/assessed needs met for kilocalories, protein, vitamins/minerals Stage II: PRO at 1.2 g/kg BW Stages III, IV: PRO at 1.3-2.0 g/kg BW Supplement of vitamin C (500 mg) Supplement of zinc (220 zinc sulfate or 50 mg elemental zinc)* Kilocalories appropriate to meet goals of weight stabilization or gain Other minerals may be of benefit: copper, boron, manganese *Use for a few weeks only; avoid excess intake

24. Palliative Care: Noncurative Care Focus of long-term care and hospice services for terminally ill Diet restrictions eased or eliminated Food provided for comfort, not treatment