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 Longs 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 Bedrest1.2 Ambulatory1.3 IF = Injury Factor Minor Surgery 1.2 Skeletal Trauma1.35 Major Sepsis1.6 Severe Burns2.1 (depends on %BSA burned)

5. Practice Example: Mrs. H is a 64 y/o female ht: 54, wt: 146# Admitted for minor surgery, after which shell be on temporary bed rest. Calculate her energy needs using Longs 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 57 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:

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 OR 21 kcal/kg if obese

11. Protein Needs Based on present nutr. status and stress level: Normal0.5 - 0.8 g/kg/day Mild 0.8 - 1.0 g/kg/day Moderate1.0 - 1.5 g/kg/day Severe1.5 - 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 clients needs.

17. The Diet Order Physicians 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 hospitals 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 Well 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 Institutions 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 havent 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 patients 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