1. NS420 Unit 4: In-Patient Counseling Brooke Benton MS, RD, LDN, CDE

2. Inpatient Counseling and The Continuum of Care

3. Benefits of Clinical Nutrition Services in Acute Care Early detection of nutrition-related problems and appropriate nutrition interventions are effective in helping the patient recover more quickly and decrease the length of stay MNT is an integral part of disease prevention, treatment, and recovery, and is necessary to maintain quality of care and achieve cost savings

4. Changes in Health Care Climate Health care has been increasingly affected by regulatory changes, increased market competition for patients & hospital mergers and affiliations Already the US has spent approx 15.3% of its gross domestic product in 2003 on medical care & it may increase to 18.7% by the year 2014 The opportunities to provide inpatient nutrition counseling continue to decrease as patients are discharged from acute care settings sooner & sicker

5. Value of Screening in Patient Outcomes and Cost Containment A nutrition screening program is an inexpensive method to streamline clinical nutrition care and identify those patients at nutritional risk who are most likely to benefit from special nutrition intervention during their hospital stay

6. Considerations for Inpatient Counseling

7. When Time is Short The typical abbreviated, but essential need to know information used in inpatient counseling involves: –Establishing behavioral diagnoses –Assessing what the client wants to learn

8. Survival Nutrition Counseling Patients and physicians expect (and accrediting agencies require) that appropriate nutrition education takes place, if possible in the hospital setting so the patient and his or her family do not aggravate, but instead encourage improvement of the patient’s physical state Survival nutrition counseling may include basic types of foods to limit or avoid, portion sizes, and meal frequency

9. QUESTIONS??

10. Learning Activity 1 For each admitting diagnosis or situation, describe your approach for inpatient nutrition care and “survival” nutrition counseling components you would address.

11. Diagnosis #1 Post Cardiac Bypass Patient

12. SURVIVAL SKILLS FOR POST CARDIAC BYPASS PATIENT Limit saturated fat intake – discuss types of food and portion sizes Limit cholesterol – discuss types of food and portion sizes Limit sodium – discuss types of food

13. QUESTIONS??

14. Diagnosis #2 Uncontrolled type 2 diabetes admitted with diabetic ketoacidosis (DKA)

15. SURVIVAL SKILLS FOR UNCONTROLLED TYPE 2 DIABETES Importance of regular meals and snacks Discuss carbohydrates and appropriate serving sizes of these foods Space out carbohydrates over meals and snacks to avoid hyperglycemia Importance of maintaining a healthy weight

16. QUESTIONS??

17. Diagnosis #3 Peptic ulcer disease, admitted with a GI bleed

18. SURVIVAL SKILLS FOR PEPTIC ULCER DISEASE Small frequent feedings Include high protein and vitamin C foods to speed healing Limit gastric stimulants

19. QUESTIONS??

20. Diagnosis #4 Acute pancreatitis with a history of alcoholic cirrhosis

21. SURVIVAL SKILLS FOR ACUTE PANCREATITIS Light, moderate fat diet Six small meals a day Tips for nausea & vomiting Omission of alcohol

22. QUESTIONS??

23. Diagnosis #5 Pneumonia with a recent weight loss of ten percent in the past month

24. SURVIVAL SKILLS FOR PNEUMONIA WITH RECENT WEIGHT LOSS If dehydrated, address fluid intake High energy foods Meal supplements to increase kcals & protein Small, frequent meals

25. QUESTIONS??

26. Group Therapy

27. Where individuals with similar nutrition-related problems come together to work through those problems Group therapy members discover that the group has the capacity to support and love, and to provide a release for anger or problem solving Group therapy usually attracts a population at less nutritional risk than those who require intense, individualized care

28. Group Process The series of actions or operations that lead growth in a group therapy setting –Humor breaks the tension and helps people share common pleasurable moments –Sensitivity to the needs and feelings of others in the group –Participation by every member of the group is the backbone of good group process –Experience is the key to learning in the small group setting –Risk should be minimized –Openness should be encouraged

29. Group Process Continued Step 1: Establish a productive counselor- participant relationship Step 2: Balance the facilitator generated and group generated information Step 3: Design problem-solving strategies Step 4: Provide the opportunity for group members to practice new skills Step 5: Use positive role models and good pacing to keep the group motivated Step 6: Ask for evaluation and feedback

30. Advantages of Groups Timesaving Cost Effective More social and peer support Members feel accepted, loved and not alone More viewpoints and problem-solving opportunities Sharing with others can help with coping or changing thoughts or behaviors

31. Disadvantages of Groups May be uncomfortable to disclose information to so many May get lost in a group and not deal with problems May get bored because discussion not on topics of interest to the member Sessions may be productive or not, depending upon personalities involved

32. Role of Facilitator The facilitator is responsible for the following: –Organizing the group and establishing a comfortable atmosphere –Keeping the group focused and productive –Monitoring the discussion and keeping any records –Stimulating exploration and self-discovery by group members –Offering strategies for cognitive and behavioral change –Acting as a nutrition resource for food choices, menu planning, new food products, and diet therapy questions –Maintaining control of the therapy situation, which may include keeping interaction between participants nonthreatening; making sure participants act and speak civil to one another; or removal of a disruptive participants

33. Why People Join or Leave Groups Factors that increase the attractiveness of the group: –Cooperation –Interaction –Size –Success

34. Potential Problems with Groups The sluggish group The hostile group The timid member The domineering member Silence serves a purpose

35. QUESTIONS??

36. A 56 year old male, E.O, is present in the hospital for dilation of the esophagus due to severe gastroesophageal reflux (GERD). Patient has a past medical history of diabetes, cardiovascular disease and hypertension. Patient indicates that over the past month he has not been able to eat much food and what he does eat keeps coming back on him. He reports that he has lost approximately 10 pounds within the past month and cannot stand to drink any supplements like Ensure. He wants to know what he can eat after the surgery. Height: 6’0” Weight: 200 pounds Weight history: 215 pounds (4/5/09) Labs: Bedside glucose- 150-200 mg/dL, Albumin 2.5 mg/dL Meds: Humalog, Lantus, HCTZ, Simvastatin What stage of change do you believe patient is in? What do you believe his compliance is after being discharged from the hospital? What is his BMI? What about his labs- should you be concerned and why? What type of diet would you provide to patient after surgery? What type of goals would you establish with him? When would you follow up with him? Counseling Inpatients

37. A 75 year old female, S. H., is present in the hospital for open heart surgery. Patient has a past medical history of angina and high cholesterol. She reports that she generally eats a well balanced diet by including fruits and vegetables and higher fiber foods, but thinks because her husband and her go out to eat frequently the salt content is too high. She reports she walks 5 days per week rain or shine for about 1-2 miles and was feeling very good and is pretty shocked she had this surgery. Height: 5’4” Weight: 130 pounds Labs: Cholesterol 240 mg/dL, LDL 150 mg/dL, HDL 45 mg/dL, Triglycerides 120 mg/dL Meds: Lisinopril, Tricor, Multivitamin, Vitamin E What stage of change do you believe patient is in? What is her BMI? What about her labs- should you be concerned and why? What type of diet would you provide to the patient? What type of goals would you establish with her? When would you follow up with her? Counseling Inpatients

38. A 6 year old female, R. F., is present in the hospital with nausea and vomiting. Patient has a past medical history of asthma. Mom reports that daughter has not been eating well in the past week and thinks she has lost some weight, but does not weigh her. She reports daughter has only had ½ piece of toast with butter and jelly and 1 cup of juice this morning for breakfast. Patient has agreed to have a milkshake in the afternoon. Height: 120 cm Weight: 55 pounds Previous weight in chart 1 year ago: 40 pounds Meds: Inhaler How does her height and weight compare to the growth charts? What type of diet would you discuss with mom and patient? What goals would you establish with the patient? When would you follow up with patient? Counseling Inpatients