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

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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 1.2

Skeletal Trauma 1.35

Major Sepsis 1.6

Severe Burns 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 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)

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

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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

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Regular Diet

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

Other Terms

• ADAT—

• DAT –

• DOC –

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