Nutrition Care Planning Process in a Health Setting Assessing Patients Needs 1. Identification of previous/current health concerns is important a.

Reading medical chart, care plan meetings with other health team, use of interview techniques b. Determining if person is overweight/underweight or has had a change in weight that may be indicative of a change in health status c. Lab values include iron status, protein status, cholesterol and other blood fats like triglycerides, BG can help determine health needs 2. Assessment should include psychosocial issues which requires excellent communication skills to promote disclosure of potentially sensitive and personal lifestyle a. Developing rapport and trust is critical Anthropmetry: body measurements of size, weight, and proportions 1. Monitor weights and heights of children and any undesirable changes should be noted w/childs family 2. Growth charts are available for Down syndrome including other genetic disorders 3. As an art, it is recommended that he same individual must serve as a primary individual to measure weights 4. For pediatric-units in an acute-care setting, daily weights may be needed to ensure dehydration is avoided 5. For long-term settings, weight monitoring is done on a monthly basis, or weekly for high-risk individuals a. Those in hospitals or long-term care settings may be weighed using a Hoyer lift or bed scale 6. Dietitians measure elbow breadth, skinfold thickness, and mid-upper-arm circumference to determine extent of bodys fat and protein stores related to body frame size and height Body Weight (Formula for weight change is amount of weight loss/usual or last recorded weight x 100) 1. Measurement must be taken at first encounter w/resident and must regularly be monitored a. Weight is usually expressed as a percentage of ideal body weight of BMI and should also include percentage of weight change b. Any change can be misleading if individual is retaining fluid or dehydrated c. Significant weight loss 1. Unplanned weight loss of 5% or more in 30 days or 10% or more in 6 months Triceps Skin Fold 1. This is an index of the bodys fat/energy stores; A low skinfold thickness measurement indicates malnutrition 2. The most common site for measuring skinfold thickness is the posterior side of the nondominant upper arm at the midpoint. Accuracy and consistency are paramount. Midarm Circumference 1. Taking the measurement of midarm circumference of upper arm means the level of bodys protein stores, which are found mainly in the muscles 2. The nondominant arm is flexed at 90-degree angle and circumference is measured w/nonstretchable measuring tape after midpoint of upper arm is determined Elbow Breadth 1. Measurement determines body frame size; a reliable measurement that changes little w/age & not affected by body fat stores a. Helpful in finding desirable weight ranges because the body frame size reflects factors that influence weight, bone thickness, muscularity, and length of trunk related to total height b. Calipers applied to either side of the 2 prominent bones of elbow while forearm is bent upward 90 degrees 2. Accurate body composition measurements can be more difficult to obtain for obese people than for thin people because of the compression factor involving the use of calipers. However, anthropometric measurements are very useful because then help justify use of special nutrition support when a person is at risk for protein-energy malnutrition Biochemical & Clinical Data 1. Lab tests: blood, urine, and skin a. Protein-energy malnutrition in its various forms can be found by monitoring blood serum levels of albumin, transferrin, and lymphocytes b. A persons level of immunity is tested via skin antigen tests 2. Nitrogen balance study also helps in finding nutritional status and is tested from the urinary urea nitrogen content of a 24-hour urine collection a. Negative test finds that the body is using some of its protein reserves for energy

b. Clinical dietitians calculate nitrogen balance w/information and determine individuals protein needs Dietary History 1. Typically assessed by an RD, but other health professionals can assist 2. A variety of ways exist to assess nutritional intake, including 24-hour food recalls, food frequency checklists, and food diaries 3. Should be used in conjunction w/physical parameters of health Minimum Data Set Forms 1. Used in long-term care settings, minimum data sets (MDS) forms were made to help promote total health care team approach to ensure health during long-term care 2. Help organize critical health information useful in resident care meetings and to reassess intervention strategies How is the Older Adults Nutritional Status Assessed? 1. Factors include bone loss and shortening of spinal column indicates need for height measurement a. Height is frequently difficult to determine because of kyphosis (hunchback; an abnormal curvature of spine often related to osteoporosis), although knee height can be used to estimate true height 2. A calibrated balance-beam scale is recommended for weighing ambulatory adults a. Calibrated chair/bed scale may be used for those in wheelchairs or bedridden b. Weight should be monitored weekly in hospitals and monthly in other facilities, and caregiver should keep in mind that fluid retention and dehydration affects status. Weight stabilization is critical to reduce mortality and morbidity 3. Goal is to aim for standard normal values a. Albumin: greater than or equal to 3.5mg/dL; less than the value results in poor immunity, poor healing and skin breakdown b. Anemia is common; from renal insufficiency Planning Strategies 1. Brings together findings of assessment phase, starting with identifying priority health concerns, long-term health goals, and short-term objectives a. Identifying small, achievable, and measurable objectives aimed at long-term goals and specified health outcomes for behavioral changes b. Objectives 1. List of food quantities needed to meet the goal of 25g fiber 2. Determine insulin-to-CHO ratio for blood glucose 3. Increase protein intake to 1.2-1.5g/kg of body weight for albumin >3.5mg/dL 4. Encourage at least 1500ml fluids 5. Describe serving sizes to meet meal goal <800mg of sodium using food labels 2. The objectives might be evaluated/measured via follow-up counseling sessions, observations, or from improved lab values a. Writing out planning process is important because it raises effectiveness of intervention and communicates care plan to other members of the health team 3. Evaluation plan is important before intervention phase and also means changes in lab values or other outcomes 4. Intervention phase starts once the planned health outcomes are written or at least thought out or expressed verbally Intervention Strategies 1. Intervention approaches start with simple, brief, reinforcing messages 2. Verbal reinforcement of written education is more effective than handing brochure a. Reviewing food labels and describe amounts of sugar, sodium and fat b. Use of Internet 3. Prioritizing messages & offering sequential information needs to be elicit and for eating changes 4. Messages given should have positive reinforcement for behavioral changes & should be based on individual needs 5. Scare tactics causes inappropriate behaviors for health improvement; follow-up reinforcement/referral to other appropriate services can be helpful to continue development of more positive health habits Evaluation Strategies 1. This is the final step during planning and intervention phases 2. Forms of evaluations: ongoing, informal via observations or informal conversation; a more-formal is monitoring lab values

3. Also focuses on knowledge gained via verbal/written questions; before-and-after tests can solve outcome of planned intervention 4. Nutrition care plan always incorporate w/total health care plan for assess, identify, plan, implement and evaluate Does Choice Help in Compliance? 1. Chronic illness often is best controlled or managed via ongoing support services a. Developing goals and small achievable objectives also important and verbal commitment from a person can help stimulate likelihood that health change will be adopted Importance of Honesty and Respect in Patient Care and Education 1. It is okay to admit lack of knowledge when questioned but there is a lot to know regarding how food and nutrition affect health 2. It is much better to admit you do not know an answer than to give inaccurate information 3. Most important aspect of communication is respect a. Without it, all attempts at effective communication will be lost b. Aspect is recognizing learning readiness Role of Medical Nutrition Therapy in Setting 1. Involves issues of acute health needs, as well as chronic health concerns. Achieving optimal status before surgery reduces associated risks a. Nurse/CAN working in home care may need to know how to apply medical nutrition therapy for meal prep. 2. When an individual is admitted to a facility, the HCP will select the type of diet, often w/input from staff dietitian a. Also responsible for ordering diets 3. Food is appealing if served at proper temepature and ASAP after preparation to maintain palatability a. Possible to cut into bite-sized pieces, butter bread, and open containers if individual is unable to perform those tasks due to weakness/pain from arthritis 4. Respect and dignity are important to the elder population, thus address by last name by Mr., Miss, or Mrs. a. Food items and their location on plate and at the place setting should be identified for a visually impaired person, and is vital that each bite of food to be explained in advance to promote trust Suggestions to Promote Intake at Mealtimes 1. Attractive food services plays a role in stimulating appetite & enjoyment of food a. Brushing teeth/rinsing of mouth before eating can stimulate appetite b. Use of colorful napkins and tray decorations also stimulates appetite 2. Persons room should be adjusted for adequate, but not glaring, light and a comfortable temperature a. If the person is blind, foods should be described before eating starts; medications for pain/nausea is sometimes recommended for improved meal intake 3. An individual is properly positioned for eating if the following are true a. Head & upper trunk are as upright as possible; feet adequately supported; table height is appropriate b. Arms are centered close to body; person seated close to table; head tipped slightly forward; hips & knees flexed to an 85-degree angle Healthcare Problems Addressed in Institution or Home: Pressure & Other Skin Ulcers 1. Skin breakdown contributes to mortality & morbidity; long-term care facilities are under strict regulations to reduce rates a. Multidisciplinary wound care teams that conduct rounds at bedsides are highly recommended b. Development affects 10% of admissions w/elderly patients at highest risk 2. Braden and Norton scales are scoring systems for determining risks of pressure ulcers a. Being elderly; immobility; incontinence; fragile skin; altered cognitions; sensory loss; polypharmacy b. Malnutrition; dehydration c. Stage 1: nonblanchable area on skin (doesnt turn white when pressure is applied) d. Stage 2: an open sore/blister involving epidermis and/or dermis layers e. Stage 3: Damage to subcutaneous region is present and a crater forms f. Stage 4: Damage down to muscle and bone, sometimes tendons, occurs 3. Other factors include ischemic ulcers (cure is revascularization), venous ulcers (cure is need adequate edema control for healing), and neuropathic ulcers (with pressure ulcers as well, the cure is pressure relief) 4. For wound healing, 500mg vit.C and 220mg zinc sulfate (50mg elemental type) is often a standard protocol

a. DRI for zinc >70 years of age is 8mg in women and 11mg for men 5. An increased amount of protein is advised (1.2-2.0g PRO/kg of body weight depending on severity) a. Arginine important for stages 3 & 4 1. L-arginine could be detrimental in an inflammatory state and advised in large doses only in critically ill persons under careful monitoring study conditions 6. 30-35kcal/kg of body weight generally needed for healing; elders is 25-30 per day Healthcare Problems Addressed in Institution or Home: Surgical Wounds 1. Those w/malnutrition risk of postop. complications (impaired healing) a. Serum zinc levels proved for delayed wound healing; zinc and/or Vit.C should be given at time of surgery Healthcare Problems Addressed in Institution or Home: Bone Fractures 1. Zinc shown to promote healing of bones; Vit.E have positive effects for healing (with peanut butter & seed oils) Healthcare Problems Addressed in Institution or Home: Burns 1. Results in fluid loss and potentially a deficit of as much as 100g PRO in a day a. Those with burns average a need of 5000kcal/day during the acute phase b. Nutrients affected include zinc and copper c. Even at intakes of 3xs the DRI, the mean plasma concentration of Zn and Cu still remain low d. Cure: Fluid intake needs to be increased during the healing of burns 2. Due to a hypermetabolic state, kcal needs are increased w/burns; arginine & glutamine may be of additional value; supplements A and C advised Healthcare Problems Addressed in Institution or Home: Critical Care 1. Diabetes: requires insulin during an acute illness; hyperglycemia is common a. Liquid nutritional supplements w/high CHO content may need to be used carefully, and postprandial BG monitoring may be warranted to ensure tolerance 2. Magnesium deficiency: associates w/higher mortality and worse clinical outcomes in an ICU setting a. Implicated in hypokalemia, hypocalcemia, tetany, and dysrhythmia Healthcare Problems Addressed in Institution or Home: Traumatic Brain Injury (TBI) 1. TBI occur via sports injury or a variety of means a. Evidence shows minimizing neurologic damage associates TBI; adequate zinc status appears to reduce amount of cell death after brain injury, but follows TBI Healthcare Problems Addressed in Institution or Home: HIV and AIDS 1. HIV results in AIDS or AIDS-related complex (ARC) a. The first stage of being HIV positive is ARC b. With immune system still functioning, it is important to balance optimal nutrition status c. Preserving lean body mass via avoidance of weight loss is critical 1. Selenium, glutamine, cysteine, and tryptophan for preserving immune function w/HIV 2. AIDS is a hypermetabolic state requiring an increased kcal intake -> 3500+kcal/day a. Thrush causes an increased need for kcal because of the accompanying fever including reduced desire to eat b. Abdominal discomfort & diarrhea associated w/malabsorption of nutrients compound the lack of eating 3. Dementia can cause disorientation; depression is common and lowers desire to eat; social isolation known as well 4. Cocktails for HIV shown significant impact on preserving immune system 5. Certain medicines used in treating HIV promotes higher triglyceride levels and central obesity Indications for Nutritional Support 1. Nutritional support is the provision of macronutrients to promote healthy weight management & status a. Used during physiologic stress (increased amounts of stress-related hormones like surgery, fractures of long bones and other trauma, burns, infection, or fevers), when oral intake from standard meals cannot keep kace with increased metabolic needs of stress state 2. Nutritional support is usel for anyone who has had an unplanned weight loss of 10% or more w/in 6mos; shows a significant muscle mass loss; serum albumin level <3g/dL, serum transferrin level <150mg/dL or both; or is scheduled for major surgery 3. Enteral nutrition: type of support if GI tract is function; liquid nutrition supplements by way of small intestine 4. High-kcal, high-protein foods, fortified foods used; w/poor intake of food, a multivitamin & mineral supplement used 5. Role of CAN is to estimate kcal and nutrients consumed in relation to requirements