Approach to the Hospitalized Patient: Nutrition Care Process and Nutrition Screening

Approach to the Hospitalized Patient: Nutrition Care Process and Nutrition Screening Screening Nutrition Assessment Nutrition Monitoring and Evaluation Nutrition Diagnosis Nutrition Intervention Nutrition Assessment • Take a systematic approach for – Data collection – Recording data – Interpretation of that data • Ongoing process – Includes assessment and reassessment Nutrition Diagnosis • Identify and label an existing nutrition problem • The nutrition professional is responsible for treating this problem • The Academy of Nutrition and Dietetics has a list of diagnoses – These may or may not meet your needs Nutrition Intervention • A purposefully-planned action or actions designed to treat a nutrition related: – Behavior – Risk factor – Environmental condition – Some other aspect of health status • This step includes both the planning and the intervention Nutrition Monitoring and Evaluation • Identify progress made • Determine if goals and/or expected outcomes are being met • Must be relevant to the initial diagnosis, intervention plan and goals Nutrition Care Algorithm Not at Risk Continued Inpatient Care? Admission Patient Screening Not at Risk Periodic Re-Screening Discharge Planning/Continuity of Care No Yes Goals Achieved Patient Monitoring At Risk Patient Assessment Development of Nutrition Care Plan JPEN J Parenter Enteral Nutr 2011;35; 16-24 Change in Status Implementation of Nutrition Care Plan Patient Re-assessment and Updating of Nutrition Care Plan Termination of Therapy References to Consider • Nutrition Care Process and Model Part 1: The 2008 Update Journal of the American Dietetic Association 2008;108:11131117 • Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process Journal of the American Dietetic Association 2008;108:1287-1293 • International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, 3rd Edition 2010 • Mueller C, Compher C, Druyan ME et al A.S.P.E.N Clinical Guidelines: Nutrition screening, assessment, and intervention in adults JPEN J Parenter Enteral Nutr 2011;35:16-24 Nutrition Screening What is Screening • WHO Definition – The use of simple tests across a healthy population in order to identify the individuals who have disease, but not yet have symptoms • Acute Care Setting: – The use of simple tests across a population in order to identify the individuals who have disease, but not yet have symptoms • Screening does not diagnose illness – Those who screen positive are sent on for further assessment Broad Categories of Diet Modifications (continued) • Adjust level, ratio, or balance or protein, fat, and carbohydrate – Examples: diabetes, ketogenic, renal, cholesterol-lowering • Rearrange number and frequency of meals – Examples: diabetes, postgastrectomy • Change route of delivery of nutrients – Examples: enteral or parenteral The Right Diet for the Right Patient • What will help your patient the most? – Your heart-failure patient is admitted with fluid overload and is on high-dose diuretics • What is the most important dietary intervention in this case? – A patient was admitted with severe nausea & vomiting, now improving and the team wants to allow the patient to eat • What you start with? More examples… • A 91 y.o woman was admitted from her nursing home with chest pain and question of an MI The admitting physician orders a “heart healthy” diet You assess the patient and find that she is severely underweight – What you recommend? – What would you differently if the patient was a 39 year old man with a BMI of 40? More to think about • Try to honor food preferences • Be aware of food allergies & intolerances – Lactose intolerant patient getting a full liquid diet?? • Honor religious food practices Other Considerations for Nutritional Care for the Hospitalized Patient • Make the menu appealing! • Attention to color, texture, composition, and temperature of foods • Sound knowledge of therapeutic diets • Patient selection of menus increases consumption Food Intake • Monitoring intake to prevent iatrogenic malnutrition • If intake is inadequate, provide other food or supplements • Communicate with nursing and food service personnel Monitoring Oral Intake • Meal rounds – Visit your patients while they are eating – Direct observation can help identify • Difficulties self-feeding • Difficulties chewing/swallowing • Talking to patient’s family members • Talking to nursing staff & patient care assistants More Ways to Monitor • Calorie counts – More objective measurement of intake – Accuracy of information will depend on who is doing the recording • Is patient motivated enough & able to by himself or herself? • Is it the person delivering & removing the patient’s tray? • Is it the patient’s nurse? – Express amounts eaten as percentages of energy & protein requirements Factors to Consider if Oral Intake is Poor • Food as a source of pleasure • Consider environment, arrangement of tray • Encourage independence in eating • Improving food acceptance • Attitude of caregiver • Therapeutic diets What you if your patient can’t eat enough? • Depending on the situation, you would consider the following: – Oral nutritional supplements • Either between meals or with meals – Nutritional support • Enteral or parenteral nutrition Oral Supplements • Between meals vs with meals • Added to foods • Added into liquids for medication pass by nursing • Enhances otherwise poor intake • May be needed by children or teens to support growth Intervention: Nutrition Education • Important part of MNT • Goal is to help patient acquire knowledge and skills to make changes, including modifying behavior • Benefits of successful nutritional change: – Control of disease or symptoms – Improved health status and quality of life – Decreased health care costs Palliative Care • Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently • Quality of life • Communication with family members Nutrition Care of the Terminally Ill or Hospice Patient • Main goals: maintain comfort and quality of life • Dietary restrictions are rarely appropriate • Consider strategies that facilitate symptom and pain control Summary • All hospitalized patients should be screened for nutritional risk • Use a validated screening tool • Nutrition intervention is planned after the nutrition assessment • Nutrition interventions may include modified diets, nutrition education, oral supplements, or nutrition support • As students progress through Medical Nutrition Therapy, they will learn how to all of these things! ... assessment and reassessment • Allows the clinician to gather more information and determine: – If there truly is a nutritional problem – The name of the nutritional problem – The severity of the nutritional... Journal of the American Dietetic Association 2008;108:11131117 • Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process. .. Implementation of Nutrition Care Plan Patient Re-assessment and Updating of Nutrition Care Plan Termination of Therapy References to Consider • Nutrition Care Process and Model Part 1: The 2008 Update