Responsibility for Health Care Members of the health care team work together to ensure that the nutritional needs of patients are met during illness. ❑ Nurses interact closely with patients (the front liners); they listen, monitor & record patients condition give feedback & provide holistic health care. ❑ Physicians prescribe the diet orders. They rely on nurses & other health professionals to alert them on nutrition related problems. Responsibility for Health Care ❑ Registered Nutritionist-Dietitian’s conduct nutrition & dietary assessment etc., plan & approve menus, provide nutrition education. ❑ Other health care professionals must assist in the health care process. Nutrition Care Plan Case Study 1: Renal Failure Tim, age 61, has a long history of hypertension, type 2 diabetes mellitus, & osteoarthritis. His latest blood work has shown an acceleration of renal failure, & he has come to the clinic to discuss additional dietary management with the nurse. He has been faithful in keeping appointments & taking medications, but he frequently jokes with the staff that he is “too far gone” to do much with diet. He has struggled with obesity his entire adult life & says he likes himself the way he is. He retired from being a mail carrier 5 yrs. ago because his knees hurt so badly. Knee replacement surgery was done 3 yrs. ago. His days are filled with reading, watching tv & visiting with a large extended family. He tells the nurse that he wants to avoid dialysis but cannot envision a diet that he & his wife could follow. The Nutrition Care Process Nutrition ASSESSMENT Data about the patient SUBJECTIVE Data Signs & symptoms as experienced & verbalized by the patient. OBJECTIVE Data Anthropometric & Clinical Data etc. Nutrition DIAGNOSIS Obesity, Diminished Renal Perfusion PLANNING- Nutrition Goal/Expected outcomes Weight loss, Accept foods with high biologic value protein, low K & low Na IMPLEMENTATION of Nutrition Interventions Limited amounts of high biologic value protein, low K & low Na Monitoring & EVALUATION of the nutrition care process Was the goal achieved/Does the intervention need to be modified? Objective Assessment ❑ Height : 5 feet 9 inches ❑ Weight: 263 pounds ❑ BMI: 38 ❑ BP: 158/88 ❑ Pulse rate 82 ❑ Respiration 16 ❑ Blood glucose 210 ❑ Blood urea nitrogen (BUN) 35 mg/dL ❑ Creatinine: 4 mg/dL ❑ Potassium: 5.2 mEq/L (milliequivalent) ❖ Note: Get sample blank form. Overall Assessment Combined findings & analysis ❑ medical history, ❑ social history ❑ diet history: ❑ biochemical analysis & ❑ physical examination. : Nutrition Diagnosis ❑ Obesity related to impaired glucose metabolism & excessive caloric intake evidenced by BMI of 38. ❑ Diminished renal perfusion related to accelerating renal failure evidenced by changing lab values. ❑ Inadequate knowledge related to stated lack of interest in learning evidenced by frequent statements that he likes himself “as is”. Implementation of Nutrition Interventions ❑ Diet Plan that includes limited amounts of high biologic value protein & food low in potassium & sodium. ❑ Review foods included as part of a diabetic diet. ❑ Refer to a dietitian specializing in renal nutrition. ❑ Review progression of renal failure. ❑ Nutrition Education by the patient Nutrition care process Evaluation ❑ Tim has continued to keep appointments for the past 2 months. His blood glucose remains stable, although elevated. His renal function tests are unchanged. ❑ He says that the diet is not his “style”, but that he has made an effort to drink less soda & orange juice. Describes himself as a “meat & potatoes man” & says he has no interest in making major dietary changes at this point. He lost 5 pounds but attributes it to taking more walks with his wife. ❑ The nurse continues to share information about the importance of using diet to delay progression of renal failure. Case study 2: Cirrhosis of the Liver ❑ Henry is seriously ill with cirrhosis of the liver related to chronic hepatitis as a result of contracting hepatitis B. The liver damage is progressive. ❑ He has developed severe ascites & mild encephalopathy. He is being treated with diuretics & lactulose to reduce ammonia levels. ❑ His fluids are restricted to 1200ml per day, & he is to consume a daily diet of 2000 calories, 20 grams protein & 1 gram sodium. ❑ However, it is becoming difficult to get Henry to eat all his food. Subjective Assessment ❑ General malaise ❑ Weakness ❑ Muscle pain ❑ Irritability ❑ Anorexia ❑ Thirst ❑ Nausea & vomiting ❑ Premorbid weight: 205 pounds Objective Assessment ❑ Abdominal distention, ascites ❑ Peripheral edema, ankles & lower legs ❑ Jaundice of skin & sclera. ❑ Muscle wasting of upper extremities & thigh ❑ Body weight: 210 pounds vs desirable body weight ❑ Dark amber urine vs normal constituents of urine ❑ Radiographs show enlargement of the liver Laboratory results: ❑ Blood urea nitrogen: 7 (normal 8-25mg/dl ❑ Hematocrit: 40% (normal 45%-52%) ❑ Albumin: 3.0 (normal-5.0gm/dL) ❑ Serum liver enzymes: elevated ❖ Compare with normal constituents of the blood Nutrition Diagnosis #1 ❑ Altered nutrition, less than body requirements related to anorexia, nausea & vomiting as evidenced by muscle wasting & loss of true body weight. #2 ❑ Fluid volume excess related to increased intrahepatic pressure & decreased colloidal pressure as evidenced by ascites & peripheral edema. Planning Nutrition Goals ❑ Provide optimal intake of nutrients & calories to promote liver tissue healing. ❑ No further weight loss other than that accounted for by fluid loss. (note: every 500ml of fluid loss is equivalent to 1 pound weight loss.) ❑ Reduce fluid excess in the body by 1000ml of fluid. ❑ Implementation # 1 (Nutrition Plan a diet high in CHO &Interventions) calories with moderate amounts of fat & protein. Small frequent meals that the client likes/preferred. ❑ Include high caloric snacks in consultation with the dietitian. ❑ Fried, fatty, dried & salty foods are to be avoided. ❑ Provide supplemental vitamins & liquid feedings such as Ensure or Ensure Plus. ❑ Record intake & output of foods & fluids. Implementation # 2 (Nutrition Interventions) ❑ Maintain sodium restriction. ❑ Restrict fluids to 1200ml per day. (300ml/meal) ❑ Give ice, hard candy & lemon wedges as tolerated for thirst. ❑ Weigh & measure fluid intake & output. ❑ Administer diuretics as prescribed & monitor side effects. ❑ Measure abdominal girth in supine position daily at 10am. ❑ Teach the importance of maintaining fluid restriction to family members. Nutrition care process evaluation Achievement of goals as evidenced by: ❑ Henry lost more than 1000ml fluid (1pound) in 1 week. ❑ Nutrition education/counseling of the patient THAT in ALL things God maybe Glorified!
