Responsibility for Health Care
Members of the health care team work together
to ensure that the nutritional needs of patients
are met during illness.
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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
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Height : 5 feet 9 inches
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Weight: 263 pounds
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BMI: 38
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BP: 158/88
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Pulse rate 82
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Respiration 16
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Blood glucose 210
❑
Blood urea nitrogen (BUN) 35 mg/dL
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Creatinine: 4 mg/dL
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Potassium: 5.2 mEq/L (milliequivalent)
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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.
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Refer to a dietitian specializing in renal nutrition.
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Review progression of renal failure.
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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.
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His fluids are restricted to 1200ml per day, & he is to consume a
daily diet of 2000 calories, 20 grams protein & 1 gram sodium.
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However, it is becoming difficult to get Henry to eat all his
food.
Subjective Assessment
❑
General malaise
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Weakness
❑
Muscle pain
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Irritability
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Anorexia
❑
Thirst
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Nausea & vomiting
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Premorbid weight: 205 pounds
Objective
Assessment
❑
Abdominal distention, ascites
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Peripheral edema, ankles & lower legs
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Jaundice of skin & sclera.
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Muscle wasting of upper extremities & thigh
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Body weight: 210 pounds vs desirable body weight
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Dark amber urine vs normal constituents of urine
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Radiographs show enlargement of the liver
Laboratory
results:
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Blood urea nitrogen: 7 (normal 8-25mg/dl
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Hematocrit: 40% (normal 45%-52%)
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Albumin: 3.0 (normal-5.0gm/dL)
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Serum liver enzymes: elevated
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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.
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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.
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Include high caloric snacks in consultation with the dietitian.
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Fried, fatty, dried & salty foods are to be avoided.
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Provide supplemental vitamins & liquid feedings such as Ensure or Ensure Plus.
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Record intake & output of foods & fluids.
Implementation # 2
(Nutrition Interventions)
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Maintain sodium restriction.
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Restrict fluids to 1200ml per day. (300ml/meal)
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Give ice, hard candy & lemon wedges as tolerated for thirst.
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Weigh & measure fluid intake & output.
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Administer diuretics as prescribed & monitor side effects.
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Measure abdominal girth in supine position daily at 10am.
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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.
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Nutrition education/counseling of the patient
THAT in ALL things God
maybe Glorified!
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