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
•
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
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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