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Week 15. Diet Manual Nutrition Screening Calculating Nutrient Needs Interpreting Nutritional Data Documenting Nutritional Data. Chapter 6. Diet Manual. Diet Manual. Specifies therapeutic diets and their application Used as a reference book Standardizes names for diets

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Week 15

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Week 15

Diet Manual

Nutrition Screening

Calculating Nutrient Needs

Interpreting Nutritional Data

Documenting Nutritional Data

Chapter 6

Diet Manual

Diet Manual

  • Specifies therapeutic diets and their application

  • Used as a reference book

  • Standardizes names for diets

  • States what foods are allowed and which ones are to be omitted

Diet Manual

  • Readily available for all caregivers

  • Dictates what information may be given

    in nutrition education

  • Recommended by the Dietitian

  • Approved by the Medical Director

  • Must be updated every 5 years

Liberalized Modified Diets

  • Advantages

    • Improved dietary compliance

    • Improved psychosocial status of resident

    • Improved appearance and flavor of food

    • Enhanced calorie and nutrient intake

    • Increased accuracy and efficiency of trayline

Liberalized Modified Diets

  • Advantages (cont)

    • Improvement of fasting blood glucose levels

    • Improvement in ability to maintain acceptable weight and nutritional parameters

    • Decreased labor and food costs

Liberalized Modified Diets

  • Advantages (cont)

    • Improved surveys due to reduced chance of error

    • Improved quality of life for residents

    • Happy, healthy, and satisfied residents

Chapter 8

Nutrition Screening

Nutrition Screening

A systematic method of identifying individuals at risk for nutritional problems.

Nutrition Screening

  • Effective Screening Process

    • Uses meaningful criteria as identified by a nutrition professional

    • Sets meaningful thresholds that correspond to known risks

Nutrition Screening

  • Effective Screening Process (cont)

    • Is applied to every resident

    • Is implemented quickly at admission

    • Is implemented uniformly and consistently

Nutrition Screening

  • The Nutrition Care Process

    • Screens patients for nutrition risk

    • Assess each patient identified in screening process as “at risk”

    • Develop a care plan for each patient

    • Document, communicate, and implement the plan

    • Re-assess patient at defined intervals

    • As appropriate, revise the plan

Nutrition Screening

  • Nutrition Care Process

    • Nutrition Assessment

      • In-depth evaluation of a client’s nutritional well-being

    • Nutrition Diagnosis

      • Defines all nutrition related problems

        • Uses standardized terminology defined by the ADA

Nutrition Screening

  • Nutrition Care Process (cont)

    • Nutrition Intervention

      • Actions taken to correct a nutrition problem

        • This starts with a care plan

    • Nutrition Monitoring/Evaluation

      • Follow-up to determine if interventions are working

        • Interventions are revised as needed

Nutrition Screening

  • Indicators

    • Pieces of information that might suggest a concern or risk

    • Four basic indicators used in screening:

      • Anthropometric measurements

      • Biochemical tests

      • Clinical information

      • Diet history

Nutrition Screening

  • Sources:

    • Professional Organizations

    • Researchers

    • Educational Institutions

    • Nutrition and Pharmaceuticals

      • Nestle and Ross

    • Software packages

Nutrition Screening: Anthropometrics

  • Ideal body weight

  • Percent of ideal body weight

  • Percentage of weight change

Nutrition Screening: Anthropometrics

  • Standards of weight loss that indicate a risk:

    • > 5 % in one month 30 days

    • >7.5 % in three months 90 days

    • >10 % in six months 180 days

Nutrition Screening: Anthropometrics

  • Lean body mass

    • Weight of all parts of the body that are not

      fat e.g.: muscles, bones and organs

Nutrition Screening: Anthropometrics

  • Body mass index [BMI]

    • Standard for evaluating body weight based on the proportion of weight to height

    • BMI = weight in kg divided by the height in meters [39.37] squared

Nutrition Screening: Anthropometrics

  • Skinfold thickness

    • Measures percentage of body fat with the use of special calipers, at specified body locations

    • Desirable range men: 13-25 %

    • Desirable range women: 17-29 %

Nutrition Screening: Biochemical

  • Laboratory values to assess malnutrition:

    • Serum Albumin

    • Serum Transferrin

    • Serum Prealbumin

    • Hemoglobin

    • Hematocrit

Nutrition Screening: Diet

  • Diet History [Hx]

    • Assessment of food intake patterns

    • Describes actual food intake

    • Offers information about food preferences

      • May include factors regarding lifestyle, social factors, medical factors and conditions as well as medications

Nutrition Screening: Initiative

  • Founded in 1989

  • Developed a tool to identify nutrition risk factors in older adults:

    • DETERMINE- warning signs checklist

Nutrition Screening: Calculations

  • Basal Energy Expenditure [BEE]

    • How much energy the body needs at complete rest:

      • Breathing, brain function, heartbeat

    • Differs between men and women

    • Accounts for two-thirds of daily needs

Nutrition Screening: Calculations

  • Total Daily Expenditure [TDE]

    • Amount of estimated calories needed with an activity factor, and injury factor if needed, to maintain sound nutrition

      • Digesting food, moving and exercising, growing or healing, and fever

Nutrition Screening: Calculations

  • Caloric needs estimate

    • Accounts for the total amount of calories needed for one day

    • Included factors to account for other energy needs

      • Activity factors

      • Injury factors

        “An estimate is only an estimate”

Chapter 9

Calculating Nutrient Intake

Calculating Nutrient Intake

  • Caloric Distribution

    • Describes what proportion of total calories come from each macronutrient and alcohol if applicable

Calculating Nutrient Intake

  • Macronutrients providing calories:

    • CHO: 4 calories per gram

    • Protein: 4 calories per gram

    • Fat: 9 calories per gram

  • Alcohol: 7 calories per gram

Calculating Nutrient Intake: Protein

  • Estimating Protein Needs

    • Healthy adult: 0.8 grams per kg

    • Malnourished client: 1.2-1.5 grams per kg

    • Following surgery: 1.0-2.0 grams per kg

    • Trauma, burns, fractures: 2.0 grams per kg

Calculating Nutrient Intake

  • Sources of Nutrient Information

    • Bowes and Church’s: “Food Values of Portions Commonly Used”

    • USDA Nutrient Database

    • www.ars.usda.gov/main/site_mainhtm? modecode=12-35-45-00

    • Nutrient Analysis Software

Calculating Nutrient Intake: Nutrition Facts Labels

  • Nutrition Fact Label

    • Nutrition information on almost every food in the grocery store

    • Easy to read format

    • Information on amount of nutrients per serving

    • Standardized serving sizes

    • Nutrient reference values as percent daily values to fit into daily diet

Calculating Nutrient Intake: Nutrition Label Facts

  • Nutrition Fact Label [cont]

    • Uniform definitions

    • Nutrition claims

    • Declaration of total percent of juice in juice drinks

Calculating Nutrient Intake: Nutrition Label Facts

  • Daily Value [DV]

    • Generalized figures for nutrients that can be applied to healthy people as a single group

  • Daily Reference Values [DRV’s]

    • References used for fat, saturated fat, cholesterol, carbohydrates “fiber”, alcohols, protein, sodium, and potassium

  • Reference Daily Intakes [RDI’s]

    • References for essential vitamins and minerals

Calculating Nutrient Intake: Fluids

  • Calculating Fluid Intake

    • Healthy Adults: 30-35cc per kg

    • Heart Failure: 25-30cc per kg

    • If BMI >30, use adjusted body weight (ABW) as fat does not hold water

      • ABW= CBW – IBW x .25 + IBW

        • ABW ÷ 2.2 x 30cc= estimated fluid intake for healthy adult

Chapter 10

Interpreting Nutritional Data

Interpreting Nutritional Data

  • Nutrition Related Information

    • Medical record

    • Direct observation

    • Interview

    • Nutrition care documents

    • Communication with the health care team

Interpreting Nutritional Data

  • Food and Drug Interactions

    • Extent of interactions between food and drugs depends on:

      • Drug dosage

      • Individual age and size

      • Specific medical condition

Interpreting Nutritional Data

  • Examples of Food/Drug Interactions

    • Tetracycline and dairy

    • Fosamax taken without food

    • Excessive consumption of foods high in Vitamin K hinders the effectiveness of anticoagulants

    • Potassium-sparing diuretics interacts with large quantities of potassium in the diet, causing irregular heartbeat

Interpreting Nutritional Data

  • Comparing Nutrient Intake to Standards

    • Identify RDA’s for age/sex

    • Consider laboratory data, physician’s diagnosis, diet history, and food frequency

    • Consider intolerances to certain foods and be able to replace these foods with appropriate nutrients

      • Milk

      • Meat (chewing/swallowing difficulties)

Interpreting Nutritional Data and Dietary Management

  • Factors to Provide Effective Dietary Care

    • Blood sugar levels

    • Blood pressure readings

    • Meal time observations – tolerance to intake

    • Weight, Percent body weight, and weight changes

    • Pressure Ulcers

Interpreting Nutritional Data and Dietary Management

  • Factors to Provide Effective Dietary Care [cont]

    • Laboratory values

    • Clinical information

    • Calorie counts

Chapter 11

Documenting Nutritional Data

Documenting Nutritional Data

  • Purpose

    • Provides a reference that you and other caregivers use on an on-going basis

    • Communication tool with other members of the healthcare team

    • Required by government agencies

    • Lays the groundwork to receive reimbursement

    • Legal record

    • Quality standard

    • Resource to monitor quality of services

Documenting Nutritional Data

  • Medical Records

    • Also known as the medical chart or “chart”

    • Formal, legal account of a patient’s health and disease includes test results, diagnosis, and treatment plans

Documenting Nutritional Data

  • Problem Oriented Medical Record [POMR]

    • A system of collecting data and planning client care that focuses on the client’s problems, includes the following:

      • Collection of data

      • Problem list

      • Plans for addressing each problem

      • Evaluation of care plans

Documenting Nutritional Data

  • Progress Note

    • Notation in the medical record by a health professional

    • Written at key intervals during the course of a patient’s stay at a healthcare institution

      • Notes in the chart are structured according t the SOAP method format

        Subjective, Objective, Assessment, Plan

Documenting Nutritional Data

  • Rules for keeping good client records

    • Medical record is a legal document

    • Follow the rules per facility policy to prevent litigation

    • Used medical abbreviations per facility policy

    • Narrative documentation is usually used in long term care [LTC] facilities

Documenting Nutritional Data: Meal Related Documents

  • Diet Order

    • Diet prescribed by the physician for a individual client

      • Written order by physician in the medical record of available diets per diet manual

      • Verbal orders are discouraged because they do not provide solid documentation

Documenting Nutritional Data: Meal Related Documents

  • Tray Card

    • Identifies the resident

      • Room

      • Diet – color code

      • Consistency

      • Restrictions

      • Food preferences

Documenting Nutritional Data

  • Federal Regulations – Center for Medicare and Medicaid Services [CMS]

    • Resident Assessment Instrument [RAI]

      • Specialized form of medical documentation required of every healthcare institution receiving funding from CMS, includes:

        • MDS

        • Triggers

        • RAPS

Documenting Nutritional Data

  • CMS (cont)

    • Minimum Data Set [MDS]

      • Standardized reporting form used by members of the healthcare team to assess each resident

        • Dietary Responsibility – Section K (Oral/Nutritional Status)

          • In some facilities, may be responsible for section L (Oral/Dental Status)

Documenting Nutritional Data

  • CMS (cont)

    • Resident Assessment Protocols [RAP]

      • Guidelines to assess specific problems or potential problems identified through the MDS

        • Also known as “triggers”

      • Dietitians are responsible for:

        • Nutritional Status

        • Feeding Tubes

        • Dehydration/Fluid Maintenance

Documenting Nutritional Data

  • Long term care assessments must be completed as follows:

    • Quarterly assessment: every 3 months

    • Annual reassessment: every 12 months

    • Significant change in status: per occurrence as determined by MDS coordinator

Documenting Nutritional Data

  • Skilled nutritional assessments must be completed as follows:

    • Admission: 5-7 days

    • 14 day assessment

    • 30 day assessment

    • 60 day assessment

    • 90 day assessment

  • If resident is admitted to hospital and returns on skilled services, the process begins all over again

Documenting Nutritional Data

  • Health Insurance Portability and Accountability Act [HIPAA]

    • A federal law intended to protect the privacy of healthcare clients

    • Standardizes exchange of healthcare information

    • Patient information will be kept secure

    • Patient privacy and the right to keep personal and medical information confidential

    • Safeguards information from physical and technical hazards

Documenting Nutritional Data



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