Week 16

1. Week 16 • Working With the Healthcare Team • The Nutrition Care Plan • Evaluating Effectiveness of Nutrition • Conducting Nutrition Education • Evaluating the Effectiveness of Education • Continuous Quality Improvement

2. Chapter 12 Working With the Healthcare Team

3. Working With the Healthcare Team • The healthcare team is the group of professionals, each with unique training and expertise who contribute to the overall care of the patient, client, or resident.

4. Working With the Healthcare Team • Members of the healthcare team: • Administrator • Dietitian • Dietetic Technician • Dietary Manager • Nurse • RN, LPN, STNA • Therapy • Physical Therapist • Occupational Therapist • Speech Pathologist • Physician • Social Worker

5. Working With the Healthcare Team • Administrator (LTC Facility) • Responsible for all aspects of patient care. • Establishes the standards for the quality of care. • Coordinates the functions of all employees in meeting the established standards. • Ensures adequacy of staffing to implement and maintain the system.

6. Working With the Healthcare Team • Dietitian • Has completed a four year program in dietetics approved by the American Dietetic Association (ADA). • Has successfully completed ADA’s credentialing examination in order to become an RD. • May be Full or Part Time, or a Consultant depending upon the size of the facility. • Assumes responsibility and accountability for nutrition screening and resident nutrition care planning.

7. Working With the Healthcare Team • Dietitian (cont) • Performs nutritional assessments. • Develops nutrition care plan. • Defines the role of the dietary manager and provides training. • Provides nutrition counseling. • Develops and evaluates educational materials • Monitors the accuracy of dietary and nutrition services • Participates in quality management

8. Working With the Healthcare Team • Dietetic Technician, DTR • Has a completed a two year degree program or four year program approved by the American Dietetic Association (ADA). • Has successfully completed ADA’s credentialing examination to become a DTR. • Nutrition Associates, Nutrition Care Technicians • Four year degree from a traditional dietetic program. • Have not taken the DTR examination, thus cannot call themselves DTR’s. • All work under the supervision of a dietitian to provide nutrition care.

9. Working With the Healthcare Team • Dietary Manager • Has completed a dietary managers training program approved by the Dietary Manager’s Association (DMA). • Has successfully completed the national credentialing examination to become a Certified dietary manager (CDM). • Interviews clients for diet history. • Conducts routine screening and collects data for assessments.

10. Working With the Healthcare Team • Dietary Manager (cont) • Calculates nutrient intake/calorie counts. • Implements diet plans. • Evaluates the effectiveness of the nutrition care plan. • Counsels clients on basic diet restrictions. • Specifies standards and procedures for food preparation in order to comply with diet restrictions

11. Working With the Healthcare Team • Nurse • RN • Primarily responsible for maintaining appropriate care for the patient and carrying out the physician’s orders. • LPN • Works under the supervision of the RN to provide the proper care. • STNA • Works under the supervision of RN/LPN to provide proper care.

12. Working With the Healthcare Team • Nurse (cont) • Assesses patient needs, develops, implements, and monitors care plan. • Delivers direct nursing care. • Ensures that resident consumes food: • Organizes the resident feeding responsibilities. • Distributes the workload • Determines need for adaptive eating devices with input from the occupational therapist • Assists with mealtimes and feeding. • Records accurate and meaningful information about the client’s food and fluid intake.

13. Working With the Healthcare Team • Therapy • Physical Therapist • Helps the patient learn to compensate physically for disease and/or disability. • Occupational Therapist • Helps the patient learn to live with disabilities and while providing therapy to develop fine motor skills. • Often recommends assistive eating devices and other techniques to help patients feed themselves. • Speech Pathologist • Evaluates chewing and swallowing function with appropriate therapy for dysphagia. • Provides evaluation and therapy for speech-related needs.

14. Working With the Healthcare Team • Physician • Evaluates medical conditions and develops diagnoses. • Plans, oversees, and monitors treatment. • Utilizes information provided by other members of the healthcare team. • Bears the major responsibility for the nutritional status of the resident. • Writes diet orders and/or approves protocol for standard orders. • Orders other treatments which affect nutritional status.

15. Working With the Healthcare Team • Social Worker • Evaluates social and supports needs. • Helps patients and families plan care upon discharge from a healthcare facility. • Assists patients and families with decision-making. • Assists with applying for other healthcare services, such as home care and meals-on- wheels. • Identifies resources. • Provides counseling.

16. Working With the Healthcare Team • Gathering and Sharing Information • While the details of each care plan may differ, the overall objectives are in unison. • Each member of the team participates in: • Assessing patient needs • Developing a plan of care • Evaluating a plan of care • Providing education to clients

17. Working With the Healthcare Team • Team Approach to Improve a Patient’s Nutritional Status: • Physician orders a diet. • Dietary Manager obtains a diet history. • Speech Therapist recommends appropriate texture. • May develop specific techniques to manage swallowing • Occupational therapist assists with strength and skills to feed self effectively.

18. Working With the Healthcare Team • Team Approach to Improve a Patient’s Nutritional Status (cont): • Nursing provides hands-on set-up and assistance at mealtime. • Nursing and dietary monitors diet tolerance and intake. • Dietary Manager develops menu and manages food production to ensure that the patient receives appropriate foods that is appetizing.

19. Working With the Healthcare Team • Typical record (chart) includes the following components: • An admission sheet listing patient information, admission date, reason for admission, names and contact information. • A section for physicians’ orders, including diet, medications, tests, and treatments. • A section for test results. • A section for progress notes.

20. Working With the Healthcare Team • Care Conferences • A meeting of the healthcare team members with the objective or planning and evaluating care for each patient at a facility. • Held at least quarterly. • All departments responsible for the care of the patient are represented. • The patient and/or family member may be present.

21. Working With the Healthcare Team • To prepare for the plan of care meeting, the dietary manager should: • Review the nutritional status of the patient. • Have knowledge of eating and feeding abilities • Have knowledge of percentage of meal consumption • Have information on fluid intake

22. Working With the Healthcare Team • Dietary Manager preparation/care conference (cont) • Be a liaison with the Dietitian to make suggestions as to resident nutritional status • Have written progress notes in compliance with MDS • Follow through with any requests from plan of care team for patient satisfaction.

23. Chapter 13 The Nutrition Care Plan

24. The Nutrition Care Plan • A Care Plan is a written plan for medical care. • It identifies the following: • Problem • Approach • Goal

25. The Nutrition Care Plan • Comprehensive Care Plans • Identifies measurable objectives for a resident to reach the best possible physical, mental, social, and spiritual well-being. • Describes the steps to accomplish these objectives. • Charts the course of action to improve a resident’s well being. • Interdisciplinary

26. The Nutrition Care Plan • Comprehensive Care Plans (cont) • Developed within seven days after completion of the comprehensive assessment. • Reviewed periodically and revised by a team of qualified professionals after each assessment. • Attended by the resident, family, or legal representative. • Desires of the resident must be documented in the plan of care

27. The Nutrition Care Plan • Steps in Developing a Nutrition Care Plan: • Identify nutrition problems. • Determine calorie, protein and fluid needs • For each problem, develop goals that are relevant, measurable, and realistic. • Establish timeframes • For each goal, choose appropriate methods or approaches to reach it.

28. Chapter 14 Evaluating Effectiveness of Nutrition Care

29. Evaluating Effectiveness of Nutrition Care The Dietary Manager must routinely re-assess the patient and revise the plan as appropriate.

30. Evaluating Effectiveness of Nutrition Care • Hydration and Dehydration • Dehydration: Lack of water in the body • Drop in blood volume • Loss of sense of thirst • Fever • Bleeding • Severe burns • Vomiting • Diarrhea

31. Evaluating Effectiveness of Nutrition Care • Hydration and Dehydration (cont) • Edema: Water retention • Can make the heart and lungs work harder. • Symptom that the heart is not functioning properly. • Kidneys cannot remove excess water.

32. Evaluating Effectiveness of Nutrition Care • Monitoring Diabetes • Maintain blood glucose levels at reasonable levels to prevent complications. • Monitor blood sugar levels. • Glycosylated hemoglobin (HbA1C) shows how well controlled the resident was over a period of time. • Check for warning signs of high or low levels of glucose. • Check on compliance to diet as ordered.

33. Evaluating Effectiveness of Nutrition Care • Monitoring Nutritional Status/Weight Loss • Weight changes • Percent IBW, UBW, BMI • Serum albumin • Prealbumin • Total lymphocyte count • Daily meal intake percentages • Fluid intake/output • Medications that may affect taste • Update food preferences • Changes in dental health • Changes to ability to safely swallow

34. Evaluating Effectiveness of Nutrition Care • Monitoring Pressure Ulcers • Evaluate meal intake, especially protein, Vitamin C rich foods, and fluids • Monitor weight • Monitor healing progress as provided by the wound nurse • Monitor labs such as albumin/prealbumin • Provide addition of MVI with zinc

35. Evaluating Effectiveness of Nutrition Care • Monitoring Enteral (Tube) Feedings • Monitor for tolerance • Abdominal cramping, diarrhea, aspiration • Monitor hydration status • Monitor for possible enteral feed/medication interaction • Some meds cannot be given within 2 hours of food • Iron supplements • Some meds may cause a gelatinous mass in the stomach • Dilantin

36. Evaluating Effectiveness of Nutrition Care • The Evaluation Process • Review or observe the following: • Resident response to treatment • Changes in physician’s orders • Intake records • Weight records • Previous nutrition progress notes • Recent laboratory values • Other recent additional information in the client’s record • Review the current plan of care

37. Evaluating Effectiveness of Nutrition Care • Documenting Progress • If progress is satisfactory: • May indicate under “P” that the plan will continue. • If progress is not satisfactory: • Recommend a revision to the plan.

38. Chapter 15 Conducting Nutrition Education

39. Conducting Nutrition Education • Nutrition Education • A process that assists the public in applying knowledge from nutrition science and the relationship between diet and health to their food practices. • Helps to develop a knowledge base • Make a commitment to good nutrition • Select nutritionally sound diets • Develop decision-making skills

40. Conducting Nutrition Education • Developing Objectives: a specific, measurable statement of the outcome of education • Think about what the learner will be able to do when you have successfully completed nutrition education. • An effective learning objective includes key elements described in the acronym, RUMBAS

41. Conducting Nutrition Education RRelevant UUnderstandable MMeasurable BBehavioral AAttainable SSpecific

42. Conducting Nutrition Education • Group Instruction • Allows the learner to share experiences and develop a sense of group motivation. • After developing learning objectives, plan an outline of the topic that includes: • Introduction • Organized detail • Practice or application • Closing

43. Conducting Nutrition Education • Group Instruction (cont) • Introduction • Orients the learner to the subject • Designed to put people at ease • Encourages open communication • Briefly describes learning objectives • Organized Detail • Outlines what is to be taught • Outlines teaching methods

44. Conducting Nutrition Education • Group Instruction (cont) • Practice or Application • Adults retain: • 20% of what they hear • 30% of what they see • 50% of what they see and hear • 90% of what they say and do • Closing • Answer questions • Reinforce key points • Evaluate if learning objectives have been met

45. Conducting Nutrition Education • Visual Aids • The most effective visual aid is one that is limited to one idea and can be communicated in 3-5 seconds. • Samples include: • Simple handouts • Posters • Models • Slides • Transparencies • Videotapes • Not to be used to replace teaching.

46. Conducting Nutrition Education • Nutrition Counseling • A supportive process, characterized by a collaborative counselor-patient/client relationship. • Set priorities • Establish goals • Create individualized action plans that acknowledge and foster responsibility of self care to treat an existing condition and promote health. American Dietetic Association

47. Chapter 16 Evaluating Effectiveness of Education

48. Evaluating Effectiveness of Education • Key purpose of the evaluation is to determine whether you have met the learning objectives. • Second reason is to obtain feedback about the educational approach itself. • Three levels of education: • Client reaction • Actual Learning • Behavioral Change

49. Evaluating Effectiveness of Education • Client Reaction • Provides feedback regarding what techniques worked best or what questions we may not have addressed. • We can use this information to revise outlines for future use. • Actual Learning • How much did the clients learn. • Can use written and verbal questions, often given as a post-test. • Verbal: Friendly question and answer session. • Behavioral Change • Have habits changed. • Give the client an activity and observe and evaluate effectiveness by observation.

50. Evaluating Effectiveness of Education • Refining Plans • Be flexible • Individual learning styles vary • Barriers to communication • Language • Ability to read • Use of terminology • Client does not understand • State of alertness • Recognize distinction between knowledge and behavior