1. ENTERAL AND PARENTERAL NUTRITION UPDATE WITH THE NUTRITION CARE PROCESS Suzanne Neubauer, PhD,RD,CNSC Framingham State University Overlook Health Center, Charlton, MA January 31, 2013

2. Objectives  Calculate basic flow rates for enteral nutrition considering interruption factors and fluid needs.  Calculate parenteral nutrition formulas, including basic electrolyte considerations.  Practice the nutrition care process for enteral/parenteral cases, focusing on new nutrition diagnosis and intervention standardized language.

3. Nutrition Diagnosis  Each nutrition diagnosis has a reference sheet  definition  possible etiology/causes  common signs or symptoms

5. New Nutrition Diagnosis Terms in 4 th edition  Intake: Multi-nutrient (5.11)  NI-5.11.1 Predicted suboptimal nutrient intake (specify)  NI-5.11.2 Predicted excessive nutrient intake (specify)  Other (NO)  NO-1.1 No nutrition diagnosis at this time

6. ADIME: Acronym for the Nutrition Care Process  A: Nutrition Assessment  D: Nutrition Diagnosis  I: Nutrition Intervention  M-E: Nutrition Monitoring and Evaluation

7. Nutrition Intervention Involves “Planning” and “Implementation”  Planning  Determine patient/client-focused goals/expected outcomes Measurable, achievable and time-defined!  Determine time and frequency of care  Implementation  Communication of the nutrition care plan  Carrying out the plan  Continued data collection, documentation and plan modification, based upon progress toward goal accomplishment

8. Nutrition Intervention Domains  Food and/or Nutrient Delivery  Nutrition Education  Nutrition Counseling  Coordination of Nutrition Care

9. Nutrition Intervention: Food and/or Nutrient Delivery  An individualized approach for food/nutrient provision, including  Meals and snacks  Enteral and parenteral nutrition  Supplements Medical food supplement Vitamin and mineral supplement Bioactive substance supplement  Feeding assistance  Feeding environment  Nutrition-related medication management

10. Nutrition Intervention: Nutrition Education  A typical intervention for nutrition education might discuss:  purpose of the nutrition education  relationship between nutrition and specific disease/health issue  Issue of most concern  basic nutrition-related educational information until client is able to return

11. Nutrition Intervention: Nutrition Education  Content:  Purpose  Priority Modifications  Survival information  Nutrition relationship to health/disease  Recommended modification  Other or related topics  Application:  Result interpretation  Skill development  Other

12. Nutrition Intervention: Nutrition Education  Nutrition Assessment MUST address baseline knowledge and not assume that more education is required.  In addition to the depth of the education your documentation must indicate the content to meet Joint Commission requirements  For example--what instructional materials were provided to the patient

13. Nutrition Intervention: Nutrition Counseling  Should document both:  Theroretical basis/approach  Theories or models used AND  Strategies  Evidence-based method or plan of action Some target change in motivation and intention to change Others target behavior change

14. Nutrition Counseling: Theoretical Basis/Approach  Cognitive-behavioral theory  Health belief model  Social learning theory  Transtheoretical model/stages of change  Other

15. Nutrition Counseling: Strategies  Motivational interviewing  Goal setting  Self-monitoring  Problem solving  Social support  Stress Management  Stimulus control  Cognitive restructuring  Relapse Prevention  Rewards/Contingency Management  Other

16. Nutrition Intervention: Coordination of Nutrition Care  Coordination and referral of nutrition care  Team meeting  Referral to RD with different expertise  Collaboration with other nutrition professionals  Collaboration with other providers  Referral to other providers  Referral to community agencies/programs

17. Nutrition Intervention: Coordination of Nutrition Care  Discharge and transfer of nutrition care to new setting or provider  Discharge and transfer to other providers  Discharge and transfer to community agencies/programs  Discharge and transfer to another nutrition professional

18. ADIME: Acronym for the Nutrition Care Process  A: Nutrition Assessment  D: Nutrition Diagnosis  I: Nutrition Intervention  M-E: Nutrition Monitoring and Evaluation

19. Nutrition Monitoring and Evaluation  Purpose: quantify progress made by the patient/client in meeting nutrition care goals  Select appropriate nutrition care indicators  Compare findings with the nutrition prescription/ intervention goals and/or reference standards

20. Nutrition Monitoring and Evaluation Domains  Food/Nutrition-Related History  Anthropometric Measurements  Biochemical Data, Medical Tests, and Procedures  Nutrition-Focused Physical Findings  Client History

21. Let’s Practice  You work as a contract dietitian in a large 150-bed long- term care institution. You notice that an 80 year old resident, Mrs. ND, is moderately malnourished due to poor dietary intake resulting from ill-fitting dentures. Her albumin is 3.2 g/dl and her current BMI is 21. The client lost 20 lbs. due to pneumonia a few months ago and her dentures are not fitting properly, so she does not wear them. You perform resident meal rounds at lunchtime and you observe that Mrs. ND is having a hard time chewing on her gums and is often choking on meat and bread. Intake records reveal that Mrs. ND consumes approximately 75% of her food at all meals. Adapted from Giroux I. Applications and case studies in clinical nutrition. Phila: Lippincott Williams & Wilkin, 2008

22. Let’s Practice  JH is a 70-year-old male with dysphagia resulting from a cerebrovascular accident. His difficulties, opening his mouth, chewing solids, and swallowing thin liquids result from a permanent partial paralysis of his tongue, jaw, and cricopharyngeal muscles, especially apparent on the left side. He has been on a ground/chopped/minced diet with fluids of nectar-like viscosity for two months and his food and fluid intake is progressively declining. The most recent reports indicate that, despite a good appetite, JH’s intake is approximately 50% at all meals. In addition, JH has lost 4 lbs in the last month; his current BMI is 24. JH is also taking some antidepressants, is constipated, and is complaining of having a dry mouth.

23. Pressure Ulcer Case  93 yo female with recent left hip fracture  Ht: 5’6” Wgt: 108 BMI 17 79% IBW  po intake @ 50-75% of meals per nursing  Skips breakfast  Eats food which family brings  PMH: stage II pressure ulcer; dementia, CHF, HTN, osteoporosis, anemia, GERD  Meds: Megace, Protonix, Lopressor, 300 mg ferrous sulfate, digoxin, colace

24. Labs  Prealbumin:13.7 mg/dL (16-40)  RBC 3.79 (4.3-5.8)  Hgb 11.8 g/dL (13-17)  Hct 35.6 % (40-51)  MCV 94 (80-100)  MCH 31pg (27-33)  BG 103 mg/dL (65-99)