Nutritional Needs in the Clinical Setting

Transcription

1 This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program. Nutritional Needs in the Clinical Setting Allison B. Kerin, MS, RD, LD Director of Employee Wellness and Recognition TTUHSC Lubbock, TX Dietetics I

2 Goals Define malnutrition in the clinical setting and its potential consequences Describe the components of nutrition screening and assessment Define the different patient population nutritional needs in the clinical setting Malnutrition Imbalance between nutritional intake and nutritional requirements Who is at risk elderly people with low income socially isolated patients with a chronic disease patients recovering from a serious illness Malnutrition Statistics Costs an estimated $157 billion/year 1 in 3 patients who enter the hospital are malnourished Malnourished patients are: 2 times more likely to develop a pressure ulcer in the hospital have a length of stay (LOS) 2 days longer have 3 times the risk of surgical site infections fall while in the hospital (45%) Reasons for Malnutrition Decreased food intake physical issues swallowing missing teeth/dentures lack of money, resources to get food cognitive issues Alzheimer's disease Increased nutritional/energy requirements chronic obstructive pulmonary disease (COPD) patients Decreased nutrient absorption Crohn s patients 2

3 Consequences of Malnutrition Reduced muscle and tissue mass Decreased mobility and stamina as a result of muscle wasting Breathing difficulties, and an increased risk of chest infection and respiratory failure Wounds take longer to heal Difficulty staying warm as a result of having less muscle and tissue mass Post-operative complications Clinical Signs of Malnutrition Weight loss over time Loss of muscle mass Loss of fat mass Fluid accumulation/edema Diminished grip strength How to Address Malnutrition Quick/thorough nutrition screening Communication to dietary services Rapid intervention by dietitians Identifying Malnutrition Nutrition screening is completed by nursing must be completed within 24 hours of admission regulatory requirement Looking for certain nutrition triggers If a patient answers yes to the triggers, a dietitian consult is ordered 3

4 Appetite nausea/vomiting Recent unexplained weight loss or gain? Feeding modality? Tube feeding (TF) or total parenteral nutrition (TPN) Serum albumin Certain allergies Certain high-risk diagnosis sepsis trauma end-stage renal disease (ESRD) wounds stroke Nutrition Triggers Limitations to Triggers If patient isn t able to communicate upon admission family not always available, willing to answer, or just do not know Nursing so busy, this box is ignored If a trigger is identified, the registered dietitian (RD) referral is often overlooked during order entry Computerized charting should help this process Nutrition Assessment Components of a nutrition assessment medical and social history diet history and intake clinical examination anthropometrics biochemical data nutritional needs estimation plan of care 4

5 Medical and Social History Information is gathered from reviewing the chart and conducting a patient/family interview Medical history diagnosis past medical history pertinent medications bowel habits Social history religion living/cooking arrangements cultural preferences family dynamics economic status Appetite and recent intake taste changes dentition dysphagia supplementation nausea/vomiting/diarrhea Eating patterns diet restrictions fad diets skipping meals Diet History and Intake Clinical Examinations Identify physical signs of malnutrition hair thin or easily plucked = protein or biotin deficiency mouth tongue fissuring = niacin deficiency decreased taste or smell = zinc deficiency fingernails muscle wasting 5

6 Anthropometrics Height Weight weekly weights use the same scale same time of day same amount of clothing record and track trends Weight history Ideal body weight Body mass index (BMI) Limitations: height: commonly overestimated in men and underestimated in women elderly: people shrink as they get older young: not many parents know the height or length of their child weight: highly influenced by fluid Biochemical Data Used to assess body stores Can be altered by medications, metabolic changes (stressed states) during illness, and fluid status Most Common Labs Albumin half-life of days most widely used indicator of long-term nutritional status affected by fluid status large acute phase response levels Prealbumin half-life of ~ 2 days responds within days to nutrition repletion levels affected by trauma-acute infections: liver disease kidney disease C-reactive protein positive acute phase respondent increases early in acute stress (up to 1000 fold) decrease correlates with end of acute phase and beginning of anabolic phase where nutrition repletion is possible BUN/creatinine indication of renal function Sodium indication of hydration status higher levels indicate dehydration lower levels indicate overhydration 6

7 Kcals Protein Fluid Estimating Nutritional Needs Estimating Kcals Harris-Benedict equation basal energy expenditure (BEE) x activity factor x injury factor = total calories needed males vs females height/weight/age Mifflin-St. Jeor (not appropriate for ICU patients) resting energy expenditure (REE) x activity factor = total calories needed Ireton Jones (for use in ICUs) males vs females trauma? burn? obesity? Quick Estimates BMI >30 = kcal/kg (help with weight loss) BMI = kcal/kg BMI = kcal/kg (maintain current weight) BMI <18.5 = kcal/kg (help with weight gain) Estimating Protein Needs Non stress: g/kg Mild stress (low fever, infections, surgery): g/kg Moderate stress (poor healing, pancreatitis, fever >102): g/kg High stress (multi-trauma, sepsis, burns, critical illness): g/kg Renal pre-dialysis:.6-.8 g/kg (restriction) hemodialysis: g/kg peritoneal dialysis: g/kg Liver hepatitis: g/kg cirrhosis: g/kg encephalopathy:.6-.8 g/kg (short term) Pressure ulcers: g/kg 7

8 Estimating Fluid Needs 1 ml/kcal Or: years old = 35 ml/kg years old = 30 ml/kg >65 years old = 25 ml/kg Dialysis patients: 1000 ml+ output or 1500 ml Congestive heart failure (CHF) patients: ml/kg Plan of Care Snacks between meals and bedtime Supplements between meals (very filling) patient flavor preference Meal fortification protein or calorie powder (odorless/tasteless) high-calorie condiments Follow up when will you return to check on patient Education needs Educational Needs Carbohydrate counting Heart healthy eating Renal diet Inpatient education, is not ideal trying to get out of the hospital lots of family, doctors, nurses in and out of room still don t feel well encourage outpatient dietitian follow up Intake: Meals and Fluid One of the most important pieces of information for a dietitian but also one of the most commonly overlooked pieces of documentation Generally, a shared responsibility between nursing and dietary staff Record in percentages: 25% 50% 75% 100% 8

9 Encourage Intake Consult the dietitian food preferences by meal set up supplementations between meals set up snacks identify possible chewing and/or swallowing issues special instruction for tray delivery calorie counts Supplementation Oral supplements many flavors disease/condition specific diabetic renal and prerenal Calorie or protein powders Send between meals No restrictions Balanced/healthy meal meat vegetable starch fruit dessert bread beverage Regular Diet Diabetic Diets Carbohydrate counting used for both type 1 and type 2 patients pediatric and adult most food options on the menu will have the amount of carbs in that serving of food helps keep blood sugars in the ideal range helps with knowing how much insulin to administer meal is based off of caloric diet MD orders

10 Renal Diet Renal diets are generally ordered for those with chronic renal failure, not acute renal failure Lab values are reviewed to determine if dietary restrictions are needed GFR determines the stage of kidney disease and need for protein restriction albumin and prealbumin are not always good indicators of protein stores: do not increase protein based on a low albumin alone potassium: above-normal values may require potassium restriction phosphorus: usually PhosLo or other medications are recommended, rather than a phosphorus restriction A traditional renal diet menu in most medical facilities is lower in phosphorus, potassium, protein, and sodium than the regular diet Potassium too much potassium in the blood can cause heart problems Renal Diet common foods high in potassium include many fruits and vegetables: bananas potatoes beets prune juice brussels sprouts prunes dried fruits spinach orange juice tomato juice Oranges tomato sauce tomatoes Protein patients undergoing dialysis usually need more protein than the average person Phosphorus too much phosphorus in the blood pulls calcium from the bones 10

11 Renal Diet foods high in phosphorus include: bran cereals cheese dried beans and peas milk Nuts peanut butter whole-wheat bread yogurt Sodium too much sodium in the blood is related to high blood pressure and congestive heart failure foods high in sodium include: canned soups deli meats processed meats bacon, sausage, hot dogs, etc. salty snack foods Used mainly on cardiac floors Low fat/low cholesterol/low sodium diet nonfat or low-fat dairy products margarine vs butter whole grain bread lean meats salt substitutes AHA/Heart Healthy Diet 11

12 Texture Modification Reasons for texture modifications: chewing problems poor dentition missing dentures sore mouth from illness surgery dental work mouth sores from chemotherapy swallowing problems (dysphagia) stroke degenerative diseases like Huntington s or Parkinson s cancer and/or radiation therapy texture modifications may be temporary or permanent, depending on what condition is causing the dysphagia Texture Modification Texture modifications defined by the National Dysphagia Diet: dysphagia pureed (level 1) all foods will have a soft mashed potato or pudding-like consistency may require additional thickening agents or you can buy premade formed pureeds dysphagia mechanically altered (level 2) foods are moist, soft-textured, and easily formed into a bolus examples include: soft canned or cooked fruits, moistened ground meat, and well-cooked pasta avoid fresh fruits and vegetables Infant/Pediatric Formula/breast milk Age appropriate foods Will generally have foods kids will prefer chicken nuggets pizza ice cream mashed potatoes 12

13 Liquid Diets Clear liquids water (plain, carbonated, or flavored) fruit juices without pulp, such as apple or white grape fruit-flavored beverages, such as fruit punch or lemonade carbonated drinks, including dark sodas (cola and root beer) Gelatin tea or coffee without milk or cream strained tomato or vegetable juice sports drinks clear, fat-free broth (bouillon or consomme) honey or sugar hard candy, such as lemon drops or peppermint rounds popsicles without milk, bits of fruit, seeds, or nuts Full liquids all of the same as clear liquids with the addition of cream soups, ice cream, milkshakes, yogurts, puddings, etc. do not eat raw or cooked vegetables do not eat ice cream or other frozen desserts that have any solids in them or on top Enteral Nutrition (TF/TPN) Tube feeding NG or DHT tube (short-term) PEG tube (long-term) dietary services provide the formula dietitian generally consulted to manage the tube feed dietary services are not allowed to send pumps or formula home with patients Other Diets DAT: diet as tolerated not a recognized diet and can lead to problems for the facility if an accrediting or auditing agency finds it it is viewed as out of the scope of practice for nursing Renal/diabetic Low or high protein No concentrated sweets 13

14 Conclusion Early nutrition intervention by a registered dietitian can help with: 25% reduction in pressure ulcer incidence 28% decrease in avoidable re-admissions 14% fewer complications reduce average LOS by approximately 2 days potentially saves the facility millions of dollars Nutritional Needs in the Clinical Setting If you have any questions about the program you have just watched, you may call us at: (800) or fax (806) Direct your inquiries to Customer Service. Be sure to include the program number, title and speaker. Dietetics I

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