Nutrition Instructor: Name Mailbox Do Not Tear Off Pages. Hand in entire packet each week! MOUNT CARMEL COLLEGE OF NURSING NURSING 309 NUTRITION INTEGRATION End of Term Evaluation Date Satisfactory / Unsatisfactory Nutrition Instructor s signature 1
NUTRITION INTEGRATION NURSING 309/399 We expect that you will complete one of these papers each week that you are in clinical this term EXCEPT the first week with orientation and any week that you have observations both days. Usually we do not have you do this the last week, but we will let you know. Hand in the entire booklet each week do NOT tear off the pages. Specific instructions for completing the form are on the next two pages. Review these before you turn in your paper. If you paper is satisfactory the S/U column will be marked with an S for each satisfactory area. If your paper is not complete in any area we will check the column headed RR REVISION REQUIRED. This revision must be completed when you turn your paper in the next week. The U = unsatisfactory will be used when you fail to make the revision required or when you continue to make the same mistakes. At the end of the term, it is necessary that you receive a Satisfactory for your nutrition integration and turn in this tool to your nutrition instructor to complete the requirements for the course. We expect that your paper will be turned in on to mailbox of your nutrition instructor. If you are ill or absent for some reason, leave us a message. We will report to your clinical nursing instructor if your paper is not in on time. Do NOT use WebCT to reach us. Use these e-mail addresses or voice mail. Pat McKnight, MS, RD, LD 234-5861 pmcknight@mchs.com Kathy Blanchard, MS, RD, LD 234-5439 (at the College M, T, R only) kblancha@mchs.com Colleen Dreifke, MS, RD, LD 234-3871 (at the College W, R, F only).cdreifke@mchs.com Doug Maier, MS, RD, LD beeper 770-4267 (at the College T-W-R) dmaier@mchs.com Greg Avellana, RD,LD,CDE. Gregrd@rrohio.com MOUNT CARMEL COLLEGE OF NURSING JUNIOR LEVEL NUTRITION INTEGRATION I. A. Assessment 1. If not possible to get actual weight you will need to estimate. Your instructor may help you with this. A tape measure may be used to figure height. 2. Use Weight Range Table: suggested weights for adults to determine weight range. 3. List all diagnosis present, not just admitting diagnosis. Please date all surgeries and procedures. Indicate length of illness if possible. 4. Use Assessment Guide-Nutritional Status to determine abnormal labs, specify levels. B. Nutrition Screening Every patient is to be screened by the RN for nutrition risk on admission. See directions and list of screening questions in this packet. If a risk is identified, a consult is sent to Nutritional Services. C. Use Guide to Energy (Calorie) Needs of Patients to determine cal/kg and total kcals needed. Make sure to use highest suggested weight if patient is overweight and lowest ideal body weight if patient is underweight for your calculations. 1. Use Guide to Energy (Calorie) Needs of Patients to determine calories provided for particular 2
diets (see reverse side). 2. Appetite. Use percentage figures charted by Nursing. 3. Pertinent information may include problems affecting intake (e.g. medications, pain, anxiety, nausea/vomiting, therapy given, poor dentition, disabilities, shortness of breath, dislike of food, etc.) Include any vitamin and/or mineral supplements taken. D. When determining I.V., T.F., or T.P.N. you must state rate and order and show your work. (e.g. Isosource 1/2 strength at 50 mls an hour) SEE REVERSE SIDE OF WEEKLY FORM 1. Indicate if patient is consuming any nutritional supplements such as Ensure or Carnation Instant Breakfast Drink. If this patient gets a supplement that is prepared in the kitchen, e.g.ensure Milkshake, call Nutrition Services to get number of calories. Include these calories in your total calorie estimate per day. Make sure your patient is consuming his supplements before including these calories. 2. Use Guide to I.V. Calculations, Tube Feeding Information to determine calories administered to your patient by these methods. 3. If patient is receiving T.P.N., ask nutrition instructor to help you with calculations. E. Include all kcals eaten or given (include I.V., T.F., T.P.N., supplements, p.o.). F. Energy needs = calorie needs. Base your answer on determination of B. and D. Nutrient needs = RDA's for vitamins and minerals and protein. -Generally if patient is consuming 1800-1500 calories of well balanced selections, he is meeting his needs. The intake should be consistent. -Use Tube Feeding Information to determine RDA's for these patients. II. Nutrition Related Diagnosis or Collaborative Problem. A. Make sure to differentiate between actual and potential diagnosis (risk for). B. May state a collaborative problem if appropriate. C. Statement should concur with your collected data. D. Use your guide to Nutrition-Related Nursing Diagnosis. III. Nursing Interventions - base interventions on collected data, nursing diagnosis and other problems. A. Nursing actions - What actions did YOU take to help meet the patient's nutritional needs? (e.g. helping feed, monitoring for tube feeding tolerance, drip rate, selecting menu, providing comfort, giving medication to decrease nausea, etc.) B. Teaching - What did YOU reinforce or teach your patient and/or family/caregiver about the patient's nutritional requirements? Did patient attend classes? Receive instructions? What materials were given? Was teaching appropriate now? Future? C. Communications with health care team - Who did you communicate with? What did you communicate/discuss regarding nutritional concerns? Is the patient taking supplements, requesting them? Is the patient requesting teaching or information for home? Is the patient having difficulty tolerating diet? Did you refer the patient to the Registered Dietitian? Diabetes Educator? IV. Community Resources Does patient have help at home? Family assistance? Social Services/Discharge planning contacted? What nutrition related needs will patient require upon discharge and possible in the future? What did you actually recommend? Who did you make the recommendations to? If resources not needed, state why patient has family support at home patient going to an ECF Note: All references underlined on these two pages have been given to you in Nursing 204/294 and 205/295. Nutrition Course Materials (Handouts from Sophomore and Junior Nursing)) are on CARMELink - under Resources. Weight Chart, Energy Guide, IV Calculation sheet, TPN Calculation sheet, and Enteral Feeding (Tube Feeding) chart can be downloaded from this site. 3
1. Must use complete NANDA Statement Nutrition Imbalanced, Less Than Body Requirements NURSING DIAGNOSIS STATEMENT 2. AMB or AEB -- needs to be what you see that leads you to the diagnosis Intake less than assessed needs or body requirements/weight loss, etc. 3. Related to: why the above is happening in the specific client's condition lack of appetite secondary to recovery from surgery/increased calorie requirements secondary to cancer/infection A "risk" diagnosis does not need an AMB/AEB. NOTE: NANDA says we cannot use the Nutrition Imbalanced diagnosis when the patient is NPO or on a Tube Feeding or TPN, because the nurse cannot change the order. Use another diagnosis -- Ineffective Health Maintenance or Therapeutic Regimen Management, Ineffective if you see a nutrition problem that needs to be considered. Readiness for Enhanced Nutrition this new diagnosis is a wellness diagnosis. Generally not appropriate for the patient in the hospital. It is for someone who is already eating well and just needs additional information!!! MOUNT CARMEL COLLEGE OF NURSING Nutrition Integration: Nursing 309/399 Date Clinical Unit Student On Time RR S/U I. Assessment A. Patient initials age sex height weight weight range from reference weight chart BMI Diagnosis (list all and surgery) Diabetes? Abnormal nutrition-related labs (specify): B. Nutrition Screening. Was this done for this patient? List any nutrition risk factors identified by screen: C. Energy needs: cal/kg = calories (IF PATIENT IS OVERWEIGHT, USE THE HIGHEST REFERENCE WEIGHT, IF PATIENT IS UNDERWEIGHT USE THE LOWEST.) Diet order calories available from diet as ordered: Pt. eats: 66-100%; 33-66%; <33% Problems affecting food intake Other pertinent information D. I.V, Tube Feeding, TPN--state order and rate: Nutritional supplement-type/amount Total calories provided by IV, T.F. TPN or supplement /day (show calculation on back of page) SEE BACK OF PAGE E. Total Calorie intake (diet, IV, TF, TPN, Supplement) calories/24 hrs. (consider amount actually eaten) 4
F. Based on all of the above information, is the patient currently meeting his/her: energy needs? nutrient needs? II. Nutrition-related nursing diagnosis or collaborative problem: III. Nutrition-related nursing interventions: (related to diagnosis) A. Nursing Actions including Teaching: What did YOU do? : B What did you communicate about nutrition /to which team members? IV. Community Resources Will this patient need any community resources to meet nutritional needs when he/she goes home? What did you recommend? If not, why not? IV Calculations What is the rate at which IV is running? ml/hr x hours = volume patient receives What is in the IV that has calories and what percent? Volume x percent of dextrose = grams of dextrose x = Calculate the calories provided by the ordered IV Grams of dextrose x 3.4 calories/gram = total calories x 3.4 = Tube Feeding Calories What is the rate at which the tube feeding is running? ml/hr x hours = volume patient receives What tube feeding? How many calories does the tube feeding provide calories/ml Volume x calories/ml = total calories x = calories if the tube feeding is running at full strength. If not, you will have to adjust your answer to ½ strength or whatever the order states. TPN Calculations 5
See order sheet in chart Grams of dextrose x 3.4 = calories from dextrose Grams of amino acids x 4 = calories from amino acids Calculate the volume of lipid, depending on how it is ordered Volume of lipid x 2 calories/ml if 20% lipid = lipid calories. Add all three together for total Dextrose Amino Acids Lipids Total TPN calories Other current diets: Bariatric diets clear liquid, full liquid and regular Dry diet Current Diabetes Diet orders: 45 g CHO/meal (1200-1500 calories) 60 g CHO/meal (1600-1800 calories) 75 g CHO/meal (2000-2400 calories) this is also the Liberal diabetic diet 90 g CHO/meal (2500-3000 calories In-house Diabetes Educators: West Jane Collins RN,CDE - 234-3853 East Julie Hitch RN,CDE 234-7114 St.Ann Suzanne Christman, MS,RD,LD,CDE These educators can talk with the patients about diabetes management and encourage attendance at Mt. Carmel s Diabetes Program. Diabetes folders should be on the units and information about diabetes management is in Patient Education 6