Enteral and Parenteral Nutrition Update with the Nutrition Care Process

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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
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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.

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Nutrition Diagnosis

• Each nutrition diagnosis has a reference sheet
• definition
• possible etiology/causes
• common signs or symptoms

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New Nutrition Diagnosis Terms in 4th 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

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ADIME Acronym for the Nutrition Care Process

• A Nutrition Assessment
• D Nutrition Diagnosis
• I Nutrition Intervention
• M-E Nutrition Monitoring and Evaluation

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Nutrition InterventionInvolves 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

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Nutrition Intervention Domains

• Food and/or Nutrient Delivery
• Nutrition Education
• Nutrition Counseling
• Coordination of Nutrition Care

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Nutrition InterventionFood 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

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Nutrition InterventionNutrition 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

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Nutrition InterventionNutrition Education

• Content
• Purpose
• Priority Modifications
• Survival information
• Nutrition relationship to health/disease
• Recommended modification
• Other or related topics
• Application
• Result interpretation
• Skill development
• Other

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Nutrition InterventionNutrition 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

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Nutrition InterventionNutrition 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

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Nutrition CounselingTheoretical Basis/Approach

• Cognitive-behavioral theory
• Health belief model
• Social learning theory
• Transtheoretical model/stages of change
• Other

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Nutrition CounselingStrategies

• Motivational interviewing
• Goal setting
• Self-monitoring
• Problem solving
• Social support
• Stress Management
• Stimulus control
• Cognitive restructuring
• Relapse Prevention
• Rewards/Contingency Management
• Other

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Nutrition InterventionCoordination 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

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Nutrition InterventionCoordination 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

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ADIME Acronym for the Nutrition Care Process

• A Nutrition Assessment
• D Nutrition Diagnosis
• I Nutrition Intervention
• M-E Nutrition Monitoring and Evaluation

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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

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Nutrition Monitoring and Evaluation Domains

• Food/Nutrition-Related History
• Anthropometric Measurements
• Biochemical Data, Medical Tests, and Procedures
• Nutrition-Focused Physical Findings
• Client History

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Lets 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
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Lets 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, JHs 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.

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Pressure Ulcer Case

• 93 yo female with recent left hip fracture
• Ht 56 Wgt 108 BMI 17 79 IBW
• po intake _at_ 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

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Labs

• Prealbumin13.7 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)