Term
| Medical Nutrition Therapy |
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Definition
"the assessment of the nutritional status of patients with an illness, diet-related condition, or injury, in order to benefit the patient's own health and reduce health-care costs."
Medical Nutrition Therapy includes:
Performing a comprehensive nutrition assessment determining the nutrition diagnosis;
Planning and implementing a nutrition intervention using evidence-based nutrition practice guidelines;
Monitoring and evaluating an individual's progress over subsequent visits with the RD. |
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Term
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Definition
| A Registered Dietitian is the only health care professional with the training necessary to acurately assess nutrition needs and adequacy of a person's diet. However, because nutrition spans medical and social aspects it must be approached as a team. |
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Term
| Health care team responsibilty for nutrition |
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Definition
The healthcare team works together to meet the patient or client's individual needs. Each institution may have different job descriptions; therefore these are general descriptions of their role with nutrition.
The physician is ultimately responsible for meeting the client's entire medical needs including nutrition. He/she will write the diet order, consult, and plan strategies for optimal nutrition. Doctors rely on the healthcare team (including dietitians and nurses) to implement his/her plan.
Dietitians are the nutrition experts. They will complete the most thorough nutrition assessments, and provide medical nutrition therapy. He/she will assess the need for education and make recommendations to physicians based on the nutrition assessment. In many facilities the dietitian is staffed at relatively low numbers. It would not be unlikely for a facility to hire one dietitian per 75-100 beds. Since it would be impossible to assess and care for every person, it is necessary to rely on other health care professionals, especially nurses and Registered Diet Technicians to prioritize those patients in greatest nutrition need. In many facilities, the dietitian spends the majority of his/her time with high risk individuals. However, the dietitian is there to assist all health care professionals in all aspects of nutrition care for patients, including answering questions about diets for the patient.
Nurses identify clients who need nutrition services and communicate that information to the doctor and registered dietitian. The nurse provides the doctor and dietitian important information regarding patients. For example, the nurse can relay information regarding the patient's dietary compliance, foods preferences, dietary needs, allergies etc. Nurses also encourage food intake, measure height and weight, record information regarding food intake, and field questions regarding special diets and food drug interactions. Because the nurse is that central role with the most patient contact, he/she is responsible for a large amount of the communication between the health care team and the patient/family.
Other healthcare professional that are involved in nutrition care include diet technicians, who assist the dietitian. He/she may asses low risk patients and provide basic dietary education. Therapists such as speech therapists will be involved with evaluating a patient's ability to swallow (and dietary changes necessary). The Occupational therapist can provide vital information regarding ability to feed oneself or prepare meals. The Social Worker is helpful in determining need for programs to ensure patients can receive adequate nutrition upon discharge. The Pharmacist is helpful in assessing and educating on drug-nutrient interactions and working on the nutrition support team for parenteral nutrition. |
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Term
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Definition
The healthcare team works together to meet the patient or client's individual needs. Each institution may have different job descriptions; therefore these are general descriptions of their role with nutrition.
The physician is ultimately responsible for meeting the client's entire medical needs including nutrition. He/she will write the diet order, consult, and plan strategies for optimal nutrition. Doctors rely on the healthcare team (including dietitians and nurses) to implement his/her plan.
Dietitians are the nutrition experts. They will complete the most thorough nutrition assessments, and provide medical nutrition therapy. He/she will assess the need for education and make recommendations to physicians based on the nutrition assessment. In many facilities the dietitian is staffed at relatively low numbers. It would not be unlikely for a facility to hire one dietitian per 75-100 beds. Since it would be impossible to assess and care for every person, it is necessary to rely on other health care professionals, especially nurses and Registered Diet Technicians to prioritize those patients in greatest nutrition need. In many facilities, the dietitian spends the majority of his/her time with high risk individuals. However, the dietitian is there to assist all health care professionals in all aspects of nutrition care for patients, including answering questions about diets for the patient.
Nurses identify clients who need nutrition services and communicate that information to the doctor and registered dietitian. The nurse provides the doctor and dietitian important information regarding patients. For example, the nurse can relay information regarding the patient's dietary compliance, foods preferences, dietary needs, allergies etc. Nurses also encourage food intake, measure height and weight, record information regarding food intake, and field questions regarding special diets and food drug interactions. Because the nurse is that central role with the most patient contact, he/she is responsible for a large amount of the communication between the health care team and the patient/family.
Other healthcare professional that are involved in nutrition care include diet technicians, who assist the dietitian. He/she may asses low risk patients and provide basic dietary education. Therapists such as speech therapists will be involved with evaluating a patient's ability to swallow (and dietary changes necessary). The Occupational therapist can provide vital information regarding ability to feed oneself or prepare meals. The Social Worker is helpful in determining need for programs to ensure patients can receive adequate nutrition upon discharge. The Pharmacist is helpful in assessing and educating on drug-nutrient interactions and working on the nutrition support team for parenteral nutrition. |
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Term
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Definition
Does the patient have any of the following:
unplanned weight loss in the last 6 months
severe food allergies
does not understand or cannot follow special diet
vomiting or diarrhea for more than 3 days
chewing or swallowing problems
religious dietary considerations
A 'yes' answer to any of these questions would initiate a nutrition consult to the dietitian for further assessment and intervention. From there, the dietitian will perform a complete nutrition assessment. The nurse, as well as other health care professionals, will also continue assessing for nutrition and other components of the individuals' illness. |
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Term
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Definition
| Nutrition assessment includes a variety of data that is gathered once the screening has been concluded. The assessment includes historical data (such as medical, social and diet history), physical assessment (including anthropometric and biochemical assays), and physical signs and symptoms. Much of the data collected in the assessment process comes from the screening tool. The next section of this module will go into the details of each data collected.Do they smoke? |
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Term
| Medical History: Illness and Treatment |
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Definition
Poor nutrition can lead to disease or illness, and difficulty in recovering from disease and illness. Under nutrition leads to nutrient deficiencies and a depressed immune system and interferes with the body's ability to heal. Excessive food intakes can cause obesity, which can lead to cardiovascular disease. Those prone to be at nutritional risk are: patients with multiple disorders or chronic diseases, elevated metabolic rates, altered organ function, those who are very young, and the very old. The medical illness alone can cause problems with digestion and absorption, etc. The treatments for health problems themselves can interfere with the body's nutrient status, such as medication reactions, NPO diets (nothing by mouth, fasting), radiation therapy, and surgeries. Patients may also need to go on a special diet, limiting food choices, and decreasing motivation to eat. All of these and many more treatments can limit food intake or interfere with the digestion and absorption of nutrients.
When a person is ill, they may have limited physical activity. A patient may be placed on bed-rest, or has lost the ability to move, as seen in spinal cord injuries. Patients who have limited movement do not use all of their muscles; therefore they are at risk for both muscle and bone loss. Immobility also places patients at risk for bedsores or pressure sores. This is the breakdown of skin and underlying tissues due to constant pressure and lack of oxygen. A bedsore is also referred to as a decubitus ulcer, and they can become infected and painful, and will increase the person's nutritional needs. For more information on pressure sores: National Pressure Ulcer Advisory Panel
Other effects on nutrition include the cost of healthcare and medications. The cost for therapies and treatments can deplete funds that would have been used to purchase nutritious foods.
Some questions that may be addressed with medical history include:
What medications are you currently taking?
Are you taking any herbal or other types of dietary supplements?
What health problems do you currently have? or history of?
Do you smoke? How much/often?
Have you had any recent changes in bowel habits? |
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Term
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Definition
The social history includes information related to a person's education level, income and religious/spiritual needs. One might wonder why the social history is important to a nutrition assessment. Ultimately, these considerations are necessary for appropriate intervention. Understanding a person's level of education will help the health care individual know how to teach nutrition information. For instance, talking above or below a person's education/experience level can be very distracting and insulting to a client. Also, someone who is illiterate will require education materials with pictures or limited words. Income level will make a difference in the approach for intervention as well. A client who is on fixed income may not be inclined to purchase expensive foods to meet his therapeutic needs. It is important to work within an individual's means so the intervention can be successful. Individuals (especially the elderly) who live alone can be at risk for malnutrition. In your basic nutrition course, you should have discussed details about why people choose to eat the foods they do. Whether because of tradition, culture, personal preference or socioeconomic status, every person's background influences their nutrition status. Assessing the social history is vital to successful intervention.
Some questions that may be addressed with social history include:
How often do you exercise? what type?
Who does the cooking in your home? grocery shopping?
Do you live alone?
What was the last grade level completed?
What is your occupation? |
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Definition
| The foods or diet a person has been consuming prior to an illness can greatly affect the outcome in health care. Some of the considerations include whether or not a person has been following a special diet, or has been consuming adequate nutrients. Assessing for these factors will make the intervention more successful. Through the assessment we may determine a person has been following a low fat diet for his heart disease, but could use additional education on the difference between good fat and bad fat. We might also learn that a person being admitted post car accident with multiple broken bones and lacerations has been following a starvation diet to lose weight. Inadequate intake of nutrients (especially protein, vitamin A, vitamin C and zinc) will greatly affect the person's ability to heal. Our intervention may require more intense nutrition support to improve the outcome of this client. We can ascertain a person's diet history in several ways: |
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Term
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Definition
| A 24 hour recall can be beneficial to obtain basic information about a person's diet. In this case, the health care provider would ask the client to explain all of the foods consumed within the last 24 hours. Unfortunately, the client may forget foods, not understand the serving sizes or neglect to tell foods that he/she knows are not allowed on his/her special diet. In a hospital or long term care setting when a client is ill, the prior 24 hours are often not representative of a typical day. |
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Term
| food frequency questionaire |
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Definition
| A food frequency questionnaire is another means of understanding a person's normal food intakes. In the food frequency questionnaire, the health care provider asks questions on the number of times a person consumes specific foods and beverages over a period of time. The questionnaire can be very detailed or very generic. Simple questions such as "how often do you drink milk in a day" or "how many fruits and vegetables do you normally consume each day" or how many meals do you eat most days" can help raise some red flags with a person's nutrition status. The problem is this does not take into account recent changes in the diet, largely relies on memory and the individual's interpretation of their intakes. |
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Term
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Definition
| the food record is another good way of obtaining diet history. Having a client write down everything he/she eats or drinks during the day can provide detailed information about the client's nutrition status. It can be very helpful in outpatient facilities where the client would bring in a log of their food record to be reviewed. Students taking this class become very familiar with food records since the diet analysis project requires students keep track of foods in this manner. In hospitals and long term care, however, it would not be very beneficial since the diet the person is eating is already determined by food service. There is no reason to have a client write this down. While food records provide one of the most accurate diet analysis, it is not perfect. Clients do not have to be truthful, and often do not know the serving sizes they are consuming. |
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Definition
Direct observation is one of the best ways to determine food intakes and nutrition adequacy. This form of gathering data is used daily in hospitals and long term care. A health care professional (usually someone on the nursing staff) will observe the amount of the food eaten at a meal and record that amount in the chart. This provides a quick and easy reference when trying to identify poor intakes over several days. The problem with direct observation is that it does not specify how much of each food the person consumed. If the client ate 50% of the meal, was that the mashed potatoes, gelatin and tea (not the main entree, milk and vegetable)? Another type of direct observation used to assess nutrition adequacy is the kcalorie count. In this case, the nurse writes down the percent consumed for each food. This is typically marked directly on the tray ticket and saved for the dietitian to assess. It gives a more realistic view of what the patient is eating and helps identify if the nutrition intervention (ie providing smaller meals more frequently) is working.
Another consideration of diet is the cultural, ethnic or religious background of their heritage. Is it also important to understand the personal choices of why a person chooses to select the foods they do. Understanding why foods are eaten, whether because a food tastes good, follows along with personal beliefs or because of a emotional reasons, is important to take into consideration in an assessment. As we discuss diet intervention, understanding people's background for food choices will make diet adherence much more likely. |
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Definition
Anthropometrictext annotation indicator measurements calculate the size and proportions of the human body. They can reveal problems in overnutrition or undernutrition. Height and weight are the most common measurements used in assessing nutrition status, but head circumference and abdominal girth have important uses as well.
Height (length) in children and infants can identify adequate growth. We know proper nutrition is essential for adequate growth. If a child does not grow appropriately, malnutrition is a concern. In adults height does not detect malnutrition, but is helpful in identifying appropriate ratio of height to weight.
Head Circumferencetext annotation indicator is a tool often used to assess infants and young children. In addition to estimating brain size, head circumference is used to measure infant growth, and can possibly detect malnutrition. Although head circumference is largely determined by genetics, an extremely small or large head can be reason for concern. If a child's head size is growing too fast and crossing percentiles on the head circumference growth chart, he or she should be watched closely for the development of hydrocephalus (water on the brain) or other neurological disorders. On the other hand, a small head circumference, especially if not following the same percentile, is of greater concern. This may indicate a condition known as microcephaly and is often associated with neurodevelopmental problems. The most common cause of microcephaly is inadequate brain growth. |
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Term
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Definition
| Weight is one of the most common measurements to determine over nutrition and under nutrition. Overweight and obese weights present many dangerous risk factors. In children, body weight is related to adequate growth. Just like with height, if weight is inadequate, malnutrition may be possible and proper nutrition must be assessed. Weight is also monitored for under nutrition in adults as well. Clinically, changes in body weight are carefully monitored. As discussed earlier in this module, hospitalized individuals with no nutrition problems, often have declining nutrition status after 3 weeks of hospitalization. Obtaining accurate weights and monitoring changes is crucial in determining when and if an individual is at risk for malnutrition. Once a weight is obtained, several calculations can be used to assess appropriate nutrition status. |
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Term
| Ideal body Weight and UBW |
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Definition
Ideal Body Weight (IBW) determines what a person should way according to their height. The following calculations are used to determine IBW.
Women: 100 pounds for the first 5 feet and 5# for each additional inch.
Men: 106 pounds for the first 5 feet and 6# for each additional inch.
Once the IBW is calculated, we need to compare it to the person's weight to determine how close to ideal the person's actual weight is.
%IBW (Percent Ideal Body Weight): Actual Body weight / Ideal Body Weight X 100
The %IBW provides idea of how overweight or underweight a person is. This calculation can help determine appropriate nutrition status and certainly raises some red flags when the weight is significantly over or under. The problem with %IBW is that is not necessarily good for those who are obese, but have lost significant amount of weight. This can put them at risk for malnutrition even though they are considered overweight according to %IBW. When assessing risk for malnutrition, another assessment tool is Percent Usual Body Weight (%UBW).
%UBW (Percent Usual Body Weight): Actual Body Weight / Usual Body Weight X 100
If an individual has 5-10% loss in UBW within 6 months, the individual is at moderate risk for malnutrition. This calculation can provide a more accurate view of sick patients current nutrition status.
Let's look at an example of how these calculations apply.
Mr. Smith is admitted to the hospital with multiple blunt trauma secondary to a car accident. Mr. Smith is 45 years old, weighs 191 pounds and is 5'10.
IBW is (5' = 106#) + (10" X 6 = 60) = 166# %IBW is 190/166 = 115%
No red flags or cause for concern would be raised with an individual who is 115% of their ideal weight. However, we learn through family that he has been following a very low calorie "Jello diet" to lose weight over the last 2 months. The family identifies his normal weight prior to weight loss was 225#. When we compare Mr. Smith's actual weight to his usual weight, it brings cause for concern.
%UBW = 190/225 = 85%
With this recent weight loss (and understanding it was not a healthy diet), we know nutrients may be limited. This person's ability to heal, fight off infection, and maintain fluid/electrolyte balance may be impaired. |
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Definition
Body fat percentage is also anthropometric data, and is used to assess for an increased health risk due to a deficient or excessive amount of fat on the body. Body fat percentages are rarely checked on children. Most often, body fat percentage is monitored when an adult is trying to lose weight or become more fit. However, rapid changes in body fat percentage can also indicate muscle loss related to wasting diseases. Although a person may lose weight rapidly, the percentage of weight coming from fat will often increase when muscle and lean body tissue is lost (broken down for energy).
As previously learned, BMItext annotation indicator (body mass index) and relates to disease state.
Underweight
<18.5
Healthy
18.5-24.9
Overweight
25-29.9
Class 1 Obesity
30-34.9
Class 2 Obesity
35-39.9
Extreme Obesity
>40 |
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Term
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Definition
| Biochemical data is largely obtained from blood analysis. Interpreting the results from biochemical analysis can be difficult because many factors affect the results including hydration status, medication, exercise, trauma and illness. However, biochemical data combined with the rest of an assessment can be very helpful. |
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Definition
| Blood proteins are often used to help determine risk for malnutrition. Since protein is part of the immune system, healing factors, blood clotting, fluid/electrolyte balance and acid/base balance, it is important to monitor protein during acute and chronic illnesses. Unfortunately, the serum proteins are largely affected by trauma, illness and hydration status. They must be considered in combination with those factors in mind. |
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Definition
| is the most abundant plasma protein, and most widely used in assessments. However, since the half-life is roughly 3 weeks, it is not the most sensitive indicator of protein status. Pre-albumin, on the other hand, has a short (3-4 day) half-life and shows much faster response to changes in protein status. Improvements made through medical nutrition therapy are much more easily detected with pre-albumin. Both labs can be effective in determining PEM, but pre-albumin is better at detecting changes with therapy. |
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Definition
| Transferrin is another protein often monitored during illness. This protein transports iron through the circulatory system. Transferrin levels are affected by both low iron and protein energy malnutrition (PEM) rather quickly. During iron deficiency, transferrin levels increase, but with PEM, transferrin levels decrease. However, improvements with medical nutrition therapy are slow to show in blood results. |
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Definition
| Hemoglobin is the protein in red blood cells (RBC) that carries oxygen through the blood. Low levels often indicate a condition of anemia where RBC, for one reason or another, are not able to carry enough oxygen to cells. Iron deficiency is one of the most common types of anemia. Simply determining low hemoglobin levels, however, only identifies anemia may be present, but not what type the person has. Additional testing is generally needed, and hydration status greatly affects hemoglobin values. Ferritin can help determine storage of iron in the body. This protein is especially helpful in identifying if the anemia is caused by iron deficiency or is the effect of a chronic disease. Ferritin is also useful in diagnosing iron overload. |
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Definition
C-Reactive Protein (CRP) is part of the immune system. It is one of the acute-phase proteins released at the onset of acute infection. This protein is considered one of the markers for hyper inflammatory response in severe infection. With increasing research on the inflammatory effects in heart disease, CRP is sometimes used in the assessment of risk factors for atherosclerosis.
Other lab values are beneficial in assisting the nutrition and medical assessment of individuals. The following are some of commonly used labs. |
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Definition
| Blood sugar is routinely monitored with glucose values. The level of glucose measures the amount of blood sugar at that moment. It is helpful in determining hypo & hyperglycemia, and monitoring diabetes treatment. To determine long-term control of blood sugars, glycosylated hemoglobin (HbA1C) is used. When blood sugars are elevated, glucose attaches to hemoglobin. Because the half-life of hemoglobin is long, the glycated hemoglobin will remain in the blood stream for long periods (1 to 3 months). Elevated levels of HbA1C is indicative of long term high blood sugars in diabetes. |
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Term
| Blood Urea Nitrogen (BUN) |
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Definition
| Blood Urea Nitrogen (BUN) is a lab often used to assess kidney function. If you may recall from your basic nutrition course, as amino acids enter the metabolic pathway, the nitrogen-containing group is cleaved off in a process called deamination. The resulting ammonia (NH3) is taken to the liver to be converted into urea to be excreted by the kidneys. High levels of this nitrogenous urea indicates the liver is working well to convert the ammonia to urea, but the kidneys have not been able to excrete all of it. This could be secondary to deterioration in the function of the kidneys. It is not a perfect lab, though. High BUN can also be indicative of excessive protein breakdown and/or dehydration. |
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Definition
| The electrolytes (sodium, chloride and potassium) are also useful in identifying hydration and acid/base balance. While most easily determined by the electrolytes, hydration status will greatly affect all of the lab results. When the blood stream is overhydrated, the blood is dilute (more fluid than particles) so the lab values of each component will generally be lower than actual. If we were to pull the excess fluids off, the numbers for most values would go up. However, if the blood stream is dehydrated, there will be less fluid compared to the amount of particles. In dehydration, the values will appear higher in most cases. As the individual is re-hydrated, the values will often go down. The hydration status is important to consider when assessing an individual's nutrition status, especially with protein status and malnutrition. |
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Term
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Definition
| Total Lymphocyte Count is an important measure of a person's immune system, which is derived from both the number of white blood cells and the percentage of lymphocytes. An increase in the total lymphocyte count usually reflects that the body is fighting an infection, while a decrease in the number usually indicates that immunity is compromised. |
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Definition
The final piece to consider in a nutrition assessment is the physical exam. Skin, eyes, lips, mouth, gums, nails, and hair can all show signs of malnutrition and hydration status. As you learned in basic nutrition class, many of the vitamin and mineral deficiencies are visible on the body. Cracking of the corners of the mouth, a smooth glossy tongue, bleeding gums, hard lumps on the skin, brittle hair/nails, etc are all physical signs of vitamin deficiencies. Additionally, physical examinations can be useful in determining hydration.The physician or nurse will also check for internal symptoms such as swelling of the liver, pulse/heart rate, blood pressure, and reflexes, all of which can possibly help identify a nutrition problem. Here are a few physical signs of nutrient deficiencies (although there are many more!):
BODY SYSTEMS
MALNUTRITION FINDING
WHAT THE FINDINGS MAY REFLECT
Hair
Dull, brittle, dry, falls out easily
PEM (Protein Energy Malnutrition)
Eyes
Pale membranes, spots, redness (especially at the corners of eyes), poor vision
Deficiency of Vitamin A, B-vitamins, zinc, and iron
Teeth and gums
Missing, discolored, and decayed teeth; gums bleed easily and are swollen and spongy
Vitamin C deficiency, mineral deficiency
Face
Pale; scaly, flaky, cracked skin
Iron deficiency, PEM, vitamin A deficiency, dehydration
Tongue
Sore, smooth, purplish, swollen
Deficiency of B vitamins
Skin
Dry, rough, scaly; lack of fat under skin;
PEM, essential fatty acid deficiency, vitamin A deficiency, vitamin C and B-vitamins deficiency
Nails
Spoon-shaped, brittle, ridged, pale underneath
Iron deficiency
Muscles and bones
Poor grip strength, bowed legs, swollen bumps on skull or ends of bones, "wasted" appearance; poor bone density
PEM, mineral and vitamin D deficiency
Fluid retention (edema) may accompany malnutrition, infection, or injury. It is often caused by impaired blood circulation with diseases of heart, kidney, liver, and lungs. Physical signs include:
Weight gain
Facial puffiness. The physician or nurse will also check for internal symptoms such as swelling of the liver, pulse/heart rate, blood pressure, and reflexes, all of which can possibly help identify a nutrition problem. Here are a few physical signs of nutrient deficiencies (although there are many more!):
Swelling of limbs
Abdominal distention
tight-fitting shoes
Ascites is a type of edema in which excessive fluid accumulates in the abdominal cavity of the body. Although the most common cause of ascites is liver disease, it can also be caused by cancers, congestive heart failure, or kidney failure. Ascites will be discussed further in a later module.
Dehydration is often a symptom of disease. It frequently accompanies fever, sweating, vomiting, diarrhea, excessive urination, skin injury or burns. Physical signs include:
Thirst
Headache
Fatigue
Dry skin or mouth
Reduced skin tension
Urine - dark yellow, or amber and volume is usually low |
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Term
| Nutrition-Related Diagnoses |
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Definition
Once the assessment has been complete, diagnosis of nutrition-related problems can be made. The dietitian will first look at whether malnutrition is an issue. Through substantial research, we better understand how malnutrition affects the body and its ability to heal, fight off infection and recover. Malnutrition leads to increased hospital stay, higher costs to treat the conditions, more complications, and increased mortality. In hospitals, malnutrition added to the main diagnosis can often increase the amount of days and money covered by insurance companies, giving health care professionals the resources needed to appropriately treat the individual. Malnutrition is generally determined by a combination of low weight (or weight loss >5% in 6 months) and low albumin.
As discussed previously, weight loss in a sick individual is best determined by calculating the Percent Usual Body Weight (%UBW). The percent Ideal Body Weight (%IBW) can be used, but is less reflective of weight changes. the following chart can be used in assessing malnutrition.
%IBW
%UBW
Nutrition Risk
80-90
85-95
Risk of mild malnutrition.
70-79
75-84
Risk of moderate malnutrition
<70
<75
Risk of severe malnutrition. |
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Term
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Definition
The word malnutrition refers to any condition caused by excess or deficient food energy or nutrient intake or by an imbalance of nutrients. A malnourished person does not necessarily lack enough food to eat. Undernutrition refers to deficient energy or nutrients, while overnutrition refers to excess energy or nutrients.
Lack of a nutrient is called a deficiency. There are different types of nutrient deficiencies. A primary deficiency is simply one in which the person does not consume adequate amounts of a certain nutrient, and therefore is likely to show deficiency symptoms or diseases. A secondary deficiency is caused by something other than inadequate intake, such as a certain disease state increasing nutrient requirements or a medication depleting the body of a nutrient. A subclinical deficiency is one in which a person does not have any obvious symptoms. A covert deficiency is what is called a "hidden" deficiency, because the person does not have any symptoms and it is very difficult to detect, even with a physical exam. Covert deficiencies often progress for years before they are detected. |
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Definition
Once the diagnoses have been identified, they must be prioritized. Once the priorities are set, the next step is to plan the intervention. Frequently in health care, the intervention is done through a care plan process. The initial step in a care plan is to identify the goal or outcome for each nutrition-related problem or goal. The outcome/goal must be measurable, reasonable, and address the nutrition problem. It must be attainable while the patient is in your care. If a person is underweight, gaining 10 pounds in a 4 day hospital stay is not reasonable, nor healthy. Once the goal is established, the intervention steps necessary to reach the goal are identified. Because a team approach to health care is ideal, many facilities will document the discipline responsible for each step (encouraging the interdisciplinary approach). An example of a nutrition care plan is below.
Intervention
Examples of intervention by various health care professionals
Food and/or nutrient delivery
Providing appropriate snacks, meals, and dietary supplements.
Providing specialized nutrition (tube and intravenous feedings).
Determining a need for feeding assistance of adjustment in feeding environment.
Nutrition Education
Providing basic, nutrition-related instruction.
Providing in-depth training to increase nutrition knowledge or skills.
Nutrition Counseling
Helping individuals set priorities and establish goals.
Motivating individuals to change behaviors.
Solving problems that interfere with the nutrition care plan.
Coordination of nutrition care
Providing referrals or consulting other health professionals or agencies that can assist with treatment.
Organizing treatments that involve other health professionals. |
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Term
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Definition
People in hospitals, long term care, and other health care facilities often have difficulty consuming adequate amounts of food. Disease states, high energy demands, lethargytext annotation indicator, medications, surgery, etc. often cause individuals to lose their appetite. As you learned in basic nutrition, lack of adequate energy will result in fat and protein breakdown to use for energy. Protein catabolism impacts the immune function, healing process, acid base and fluid balance. Simply improving a client's food intakes can dramatically improve the individual's outcome while hospitalized (and even when they are discharged). The following table offers suggestions on improving food intakes.
Help Clients Improve Food Intakes
Empathize with the individual. show that you understand how difficult eating may be. Imagine feeling too sick to move or too tired to sit up.
Motivate. Be sure the individual understands the importance of nutrition to recovery.
Help individuals select the food they like and mark menus appropriately when in a medical facility. When appropriate request special food from food service.
For people who are weak, suggest foods that require little effort to eat. Soup, puddings, drinks, etc. that require less chewing can be helpful.
Help patients in a medical facility prepare for meals. Help them get comfortable in the bed or a chair. Provide a stool for their feet if they cannot reach the ground and adjust the table for the right height.
When the food cart arrives, verify the foods are the correctly ordered foods, and are appealing. Order a new tray if they are not.
Help with eating, if necessary, or arrange for family to assist. Help open containers, cut foods, etc.
Try to solve eating problems. Sometimes medications cause a dry mouth and the patient would benefit from drinks before eating a sandwich. Sometimes patients prefer cold rather than hot foods, especially when they are nauseous. Encourage eating the most nutritious foods first.
Take a positive attitude toward the hospital's food. |
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Term
| Interdisciplinary Approach |
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Definition
The nutrition intervention is approached by the entire health care team and includes the diet order, education, and documentation. Care plans with the intervention are individualized for each person's nutrition and education needs. Sometimes the goals and intervention are included in a critical pathwaytext annotation indicator. The critical pathway is a daily plan of intervention for all disciplines. These pathways are usually set up for specific diagnoses to keep medical care on course. For example, an individual may be admitted to the hospital for open heart surgery. The hospital has a specific number of days and money allotted by the insurance company. The health care team knows what medical care is necessary for the post operation day 1, day 2, etc. from medications and diet to therapies, and education. The intervention for all health care is written on one pathway/plan for all disciplines to document. Health care professionals mark on the chart as goals/outcomes are met. When an outcome is not met, more thorough documentation is usually needed. This type of documentation by exception decreases the amount of time the health care team spends doing paperwork. It also helps identify patients who are not following the normal course/pathway and require additional care.
Example of a critical pathway.
As mentioned, education is part of nutrition intervention. Sometimes education is as simple as explaining why a person is NPO (nothing by mouth) for a procedure. But, many times education is quite complex, whether as part of discharge planning from a hospital or in ongoing visits at a doctor or dentist office. Many considerations need to be taken into account, and it all falls back on the assessment we discussed earlier in this module. In the assessment, we talked about the medical, social, and diet history in addition to the biochemical and anthropometric data. All of it becomes very important to intervention, including education. Certainly, having an individual with financial constraints (whether homeless, on welfare or following a budget), will affect the education process. The foods we tell a person they should be consuming must be attainable for them. Social workers can help identify programs available to assist individuals with financial concerns. Education level is important so the information we tell them is not lost. Having that information before approaching education or counseling is crucial so appropriate materials can be used. Medical history will dictate much of the education process because the diet order is often prescribed based on that. However, if the individual has specific religious or ethnic preferences in his/her foods, it can conflict with the diet order. Discussing these issues with the physician and dietitian will help identify and prioritize the restrictions. At the end of this module you will see some of the most common cultures found in the United States. Most any diet can be adjusted, and religious preferences honored. It is a matter of being sensitive to the individual's needs both medically and socially/spiritually. |
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| Part of the dietitian's assessment is to determine an individual's energy needs. In your basic nutrition course, you should have learned about energy needs based on BMR, thermic effect of food and thermic effect of exercise. The same formulas are often used by dietitians in outpatient counseling, especially when weight loss is desired and increased physical activity is prescribed. In a hospital or long term care, patients/residents are not physically active and normally have diseases affecting their bodies. Typically, the dietitian will determine the individual's resting metabolic rate (RMR) and apply stress factors caused by medical conditions and/or treatments. The most accurate measure is using indirect calorimetry. Often referred to as a metabolic cart, indirect calorimetry measures oxygen content inhaled and carbon dioxide exhaled. The process requires specialized equipment and is often labor intensive. Most dietitians use predictive equations to determine resting metabolic rate. The Harris Benedict and Mifflin-St. Jeor are two common formulas used by clinicians. Obesity presents a special challenge in determining energy needs. The adipose tissue is much less metabolic active than lean tissue. But, using and ideal weight is not accurate either. Often an adjustment is made to overweight and obese individuals' weights before utilizing the formulas. In the next module, we go into more specifics about how energy needs are established for critically ill patients. |
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While the dietitian provides the most in depth diet education and nutrition counseling, all health care professionals provide nutrition education throughout the day. The nurse may explain why a person is NPO (nothing by mouth) for a procedure. A pharmacist may educate a client on drug nutrient interactions, and so on. However, when long term changes are needed with nutrition, education has to take several factors into account.
Take into account the individual's readiness for change. This is important whether in a hospital or a doctor's office. How ambitious the plan is will be determined by the patient's readiness.
The plan is tailored to a person's age, education (level of literacy), cultural background and learning style. Any diet can be tailored to meet these needs. It is a matter of finding the foods with their modifications that meet their culture, cost, etc.
Emphasize what to eat, rather than what the person should not eat. Emphasizing the positive (foods the person can eat) makes the the diet more attractive.
Suggesting only one or two changes at a time. If the person is highly motivated, more can be accomplished at once. But for most, tackling 1-2 changes at a time is more successful at long term compliance.
Provide written materials suited to the individual's literacy.
Verify the person understands the information on changes needed. The person should be able to verbalize key aspects of the diet plan back to the individual. Patients cannot make changes they don't understand.
Follow-up. While this works well in outpatient facilities, you may never see a hospitalized patient again after he/she is discharged. It is important, therefore, to give referrals for outpatient follow-up. During the follow-up the individual to be evaluated for success in meeting the desired outcomes. If the goal was not met, strategizing to identify a new approach may help. When goals are met, evaluation of the need for new goals should be considered. |
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All health care professionals document in the medical record. It is a legal document that records a patient's health history, assessment, prognosis of medical problems, measures being taken to treat those problems, and the outcomes of the therapy. Writing in the medical record allows us to document the actions taken to comply with physicians' orders, the client's response to actions, and recommendations. This information helps determine if medical orders are being followed and directs future care. Critical pathways are also kept in the medical record along with laboratory results, and procedures. This documentation is crucial to the care of a person's health. If the care provided has not been documented in the medical record, the care did not happen. One of the most difficult aspects of documentation is that of education. Heath care professionals educate their patients all day long, and all of it must be documented. Most health care facilities adopt a specific way of documenting education that makes the process interdisciplinary. But, the problem of writing it all down can be a cumbersome task.
Most Registered Dietitians will chart in the medical record progress notes or in a separate section designated for nutrition. The nutrition notes are often written in a format of SOAP or ADIME.
The SOAP format is one of the oldest methods for documentation and remains one of the most popular formats.
S: subjective data includes assessment data obtained from the client (or the clients history/screen) that pertains to the client nutrition status.
O: objective data includes assessment based on concrete data such as biochemical analysis, weight, etc. that pertains to the client nutrition status.
A: assessment is a brief evaluation of the objective and subjective data in relation to nutrition status.
P: plan or intervention to reach the nutrition goal.
The ADIME format most closely reflects the care planning process.
A: assessment summaries relevant subjective and objective data interpreting current nutrition status.
D: diagnosis of the nutrition related problem (s).
I: intervention or treatment necessary to reach the expected nutrition outcome/goal.
M & E: Monitoring and Evaluation is record of the ongoing changes in the patient's condition and adjustments needed in the care plan. |
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The diet ordertext annotation indicator is given by the physician, however, other health care professionals will assist in evaluating if the diet order is appropriate for the individual. For instance, the dietitian may recommend increased protein, snacks or supplements when poor intakes are identified. The speech language pathologist may suggest consistency changes in foods and drinks based on swallow evaluations. The nurse may recommend consistency changes based on chewing problems observed secondary to poor dentition. The diet ordered can be divided into two categories, standard and modified. The standard diet is also referred to as a regular diet with no limitations or restrictions. A modified diet, however, is altered in consistency or nutrient content to meet an individual's specific needs. A modified diet is often referred to as a therapeutic diet because it is part of the treatment for a specific condition or disease. As we go through each of the disease states, we will discuss the specifics of the diet required for each. The following contains general information on some of the modified diets.
Changes in consistency or texture are usually done for chewing and swallowing problems.
Mechanical Soft: ground consistency prescribed for chewing difficulties (usually dentition problems) or mouth pain.
Dysphagia diets: ground to pureed consistency of foods prescribed for individuals with swallowing problems.
Changes in nutrients are generally done to treat or prevent complications with a disease state.
Low Residue diets: designed to decrease the load on the large intestine, low residue diets are low in fiber and other foods with a lot of residue left that is not digested and absorbed (such as milk products).
Fat Restricted diets: designed to decrease symptoms in people with absorption problems, pancreatitis, and cystic fibrosis, the fat restricted diet limits fat as low as 25 grams per day.
Sodium Restricted diets: designed to prevent or correct fluid imbalances in disorders such as high blood pressure, kidney failure, and congestive hear failure, sodium is normally restricted to 2,000 - 3,000 mg per day. However, more strict 1,000 mg per day sodium restrictions are sometimes warranted.
High Calorie, High Protein diets: individuals with very high energy demand, malnutrition, or eating poorly, a high calorie high protein diet can help meet their bodies' demands. If tolerated, fat will often be increased in the diet when energy demand is high. Protein is increased often when individuals need excess kcalories as well as when they require extra healing.
Special Diet Orders are used before and after treatments and procedures to reduce the complications with treatment or tolerating the diet.
NPO: nothing by mouth is often ordered both before and after procedures when an empty stomach is needed. NPO may also be ordered when bowel rest is needed or the patient cannot tolerate oral nutrition.
Routine Progressive Diet: after an individual has been without oral nutrition, we must gradually introduce foods to make sure they tolerate it. The routine progressive diet starts after the NPO order has been lifted. It progresses from clear liquid to full liquid to soft, to the regular or modified diet.
Clear liquid: clear fluids and foods that are liquid at body temperature and have little to no undigested material (residue) left after digestion. Foods allowed include pulp free juices, carbonated beverages, gelatin, clear broths, popsicle, and fruit ice. This diet does not meet nutritional needs, only fluid and electrolytes.
Full liquid: includes all of the clear liquid foods plus milk, eggnog and cream soups. The necessity of this diet in progression is questionable, but still often used especially in the case of gastrointestinal disorders.
Soft/Bland: the soft diet is gastrointestinally soft, and is different than the mechanical soft ordered for chewing problems. The soft diet includes regular consistency foods, but limits spices, fiber/residue, and caffeine. This diet is not always necessary in the diet progression, and is often not used.
Alternative Feeding Routes are often required when an individual is not able to meet his/her nutritional needs with diet alone.
Enteral nutrition delivers a nutritionally complete formula via a tube into the gastrointestinal tract (often referred to as tube feeding).
Parenteral nutrition delivers a nutritionally complete formula via a catheter directly into the circulatory system. |
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| Most health care facilities have a diet manual in the food service department as well as on the units near the nursing station. The diet manual contains information on the diets, rationale for their usage and foods (or food preparations) allowed and not allowed. When patients have questions regarding their diets, the nurse can refer to the diet manual. However, if the diet manual does not answer the question a patient has, the registered dietitian is the best reference. He/she has the most knowledge of the diet orders and which foods are allowed or not allowed on the diet. |
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The Food Service Department in hospitals and nursing homes are in charge of budgeting, purchasing, preparing, and delivering appropriate meals. This department often prepares meals for both patients on the floors/units and the employées through the cafeteria. Many hospital facilities also have catering for corporate hospital events as well. The menus designed for patients are often selective menus, where patients choose foods from 2 or more options. Each selective menu is prepared for specific diet modifications. So, even on a restricted diet, patients will have a choice of foods within their diet order. In attempts to cut costs, some facilites have gone to non-selective menus. With a non-select menu, pre-selected foods are delivered to each patient. However, that does not mean requests for other foods cannot be made. If a patient does not like the foods being offered on the menu, he/she normally has the option of calling food service prior to the meal to change the foods. Often the nurse will assist patients in requesting special foods, especially as the nurse identifies poor oral intakes in a patient. As long as it is within his/her diet restrictions, most requests will honored. With malnutrition so prevalent in hospitals, and with the increased complications and costs secondary to malnutrition, it is essential for the nurse to be monitoring those at greatest need and encouraging them to eat, as well as notifying the dietitian of those patients.
Within a hospital, dietitians are usually part of the food service department. Dietitians help set the menus and assist in quality assurance of the trays being delivered to patients. The food service director is often not a registered dietitian, but has expertise in food service and management. A chief clinical dietitian (often a manger below the food service director) manages the clinical dietitian staff. Most hospitals also have a Chef and Food Service Manager as well. Together, the managers design the menus that are appropriate and cost effective for the patient trays.
Meals provided to patients are normally generated in the kitchen through a trayline. A tray ticket identifying what goes on each tray in addition to the patient's name and room number is placed on the tray and sent down the line. On the line are food service workers with various foods to dish out. Usually the hot foods are placed together, then hot starches and vegetables, then the cold foods, condiments and utensils. Having a trayline for service can present unique challenges to designing menus. Limited space can reduce the amount of options available to patients. Some foods (especially certain types of fish/shellfish) do not hold well at the correct temperatures on a trayline. Depending on the number of patient rooms, the trayline can take several hours from beginning to end. Having foods that hold well at temperature is essential. |
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| Medications are necessary in the treatments of many diseases. Drugs can be obtained via prescription, or over the counter. All medications have possible side effects, drug-drug interactions, and food-drug interactions. Therefore, it is very important that the patient provides his/her physician and medical team with an accurate drug and diet history. Medication errors do often occur, unfortunately. Patients at high risk include children, pregnant women, the elderly, and those who suffer from chronic disease or are on many medications (poly-pharmacy). Many medications are prescribed by weight, therefore an inaccurate weight may cause over or under medicating. |
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Dietary supplements including herbals do not need FDA approval. However, many people use these products in place of medications to treat or prevent diseases. Consumers should be aware that these products have limited clinical studies justifying their medical benefits. The consistency of the herbal products' ingredients is also unknown since these products are not regulated. Consumers should inform their health care providers about use of dietary supplements, as many of them have side effects or interactions with medications and food. The side effects of an interaction can sometimes be serious and irreversible.
Problems with Consistency of ingredients: Preparation of herb can cause variations in composition. It is difficult to determine which ingredient is in a product and how much is beneficial. Also, active ingredients may vary with plant and amount in the supplement (may not be enough for the benefit it states.
Safety Issues : Toxic effects causing diarrhea, nausea and vomiting are the most likely side effects observed. Kava, Chaparral and Comfrey have been shown to cause liver damage. Certain herbals, such as ephedra, cause high blood pressure and some interfere with medications (garlic and ginko increase effects of anticoagulants). Contamination of products imported from other countries is a large concern, especially if you do not know where your herbals are distributed (herbals from Asia 10% had lead, 14% arsenic and 14% mercury).
List of common herbs (function, concerns, etc). |
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Studies have shown that multiple medication use puts a person at risk for malnutrition. Interactions can range from mild to severe. Medications can alter nutrient needs, and food components can alter the medication effectiveness. These mostly occur in people with chronic diseases that require the use of multiple medications over a long period of time. It can also occur with people with altered organ functioning, malnutrition, and people who do not take medications as prescribed either due to finances or impaired mental functioning. Due to the amount of medications they typically take, the elderly are most prone to nutrient-drug interactions.
Medications can reduce food intake by decreasing appetite, altering taste sensations and smells, and causing dry mouth, mouth sores, nausea, vomiting, and dizziness etc. Foods may reduce or delay absorption of medications. For example, aspirin is better absorbed on an empty stomach but may cause nausea or stomach irritation. Therefore, it is often recommended that aspirin be taken with food. Some non-nutrients found in food can also have effects. Phytates (in the husks of grains, legumes and seeds) and oxalates (in beets, nuts, chocolate, tea wheat, bran) in foods can bind medications.
Nutrients and non-nutrients can significantly affect a medication's metabolism. For example, vitamin K intake may have to be carefully controlled if a person is on an anticoagulant (blood thinner) medication such as coumadin, since vitamin K is needed for blood clotting and can interact with the medication. A patient on an anticoagulant medication should be instructed to keep their intake of vitamin K (such as from green, leafy vegetables) consistent from day to day, but does not need to avoid foods containing vitamin K.
Sometimes a food or beverage can have properties which enhance the effect and/or increase the side effect of a medication. This is often seen with grapefruit, which contains chemicals that can interfere with the enzymes that metabolize various medications in the digestive system, especially certain blood pressure medications (calcium channel blockers) and cholesterol lowering (statin) medications. This can result in excessively high levels of these drugs in the blood and an increased risk of potentially serious side effects. People on these medications should be warned to avoid grapefruit and grapefruit juice at any time while being treated with the medication.
Both diet and medications can affect excretion of nutrients. Diuretics are intended for people with edema to help get rid of excess water from the body. But they also may cause a loss of electrolytes and other nutrients. Some diuretics can deplete calcium, potassium, magnesium and thiamin. However, some diuretics cause the minerals to be retained. Folate is the nutrient that has the most interactions with medications and is easily depleted by the body. Other ingredients found in medications can be undesirable such as sugar, sorbitol, lactose, sodium and caffeine, and can have bad effects on those with diabetes, allergies, etc.
Antibiotics are one of the most frequently prescribed short-term medications. Some are best when taken with food, and some are best when consumed on an empty stomach. Some vitamins and minerals may impair the absorption of antibiotics (such as calcium), so it is best not to take supplements or drink milk within two hours of taking the medication. It is always important to read the patient information and warnings on the label before taking a prescribed medication.
The following table summarizes the effects of diet-drug interactions.
Examples of Diet-Drug Interactions
Drugs may alter food intake by:
Altering the appetite (amphetamines suppress appetite; corticosteroids increase appetite).
Interfering with taste or smell (amphetamines change taste perceptions).
Inducing nausea or vomiting (digitalis may do both).
Interfering with oral function (some antidepressants may cause dry mouth).
Causing sores or inflammation in the mouth (methotrexate may cause painful mouth ulcers).
Drugs may alter nutrient absorption by:
Changing the acidity of the digestive tract (antacids may interfere with iron and folate absorption)
Damaging mucosal cells (cancer chemotherapy may damage mucosal cells).
binding to nutrients (bile acids binders bind to fat-soluble vitamins).
Foods and nutrients may alter drug absorption by:
Stimulating the secretion of gastric acid (the antifungal agent ketocanazole is absorbed better with meals due to increased acid secretion).
Altering the rate of gastric emptying (intestinal absorption of drugs may be delayed when they are taken with food).
Binding to drugs (calcium binds to tetracycline, reducing the absorption of both substances).
Competing for absorption sites in the intestine (dietary amino acids interfere with levo dopa absorption).
Drugs and nutrients may interact and alter metabolism by:
Acting as structural analogs (as do warfarin and vitamin K)
Using similar enzyme systems (phenobarbital includes liver enzymes that increase the metabolism of Folate, vitamin D, and vitamin K).
Competing for transport on plasma proteins (fatty acid and drugs may compete for the same sites on the plasma protein albumin.
Drugs may alter nutrient excretion by:
Altering nutrient reabsorption in the kidneys (some diuretics increase excretion of sodium and potassium).
Causing diarrhea or vomiting (diarrhea and vomiting may cause electrolyte loss)
Food substances may alter drug excretion by:
Inducing the activities of liver enzymes that metabolize drugs, increasing drug excretion (components of charcoal-broiled meats increase the metabolism of warfarin, theophylline and acetaminophen).
Food substances and drugs may interact and causes toxicity by:
Increasing side effects of the drug (the caffeine in beverages can increase the adverse effects of stimulants).
Increasing drug action to excessive levels (grapefruit components inhibit the enzymes that degrade certain drugs, increasing drug concentration in the body). |
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