Lecture notes for chapter 17-1
Notes from lecture by professor Betty Cohen as of 4/02/2001 recorded by Michael D.
Nutrition Care plan
In today’s lecture we will be discasing what we call Nutrition care plan. Before we
get into that however, we need to first review few steps that precede this process. One of
the most important things for us to appreciate is that after patient is admitted into the
hospital we need to do on him screening within 48 hours of admission. This screening
process will put him into a various category for protein kcal malnutrition. These
categories vary based on individual hospital. In general however, we distinguish between
-no risk
-low risk
-moderate risk
-high risk
How we will determine into which category we will place the patient, is again
based upon individual set of criteria set by every hospital. In general we recognize
these major criteria
-change in appetite
-weight loss
-level of albumin
-diagnosis
-chewing and swallowing difficulties
The general practice for most hospitals is that DT is responsible for patients in no -
low- and moderate . Pt in high risk are domain of RD. In nursing home the DT is usually
responsible for all risk categories, and RD is usually in managerial -administrative
position. Here everybody needs to have nutrition care plan that is evaluated every 3
months.
When we are making nutrition care plan, we are using all the information from our
assessment. The nutrition care plan becomes essentially objective for the patient.
Objectives that came from the “problem list” - list we made when we identified what is
wrong with the patient during assessment. For example : you found that there is a
problem with dry skin and chewing. - this is what you will then address in your care
plan. So in short we can say, that the Nutrition Care Plan (NCP) is looking at nutrition
problems, and writes down objectives for the patient.
These objectives need to be
a) realistic
b) achievable = both within realistic time frame
c) measurable
After you complete all the above, you are going to implement these objectives. -“How
are you going to achieve all the above objectives.”- Eg. Giving the patient high kcal diet,
high protein diet, provide education- this needs to be within patient ability to learn.
Next step is Evaluation. This has to be measurable- what will he be able to do.
Diets, Menu, Meals
Each facility has their own diet manual. This diet
manual contains all the diet that can be ordered by the doctor.
Diet that is not included in this manual, cannot be ordered.
When we closely examine the diet manual, we can see that for
every diet presented to us, we can find
a)Rationale- why is this diet ordered for this particular
disease Eg. - for diabetics there will be carbohydrate
controlled diet. In the rationale you will find that this
diet is ordered to control serum glucose which is done through
the control of carbohydrate intake. In other words it needs to
physiologically explain why this particular diet was ordered.
B) Allowed/not allowed foods- this is another category in our diet manual.
Here we have foods listed in their food
groups. Many Dietitians use wrongly this page
as a teaching tool for patients. In many cases
this page is handed to patient with words “This is
what you can, and cannot eat”
This is what can be at the core of patients non - compliance with
recommended diet. Patient see his favorite foods in “forbidden” column, and
immediately concludes that he cannot follow this particular diet. While patient
on low potassium diet will not have on their tray in the hospital orange juice
or tomato, it doesn’t mean that he cannot have it at all!!. He can easily have
a little bit of orange juice at home or a slice of tomato on his sandwich.
All that needs to be done is to teach this patient that he shouldn’t eat this
particular food items on every day basis in large amount, because of his medical
condition.
What the above information is then really used for is only to
DEVELOP MENUS. It is a tool for yourself, to be able to explain this diet
to a patient.
Once you have developed the menu, you need to look at nutritional needs
of patient. You need to look at al 6 nutrients- proteins, fat, CHO, minerals,
vitamins and water. You have to realize that RDA is only for healthy people and
we are really not using it in the hospital. In the hospital RDA is really the
minimum what we have to provide our patients with in our menu. From there we go
into individual modifications for specific nutrients based on patients condition
- we can either increase or decrease amount of specific nutrient.
If we need to assess somebodies food intake very quickly, we can use our
familiar Food Guide Pyramid (FGP), because this will tell you if this person has
variety in his eating pattern- this variety should be variety withing
individual food groups as well.
If we need to calculate more precisely how much protein, carbohydrate, and
fat somebody is eating, we use different tool. We call this tool Exchange system.
In order to make use of this unique technique of calculating kcal from food, we need
to establish certain given criteria. Most regular menus have total kcal divided into
50% CHO, 20% protein and 30% fat. But you can find ones that divide total kcal
55% CHO, 20% protein and25% fat.
From this regular menu, you can then modify all the specific diets
prescribed for specific diseases.
Exchange System
When we look at exchange system we see that it groups food with similar
content of CHO, protein and fat This will be for a specific amount - an ”exchange unit”.
For example 1 meat exchange = 1 oz
Aditional Links
1)Go to Chapter 17 For more detailed description of exchange list
2)Diet Exchange list web site with detailed description
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