Dietetic Internship Week 4: Nutrition Care I

An important aspect of the nutrition care process is documenting, or charting, what we did. I got to practice this skill throughout the NCI module, and here’s a brief summary of what I’ve learned.

In Fraser Health, the charting we do is posted online for other health care team members (and ourselves) to access. There are set templates for various scenarios. In-patient nutrition assessment, in-patient follow up, enteral feeding assessment, and enteral feeding follow-up, are some of the more commonly used ones during this placement. Each template has sections with pre-written headings, which we need to fill out.

I’ve divided this post into sections that are more or less like the headings in an initial nutrition assessment chart note. And I’ve included a few additional notes about adding protein powders and tube feed initiations.

Wasps' Nest
Empty wasps’ nest camouflaged in tree.

Medically Relevant Information

  • Why the patient is in hospital: anything GI-related should be a red flag, stroke, heart disease, psychiatric illness, infections, burns, wound healing, trauma, pneumonia, alcohol withdrawal (and if pt. is on alcohol withdrawal protocol), are some of the common issues I’ve seen in the past few weeks.
  • The medically relevant information could give some clues about why the patient is being followed by the dietitian. For example, a patient may not be able to eat due to decreased level of consciousness and may require a tube feed; wound healing has higher protein requirements, etc.
  • Include any major progress since the last chart note, for example, if a new PEG has been ordered for a patient who was previously on a nasogastric tube feed, or if a patient’s been certified to stay in hospital under the Mental Health Act (pg 7), or if the patient’s medical condition has improved/ deteriorated.
  • Medical history: this can include comorbidities such as diabetes, hard of hearing, chronic kidney disease, hypertension, gout, hyperlipidemia, COPD, coronary artery disease, or past singular events like UTIs, kidney stones, or amputations. The level of detail included here probably varies depending on the person charting, but nutritionally-relevant ones should be noted.
  • Social history: whether the person was living in the community (single or with a partner), or needed medical assistance from a partner, home health nurse, assisted living, meal-delivery services, or if they were living in a long-term care home.
  • Labs: pay attention to electrolytes– Na, K, Mg, PO4 — and suggest these be repleted if they’re low and no orders have been put in for repletion yet. Vitamin B12 levels should be >250 pg/mL. If Hgb is low, MCV is high, RBC is low, and B12 is borderline, suggest replete B12 levels, especially for the elderly and those with alcohol abuse. If the patient is diabetic: note down HbA1C test result (if available), any blood glucose test results. Kidney function tests such as: BUN, creatinine, and eGFR are also good to note.
  • Medications: Note down the IV– what’s the composition? And what’s its rate? Diuretics, vitamins/minerals, proton-pump inhibitors, electrolyte repletions, diabetes meds (including sliding scale insulin, and whether it was administered or not), antibiotics, oxycodone, sennosides, oral / IV dilantin… these are a few of nutritional relevance I’ve picked up these weeks, I’m sure there will be more.

Nutritionally Relevant Information 

  • Note down current diet type, texture, how long they’ve been on that diet, any fluid restrictions, any supplements / protein powders they’re receiving.
  • If the diet  was ordered by an SLP, note down that pt. has been assessed by an SLP.
  • The patient’s current intakes: are they eating all/ most/ some of their food? Are their feeds running uninterrupted? What are their appetites like?
  • Are they experiencing any nausea/ vomiting/ constipation/ diarrhea? If so, what’s the severity/ frequency? Note down bowel movements.
  • Patient’s historical intakes: what was their eating/ feeding like before they got into the hospital? What types of foods did they eat? Where they on any therapeutic diets/ textures? Who prepared the food?
  • Physical assessment: seek permission before conduction a physical assessment. Check fat and muscle stores in the temples, whether the clavicle is protruding, assess muscle and fat stores in biceps/ triceps.

If patient is receiving tube feeds:

  • Note down: type of formula, rate (look on pump), route of delivery (NG, PEG, GJ?), schedule (intermittent, continuous?) and flushes. It’s also good practice to include the amount of energy, protein, and fluid provided by the tube feed and flushes.

Anthropometrics 

  • Current body weight, height, and calculated BMI
  • Usual body weight
  • Any % change in body weight, figure out if this represents a severe loss, or significant loss of body weight.
  • Ideal body weight if patient is grossly under/ overweight
  • Adjusted body weight  if patient is grossly under/ overweight / had amputations

Nutrition Problem(s)

  • There’s a whole list of them here. Choose one or two wisely, and format it in a Problem-Etiology-Symptoms (PES) statement. Ex: [problem x] related to [etiology y] as evidenced by [symptom z].
  • This should flow from the previous 3 sections: medical information, nutritional information, and anthropometrics, and directly relate to the nutritional goals, implementation and follow up.

Goals & Implementation 

  • There are pre-set goals, like “maximize intakes”, “improve nutritional status”, or “weight gain”. Choose from these, or make your own based on the nutrition problem.
  • Write down what you did for the patient. This could include: catering to pt. preferences, changing diet order/ type, adding supplements or nutrient-dense menu items, liaising with health care team members, family, or previous health care providers, providing patient / family education, initiating tube feed…
  • If patient is remaining on the same diet/ tube feed order as before, indicate that as well.

If adding protein powder

  • Justify why the patient needs it (i.e.: not meeting estimated protein needs for wound healing, or additional protein needed due to poor oral food intakes): calculate estimated protein requirements, and calculate average protein/day from diet/ feed.
  • Include how much extra protein the protein powder contributes, and the new amount of total protein supplied.

If initiating a tube feed (TF)

  • Calculate and record the estimated energy, protein, and fluid requirements. One possibility is to use several prediction equations to come up with a range of values, then choose somewhere in between to use as the target value for your intervention. Make sure to document the calculation process.
  • Calculate and record the amount of energy, protein, and free fluid provided by the TF and flushes. This should be within the range of estimated requirements as calculated above.
  • If a patient is on a dextrose-containing IV, the dextrose will likely be stopped once the TF starts, so there’s no need to take into account the energy from the IV. Make sure the doctor is aware that the TF is starting and that the IV will need to be adjusted accordingly.
  • Flushes: 25-30 mL Q4H if IV running to keep tube patent.
  • Note about the role of nursing: nurses are responsible for starting the tube feed per schedule. They set the pump to the rate and dose indicated at the start time (more or less), and the pump will automatically stop when the dose is finished. Try to avoid starting tube feeds around shift changes for nurses. This helps ensure tube feeds are not forgotten during the shift change.

If patient is transitioning to an intermittent feeding schedule

  • Leave 2-3 hours between each feed.
  • Stop the continuous feed at 23:00 the night before day 1 of the intermittent schedule so patient will have an appetite in the AM.
  • Take 2-3 days to transition patient from a continuous to an intermittent schedule, increasing the rate the delivery rate of the formula each meal.
  • Monitor for signs and symptoms of intolerance closely, until patient reaches goal rate.

Follow-Up

  •  This section has fields with pre-populated options, or we can write our own areas for follow-up. The common ones I’ve been using include “intakes”, “tube feed initiation/tolerance”, and “medical plans”.
  • The key with the follow-up section is that it should match with the nutrition problem identified previously. For example, if inadequate vitamin D intake was the problem, then “micronutrient intakes” (or something to that effect) should be part of the follow-up plans.
  • There’s also an option that says the patient will not be followed up with by the dietitian. This option can be used when the patient is nutritionally stable or if nutrition care is not indicated for a patient (examples: when nutrition care is not in line with goals of care, when the client refuses dietetic services).

    Moon rising over Van Tech Secondary School
    Moon rising over Van Tech Secondary School
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