Nutrition protocols improve outcomes
Nutrition protocols improve outcomes
The Chicago-based American Dietetic Association (ADA) has medical nutrition therapy protocols for the prevention of unintentional weight loss and treating pressure ulcers, developed by dietitians and published by the ADA and Mobile, AL-based Morrison Health Care. (See story, p. 42, for an easily implemented nutrition program for nursing home patients.)
Case managers may use the protocols to monitor ulcer care plans and help providers improve outcomes. Here’s how the protocols work:
1. Pressure ulcer (stages I-IV):
The nurse should obtain baseline measurements of the patient’s biochemical/blood work within 30 days of the first session. The nurse also should obtain the patient’s baseline weight and clinical signs and symptoms of stage I, II, III, or IV pressure ulcers.
The first step is to include nutrition standards in your assessment, says Jody Vogelzang, MS, RD, LD, FADA, president of JLV and Associates in Southlake, TX. Vogelzang chairs the dietetic practice group of the ADA. "If there is a nutrition risk, it should be flagged, and something has to be done about it."
Nurses also should assess the following items:
• Functional outcomes:
— activities of daily living;
— Braden scale for predicting pressure sore risk score;
— incontinence/urinary/fecal status;
— chewing and swallowing problems;
— quality-of-life evaluation.
• Behavioral outcomes:
— whether oral intake is adequate in protein, calories, fluids, vitamin C, and zinc;
— patient’s knowledge of food and drug interaction;
— review of appropriate care and treatment as prescribed.
All of those items except for the biochemical measure should be evaluated four times. The biochemical measure should be evaluated during the last intervention. The expected outcomes include the following:
• improve, achieve, or maintain appropriate biochemical values when properly hydrated;
• raise or maintain body weight as appropriate;
• hydrate the wound and improve the wound status through healing without further breakdown;
• have the patient be able to feed self and/or eat with assistance, and raise the mobility and activity level;
• raise the Braden scale score;
• reduce incontinence through bowel and bladder training;
• have the patient consume the appropriate amounts of food and fluid;
• improve the patient’s quality of life;
• have the patient consume adequate nutrients to heal the wound;
• have the patient consume food and drugs at appropriate times and in appropriate amounts;
• teach patient that wound care with adequate nutrition heals wounds.
Vogelzang says case managers should consider environmental factors that could negatively affect any of these measures. For example, the patient’s care plan may say the patient needs to increase protein, which generally is found in meat. But if the patient has ill-fitting dentures, the patient might have trouble chewing meat. "The meat will sit on the plate," Vogelzang says. "What looks good on paper may not translate into increased protein for that patient." Solutions include having the patient puree meat or to obtain protein through a nutritional drink.
The ideal goals are:
• biochemical measures of less than 3.5 g/dl for albumin, 11 g/dl of HgB, and 33% Hct;
• avoiding weight loss of >= 5% in 30 days or >= 10% in six months;
• consuming nutrition as prescribed;
• Braden score of 17 or higher;
• increasing mobility and activity based on the patient’s health condition;
• controlling incontinence to prevent further skin breakdown;
• achieving or maintaining adequate nutrition and hydration;
• improving a quality of life appropriate to the patient;
• maintaining an oral intake of 1.25-1.50 g total protein per kg of body weight with 70% high-biological value;
• minimum of 30-35 ml/kg body weight;
• no evidence of food and drug interaction.
2. Prevention of unintentional weight loss:
Case managers should obtain baseline measures of the biochemical parameters of albumin, HgB, Hct, BUN, and creatinine. They also should assess the patient’s weight, height, and body mass index; hydration status; and blood pressure. "Albumin shows the protein status, and it’s so important for the patient to have an adequate protein source," Vogelzang says. "Generally it’s the protein source that is used for energy when weight loss is occurring." Also, clinicians should check to see if the patient has dry mucus membranes, which could indicate clinical dehydration.
Next, the case manager should look at functional outcomes, including these:
• activities of daily living;
• exercise tolerance;
• whether patient demonstrates self-feeding skills.
Again, the patient’s quality of life should be evaluated, including these behavioral outcomes:
• food and meal planning;
• vitamins and mineral supplements with acceptable doses, if required;
• tolerance of the consistency of foods served;
• knowledge of food and drug interactions.
Expected outcomes are:
• laboratory tests repeated, based on the client’s condition;
• increase or maintenance of weight as appropriate;
• prevention of dehydration and edema;
• blood pressure within normal limits of client’s history;
• activities of daily living maintained or improved;
• increased mobility and activity level;
• maximized food intake through self-help devices or feeding assistance;
• improved quality of life;
• consumption of nutrient-dense foods, snacks, and supplements with greater than 30 to 35 kcal/kg;
• if needed, alternative nutrition support to prevent further weight loss and reduce complications;
• no signs or symptoms of vitamin or mineral deficiencies;
• consumption of 90% to 100% of meals, snacks, and supplements without distress;
• dietary adjustment for food/drug interaction.
The ideal goals are:
• biochemical values of: albumin at 3.5 g/dl; HgB at 11 g/dl; Hct at 33%; BUN at 8-20 mg/dl, and creatinine at 0.7-1.5 mg/dl;
• patient maintains weight of greater than 85% of usual body weight;
• patient’s blood pressure is less than 120/80 mm/Hg;
• patient is able to participate in exercise appropriate for tolerance;
• quality of life is improved as appropriate to the patient;
• patient has an increase of intake of nutrient dense foods and maintains or increases weight gradually;
• patient has no complications associated with low body weight, medication noncompliance, or vitamin or mineral deficiencies.
Each protocol includes four interventions that are spaced two to four weeks apart, Vogelzang says. The protocols also include flowcharts and a second page with spaces for the clinician to check specific assessment items for each intervention date. The Braden scale for predicting pressure sore risk also is included in the protocol packet.
[Editor’s note: For more on the pressure ulcer and unintentional weight loss nutrition protocols, contact the American Dietetic Association at (800) 877-1600, ext. 5000.]
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