Best Practices Guidelines 01-2016

105 Pages·2016·18.23 MB·English

#####################################Best#Practice#Guidelines#
############################################Table#of#Contents#
#
#
•! Recommendations%for%Disease%States%
o! Cancer% o! Metabolic%Syndrome%
o! Celiac%Disease%/%Gluten%Intolerance% o! Overweight%/%Obese%
o! Chronic%Kidney%Disease%(CKD)% o! Pancreatitis%
o! COPD% o! Parkinson’s%
o! CHF% o! Spinal%Cord%(Quad,%para)%
o! DM% o! Underweight%
o! Elderly%–%65% o! Wounds%
o! Liver%/%Hepatitis%/%Cirrhosis%
•! Hydration%and%Fluids%
o! Evaluation%Hydration%Status%
o! Clinical%Symptoms%of%Excess/Deficit%Fluids%
o! Estimating%Fluid%needs%
•! Monthly%Dialysis%Review%
•! Enteral%Nutrition%%
•! Physician%Prescribed%Weight%Loss%
•! Workflow%Guidelines%
•! Predictive%Equations%/%Energy%Needs%Estimation%%
o! MSJ% o! Injury%factors%
o! Harris%Benedict% o! Shortcut%method%–%calories%per%kg%
o! Ireton%Jones% o! Protein%needs%for%Adults%
o! Activity%Factors%
•! TPN%–%Total%Parenteral%Nutrition%
•! Care%Plans%
o! Problem%
o! Goals%
o! Interventions%
•! Body%Weight%Considerations%
o! Amputations%
o! Paraplegia/quadriplegia%
o! Body%Mass%Index%
o! Other%Body%Weight%Considerations%
o! Weight%Loss%Interventions%
•! Nutrition%Care%Process%–%Note%Formats%
o! ADIME%
o! PIER:%wt/wound/TF/dialysis%review%templates%
•! Ventilator[Dependent%Residents%
o! Estimated%Needs%
o! Notes%
o! Basic%Modes%of%Mechanical%Ventilation%%
•! Selected%Medications%
Page%1%of%10%
%
•! Labs%
o! Lab%Diagrams%
o! Lab%Values%Guides%
!! Guide%to%Anemias%
!! Selected%Lab%Values%for%Adults%
•! Resource%Access%
•! APPENDIX%Table%of%Contents%
o! A:%TF%pump%Diagram%and%how%to%check%dose%limit%
o! B:%MSJ%Cheat%Sheet%
o! C:%Fluid%Adjustment%Cheat%Sheet%
o! D:%Top%Diet%Handouts%for%Residents%
!! Weight%loss%tips% !! Diabetes%and%Chronic%Kidney%
!! Low[Na%Nutrition%Therapy% Disease%Stage%1[4:%Nutrition%
!! Cirrhosis%Nutrition%Therapy% Guidelines%
!! Healthy%Ways%to%Add%Calories% !! Chronic%Kidney%Disease%Stage%5:%
!! Carbohydrate%Counting%for% Tips%for%People%NOT%on%Dialysis%
People%with%Diabetes% !! Chronic%Kidney%Disease%Stage%5:%
!! Label%Reading%Tips%(DM)% Tips%for%People%on%Dialysis%
!! Fluids%and%Fluid%Restrictions% !! Heart%Healthy%Nutrition%Therapy%
o! E:%Diet%Refusal%Education%
o! F:%Optimal%RDN%Solutions%Paper%Forms%
!! Nutrition%Monitoring% !! 2010%Dietary%Guidelines%for%
Flowsheet%(color%and%B&W)% Americans%–%Summary%%
!! RD%Consultant%Daily%Summary% !! Kitchen%Sanitation%Audit%
!! Dialysis%Pt%Nutritional% !! Meal%Observation%Form%
Review%/%Care%Coordination% !! Resident%Meal%Satisfaction%Survey%
!! RD%Pressure%Ulcer%Review% !! In[Service%Education%Sign[In%
!! RD%Weight%Review% !! Quarterly%Nutritional%Review%
!! RD%Nutrition%Risk%Review% !! Dietary%Supervisor%Admission%
(Initial%Assessment)% Intake%
!! Modified%Diet%Cheat%Sheet% !! RD%Tube%Feeding%Review%
!! RD%Menu%Review%–%Assisted%Living%
•! Resources%
# #
Page%2%of%10%
%
###########################################Best#Practice#Guidelines#
#
RECOMMENDATIONS#FOR#DISEASE#STATES#
Cancer#(CA)%
CALORIES% PROTEIN% FLUID%
•! Use%Harris[Benedict%Equation%w/%actual%weight1%%%%%% 1.1#to#1.4#g#/#kg1% %
•! Nutrition%Repletion/Wt%gain:%30E35#kcal/kg16% •! %Non[Stressed:%1.0#to#1.216% No%special%adjustments%
•! Inactive/Non[ambulatory:%25E30#kcal/kg16% •! Hypercatabolic:%1.2#to#1.616% noted.%Needs%increased%
•! Hyper[Metabolic/Stressed:%35#kcal/kg16% •! Severe%Stress:%1.5#to#2.516% w/%vomiting%/%diarrhea.%%
•! Sepsis:%25E30#kcal/kg16%
•! Nutrition%Support:%
•! Head/Neck%CA:%35E40#kcal/kg16% 1.6#to#2.0%%g#/#kg16%
•! Persistent%Weight%Loss:%Once%symptoms%and%inadequate%intake%already%addressed,%consider%fish#oil#
supplement%(0.26g%to%6.0g%EPA/day)%to%help%preserve/improve%wt%and%lean%body%mass.%1%
•! Neutropenia:%Provide#dietary#counseling%on%safe%food%handling%and%foods%which%may%pose%infectious%
risks.%(Neutropenic%diet%isn’t%necessary%(research%has%not%demonstrated%its%effectiveness),%but%safe%food%
counseling%is%appropriate.)%1%
•! Fluid#accumulation#may#mask#weight#loss.%%
%
For%More%Info:%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Oncology"%Accessed%08%August%
2015:%http://www.andeal.org/topic.cfm?menu=5291%,%https://www.nutritioncaremanula.org%%
Celiac#Disease#/#Gluten#Intolerance%
•! Gluten[Free%Diet:%Gluten%=%protein%found%in%wheat,%barley,%malt,%and%rye%(*and%oats,%unless%gluten%free).%
The%follow%foods%are%ok%to%eat:%arrowroot,%buckwheat,%cassava,%corn,%flax,%Legumes,%millet,%nuts,%
potatoes,%quinoa,%rice,%seeds,%soy,%tapioca,%Tef,%wild%rice,%Yucca.%17%%Diet%compliance%improves%outcomes%
r/t%bone%density,%iron%deficiency%anemia,%villous%atrophy,%GI%and%neurological%symptoms,%pregnancy%
outcomes,%and%quality%of%life.%2%%NOTE:%diet%tends%to%be%deficient/low%in%carbohydrates,%iron,%folate,%
calcium,%Vitamin%B12,%phosphorous,%niacin,%zinc%and%fiber.%2%
•! Educate%about%diet%and%cross[contamination%in%prep/manufacturing.%%
•! Multivitamin%with%minerals:%If%usual%intake%shows%nutritional%inadequacies,%add%a%gluten%free,%age%and%sex%
specific%supplement.%If%serum%Vit%D%low,%add%CA#&#Vit#D%through%food%or%gluten[free%supplements.%2%
•! Bone%Density:%Reduced%bone%mineral%content%/%bone%density%has%been%shown%in%untreated%adults%with%
celiac%disease;%consider%bone%density%screening%within%the%first%year.%
%
For%More%Info:%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Celiac%Disease"%Accessed%08%August%
2015:%http://www.andeal.org/topic.cfm?menu=5279%,%https://www.nutritioncaremanula.org%%
Chronic#Kidney#Disease#(CKD)%
CALORIES% PROTEIN% FLUID%
Adult%+%CKD,%including%dialysis%&%post[transplant:% Non[HD,%Non[DM,%eGFR%<50:%3% %
•! 23#to#35#kcal/kg#EDW#or#IBW3# •! 0.6g#to#0.8g#/#kg# •! 25#mL/kg13%%%%%OR%
Based%on:%wt%status/goals,%age%and%gender,%level%of% Adult%w/%DM%nephropathy:%3% %
physical%activity,%and%metabolic%stressors.%3% •! 0.8g#to#0.9g#/#kg# •! Urine#Output#+#
•! Adult%<60%Years:%35#kcal/kg16%% S/P%recovery%from%transplant.3% 500#mL/day9%
•! Adult%>60%Years:%30E35#kcal/kg16% •! 0.8g#to#1.0g#/#kg#
Adults%on%Dialysis:%16%
Page%3%of%10%
%
Do%not%use%actual%BW%because%as%kidney%function% •! >/=#1.2g#/#kg%
declines,%the%ability%to%regulate%fluid%balance%may%
be%compromised%affecting%measured%weight.%3%%
%
#################################RESTRICT####################################_%
• PHOSPHOURS:#
oCKD%stage%III%to%IV:%Low[%phos%diet%(800[1,000%
mg/day%or%10[12%mg%Phos%per%gm%of%pro).%To%
prevent%secondary%hyperparathyroidism,%
renal%bone%disease,%&%soft%tissue%calcification3%
oAfter%Transplant:%Hypophosphatemia%is%
common%post[transplant.%Recommend%high[
phos%intake%(diet%or%supplements).%3%
• POTASSIUM%–%If%pt%exhibits%hyperkalemia,%rec%K+%
intake%of%less%than%2.4g/day.%Can%adjust%rx%based%
on%serum%K+,%blood%pressure,%medications,%etc…%
Hypo/hyperkalemia%has%potential%for%cardiac%
arrhythmia/sudden%death.%3%%%
• SODIUM3%–%Intake%less%than%2.4%g/day,%with%
adjustments%as%needed:%EX%–%Blood%pressure,%GI%
issues:%vomiting,%diarrhea,%constipation,%etc…%
#############################SUPPLEMENT##################################_%
• CALCIUM#–%Total%Ca%should%not%exceed%2,000%
mg/day:%(dietary%Ca%+%Ca%supplement%+%Ca[based%
Phos%binders).%3%
• VITAMIN#D%–%Recommend%supplement%if%serum%
level%of%25[hydroxyvitamin%D%is%less%than%30%
NG/mL%(75nmol/L).%3%%%
• IRON3%–%Rec%Oral%or%IV%iron%if%serum%ferritin%is%
below%100%ng/mL%and%TSAT%is%below%20%.%
%
%%%Chart&from&Source&18:&Resource&Pocket&Guide&for&Nutrition&Assessment,&2009&
%• VITAMIN#C3%–%in%pts%w/%anemia%to%improve%iron%absorption,%recommend%DRI%for%Vitamin%C;%there%is%insufficient%
%
evidence%to%recommend%above%DRI%d/t%risk%of%hyperoxalosis.%%
%
• VITAMIN#B12#and#FOLIC#ACID3%–%Recommend%supplement%if%MCV%is%over%100%ng/mL%and%serum%levels%of%B12/folic%acid%
%
are%below%normal%values.%%
%
%• FISH#OIL#/#OMEGAE3#FATTY#ACIDS3%–%Recommend%supplement%to%reduce%oxidative%stress%and%improve%lipid%provide%as%
% needed.%(NOTE:&Not&proven&to&improve&renal&function).%%
%• RENAL#MVI3%–%Recommended%to%pts%at%higher%nutritional%risk%d/t%poor%po,%decreasing%GFR,%etc...%3%
%• DM#+#CKD%–%Achieve%target#A1C#of#~7%%to%prevent%diabetic%kidney%disease%(DKD),%and%may%slow%progression%of%
% established%kidney%disease.%3%
%
For%More%Info:%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Chronic%Kidney%Disease"%Accessed%08%August%
2015:%http://www.andeal.org/topic.cfm?menu=5303%.%%https://nutritioncaremanual.org%%
Chronic#Obstructive#Pulmonary#Disease#(COPD)%
•! NOTE:%Inflammation%increases%REE.%4%Studies&report&that&the&total&daily&energy&needs&of&individuals&w/&COPD&are&highly&variable.%4%
•! Protein#Requirement:%100[125%gm%protein/day%total.%18%%
•! Bone#Density:%D/T%increased%risk%for%osteoporosis%and%vertebral%fxs,%consider%recommending%a%bone%
density%screening.%4%%
Page%4%of%10%
%
•! Appetite:%often%diminished:%Small%frequent%meals%recommended%and%high%calorie%beverages.%Eat%slowly%
and%chew%foods%well.%Avoid%low%nutrient/low%calorie%foods%like%diet%foods/diet%sodas.%4,17%
•! Milk#consumption#and#Mucus#Production:%consumption%of%milk/milk%products%is%unrelated%to%mucus%
production;%studies%find%no%significant%effect%despite%individual%sensory%perception.%4%%
•! Supplement:%for%pts%with%BMI%under%20,%unintended%wt%loss,%or%reduced%oral%intake,%consider%
supplement%(Boost,%Ensure,%MedPass,%etc…).%Base%choice%of%supplement%more%on%pt%preference%and%not%
percent%of%fat%or%carbohydrate.%%
•! Intradialytic#Parenteral#Nutrition#(IDPN):%18%%See%TPN%section%of%this%guide%for%details.%#
%
For%More%Info:%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Chronic%Obstructive%Pulmonary%Disease"%Accessed%
08%August%2015:%http://www.andeal.org/topic.cfm?menu=5301%.%%%https://www.nutritioncaremanual.org%%
Congestive#Heart#Failure#(CHF)%
CALORIES% PROTEIN% FLUID%
•! Use%25#calories#/#kg16%%%%%OR% •! 1.2#to#1.4#g#/#kg5% 1400#to#1900#mL/day5##
•! MSJ#with%actual%body%weight.% •! Maintenance:%1.2#g/kg16% OR:%%%%25#mL/kg13#
Adjust%for%increased%catabolic%state.%5% •! Repletion:%1.0#to#1.516% [Depending%on%sx%(edema,%
fatigue,%shortness%of%breath).%
[Fluid%rx%will%improve%clinical%
4
symptoms%and%quality%of%life %%
•! SODIUM%intake%less%than%2000%mg%(2g)%per%day.%5%Restriction%improves%symptoms%(edema,%fatigue)%and%
quality%of%life.%5%%Other%research%recommends%sodium%restriction%of%2000%to%4000%mg/day.%16%%%
•! Avoid%processed%foods%and%meats;%eat%more%fresh%foods.%Avoid%adding%salt%to%food;%use%lemon,%lime,%fruit,%
juice,%vinegar,%fresh%herbs,%pepper,%etc…17%%
•! B6,#B12,#and#FOLATE:%Encourage%patients%to%consume%at%least%DRI%for%folate%through%food%and/or%
supplementation.%5#For%VITAMIN#B12,##200[500%mcg%daily%has%been%shown%to%be%beneficial.54%NOTE:%
DIURETICS%use%can%lead%to%THIAMINE%deficiency;%encourage%intake%amount%of%DRI.5%Low%MAGNESIUM%
may%occur%causing%irregular%heart%rhythms;%encourage%intake%amount%of%DRI.%5%
•! ALCOHOL:%One%drink%per%day%for%women%and%two%drinks%per%day%for%men%has%been%demonstrated%not%to%
be%harmful%in%heart%failure%patients.%5%
•! FLUID:%Limit%fluids;%too%much%may%cause%SOB,%poor%appetite,%wt%gain%from%swelling/edema.%%
%
For%More%Info:%%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Heart%Failure"%Accessed%08%August%
2015:%http://www.andeal.org/topic.cfm?menu=5289%.%%%https://nutritioncaremanual.org%%
Diabetes#(DM)%
CALORIES% PROTEIN% FLUID%
% Normal%Renal%Function:% %
No%special%adjustments%noted.% •! 15E20%#of#Calories8# No%special%adjustments%
DM%Nephropathy% noted.%%
•! </=#1#g#/#kg8#
CKD%stage%3[5%w/%Diabetes%
•! 0.8#to#0.9##g#/#kg8#
•! Recommend%Macronutrients%based%on%the%DRI#for#healthy#adults.%Research%does%not%support%any%ideal%
percentage%of%energy%from%macronutrients.%8%
•! Consistent#carbohydrate#intake%results%in%improved%glycemic%control.%There%is%conflicting%evidence%on%
the%effectiveness%of%the%use%of%Glycemic%Index%for%meal%planning.8%
•! Recommend%dietary#fiber#(food#+#supplement)#25E30#grams#per#day%with%special%emphasis%on%soluble%
fiber%(7[13%g).%Diets%high%in%fiber%can%help%reduce%total%cholesterol%by%2[3%%and%LDL%by%up%to%7%.8%
Page%5%of%10%
%
%
For%More%Info:%%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Diabetes%Type%1%and%2"%Accessed%08%August%
2015:%http://www.andeal.org/topic.cfm?menu=5305%.%%%https://nutritioncaremanual.org%
Elderly#–#65#Years#or#Older%
CALORIES% PROTEIN% FLUID%
Chronically%or%Acutely%ill%and/or%Underweight10% % %
•! 25[30%kg/kg/day%% No%special%adjustments%noted% No%special%adjustments%
Healthy%Females:10%%25E35#kcal/kg%per%day% noted.%%
Healthy%Males:10%%30E40#kcal/kg%per%day%
•! Recommend%liberalization#of#diets%when%possible%except%texture%modification.%Research%has%not%
demonstrated%benefits%of%restriction%Na,%Chol,%Fat,%and%Carbohydrate%in%older%adults.%10%%
•! Goal%of%nutrition%intervention%for%older%adults%is%to%maintain%good%health%and%well[being%and%reduce%risk%
of%chronic%and%debilitating%diseases.%17%
•! Encourage%food%intake%meeting%DRI#for#micronutrients;%recommend%MVI#if%food%intake%is%low.%10%
•! Recommend%medical#food#supplement%for%those%who%are%undernourished%or%at%risk%of%undernutrition%(i.%
e.,%frail,%infection,%impaired%wound%healing,%PU,%depression,%dementia,%after%hip%fx%&%orthopedic%sx).%10%
•! Even%when%weight%is%stable,%generally%muscle%mass%decreases%/%fat%mass%increases%over%time.%NOTE:%
Research%does%show%an%association#between#depression#and#weight#loss#or#poor#nutrition#status.%10%
•! For%wt%loss,%try%medical%food%supplements%&%depression%tx%first;%if%ineffective,%may%try%appetite#
stimulants.%There%is%no%research%on%their%effectiveness%for%older%adults.%10%
•! On%discharge,%provide%information%to%social%services%and%encourage%eligible%older%adults%to%participate%in%
the%following%programs%when%applicable:%10%
o! Supplemental%Nutrition%Assistance%Program%(SNAP)%aka:&Food&Stamps%
o! Senior%Farmer’s%Market%Nutrition%Program%(SFMNP)%
o! Child%and%Adult%Care%Food%Program%(CACFP)%
o! Emergency%Food%Assistance%Program%
o! Commodity%Supplemental%Food%Program%(CSFP)%
o! Older%Americans%Act%(OAA)%Congregate%Nutrition%Program%
o! OOA%Home%Delivered%Nutrition%Program%
For%More%Info:%%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Food%and%Nutrition%for%Older%Adults"%Accessed%08%
August%2015:%http://www.andeal.org/topic.cfm?menu=5314%.%%%%%https://nutritioncaremanual.org%
Liver#/#Hepatitis#/#Cirrhosis%
CALORIES% PROTEIN% FLUID%
•! Cirrhosis%w/%Encephalopathy:%% •! Cirrhosis%w/%Encep:% %
25E35#kcal#/#kg16% 1.0#to#1.2#g#/#kg16% Fluid%needs%may%be%
•! Cirrhosis%w/%or%Chronic%Acute%Encep:% •! Cirrhosis%w/%Acute%Enc:% decreased%with%hepatic%
30E35#kcal#/#kg16% 0.6#to#0.8#g#/#kg16% failure%with%ascites.%18%%
% •! Chronic%Encep:%
0.8#to#1.2#g#/kg16%
•! Hepatic%Encep:%
1.0#to#1.3#g#/#kg16%
•! Hepatic%Failure%
0.25E0.5#g#/#kg18#
Page%6%of%10%
%
•! May%do%better%with%4[6%smaller%meals%per%day%instead%of%3%large%meals/day.%%If%appetite%is%poor,%consider%
nutrition%supplement%/%medical%food.%17%
•! If%Edema,%reduce%sodium%intake.%17%%
•! Avoid%foods%that%may%cause%foodborne%illness%(raw%milk,%undercooked%meat/poultry/eggs,%sushi,%
unwashed%fruits%and%vegetables,%unpasteurized%juices,%raw%vegetable%sprouts.%17%)%
•! Stay%as%active%as%possible.%17%%
•! Ammonia%–%lactulose%sometimes%prescribed%when%ammonia%is%elevated.%%
%
For%More%Info:%%
Pocket%Resource%for%Nutrition%Assessment:%http://dpg[storage.s3.amazonaws.com/dhcc/resources/PocketResources/PRNA%202009.pdf%%
Nutrition%Care%Manual:%https://www.nutritioncaremanual.org%%
Metabolic#Syndrome#
•! Weight%loss%is%recommended%if%patient%is%overweight.%Encourage%intake%of%whole%grains%and%fiber;%reduce%
intake%of%saturated%fats,%trans%fats,%and%cholesterol.%17%
•! Triglycerides%are%elevated%with%metabolic%syndrome%(>150%mg/dL).%18%
•! HDL%(high%density%lipoprotein)%is%decreased%with%metabolic%syndrome.%18%%
•! Gamma[glutamyl%transferase%(GGT)%and%Gamma[glutamyl%transpeptidase%(GGTP)%increased.%*GGT%and%
GGTP%are%synthesized%in%the%liver;%also%found%in%kidneys,%pancreas,%brain,%heart,%salivary%and%prostate%
glands.%Functions%to%transfer%Amino%Acids%and%peptides%into%cell%membranes.%Also%involved%in%glutathione%
metabolism.%18%%
%
For%More%Info:%%
Pocket%Resource%for%Nutrition%Assessment:%http://dpg[storage.s3.amazonaws.com/dhcc/resources/PocketResources/PRNA%202009.pdf%%
Nutrition%Care%Manual:%https://www.nutritioncaremanual.org%
Overweight#/#Obese#
CALORIES% PROTEIN% FLUID%
Use%MSJ%w/%actual%BW%to%calculate%RMR.%12% 15[35%%of%Calorie%from%Protein% •! [(kg#body#wt#–#20)#
Multiple%RMR%by%an%activity%factor:%12% % x#15]#+#150013#
•! Sedentary:%1.0%to%<1.4% (35[60%%From%CHO)% %
OR%
•! Low&Active:%1.6%to%<1.6% (25[35%%From%Fat)%
#
•! Active:%1.6%to%<1.9%
•! 1#mL/kcal9%%%%%%%%%
•! Very&Active:%1.9%to%<2.5%
If%resident%desires%wt%loss,%encourage%realistic%goal%setting:%12%
•! Up%to%two%pounds%per%week%
•! Up%to%10%%of%baseline%body%weight%
•! 3%%to%5%%of%baseline%body%wt%if%cardiovascular%risks%are%present%(HTN,%HLD,%hyperglycemia).%
%%
For%weight%loss,%use%a%calorie#deficit#of#500#to#750#kcals/day%(decreased%intake%+%increased%activity;%recommend%
2.5%to%7%hours%per%week%of%physical%activity).%12%
%
For%More%Info:%%
Academy%of%Nutrition%and%Dietetics%Evidence%Analysis%Library.%"Adult%Weight%Management:%Executive%Summary%of%Recommendations%(2014)"%
Accessed%08%August%2015:%%http://www.andeal.org/topic.cfm?menu=5276&cat=4690%.%%%%%%%%%%%https://nutritioncaremanual.org%
Pancreatitis#
CALORIES% PROTEIN% FLUID%
•! Acute:%25E35#kcal/kg16% •! Acute:%1.5#g/kg16% •! 1#mL/kcal9%%%%%%%%OR%
•! Chronic:%30E35#kcal/kg16% •! Chronic:%1.0#to#1.5#g/kg16% •! 25E35#mL/kg13%
•! Parenteral%Nutrition%is%sometimes%used%to%allowed%prolonged%bowel%rest%with%severe%pancreatitis.%18#
Page%7%of%10%
%
•! May%affect%digestion%or%absorption%of%food.%18%%Reduce%fat%in%the%diet;%total%fat%should%not%exceed%25[30%%
of%total%calories.%17%#
•! Pancreatic%enzymes%are%sometimes%prescribed;%low[fat%diet%often%no%longer%necessary%once%on%enzymes.%
17%#
•! Avoid%alcohol.%17%#
%
For%More%Info:%%
Pocket%Resource%for%Nutrition%Assessment:%http://dpg[storage.s3.amazonaws.com/dhcc/resources/PocketResources/PRNA%202009.pdf%
Nutrition%Care%Manual:%%%https://nutritioncaremanual.org%#
Parkinson’s#Disease#
•! There%is%no%diet%or%nutrition%therapy%specific%to%Parkinson’s.%17%%%
•! Symptoms%can%affect%nutritional%status:%weight%loss,%feeding%problems,%dysphagia.%On%nutrition%
assessment,%assess%chewing/swallowing/ingestion%ability%and%wt%history.%17%
•! Protein[modified%diet%is%sometimes%used%for%nutrient[medication%interaction%with%levodopa.%Not%all%
patients%on%levodopa%are%affected.%Patients%who%do%not%take%levodopa%do%not%need%to%modify%protein%
intake.%17%
•! If%a%patient%is%unable%to%meet%nutrition%needs%via%PO%intake,%EN%may%be%considered,%however%continuing%
PO%intake%for%oral%gratification%can%enhance%quality%of%life.%17%
%
For%More%Info:%
Nutrition%Care%Manual:%%%https://nutritioncaremanual.org%
Spinal#Cord#Injury##(Quadriplegia,#Paraplegia)#
CALORIES% PROTEIN% FLUID%
Quadriplegic:####23#kcal/kg#per#day18% % %
None%specified.% None%specified.%
Paraplegic:%%%%%%%%28#kcal/kg#per#day18%
•! Estimated%energy%needs%for%paraplegics/quadriplegics%are%adjusted%by%reducing%calculated%desirable%body%
weights%because%immobilized%patients%lose%muscle.%18%%
•! Calculate%estimated%body%weight:%first%determine%ideal%body%weight,%then%subtract:%
o! Paraplegics:%5[10%,%%%%%Quadriplegics:%10[15%.18%
•! Low%BMI%is%expected%d/t%decreased%muscle%mass%(Muscular%Disuse%Atrophy).%18%
%
For%More%Info:%%
Pocket%Resource%for%Nutrition%Assessment:%http://dpg[storage.s3.amazonaws.com/dhcc/resources/PocketResources/PRNA%202009.pdf%
Underweight#
CALORIES% PROTEIN% FLUID%
•! 30E35#kcal/kg%per%day18% % %
(may%need%additional%w/%wt%loss,%wounds,%etc…)% None%specified;%based%on% None%specified.%
Underweight%Older%Adults10% condition.%%
•! 25E30#kcal/kg%per%day%or%higher%for%wt%gain10%
•! Defined%as%BMI%<18.5.%18%%
•! Consider%diet%liberalization.%18%Eat%at%least%5%small%meals/day.%Drink%healthy%beverages%that%add%calories.%
Drink%nutrition%supplements.%Choose%more%calorie[dense%foods%and%foods%high%in%protein.%Add%high%fat%
foods%to%meals/snacks.%17%%
%
For%More%Info:%%
Pocket%Resource%for%Nutrition%Assessment:%http://dpg[storage.s3.amazonaws.com/dhcc/resources/PocketResources/PRNA%202009.pdf%
Nutrition%Care%Manual:%%%https://nutritioncaremanual.org%
%
#
Page%8%of%10%
%
Wounds%
CALORIES% PROTEIN% FLUID%
Any%Pressure%Ulcer:%6% Any%Pressure%Ulcer:%6% •! 1#mL/kcal9%%%%%%%%OR%
•! 30[35%kcals%/%kg% •! 1.25%to%1.5%g%/%kg% •! 25E35#mL/kg13%
(Underweight%individuals%may%need%additional%calories).%6% (Assess%renal%fx%to%ensure%high%pro%is% NOTE:%pts%consuming%high%pro%
appropriate).%6% may%require%additional%fluid.6%
Estimate%on%high%end%if%pt%has%
a%draining%wound.%13%%%
•! RD%will%review#the#nutrition#needs#of#the#resident#within#14#days%of%admission%and%revise%or%add%to%the%
plan%of%care%as%indicated%by%the%resident’s%individual%needs.%11%
•! When%admitted%with%a%Pressure%Ulcer%(PU)%or%new%PU%identified%by%the%Treatment%nurse,%nurse%should%
immediately%implement%the%following%interventions%after%receiving%an%MD%order%(NOTE:%these%
interventions%may%be%renewed%or%revised%as%appropriate%by%the%RD%or%MD):%11%
o! Vitamin#C,%500%mg%tab%PO%daily.%11%
o! Multivitamin#with#Minerals%(senior%tab%recommend;%it%has%100%%Vit%C%and%Zinc).%11%%
o! Protein#supplement%(ProStat,%ProMod,%etc…),%30%mL%Q%day.%Additional%amounts%may%be%
recommended%by%the%RD.%Protein%supplement%is%ok%to%use%with%dialysis%patients%and%wound%care.%
Contraindicated%for%acute/chronic%renal%failure%without%RD%assessment.%11%%
o! House#Oral#Supplements:%11%
!! Diabetic%with%wounds:%Glucerna%or%Diabetasource%120%mL%PO%TID%x2%weeks%
!! Non[DM%with%wounds:%Ensure%Plus%or%Boost%Plus%120%mL%PO%TID%x2%weeks%
!! Renal%on%Dialysis%with%wounds:%Nepro%or%Novasource%Renal,%120%mL%PO%TID%x2%weeks%
!! Chronic%Kidney%Disease%with%wounds:%Suplena%or%RenalCal,%120%mL%PO%TID%x2%weeks%
•! Liberalize%dietary%restrictions%when%restrictions%result%in%decreased%food%and%fluid%intake.%6%
%
For%More%Info:%
National%Pressure%Ulcer%Advisory%Panel.%
http://journals.lww.com/aswcjournal/Fulltext/2015/04000/The_Role_of_Nutrition_for_Pressure_Ulcer.7.aspx%%
Pocket%Resource%for%Nutrition%Assessment:%http://dpg[storage.s3.amazonaws.com/dhcc/resources/PocketResources/PRNA%202009.pdf%
Nutrition%Care%Manual:%%%https://nutritioncaremanual.org%
HYDRATION#AND#FLUID#
#
Evaluating#Hydration#Status:##
•! Urine%specific%gravity%(Usg)%–%Normal%=%1%to%1.3;%elevated%w/%dehydration,%UTI,%etc…%
•! Urine%osmolality%(Uosm),%serum%osmolality%(Sosm),%and%urine%color%(Ucol)%are%good%indicators%of%
hydration%status.%9%%%
•! Body%weight%loss%greater%than%3%%is%also%a%good%indicator%of%acute%dehydration.%9%%%
•! Physical%signs%of%dehydration:%dry%tongue,%longitudinal%tongue%furrows,%dry%mucous%membranes%of%nose%
and%mouth,%eyes%that%appear%recessed%in%their%sockets,%upper%body%muscle%weakness,%speech%difficulty,%
confusion.%9%%
•! Additional%signs%of%dehydration%to%monitor:%changes%in%weight,%skin%turgor,%urine%output,%elevated%serum%
sodium,%calculated%serum%osmolality.%9%%
•! Capillary%Refill:%Normal%=%<2%seconds;%<3%seconds%for%elderly%adults.%%
•! Consider%Meal%PO%
•! BUN/Creat%ratio%
•! BNP%
%
%
%
Page%9%of%10%
%
•! Serum#Osmolality#Calculation:%18%Measures%the%concentration%of%particles%in%solution.%Osmolality%
increases%with%dehydration%(loss%of%water%without%loss%of%solutes)%and%decreases%over[hydration.%%
o! CALCULATION:%%%(2%x%(Na%+%K))%+%(BUN%/%2.8)%+%(glucose%/%18).%
o! Normal%Range=%285%–%295%mOsm/kg.%%
!! DECREASED%levels%may%indicate:%Dehydration,%Diabetes%Insipidus,%Hyperglycemia,%
Hypernatremia,%Uremia.%%
!! INCREASED%levels%may%indicate:%Hyponatremia,%Over[hydration,%inappropriate%ADH%
secretion.%%
%
Clinical#Symptoms#of#Excess/Deficit#Fluids:%18#
Parameter# Deficit#Fluids# Excess#Fluids#
Blood%pressure% Decreased% Increased%
BUN/creatinine% Increased% Decreased%
Cardiac%Output% Decreased% Increased%
Central%venous%pressure% Decreased% Increased%
Edema% [! % Present%
Electrolyte%abnormalities% Increased%Na,%Cl% Decreased%Na,%Cl%
Eyes% Sunken% Puffy%(eyelids)%
Heart%rate% Increased% [! %
Hemoglobin/Hematocrit% Increased% Decreased%
Intake/Output% Output%>%Intake% Intake%>%Output%
Neck%veins% Flat% Distended%
Pulse% [! % Increased%
Serum%Osmolality% Increased% Decreased%
Shortness%of%Breath% [! % Present%
Skin% Poor%turgor% Moist%
Systemic%vascular%resistance% Increased% [! %
Tachycardia/Bradycardia% [! % Possible%
Urine%Specific%Gravity% Increased% Decreased%
Weight% Decreased% Increased%
%
Estimating#Fluid#Needs:%#
Equations%commonly%used%in%adult%populations:%9%
•! RDA#Method#(Energy#Method):%9%%%1%mL/kcal%
•! Fluid#Balance#Method:#9%%%%%Urine%Output%+%500%mL/day%
•! Obese#Adults:%13%%%%%[(kg%body%weight%–%20)%x%15]%+%1500%
•! ML#per#KG#Recommendations:#(*Use&Adjusted&Body&Weight&with&Obese&Adults&when&using&this&method).%%
o! Generally%25[35%mL/kg13%
o! CHF%or%Renal%Disease:%25%mL/kg13%
o! Average%Adult:%30%mL/kg13%
o! Infection%or%Draining%Wound:%35%mL/kg13%
o! Adult%>65:%25%mL/kg15%
•! Factors#that#may#INCREASE#fluid#needs:%18#
Anabolism,%Burns,%Constipation,%Dehydration,%Diarrhea,%Emesis,%Fever*,%Fistulas/drains,%hemorrhage,%hot%
or%dry%environment,%hyperventilation,%hypotension,%medications,%nasogastric%suctioning,%polyuria**.%
*Fluid%needs%increase%7%%for%each%oF%above%normal;%13%%for%each%oC.%
**Poor%glucose%control;%excess%alcohol,%caffeine;%osmotic%diuresis%can%all%cause%polyuria.%%
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