Chapter 5 Nutrition Care Process

Client History (CH): ●

➤ ➤ ●

59 Personal data (CH-1.1):

Age (CH-1.1.1): 77 years old Gender (CH-1.1.2): Female

Patient/client chief nutrition complaint (CH-2.1.1): Elevated HbA1c; overweight is a concern of the family; client wants to avoid taking medication for diabetes

●

Treatments/therapy (CH-2.2): Medical treatment/ therapy (CH-2.2.1): Prescription medication use: Flovent, albuterol, Nasonex, and Synthroid. She uses Flovent in the fall and albuterol and Nasonex as needed.

Comparative Standards (CS): ●

➤ Weight and growth recommendations (CS-5):

Ideal/reference body weight (IBW) (CS-5.1.1): IBW is 110 +/–10 lbs

➤

Recommended body mass index (BMI) (CS-5.1.2): 23

●

Energy needs (CS-1): Estimated energy needs (CS-1.1):

➤

Total energy estimated needs (CS-1.1.1): 1,478 kcal/d

➤

Method for estimating needs (CS-1.1.2): Using Mifflin-St Jeor’s calculations, current esti- mated resting metabolic rate (RMR) is 1,137 kcal; estimated total daily energy expenditure (TDE) of 1,478 kcal is calculated as RMR × activity factor (1.3) × injury factor (1).

● Estimated protein needs (CS-2.2): ➤

Total protein estimated needs (CS-2.2.1): 50 to 69.4 g/d

➤

Method of estimating needs (CS-2.2.3): 1 g protein per kg IBW–1 g protein per kg of actual body weight (ABW) (13)

● Fluid needs (CS-3): ➤

Total fluid estimated needs (CS-3.1.1): 2,100 mL/d

➤

Method of estimating needs (CS-3.1.2): 30 mL/kg ABW

Note: The NCP codes are listed only for reference and are not included in the documentation.

Nutrition Diagnosis

The second step is to determine whether a nutrition diagnosis exists. There may be more than one possible nutrition diagnosis. The RDN must evaluate all possi- bilities and determine the most viable nutrition diagno- sis to proceed with the care of the resident/client, knowing that there may not be a nutrition diagnosis with every case. When a nutrition diagnosis has been

➤ ➤ ➤

determined, it is expressed as a PES statement. There may be more than one PES statement to address at one time. However, the goal is to keep it to one or two nutrition diagnoses. Often once the original nutrition diagnosis has been resolved, other problems can be identified and/or may also resolve.

For JM, three possible nutrition diagnoses are

excessive energy intake (NI-1.3), overweight/obesity (NC-3.3), and physical inactivity (NB-2.1). The first diagnosis was selected because it is in the Intake domain. The following is the PES statement for JM:

Excessive energy intake (P) related to intake greater than energy expenditure (E) as evidenced by BMI greater than 25 (overweight) (S).

Nutrition Intervention

The third step is to determine the nutrition interven- tions. The interventions are directed at the etiology of the PES statement and designed to resolve the root cause of the problem. The RDN will plan the nutrition prescription and interventions with input from the resi- dent/client and others. The implementation of the selected interventions is agreed upon with the resident/ client/others. The nutrition prescription is the RDN’s recommendation for energy, protein and nutrients, or foods and beverages.

●

Nutrition prescription (NP): 1,400 kcal/d meal plan, consisting of three meals and two snacks

● Interventions: ➤

Energy-modified diet (ND-1.2.2): 1,400 kcal/d meal plan. Goals: 1,400 kcal energy intake per day for stable weight; gradual weight loss desired.

Composition of meals/snacks (ND-1.2): Three meals and two snacks. Goal: Plan a routine meal schedule.

➤

Schedule of food/fluids (ND-1.3): eight to nine (8-oz) beverages with and between meals per meal plan. Goal: Achieve adequate daily fluid intake of 2,100 mL.

Nutrition education—content (E-1.4): Nutri- tion relationship to health/disease: discuss weight management. Goals: Achieve a healthier BMI of 23 and improve HbA1c.

➤

Nutrition education—skill development (E-2.2): Discuss meal planning and food groups, portion control, and fluid needs. Goals: Understand portion control and food groups to aid in weight management/ healthier food/beverage choices.

Nutrition counseling: Theoretical basis/ approach (C-1): Cognitive-behavioral theory (C-1.1): Establish goals for improved physical activity with client and family. Nutrition