Evaluating the Nutrition Care Plan
After you have implemented your nutrition care plan (NCP), you need to follow-up and evaluate it to ensure that it has been effective in addressing your patient’s nutrition concerns. This can help you to decide on appropriate changes to make to the nutrition care plan moving forward. When evaluating your plan in a inpatient setting, you will need to gather updated information from the same key areas of nutrition concern that you identified in your initial assessment. This will include, but is not limited to: enteral feeding delivery/tolerance, daily intake and outputs, laboratory values, medications, disposition, and any changes to the medical care plan.
|Common Nutrition Issues||Evaluate effectiveness of NCP|
|Daily Input and Output||
|Medical Care Plan||
|Common Nutrition Issues||Evaluate effectiveness of NCP||Outcome|
|Enteral Feeds||Has reached goal rate. Only complication is diarrhea today (3rd day of enteral feeds).||Evaluate feeds, fluids, medications and bowel routine. What is likely causing his diarrhea?|
|Daily Input and Output||Experiencing loose stools.||
|Malnutrition||Only three days since initiation. No need for evaluation at this time.||N/A|
Electrolytes have been normal over the past three days. No evidence of refeeding syndrome.
Continue to monitor (up to 7 days). Liaise with team regarding replacements, if necessary (in light of recent diarrhea – risk of greater losses).
|Medical Care Plan||
No changes to medical care plan. Will start chemotherapy/radiation therapy. Prepare for discharge home once stable on enteral feeds.
Consider progression to bolus feeding.
Bolus Feedings Prior to Discharge
Consider transitioning patients to a bolus feeding schedule in preparation for discharge home. Bolus feeding has many benefits for patients who are no longer in a hospital setting, including:
- Hunger/satiety (preparation for eventual transition to oral diet)
- Liberalization from enteral feeding equipment
- Ease of feeding out of the home
- Improved quality of life (QOL)
- Better sleep (due to flexibility in sleep positioning, no equipment noise)
- Ease of participation in therapy/treatments/appointments
- Better glycemic control
- Metabolic optimization
When patients are tolerating their continuous enteral regime at goal volume with no GI/metabolic concerns and it is deemed appropriate/safe/feasible, you can change their feeding schedule to an intermittent or bolus feeding regime.
In Carson’s case, he will be receiving long-term enteral feeds at home with low likelihood of resuming an oral diet while undergoing cancer treatment. He will benefit from a bolus feeding schedule for increased comfort, improved QOL & to make nutrition optimization feasible with his daily cancer treatment schedule.
Consider finances and coverage of enteral supplies and formulas when choosing an enteral regime for patients being discharged home. Also consider what supports patients may require to administer their enteral feeds if they are not able to be independent with the task.
Progression to Bolus Feeding
Consider the following if you are planning a progression to bolus feeding:
- Is it appropriate/safe/feasible?
- Quality of life: discuss bolus feeding schedule (number of cans needed, volume of flushes, administration times, flexibility) with patients and families to assess compatibility with their activities of daily living (i.e. do not schedule 5 AM feeds for a patient who does not wake before 9 AM). Consider sleeping schedules (including naps), medication schedules (especially of time sensitive drugs or those with drug-nutrient interaction), mealtimes/social aspect of feeding, work schedules, therapy/treatment/appointment schedules and family members schedules (if they will be assisting the patient with enteral administration).
- Tolerance: some patients can tolerate high volumes of enteral feeds over short periods of time, others cannot (i.e. 1 carton over 15 minutes vs. 1 carton over 1 hour). This is based on the individual; it is important to try the proposed schedule before going home and things can be further adjusted/optimized in the community.
- Advice and Guidance: some patients require strict schedules (i.e. exact times, amounts, procedures) whereas others desire more general guidelines (i.e. you require 5 cans of formula daily with an additional 1000 mL free water and the patient/family member(s) can choose how/when to administer it, as long as the recommended total volume is received over 24 hours).
- Follow-up and progression: It is also possible to use combination regimes (i.e. bolus feed 3 times throughout the day and provide additional continuous feeds overnight). It is important to ensure that patients who are being discharged home on enteral feeds have RD follow up post-discharge to adjust enteral regimes if needed.
Carson’s current enteral feeding regime is Isosource 1.2 @ 75 mL/hr × 20 hours for a total of 1500 mL enteral formula. 1 carton of Isosource 1.2 is 250 mL. Therefore, Carson would need 6 cartons/day to meet his needs. This will provide 1800 kcal/day (31 kcal/kg), 81 g protein/day (1.4 g/kg), and 1215 mL free water. Therefore, Carson will require 550 mL of water flushes per day through his G-tube to meet his hydration requirement.
- Current Enteral Regime: Isosource 1.2 @ 75 mL/hr × 20 hours = 1500 mL enteral volume.
- Bolus feeds: 1 carton Isosource 1.2 = 250 mL; 1500 mL⁄250 mL = 6 cartons/day.
- 6 cartons/day = 1500 mL = 1800 kcal/day (31 kcal/kg), 81 g protein/day (1.4 g/kg), 1215 mL free water
- Water flushes: 2065 mL (requirement) − 300 mL (medications) − 1215 mL (free water) = 550 mL
Here is a general plan for Carson to transition to bolus feeding while he is in hospital. To be conservative, it is important to estimate that a longer hang time via gravity drip of 1 hour per carton would be required for tolerance. This can be adjusted after assessing for tolerance.
- Proposed Schedule: 2 cartons (breakfast), 1 carton (lunch), 2 cartons (dinner), 1 carton (evening snack)
- 2 cartons (500 mL) Isosource 1.2 via gravity drip over 2 hrs at 0600 & 1800 hrs
- 1 carton (250 mL) Isosource 1.2 via gravity drip over 1 hr at 1200 & 2200 hrs
- Flush G-tube with 60 mL water pre and post feeds (480 mL)
- >45 degrees while feeding
- This regime does not avoid drug-nutrient interaction with levothyroxine at 0800 hrs; consider changing the administration time of levothyroxine (for example to 1000 hrs).
- This bolus feeding plan works in the hospital, but Carson will be receiving chemotherapy and radiation therapy from 1200 h to 1430 h daily on discharge. You will need to adjust the proposed regime (i.e. more concentrated formula to decrease volume & changing feeding times) so he can meet his treatment goals.
Here is an example of how you may change the feeding plan to meet Carson’s daily needs/ treatment plan. This new plan would likely work much better for Carson and still meets his estimated requirements. The updated plan should be implemented in hospital to make sure Carson can tolerate it before being discharged home.
- Isosource 1.5 × 5 cartons/day (more concentrated formula = less enteral volume and number of cartons) to provide:
- 1875 kcal/day (32 kcal/kg)
- 85 g protein/day (1.4 g/kg)
- 950 mL free water
- Flushes: 135 mL pre & post feeds × 6 (810 mL) + 300 mL meds + 950 mL free water = 2060 mL/day (35 mL/kg)
- Levothyroxine at 0600 hrs
- 2 cartons (500 mL) via gravity drip over 2 hrs + 135 mL water pre/post feeds at 0800 – 1000 hrs
- Chemotherapy/radiation therapy: 1200 -1430 hrs
- 1 carton (250 mL) via gravity drip over 1 hr + 135 mL water pre/post feeds at 1500 – 1600 hrs
- 2 cartons (500 mL) via gravity drip over 2 hrs + 135 mL water pre/post at 2000 – 2200 hrs
The Nutrition Care Process Model
As you use the Nutrition Care Process Model and the learning from this case study as a guide throughout your patient care in practicum, please keep in mind that the process is dynamic, and not step-by-step as all cases are different. You are encouraged to complete the recommended readings for this module and continue to expand your learning in this clinical area of practice.
PART 4: EVALUATE COMPLETE. Pause to reflect on the evaluation strategies discussed, and review the readings and resources in the following section for your information.
You’ve now completed the Enteral Nutrition module. Please consider providing feedback through the embedded form in the next section.
Emily Opperman, MSc, RD
Michaela Kucab, MHSc, RD
Head of bed