Team Rounds

Team rounds are an opportunity to collaborate and communicate with the interdisciplinary team about your patient’s care plan and gather important information on their diagnosis, prognosis, consults, current status, expected progression, next steps and disposition planning. In an in-patient setting, this is how you will start your day and help inform you about your patients care plan.

Common PES Statement Terminology

• Inadequate energy intake
• Inadequate protein intake
• Inadequate oral intake
• Inadequate fluid intake
• Increased nutrient needs
• Malnutrition
• Inadequate vitamin/mineral intake
• Swallowing difficulty
• Impaired GI function
• Intake of unsafe food
• Physical inactivity
• Inability or lack of desire to manage self-care

Creating a Nutrition Care Plan

• Tolerance: Does the patient have any symptoms, complaints, or complications? If so, does this impact the nutrition care plan? Is the complication a result of the nutrition care plan?
• Inputs and Outputs: What is the patients ostomy and urine output? What orders is the patient receiving?
• Labs: Are the patients laboratory values normal? Have they changed? Did they receive replacements?
• Orders: What is the diet order? Changes in medical (medications, IV fluids) orders? What other orders may impact the nutrition care plan? Does it need to be changed?
• Dietary Intake: Is the patient eating and drinking? Is it sufficient? Need for supplements? Changes to the nutrition care plan?
• Education: What does the patient already know? What education do they need to be provided? Do they need RD follow-up?

Nutrition Care for Inflammatory Bowel Disease (IBD)

The key purposes of nutrition care for IBD are to:

• Prevent or minimize gastrointestinal symptoms
• Prevent malnutrition
• Prevent micronutrient deficiencies
• Normalize bowel function
• Improve quality of life

Calorie Counts

Calorie counts are a tool in hospital to evaluate intake. There are limitations with calorie counts, but they are commonly used and easy to implement.

For calorie counts to be effective, it is important that you plan with your interdisciplinary team. Communicating with the nurse and patient is essential to receiving accurate and useful information.

The patient or nurse (depending on ability) will fill out the hospital order sheet for each meal by indicating how much of the meal, snack, or drink was consumed. It is important to remind the patient and nurse to document any outside meals (if applicable).

It is up to you (the Dietitian) to evaluate the intake by estimating the caloric, protein and fluid amounts in each meal (resulting in a daily intake to compare against your estimated requirements). You can also talk to the patient (24hr recall, if warranted) or the nurse to determine the accuracy of the documentation.

Calorie counts are completed as an “order” in the patient’s chart, and it is important to go to the patient’s room each day to receive and evaluate the intake.

Nutrient Deficiencies

• Vitamin B12: increased risk with extensive inflammation in the ileum or removal of it.
• Folate: increased risk with sulfasalazine use or extensive inflammation in the jejunum or removal of it.
• Vitamins D, E, K: increased risk with inflammation of large portion of jejunum or ileum.
• Magnesium: increased risk with extensive inflammation, chronic diarrhea, or removal of large portions of jejunum or ileum.
• Calcium: increases risk with avoidance of dairy foods for lactose intolerance, prednisone use, extensive inflammation in small intestine.
• Potassium: increased risk with chronic vomiting and diarrhea or prednisone use.
• Iron: increased risk with blood loss from ulceration of colon or clinical signs of deficiency.

Nutrition Care for Ostomies

• Minimize the risk of obstruction or stoma blockage
  • In the first 6 to 8 weeks. Low residue (to prevent food blockage) and high in soluble fibre to slow down transit time and aid with water absorption; therefore, minimize risk of dehydration.
• Prevent fluid and electrolyte imbalances and prevent dehydration
• Reduce excessive output
• Minimize gas and unpleasant odors
• Maintain weight (calories and protein)
• Manage potential micronutrient deficiencies

After surgery, the diet will begin with clear fluids and can progress slowly in the following order:

1. Clear fluids:  concentrated fruit juices (apple, grape) may need to be diluted to prevent osmotic diarrhea.
2. Full fluids
3. Small portions of food: low residue, well cooked, and well chewed. Patient may find it easier to eat 4 – 6 small meals per day.
4. Regular diet: should be achieved by 6 – 8 weeks after surgery.

Here are some additional considerations:

• Diet is based on individual food tolerances, which are highly variable.
• Foods high in soluble fiber (e.g. oatmeal, applesauce, banana, and rice) may help reduce fluid losses.
• Evaluate patient risk for micronutrient deficiencies. Patients who have had extensive resection (removal >100 cm of terminal ileum) may experience deficiencies of fat-soluble vitamins, vitamin B12 and bile salts.  In such cases, consider the need for supplements and B12 injection.
• The patient’s diet should be progressed during hospital admission with education provided by RD to continue and manage after discharge.

Nutrition Care for Pancreatitis

In general, macronutrient requirements for pancreatitis are as follows:

• Calories: 25 – 35 kcal/kg/d
• Protein: 1.2 – 1.5 g/k

The table below provides an general overview of factors that cause deterioration of nutritional status in acute and chronic pancreatitis.

Chronic Pancreatitis

These are considerations for patients with chronic pancreatitis:

• When energy expenditure >110% of predicted values, a higher calorie intake is typically recommended (35 g/kg/day, especially if weight gain is required)
• Most patients can be treated with a regular diet supplemented with pancreatic enzymes.

Principles of chronic pancreatitis management include:

• preventing hypoglycemia and hyperglycemia
• preventing the exacerbation of malnutrition
• improving healthy eating
• reducing the risk of associated co-morbidities

• No smoking: general recommendation, other healthcare providers may provide education for smoking cessation
• Pain management: general recommendation, other healthcare providers involved
• No alcohol: RD or general recommendation, depending on degree of abuse or need for counselling
• Pancreatic enzymes when required:  RD recommendation, coordination and implementation but will involve other team members
• Blood sugar management: RD recommendation, coordination and implementation but will involve other team members
• Low fat diet emphasizing restriction of saturated fats (e.g. Mediterranean diet): RD recommendation

• Why is this important?
• How does this relate to the principles of management for chronic pancreatitis?
• How would I explain these to a patient?
• Are there further readings and resources I can seek on implementing and providing plain-language education?

Acute Pancreatitis

For acute pancreatitis, there are two general categories: mild and severe. These result in a differing approach to nutrition care.

Mild acute pancreatitis:

• Has little effect on metabolic rate.
• Oral diet initiation as soon as possible (if there is no nausea or vomiting, and abdominal pain has resolved). It is important to still encourage an oral diet even if the patient has pain. If this is the case, coordinate with the team for pain medications and suggest small frequent meals. Oral Nutrition Supplements (ONS) are often tolerated better than solid food because the patient requires smaller volumes to achieve daily estimated requirements (especially in a case where the patient has a history of alcohol abuse).
• Clear fluids vs regular low-fat diet (evaluate patient tolerance).
• If unable to tolerate due to pain, nausea, vomiting – the patient should be allowed to self-advance to regular diet as tolerated.

Severe acute pancreatitis and necrotizing pancreatitis:

• Substantial protein catabolism and increased energy requirements.
• Stress hyperglycemia and insulin resistance is common.
• Early nutrition support is indicated (initiate as soon as possible within 48 hours of admission).
• Oral diet, if tolerated and intake is optimal/ meeting needs. If not, enteral nutrition (EN) preferred (refer to Enteral Nutrition).
• Continuous EN infusion preferred.
• Gastric or jejunal feeding is safe/ appropriate – seek further readings regarding tube placement.
• Parenteral nutrition (PN) indicated only when EN is not feasible or poorly tolerated (i.e. persistent ileus, small bowel obstruction, or complex pancreatic fistula).

Nutrition Care Plan Summary