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
As you interpret the data from the assessment, you can form PES statements or nutrition diagnoses that help identify nutrition concerns that need to be addressed in your plan. If you are not familiar with how to write a PES statement please review this resource from the Academy of Nutrition and Dietetics. Here are some common nutrition problems:
- Inadequate energy intake
- Inadequate protein intake
- Inadequate oral intake
- Inadequate fluid intake
- Increased nutrient needs
- Inadequate vitamin/mineral intake
- Swallowing difficulty
- Impaired GI function
- Intake of unsafe food
- Physical inactivity
- Inability or lack of desire to manage self-care
Based on our assessment, here are some examples of PES statements for Sam.
- Inadequate protein-energy intake related to progressive Crohn’s disease flares as evidenced by dietary recall (low protein and energy intake), loss of appetite and severe weight loss (19.4%).
- Inadequate oral intake related to progressive Crohn’s disease flares as evidenced by loss of appetite, dietary history (consumption of ~600 kcal/day) and severe weight loss (19.4%).
- Malnutrition related to a 2-month history of worsening Crohn’s disease and poor dietary intake as evidenced by dietary history (consumption of ~600 kcal/day), severe weight loss (19.4%), and physical assessment of moderate muscle wasting and loss of subcutaneous fat.
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?
- Diet progression: while in hospital it is important to progress Sam’s diet to recommendations (as tolerated). He is malnourished so it is important to emphasize intake.
- Monitoring: complications that influence the nutrition care plan and Sam’s medical status need to be monitored. This includes ostomy outputs, fluid intake, and electrolyte imbalances.
- Oral intake: Sam is malnourished with recent severe weight loss and evidence of muscle wasting. It is important to prioritize (when possible and as tolerated) increasing his caloric and protein intake.
- Education: remind Sam of IBD recommendations and provide ostomy education (re-recent ileostomy) for adherence in and outside of the hospital to reduce the risk of complications.
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 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.
- 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.
- Implement calorie counts: Sam is malnourished (as a result of his worsening Crohn’s disease) and it may be worthwhile to evaluate the progression of his intake while in hospital.
- Education: In light of recent surgery and treatment, emphasize and educate about high calorie and protein diets. Educate Sam about the risk of malabsorption and importance of nutrition.
- Supplements: continue with Vitamin D and Calcium supplements. In light of recent surgery (removal of 70cm of terminal ileum), may want to consider liaising with patient and team regarding B12 injections and other supplements (fat-soluble vitamins).
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:
- Clear fluids: concentrated fruit juices (apple, grape) may need to be diluted to prevent osmotic diarrhea.
- Full fluids
- Small portions of food: low residue, well cooked, and well chewed. Patient may find it easier to eat 4 – 6 small meals per day.
- 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.
|High output ostomy (ileostomy, jejunostomy)||Low output colostomy|
Sam is tolerating clear fluids and increasing his oral intake.
It is now day 2 post-op and based on the assessment data including tolerance, outputs, physical assessment, and laboratory values, we can take the next step of moving to full fluids.
- Order Ensure® Vanilla Plus with breakfast, lunch and dinner (if consumed, provides 1050 kcal and 39 g of protein): Sam was drinking this supplement prior to hospital admission and he is moderately malnourished. It is important to include fluids that increase his caloric and protein intake while he is on the full fluid diet.
- Monitor ostomy output: if outputs do not start to decrease <1 L (ideally an average of 750 mL) consider modifications (liaise with team, diet order changes).
- Continue to drink fluids: emphasize the importance of fluids and sources of electrolytes (education) to Sam. Recommend including an Oral Rehydration Solution.
- Education: provide education on minimizing bowel obstruction risk, managing high outputs, preventing fluid/ electrolyte imbalances, and managing gas and odour.
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.
(degree of deterioration)
(degree of deterioration)
|Reduced oral intake||significant||moderate|
|Altered CHO and fat metabolism||significant||moderate|
(diarrhea, fistulas, inflammation)
|Delayed gastric emptying||moderate||significant|
|Continued alcohol abuse||moderate||significant|
|Gastric outlet obstruction||moderate||significant|
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?
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
Review the final summary for Sam’s nutrition care plan.