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A doctor, nurse, and other medical staff are pictured conducting rounds in a hospital. Photo by Madailein Abbott<\/a> is licensed under Public Domain.<\/a>[\/caption]\r\nCommon PES Statement Terminology<\/h1>\r\n\r\n\r\nAs 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<\/a>. Here are some common nutrition problems:\r\n\r\n<\/div>\r\n\r\n \t- Inadequate energy intake<\/li>\r\n \t
- Inadequate protein intake<\/li>\r\n \t
- Inadequate oral intake<\/li>\r\n \t
- Inadequate fluid intake<\/li>\r\n \t
- Increased nutrient needs<\/li>\r\n \t
- Malnutrition<\/li>\r\n \t
- Inadequate vitamin\/mineral intake<\/li>\r\n \t
- Swallowing difficulty<\/li>\r\n \t
- Impaired GI function<\/li>\r\n \t
- Intake of unsafe food<\/li>\r\n \t
- Physical inactivity<\/li>\r\n \t
- Inability or lack of desire to manage self-care<\/li>\r\n<\/ul>\r\n
\r\nSam's PES Statements<\/h2>\r\n<\/header>\r\n\r\n\r\nBased on our assessment, here are some examples of PES statements for Sam.\r\n\r\n \t- Inadequate protein-energy intake related to progressive Crohn\u2019s disease flares as evidenced by dietary recall (low protein and energy intake), loss of appetite and severe weight loss (19.4%).<\/li>\r\n \t
- Inadequate oral intake related to progressive Crohn\u2019s disease flares as evidenced by loss of appetite, dietary history (consumption of ~600 kcal\/day) and severe weight loss (19.4%).<\/li>\r\n \t
- Malnutrition related to a 2-month history of worsening Crohn\u2019s 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.<\/li>\r\n<\/ul>\r\nPractice writing other PES statements for Sam!<\/strong><\/div>\r\n<\/div>\r\n<\/div>\r\n
Creating a Nutrition Care Plan<\/h1>\r\nWhen creating a nutrition care plan you will utilize your assessment data. Often, you will have an extensive amount of assessment data, some of which is relevant to your nutrition care plan and other data that is not. It is still important to collect and seek out all this data as it will inform your direction, but it is also important to create priorities based on your patient and their needs. In this case, a few key areas to consider for our nutrition care plan include:<\/div>\r\n\r\n \t- Tolerance<\/strong>: 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?<\/li>\r\n \t
- Inputs and Outputs<\/strong>: What is the patients ostomy and urine output? What orders is the patient receiving?<\/li>\r\n \t
- Labs<\/strong>: Are the patients laboratory values normal? Have they changed? Did they receive replacements?<\/li>\r\n \t
- Orders<\/strong>: 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?<\/li>\r\n \t
- Dietary Intake<\/strong>: Is the patient eating and drinking? Is it sufficient? Need for supplements? Changes to the nutrition care plan?<\/li>\r\n \t
- Education<\/strong>: What does the patient already know? What education do they need to be provided? Do they need RD follow-up?<\/li>\r\n<\/ul>\r\n
\r\nSam's Priorities for Nutrition Care<\/h2>\r\n<\/header>\r\n\r\nBased on Sam\u2019s assessment data, it is important to create priorities for nutrition care.<\/strong> Here are a few priorities for Sam for the purposes of this case study. It is important to remember that there may be other considerations in practice or more complex cases:<\/div>\r\n\r\n \t- Diet progression<\/strong>: while in hospital it is important to progress Sam\u2019s diet to recommendations (as tolerated). He is malnourished so it is important to emphasize intake.<\/li>\r\n \t
- Monitoring<\/strong>: complications that influence the nutrition care plan and Sam\u2019s medical status need to be monitored. This includes ostomy outputs, fluid intake, and electrolyte imbalances.<\/li>\r\n \t
- Oral intake<\/strong>: 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.<\/li>\r\n \t
- Education<\/strong>: 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.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Nutrition Care for Inflammatory Bowel Disease (IBD)<\/h1>\r\nThe key purposes of nutrition care for IBD are to:\r\n\r\n \t- Prevent or minimize gastrointestinal symptoms<\/li>\r\n \t
- Prevent malnutrition<\/li>\r\n \t
- Prevent micronutrient deficiencies<\/li>\r\n \t
- Normalize bowel function<\/li>\r\n \t
- Improve quality of life<\/li>\r\n<\/ul>\r\n
Calorie Counts<\/h2>\r\nCalorie counts are a tool in hospital to evaluate intake. There are limitations with calorie counts, but they are commonly used and easy to implement.\r\n\r\nFor 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.\r\n\r\nThe 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).\r\n\r\nIt 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.\r\n\r\nCalorie counts are completed as an \u201corder\u201d in the patient's chart, and it is important to go to the patient\u2019s room each day to receive and evaluate the intake.\r\nNutrient Deficiencies<\/h2>\r\nHere are a few nutrient deficiencies to be aware of associated with IBD. You should seek further readings and details regarding these nutrients and common treatments:<\/div>\r\n\r\n \t- Vitamin B12<\/strong>: increased risk with extensive inflammation in the ileum or removal of it.<\/li>\r\n \t
- Folate<\/strong>: increased risk with sulfasalazine use or extensive inflammation in the jejunum or removal of it.<\/li>\r\n \t
- Vitamins D, E, K<\/strong>: increased risk with inflammation of large portion of jejunum or ileum.<\/li>\r\n \t
- Magnesium<\/strong>: increased risk with extensive inflammation, chronic diarrhea, or removal of large portions of jejunum or ileum.<\/li>\r\n \t
- Calcium<\/strong>: increases risk with avoidance of dairy foods for lactose intolerance, prednisone use, extensive inflammation in small intestine.<\/li>\r\n \t
- Potassium<\/strong>: increased risk with chronic vomiting and diarrhea or prednisone use.<\/li>\r\n \t
- Iron<\/strong>: increased risk with blood loss from ulceration of colon or clinical signs of deficiency.<\/li>\r\n<\/ul>\r\n
\r\nSam's Nutrition Care Plan: IBD<\/h2>\r\n<\/header>\r\n\r\nSam was diagnosed with Crohn\u2019s 5 years ago. It is likely that he has received education for nutrition and management of symptoms and complications. However, it is important to still ask Sam if he has received this education and provide him with the opportunity to ask you questions.<\/div>\r\n\r\n \t- Implement calorie counts:<\/strong> Sam is malnourished (as a result of his worsening Crohn\u2019s disease) and it may be worthwhile to evaluate the progression of his intake while in hospital.<\/li>\r\n \t
- Education:<\/strong> 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.<\/li>\r\n \t
- Supplements:<\/strong> 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).<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Nutrition Care for Ostomies<\/h1>\r\nThe key purposes of nutrition care for ostomies are to:<\/div>\r\n\r\n \t- Minimize the risk of obstruction or stoma blockage\r\n
\r\n \t- 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.<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Prevent fluid and electrolyte imbalances and prevent dehydration<\/li>\r\n \t
- Reduce excessive output<\/li>\r\n \t
- Minimize gas and unpleasant odors<\/li>\r\n \t
- Maintain weight (calories and protein)<\/li>\r\n \t
- Manage potential micronutrient deficiencies<\/span><\/li>\r\n<\/ul>\r\nAfter surgery, the diet will begin with clear fluids and can progress slowly in the following order:\r\n
\r\n \t- Clear fluids<\/strong>:\u00a0 concentrated fruit juices (apple, grape) may need to be diluted to prevent osmotic diarrhea.<\/li>\r\n \t
- Full fluids<\/strong><\/li>\r\n \t
- Small portions of food<\/strong>: low residue, well cooked, and well chewed. Patient may find it easier to eat 4 - 6 small meals per day.<\/li>\r\n \t
- Regular diet<\/strong>: should be achieved by 6 - 8 weeks after surgery.<\/li>\r\n<\/ol>\r\nHere are some additional considerations:\r\n
\r\n \t- Diet is based on individual food tolerances, which are highly variable.<\/li>\r\n \t
- Foods high in soluble fiber (e.g. oatmeal, applesauce, banana, and rice) may help reduce fluid losses.<\/li>\r\n \t
- 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.\u00a0 In such cases, consider the need for supplements and B12 injection.<\/li>\r\n \t
- The patient's diet should be progressed during hospital admission with education provided by RD to continue and manage after discharge.<\/span><\/li>\r\n<\/ul>\r\n
Nutrition management guidelines for ostomies<\/caption>\r\n \r\n\r\n<\/td>\r\n High output ostomy (ileostomy, jejunostomy)<\/th>\r\n Low output colostomy<\/th>\r\n<\/tr>\r\n \r\nFibre<\/th>\r\n \r\n\r\n \t- Low insoluble fibre<\/li>\r\n \t
- Increase soluble fibre<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n \t- High fibre-all sources<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nFluids<\/th>\r\n \r\n\r\n \t- Oral Electrolyte Replacement (OER)<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n \t- Increase fluid from all sources to promote regularity and minimize strain<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nElectrolytes<\/th>\r\n \r\n\r\n \t- Need to add potassium and sodium<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n \t- No additions required<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nSugars<\/th>\r\n \r\n\r\n \t- Low simple sugar<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n \t- As desired<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nVitamin\/Minerals<\/th>\r\n \r\n\r\n \t- Usually necessary<\/li>\r\n \t
- Especially B12 and\u00a0 sometimes Magnesium<\/li>\r\n \t
- Suggest daily multivitamin<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n \t- Not usually needed<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
\r\nSam's Nutrition Care Plan: Ileostomy<\/h2>\r\n<\/header>\r\n\r\n\r\nSam is tolerating clear fluids and increasing his oral intake.\r\n\r\nIt 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.\r\n\r\n \t- Order Ensure\u00ae Vanilla Plus<\/strong> 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.<\/li>\r\n \t
- Monitor ostomy output<\/strong>: if outputs do not start to decrease <1 L (ideally an average of 750 mL) consider modifications (liaise with team, diet order changes).<\/li>\r\n \t
- Continue to drink fluids<\/strong>: emphasize the importance of fluids and sources of electrolytes (education) to Sam. Recommend including an Oral Rehydration Solution.<\/li>\r\n \t
- Education<\/strong>: provide education on minimizing bowel obstruction risk, managing high outputs, preventing fluid\/ electrolyte imbalances, and managing gas and odour.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Nutrition Care for Pancreatitis<\/h1>\r\nNote<\/strong>:\u00a0<\/strong>This section of the Plan stage does not concern our client Sam, and is meant to provide a brief overview of nutrition care\u00a0 considerations for pancreatitis. You should seek further readings and educational resources on pancreatitis.<\/div>\r\nIn general, macronutrient requirements for pancreatitis are as follows:\r\n\r\n \t- Calories: 25 \u2013 35 kcal\/kg\/d<\/li>\r\n \t
- Protein: 1.2 \u2013 1.5 g\/kg<\/li>\r\n<\/ul>\r\nThe table below provides an general overview of factors that cause deterioration of nutritional status in acute and chronic pancreatitis.\r\n
Factors that deteriorate nutritional status of patients with acute and chronic pancreatitis<\/caption>\r\n \r\n\r\nFactors<\/th>\r\n Acute Pancreatitis\r\n(degree of deterioration)<\/th>\r\n Chronic Pancreatitis\r\n(degree of deterioration)<\/th>\r\n<\/tr>\r\n \r\nHypermetabolism<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\nReduced oral intake<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\nNausea, vomiting<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\nAltered CHO and fat metabolism<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\nAbdominal pain<\/th>\r\n significant<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\nProtein loss\r\n(diarrhea, fistulas, inflammation)<\/th>\r\n significant<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\nDelayed gastric emptying<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\nContinued alcohol abuse<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\nMaldigestion, malabsorption<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\nGastric outlet obstruction<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nChronic Pancreatitis<\/h2>\r\nThese are considerations for patients with chronic pancreatitis:\r\n\r\n \t- When energy expenditure >110% of predicted values, a higher calorie intake is typically recommended (35 kcal\/kg\/day, especially if weight gain is required)<\/li>\r\n \t
- Most patients can be treated with a regular diet supplemented with pancreatic enzymes.<\/li>\r\n<\/ul>\r\nPrinciples of chronic pancreatitis management include:\r\n
\r\n \t- preventing hypoglycemia and hyperglycemia<\/li>\r\n \t
- preventing the exacerbation of malnutrition<\/li>\r\n \t
- improving healthy eating<\/li>\r\n \t
- reducing the risk of associated co-morbidities<\/li>\r\n<\/ul>\r\nEducation for patients with chronic pancreatitis should include the following:<\/div>\r\n
\r\n \t- No smoking<\/strong>: general recommendation, other healthcare providers may provide education for smoking cessation<\/li>\r\n \t
- Pain management<\/strong>: general recommendation, other healthcare providers involved<\/li>\r\n \t
- No alcohol<\/strong>: RD or general recommendation, depending on degree of abuse or need for counselling<\/li>\r\n \t
- Pancreatic enzymes<\/strong> when required:\u00a0 RD recommendation, coordination and implementation but will involve other team members<\/li>\r\n \t
- Blood sugar management<\/strong>: RD recommendation, coordination and implementation but will involve other team members<\/li>\r\n \t
- Low fat diet <\/strong>emphasizing restriction of saturated fats (e.g. Mediterranean diet): RD recommendation<\/li>\r\n<\/ul>\r\nFor each of the education topics listed above, ask yourself:<\/div>\r\n
\r\n \t- Why is this important?<\/li>\r\n \t
- How does this relate to the principles of management for chronic pancreatitis?<\/li>\r\n \t
- How would I explain these to a patient?<\/li>\r\n \t
- Are there further readings and resources I can seek on implementing and providing plain-language education?<\/li>\r\n<\/ul>\r\n
Acute Pancreatitis<\/h2>\r\nFor acute pancreatitis, there are two general categories: mild and severe. These result in a differing approach to nutrition care.\r\n\r\nMild acute pancreatitis:<\/strong>\r\n\r\n \t- Has little effect on metabolic rate.<\/li>\r\n \t
- 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).<\/li>\r\n \t
- Clear fluids vs regular low-fat diet (evaluate patient tolerance).<\/li>\r\n \t
- If unable to tolerate due to pain, nausea, vomiting \u2013 the patient should be allowed to self-advance to regular diet as tolerated.<\/li>\r\n<\/ul>\r\nSevere acute pancreatitis and necrotizing pancreatitis:<\/strong>\r\n
\r\n \t- Substantial protein catabolism and increased energy requirements.<\/li>\r\n \t
- Stress hyperglycemia and insulin resistance is common.<\/li>\r\n \t
- Early nutrition support is indicated (initiate as soon as possible within 48 hours of admission).<\/li>\r\n \t
- Oral diet, if tolerated and intake is optimal\/ meeting needs. If not, enteral nutrition (EN) preferred (refer to Enteral Nutrition<\/a>).<\/li>\r\n \t
- Continuous EN infusion preferred.<\/li>\r\n \t
- Gastric or jejunal feeding is safe\/ appropriate - seek further readings regarding tube placement.<\/li>\r\n \t
- Parenteral nutrition (PN) indicated only when EN is not feasible or poorly tolerated (i.e. persistent ileus, small bowel obstruction, or complex pancreatic fistula).<\/li>\r\n<\/ul>\r\n
Nutrition Care Plan Summary<\/h1>\r\n\r\nSam's Nutrition Care Plan: Summary<\/h2>\r\n<\/header>\r\n\r\n\r\nReview the final summary for Sam's nutrition care plan.\r\nSummary of Sam's nutrition care plan<\/caption>\r\n \r\n\r\nPriority Area<\/th>\r\n Plan<\/th>\r\n<\/tr>\r\n \r\nDiet Progression<\/td>\r\n \r\n\r\n \t- Progress to full-fluid diet on day 2<\/li>\r\n \t
- If tolerated, progress to regular low-residue diet on day 3-4<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nMonitoring<\/td>\r\n \r\n\r\n \t- Monitor ostomy outputs<\/li>\r\n \t
- Monitor laboratory values, specifically\u00a0 electrolytes<\/li>\r\n \t
- Monitor fluid intake and urine output<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nOral Intake<\/td>\r\n \r\n\r\n \t- Implement calorie counts while in hospital to evaluate intake and progress with changes to diet order<\/li>\r\n \t
- Include Ensure Plus (vanilla) with breakfast, lunch and dinner<\/li>\r\n \t
- Include ORS to prevent dehydration<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\nEducation<\/td>\r\n \r\n\r\n \t- Inflammatory bowel disease review: nutrition during flares and maintenance. Since Sam is malnourished resulting from his Crohn\u2019s disease, it is important to provide education on increasing caloric and protein intake.<\/li>\r\n \t
- New ileostomy education (6-8 weeks post-op & maintenance): minimizing bowel obstruction risk, managing high outputs, controlling gas and odour, and fluid\/ electrolyte intake.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<\/div>\r\n \r\nPART 2: PLAN COMPLETE. Pause to reflect on the nutrition care plan we created for Sam. When you\u2019re ready, move on to Part 3: Implementation.<\/div>\r\n ","rendered":"\n
Page Contents<\/p>\n
- \r\n \t
- Inadequate energy intake<\/li>\r\n \t
- Inadequate protein intake<\/li>\r\n \t
- Inadequate oral intake<\/li>\r\n \t
- Inadequate fluid intake<\/li>\r\n \t
- Increased nutrient needs<\/li>\r\n \t
- Malnutrition<\/li>\r\n \t
- Inadequate vitamin\/mineral intake<\/li>\r\n \t
- Swallowing difficulty<\/li>\r\n \t
- Impaired GI function<\/li>\r\n \t
- Intake of unsafe food<\/li>\r\n \t
- Physical inactivity<\/li>\r\n \t
- Inability or lack of desire to manage self-care<\/li>\r\n<\/ul>\r\n
\r\n Sam's PES Statements<\/h2>\r\n<\/header>\r\n
\r\n\r\nBased on our assessment, here are some examples of PES statements for Sam.\r\n- \r\n \t
- Inadequate protein-energy intake related to progressive Crohn\u2019s disease flares as evidenced by dietary recall (low protein and energy intake), loss of appetite and severe weight loss (19.4%).<\/li>\r\n \t
- Inadequate oral intake related to progressive Crohn\u2019s disease flares as evidenced by loss of appetite, dietary history (consumption of ~600 kcal\/day) and severe weight loss (19.4%).<\/li>\r\n \t
- Malnutrition related to a 2-month history of worsening Crohn\u2019s 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.<\/li>\r\n<\/ul>\r\nPractice writing other PES statements for Sam!<\/strong><\/div>\r\n<\/div>\r\n<\/div>\r\n
Creating a Nutrition Care Plan<\/h1>\r\n
When creating a nutrition care plan you will utilize your assessment data. Often, you will have an extensive amount of assessment data, some of which is relevant to your nutrition care plan and other data that is not. It is still important to collect and seek out all this data as it will inform your direction, but it is also important to create priorities based on your patient and their needs. In this case, a few key areas to consider for our nutrition care plan include:<\/div>\r\n- \r\n \t
- Tolerance<\/strong>: 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?<\/li>\r\n \t
- Inputs and Outputs<\/strong>: What is the patients ostomy and urine output? What orders is the patient receiving?<\/li>\r\n \t
- Labs<\/strong>: Are the patients laboratory values normal? Have they changed? Did they receive replacements?<\/li>\r\n \t
- Orders<\/strong>: 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?<\/li>\r\n \t
- Dietary Intake<\/strong>: Is the patient eating and drinking? Is it sufficient? Need for supplements? Changes to the nutrition care plan?<\/li>\r\n \t
- Education<\/strong>: What does the patient already know? What education do they need to be provided? Do they need RD follow-up?<\/li>\r\n<\/ul>\r\n
\r\n Sam's Priorities for Nutrition Care<\/h2>\r\n<\/header>\r\n
\r\nBased on Sam\u2019s assessment data, it is important to create priorities for nutrition care.<\/strong> Here are a few priorities for Sam for the purposes of this case study. It is important to remember that there may be other considerations in practice or more complex cases:<\/div>\r\n- \r\n \t
- Diet progression<\/strong>: while in hospital it is important to progress Sam\u2019s diet to recommendations (as tolerated). He is malnourished so it is important to emphasize intake.<\/li>\r\n \t
- Monitoring<\/strong>: complications that influence the nutrition care plan and Sam\u2019s medical status need to be monitored. This includes ostomy outputs, fluid intake, and electrolyte imbalances.<\/li>\r\n \t
- Oral intake<\/strong>: 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.<\/li>\r\n \t
- Education<\/strong>: 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.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Nutrition Care for Inflammatory Bowel Disease (IBD)<\/h1>\r\nThe key purposes of nutrition care for IBD are to:\r\n
- \r\n \t
- Prevent or minimize gastrointestinal symptoms<\/li>\r\n \t
- Prevent malnutrition<\/li>\r\n \t
- Prevent micronutrient deficiencies<\/li>\r\n \t
- Normalize bowel function<\/li>\r\n \t
- Improve quality of life<\/li>\r\n<\/ul>\r\n
Calorie Counts<\/h2>\r\nCalorie counts are a tool in hospital to evaluate intake. There are limitations with calorie counts, but they are commonly used and easy to implement.\r\n\r\nFor 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.\r\n\r\nThe 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).\r\n\r\nIt 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.\r\n\r\nCalorie counts are completed as an \u201corder\u201d in the patient's chart, and it is important to go to the patient\u2019s room each day to receive and evaluate the intake.\r\n
Nutrient Deficiencies<\/h2>\r\n
Here are a few nutrient deficiencies to be aware of associated with IBD. You should seek further readings and details regarding these nutrients and common treatments:<\/div>\r\n- \r\n \t
- Vitamin B12<\/strong>: increased risk with extensive inflammation in the ileum or removal of it.<\/li>\r\n \t
- Folate<\/strong>: increased risk with sulfasalazine use or extensive inflammation in the jejunum or removal of it.<\/li>\r\n \t
- Vitamins D, E, K<\/strong>: increased risk with inflammation of large portion of jejunum or ileum.<\/li>\r\n \t
- Magnesium<\/strong>: increased risk with extensive inflammation, chronic diarrhea, or removal of large portions of jejunum or ileum.<\/li>\r\n \t
- Calcium<\/strong>: increases risk with avoidance of dairy foods for lactose intolerance, prednisone use, extensive inflammation in small intestine.<\/li>\r\n \t
- Potassium<\/strong>: increased risk with chronic vomiting and diarrhea or prednisone use.<\/li>\r\n \t
- Iron<\/strong>: increased risk with blood loss from ulceration of colon or clinical signs of deficiency.<\/li>\r\n<\/ul>\r\n
\r\n Sam's Nutrition Care Plan: IBD<\/h2>\r\n<\/header>\r\n
\r\nSam was diagnosed with Crohn\u2019s 5 years ago. It is likely that he has received education for nutrition and management of symptoms and complications. However, it is important to still ask Sam if he has received this education and provide him with the opportunity to ask you questions.<\/div>\r\n- \r\n \t
- Implement calorie counts:<\/strong> Sam is malnourished (as a result of his worsening Crohn\u2019s disease) and it may be worthwhile to evaluate the progression of his intake while in hospital.<\/li>\r\n \t
- Education:<\/strong> 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.<\/li>\r\n \t
- Supplements:<\/strong> 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).<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Nutrition Care for Ostomies<\/h1>\r\n
The key purposes of nutrition care for ostomies are to:<\/div>\r\n- \r\n \t
- Minimize the risk of obstruction or stoma blockage\r\n
- \r\n \t
- 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.<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Prevent fluid and electrolyte imbalances and prevent dehydration<\/li>\r\n \t
- Reduce excessive output<\/li>\r\n \t
- Minimize gas and unpleasant odors<\/li>\r\n \t
- Maintain weight (calories and protein)<\/li>\r\n \t
- Manage potential micronutrient deficiencies<\/span><\/li>\r\n<\/ul>\r\nAfter surgery, the diet will begin with clear fluids and can progress slowly in the following order:\r\n
- \r\n \t
- Clear fluids<\/strong>:\u00a0 concentrated fruit juices (apple, grape) may need to be diluted to prevent osmotic diarrhea.<\/li>\r\n \t
- Full fluids<\/strong><\/li>\r\n \t
- Small portions of food<\/strong>: low residue, well cooked, and well chewed. Patient may find it easier to eat 4 - 6 small meals per day.<\/li>\r\n \t
- Regular diet<\/strong>: should be achieved by 6 - 8 weeks after surgery.<\/li>\r\n<\/ol>\r\nHere are some additional considerations:\r\n
- \r\n \t
- Diet is based on individual food tolerances, which are highly variable.<\/li>\r\n \t
- Foods high in soluble fiber (e.g. oatmeal, applesauce, banana, and rice) may help reduce fluid losses.<\/li>\r\n \t
- 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.\u00a0 In such cases, consider the need for supplements and B12 injection.<\/li>\r\n \t
- The patient's diet should be progressed during hospital admission with education provided by RD to continue and manage after discharge.<\/span><\/li>\r\n<\/ul>\r\n
Nutrition management guidelines for ostomies<\/caption>\r\n \r\n\r\n <\/td>\r\n High output ostomy (ileostomy, jejunostomy)<\/th>\r\n Low output colostomy<\/th>\r\n<\/tr>\r\n \r\n Fibre<\/th>\r\n \r\n - \r\n \t
- Low insoluble fibre<\/li>\r\n \t
- Increase soluble fibre<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n - \r\n \t
- High fibre-all sources<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Fluids<\/th>\r\n \r\n - \r\n \t
- Oral Electrolyte Replacement (OER)<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n - \r\n \t
- Increase fluid from all sources to promote regularity and minimize strain<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Electrolytes<\/th>\r\n \r\n - \r\n \t
- Need to add potassium and sodium<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n - \r\n \t
- No additions required<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Sugars<\/th>\r\n \r\n - \r\n \t
- Low simple sugar<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n - \r\n \t
- As desired<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Vitamin\/Minerals<\/th>\r\n \r\n - \r\n \t
- Usually necessary<\/li>\r\n \t
- Especially B12 and\u00a0 sometimes Magnesium<\/li>\r\n \t
- Suggest daily multivitamin<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n - \r\n \t
- Not usually needed<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
\r\n Sam's Nutrition Care Plan: Ileostomy<\/h2>\r\n<\/header>\r\n
\r\n\r\nSam is tolerating clear fluids and increasing his oral intake.\r\n\r\nIt 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.\r\n- \r\n \t
- Order Ensure\u00ae Vanilla Plus<\/strong> 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.<\/li>\r\n \t
- Monitor ostomy output<\/strong>: if outputs do not start to decrease <1 L (ideally an average of 750 mL) consider modifications (liaise with team, diet order changes).<\/li>\r\n \t
- Continue to drink fluids<\/strong>: emphasize the importance of fluids and sources of electrolytes (education) to Sam. Recommend including an Oral Rehydration Solution.<\/li>\r\n \t
- Education<\/strong>: provide education on minimizing bowel obstruction risk, managing high outputs, preventing fluid\/ electrolyte imbalances, and managing gas and odour.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Nutrition Care for Pancreatitis<\/h1>\r\n
Note<\/strong>:\u00a0<\/strong>This section of the Plan stage does not concern our client Sam, and is meant to provide a brief overview of nutrition care\u00a0 considerations for pancreatitis. You should seek further readings and educational resources on pancreatitis.<\/div>\r\nIn general, macronutrient requirements for pancreatitis are as follows:\r\n- \r\n \t
- Calories: 25 \u2013 35 kcal\/kg\/d<\/li>\r\n \t
- Protein: 1.2 \u2013 1.5 g\/kg<\/li>\r\n<\/ul>\r\nThe table below provides an general overview of factors that cause deterioration of nutritional status in acute and chronic pancreatitis.\r\n
Factors that deteriorate nutritional status of patients with acute and chronic pancreatitis<\/caption>\r\n \r\n\r\n Factors<\/th>\r\n Acute Pancreatitis\r\n(degree of deterioration)<\/th>\r\n Chronic Pancreatitis\r\n(degree of deterioration)<\/th>\r\n<\/tr>\r\n \r\n Hypermetabolism<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\n Reduced oral intake<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\n Nausea, vomiting<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\n Altered CHO and fat metabolism<\/th>\r\n significant<\/td>\r\n moderate<\/td>\r\n<\/tr>\r\n \r\n Abdominal pain<\/th>\r\n significant<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\n Protein loss\r\n(diarrhea, fistulas, inflammation)<\/th>\r\n significant<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\n Delayed gastric emptying<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\n Continued alcohol abuse<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\n Maldigestion, malabsorption<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n \r\n Gastric outlet obstruction<\/th>\r\n moderate<\/td>\r\n significant<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n Chronic Pancreatitis<\/h2>\r\nThese are considerations for patients with chronic pancreatitis:\r\n
- \r\n \t
- When energy expenditure >110% of predicted values, a higher calorie intake is typically recommended (35 kcal\/kg\/day, especially if weight gain is required)<\/li>\r\n \t
- Most patients can be treated with a regular diet supplemented with pancreatic enzymes.<\/li>\r\n<\/ul>\r\nPrinciples of chronic pancreatitis management include:\r\n
- \r\n \t
- preventing hypoglycemia and hyperglycemia<\/li>\r\n \t
- preventing the exacerbation of malnutrition<\/li>\r\n \t
- improving healthy eating<\/li>\r\n \t
- reducing the risk of associated co-morbidities<\/li>\r\n<\/ul>\r\nEducation for patients with chronic pancreatitis should include the following:<\/div>\r\n
- \r\n \t
- No smoking<\/strong>: general recommendation, other healthcare providers may provide education for smoking cessation<\/li>\r\n \t
- Pain management<\/strong>: general recommendation, other healthcare providers involved<\/li>\r\n \t
- No alcohol<\/strong>: RD or general recommendation, depending on degree of abuse or need for counselling<\/li>\r\n \t
- Pancreatic enzymes<\/strong> when required:\u00a0 RD recommendation, coordination and implementation but will involve other team members<\/li>\r\n \t
- Blood sugar management<\/strong>: RD recommendation, coordination and implementation but will involve other team members<\/li>\r\n \t
- Low fat diet <\/strong>emphasizing restriction of saturated fats (e.g. Mediterranean diet): RD recommendation<\/li>\r\n<\/ul>\r\n
For each of the education topics listed above, ask yourself:<\/div>\r\n- \r\n \t
- Why is this important?<\/li>\r\n \t
- How does this relate to the principles of management for chronic pancreatitis?<\/li>\r\n \t
- How would I explain these to a patient?<\/li>\r\n \t
- Are there further readings and resources I can seek on implementing and providing plain-language education?<\/li>\r\n<\/ul>\r\n
Acute Pancreatitis<\/h2>\r\nFor acute pancreatitis, there are two general categories: mild and severe. These result in a differing approach to nutrition care.\r\n\r\nMild acute pancreatitis:<\/strong>\r\n
- \r\n \t
- Has little effect on metabolic rate.<\/li>\r\n \t
- 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).<\/li>\r\n \t
- Clear fluids vs regular low-fat diet (evaluate patient tolerance).<\/li>\r\n \t
- If unable to tolerate due to pain, nausea, vomiting \u2013 the patient should be allowed to self-advance to regular diet as tolerated.<\/li>\r\n<\/ul>\r\nSevere acute pancreatitis and necrotizing pancreatitis:<\/strong>\r\n
- \r\n \t
- Substantial protein catabolism and increased energy requirements.<\/li>\r\n \t
- Stress hyperglycemia and insulin resistance is common.<\/li>\r\n \t
- Early nutrition support is indicated (initiate as soon as possible within 48 hours of admission).<\/li>\r\n \t
- Oral diet, if tolerated and intake is optimal\/ meeting needs. If not, enteral nutrition (EN) preferred (refer to Enteral Nutrition<\/a>).<\/li>\r\n \t
- Continuous EN infusion preferred.<\/li>\r\n \t
- Gastric or jejunal feeding is safe\/ appropriate - seek further readings regarding tube placement.<\/li>\r\n \t
- Parenteral nutrition (PN) indicated only when EN is not feasible or poorly tolerated (i.e. persistent ileus, small bowel obstruction, or complex pancreatic fistula).<\/li>\r\n<\/ul>\r\n
Nutrition Care Plan Summary<\/h1>\r\n
\r\n Sam's Nutrition Care Plan: Summary<\/h2>\r\n<\/header>\r\n
\r\n\r\nReview the final summary for Sam's nutrition care plan.\r\nSummary of Sam's nutrition care plan<\/caption>\r\n \r\n\r\n Priority Area<\/th>\r\n Plan<\/th>\r\n<\/tr>\r\n \r\n Diet Progression<\/td>\r\n \r\n - \r\n \t
- Progress to full-fluid diet on day 2<\/li>\r\n \t
- If tolerated, progress to regular low-residue diet on day 3-4<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Monitoring<\/td>\r\n \r\n - \r\n \t
- Monitor ostomy outputs<\/li>\r\n \t
- Monitor laboratory values, specifically\u00a0 electrolytes<\/li>\r\n \t
- Monitor fluid intake and urine output<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Oral Intake<\/td>\r\n \r\n - \r\n \t
- Implement calorie counts while in hospital to evaluate intake and progress with changes to diet order<\/li>\r\n \t
- Include Ensure Plus (vanilla) with breakfast, lunch and dinner<\/li>\r\n \t
- Include ORS to prevent dehydration<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
\r\n Education<\/td>\r\n \r\n - \r\n \t
- Inflammatory bowel disease review: nutrition during flares and maintenance. Since Sam is malnourished resulting from his Crohn\u2019s disease, it is important to provide education on increasing caloric and protein intake.<\/li>\r\n \t
- New ileostomy education (6-8 weeks post-op & maintenance): minimizing bowel obstruction risk, managing high outputs, controlling gas and odour, and fluid\/ electrolyte intake.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<\/div>\r\n \r\nPART 2: PLAN COMPLETE. Pause to reflect on the nutrition care plan we created for Sam. When you\u2019re ready, move on to Part 3: Implementation.<\/div>\r\n ","rendered":"\n
Page Contents<\/p>\n
- Pain management<\/strong>: general recommendation, other healthcare providers involved<\/li>\r\n \t
- No smoking<\/strong>: general recommendation, other healthcare providers may provide education for smoking cessation<\/li>\r\n \t
- Monitor ostomy output<\/strong>: if outputs do not start to decrease <1 L (ideally an average of 750 mL) consider modifications (liaise with team, diet order changes).<\/li>\r\n \t
- Order Ensure\u00ae Vanilla Plus<\/strong> 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.<\/li>\r\n \t
- Not usually needed<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
- As desired<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
- Low simple sugar<\/li>\r\n<\/ul>\r\n<\/td>\r\n
- No additions required<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
- Need to add potassium and sodium<\/li>\r\n<\/ul>\r\n<\/td>\r\n
- Increase fluid from all sources to promote regularity and minimize strain<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
- Oral Electrolyte Replacement (OER)<\/li>\r\n<\/ul>\r\n<\/td>\r\n
- High fibre-all sources<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
- Full fluids<\/strong><\/li>\r\n \t
- Clear fluids<\/strong>:\u00a0 concentrated fruit juices (apple, grape) may need to be diluted to prevent osmotic diarrhea.<\/li>\r\n \t
- Education:<\/strong> 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.<\/li>\r\n \t
- Folate<\/strong>: increased risk with sulfasalazine use or extensive inflammation in the jejunum or removal of it.<\/li>\r\n \t
- Vitamin B12<\/strong>: increased risk with extensive inflammation in the ileum or removal of it.<\/li>\r\n \t
- Monitoring<\/strong>: complications that influence the nutrition care plan and Sam\u2019s medical status need to be monitored. This includes ostomy outputs, fluid intake, and electrolyte imbalances.<\/li>\r\n \t
- Inputs and Outputs<\/strong>: What is the patients ostomy and urine output? What orders is the patient receiving?<\/li>\r\n \t
- Tolerance<\/strong>: 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?<\/li>\r\n \t