Sodexo Distance Education Dietetic Internship

Sodexo Distance Education Dietetic Internship

Clinical and Patient Assessment Assignment

Name: Dawn Ortiz

Part 1: to be completed prior to beginning clinical –
begin at orientation after Nutrition Assessment Class

Part 2: to be completed by the end of clinical 1

Email your completed assignment to the specific reviewer indicated on the assignment checklist. Turn in assignment once you have completed Part 1 and Part 2.

1. What is the objective of nutritional screening?
   

The objective of a nutrition screening is to find out the characteristics associated with nutrition problems with the purpose of identifying patients that are at nutritional risk or malnourished. The screen is usually completed by the nurse or diet clerk. If the patient is determined to be high risk nutritional risk, the dietitian is alerted to visit the patient.

1. What is the objective of nutritional assessment?
   The objective of a nutritional assessment is to obtain, verify and interpret the data necessary to identify nutrition-related problems, causes and significance in order to make the diagnosis in the Nutrition Care Process. A nutrition assessment is an ongoing process, which includes a nutrition diagnosis, intervention, monitoring and evaluation (ADIME). Specific assessment structures are defined in a hospital’s standard of care policy. Some of the most common conditions requiring an RD’s assessment include; pregnancy, significant unintentional weight loss, transplants, nutrition support and NPO orders.
   
2. List the 4 categories of information you should collect and consider when completing a nutritional assessment of a hospitalized patient. (hint: ABCD)

When completing a nutrition assessment it is important to collect relevant data in the following categories; anthropometric measures (current BMI and bodyweight changes), biochemical lab values and medical tests, clinical signs and symptoms, and medical diagnosis (past and present).

1. What are the two visceral proteins still often used in nutritional assessment?
   Two visceral proteins which are still often used in nutritional assessments are albumin (main protein in serum and produced in the liver) and prealbumin (only 2-3 day half-life).
   

What are the normal ranges for these two proteins?

What limitations do these parameters have?

What is a decrease of these likely to indicate?

Albumin / Prealbumin
Normal Range / ~3.5-4.8g/dL / ~19-35mg/dL
Reference Limitations / -Not a good indicator of nutrition in the acute setting.
-It is always low in stressed hospital patients.
-MDs still want to use as malnutrition indicator.
-Long half-life / -More expensive to test for than albumin, so not used often.
Decrease likely to indicate / -Hypoalbuminemia
-Inflammation
-Infection
-Over hydration (due to large quantities of IVF)
-Chronic diseases / -Short term malnutrition
-Inflammation
-Infection
-Chronic disease
-Severe burns/wounds
-Digestive disorders

1. Besides lab values, how can you assess protein stores in your patient, and how does this impact the patient's nutritional status?

Beside lab values, protein stores may be measured using the nitrogen balance. The nitrogen balance evaluates the adequacy of protein intake and estimates protein requirements via a calorie count and 24 hour urine collection. A positive value indicates sufficient protein stores, while a negative value indicates increased protein needs. A nitrogen balance test should only be used for patients that are currently in the ICU, on tube feeding and catheterized.

1. What are the key elements of a nutrition history?
   The key elements to discover during a nutrition history assessment are dietary intake and nutritional status (based on weight history, meal patterns, current appetite, food preferences, food sources/who prepares the meals, food allergies/intolerances and ethnic/cultural considerations). Next, based on medical history, lab values and dietary intake, determine if MNT is necessary, monitor changes in nutritional status and evaluate the effectiveness of nutritional intervention.
   
2. If a female is 5’6” and weighs 190#, what is her IBW and what is her %IBW?
   

If a female is 5’6” and weighs 190#, her IBW is 130# and her %IBW is 146%.

1. If her weight 6 months ago was 210#, what is her %UBW?
   If her weight was 210# 6 months ago, her current %UBW is 90%.

1. State two ways to estimate frame size.
   When calculating ideal body weight, estimate frame size by adding 10% for a larger frame or subtracting 10% for a smaller frame. Another way to estimate frame size is to measure the person’s wrist circumference in relation to height.
   

How does frame size affect calorie requirements?
Frame size takes into account an individual’s bone structure and may either increase or decrease calorie requirements.

1. What is meant by anthropometric data?
   Anthropometric data is a measurement or description of the physical dimensions and properties of the body; typically, used on upper and lower limbs, neck and trunk. Anthropometrics are used to obtain a nutrition diagnosis and monitor nutrition care plan interventions. Typical anthropometric data includes height and weight, BMI, waist/hip circumference and body composition.
   

1. How is nitrogen balance calculated and what can it tell you?
   Nitrogen Balance: Protein Intake (g)/6.25 – Urine Urea Nitrogen (g) + 4
   

*A positive value indicates sufficient protein stores, while a negative value indicates increased protein needs.

What are its’ limitations?
Nitrogen balance should only be used for patients on nutrition support with a catheter. It is too difficult to obtain an accurate nitrogen balance for PO patients (without a catheter) because it is difficult to measure exact fluid intake and urine output.

1. What is the rule of thumb for estimating fluid requirements for the average individual?
   A rule of thumb for estimating fluid needs is the RDA Method (1ml fluid per 1 kcal of estimated needs). Fluids may be restricted if patient is experiencing renal failure.
   

When might fluid requirements be increased?
Fluid needs may increase if a patient has a fever, excessive sweating, extraordinary gastric (vomiting and diarrhea), renal fluid losses, chronic diseases, pressure ulcers, has a nasogastric tube for suctioning or is on certain medications.

When might fluid requirements be decreased?
Fluid needs may decrease if a patient has CHF, renal disease, hyponatremia, edema or ascites.

------

Part 2: Question to be answered on your clinical facility

1. Does your facility use the Nutrition Care Process? Explain process.
   Sharp hospitals use the Nutrition Care Process. RDs receive either a level 1 or 2 screen which require nutrition assessments. Level 1 screens are generally for patients that have been diagnosed with a medical condition that has a direct impact on their nutritional status, such as malnutrition, pressure ulcers or failure to thrive. Level 2 screens usually occur after the patient has been in the hospital for some time. They come from diet tech screens that show up as high nutritional risk or if a patient has been NPO for five or more days. Upon receiving either of these screens, the RD views the patient’s electronic medical chart, using a software program called Cerner, to collect data before meeting with the patient. After performing the assessment the RD enters a nutrition note into the patient’s chart according to the nutrition care process. Pertinent data such as; reason for visit, height, weight (including: admit, current measured, UBW, IBW and feeding weights), BMI, previous medical history, lab values, current medications, diet order, etc. are all included in the assessment. Each patient is also given a rating based on their current nutritional status based on the Subjective Global Assessment (A= well-nourished, B= moderately malnourished, or C= severely malnourished) and nutrition severity of illness (1= mildly stressed, 2= moderately stressed, or 3= severely stressed). The next step of the NCP, the diagnosis is then entered by checking the appropriate box (or you can choose “other” and write your own), which automatically displays the PES statement using the correct terminology. Next, there are boxes to check for intervention goals, again there is room to write others that are not listed. Finally, there are two blank boxes to fill in the monitor and evaluation plans and goals. This is where the RDs take time to carefully fill out all interaction with the patient, nurses, doctors and families. The RD uses the recommendations box to notify the MD of specific actions regarding nutrition to consider.
   
2. Does your facility use an electronic health record (EHR) and /or an electronic order entry system? If yes, which type of system? If no, what is the method of charting do they use.
   Yes, Sharp uses Cerner, an electronic charting system. All medical charting, including; assessments, diet orders and prescriptions go through Cerner.
   
3. Does your facility use an adjusted body weight (Adj.BW) for patients with obesity? If so, what method do they use to calculate the Adj.BW?
   If a patient weight is ≥ 120% IBW, the Adj.BW is calculated.

Adj.BW= IBW + .25 (actual weight – IBW)

If patient weight is < 120% IBW, then actual weight is used for feeding needs.

1. Where are height and weight recorded in the medical record?
   Height and weight are recorded under Recent Reviews Measurements

There is usually an admit weight, dosing weight, patient stated weight and measured weight recorded.

1. What method does your facility use for estimating energy needs?
   The general guidelines for energy needs are as follows:

Kcal: 25-30 kcal/kg/day (risk of refeeding, start low and advance slowly) (max 5 kcal range).
Protein: range 0.8-1.5 g/kg (generally: 1.0-1.2 g/kg), choose range within this as appropriate (max 0.2-0.3 g range).

Fluid: Adult 18-64 yo: 30-35 mL/kg; Adult ≥ 65 yo: 25-30 mL/kg.

1. What factors can affect calorie needs (both increases and decreases)?
   Caloric needs may be decreased based on the following conditions; initial cachexia and may be at risk for refeeding syndrome, diabetes (carbohydrate counting), obesity, short bowel syndrome, gastroparesis and cardiac issues requiring a vent. Caloric needs may be increased based on the following conditions; advancing stages of cachexia, repletion for cancer, fistulas, renal failure requiring CRRT, SLED or HD, and wound healing.
   
2. What factors can affect protein needs (both increases and decreases)?

Protein needs are increased if a patient has a surgical procedure, wounds/burns, fractures, chronic illness, obesity, pancreatitis, CRRT/HD/PD, short bowel syndrome, sepsis, cachexia, cancer repletion, fistula, liver disease, hyperglycemia and pregnancy. Protein needs are decreased when a patient is pre-dialysis from renal failure.

1. Where do you find the interdisciplinary care plan and what information on it may be useful to a dietitian?
   The interdisciplinary care plan can be found in the Cerner electronic medical chart. These notes are entered by the medical team assessing the patient. The dietitian can find notes from speech therapy, physical therapy, occupational therapy, the wound team andany other specialists involved in treating the patient’s conditions. This is where the RD notes appear as well.
   
2. What is the I&O record, where do you find it, and how can it be helpful to you?
   The I/O record is also in the medical chart and tracked by the hour. The patient’s total intake (mL), including oral fluids, tube feeding, IV fluids, TPN, etc. is monitored. The patient’s total output, including urine, wound and fistula draining, vomit, liquid feces and tube drainage is also monitored. Urine output is recorded as either an exact urine amount in mL, diapers or urine count if the patient has bathroom privileges. The 24-hour total input versus output amounts are tracked and the net balance is automatically calculated.
   
3. What types of information can you gather from a visual assessment of the patient?
   A visual assessment can provide an RD with signs of malnutrition, such as muscle wasting and subcutaneous fat loss. You may also be able to see skin breakdown, breathing alterations, signs of dysphagia, dental condition and overall weakness and discomfort which may be causing appetite loss.
   
4. What are the most common potential food-drug interactions at your facility?
   The most common food and drug interactions at Sharp hospitals are; Coumadin with vitamin K intake. Patients are educated on the importance of maintaining consistent consumption of vitamin K when taking Coumadin to avoid working against the medication. The only other common interaction I have heard of is grapefruit with statins, there are no grapefruit products at Sharp hospitals.
   
5. Complete the following chart based on your facility’s normal ranges
   

Lab Test / Normal range in
|your facility / Conditions when decreased value is expected / Conditions when increased value is expected
Na / 136-145 mmol/L / Hyponatremia, Fluid retention, prolonged vomiting and diarrhea / Hypernatremia, dehydration
K / 3.4-5.0 mmol/L / Hypokalemia, vomiting and diarrhea, kidney disease, metabolic disturbances, excessive sweating, diuretic and laxative meds, refeeding syndrome / Hyperkalemia, renal failure, heart disease
BUN / 5-25 mg/dL / Liver disease, malnutrition, over-hydration / Acute and chronic kidney disease, dehydration, CFH, recent MI
CREAT / 0.5-1.3 mg/dL / Pregnancy, muscle wasting / Renal failure, urinary tract obstruction, pyelonephritis, glomerulonephritis, CHF, DM
Albumin / 3.5-5.0 g/dL / Inflammation, over-hydration, hospitalized stressed patients, liver and other chronic disease / Dehydration
Prealb / 18-40 mg/dL / Inflammation, short term malnutrition, trauma, hyperthyroidism, liver and most other chronic diseases / May be seen in Pregnancy, but not used to determine any medical conditions
Glucose / 70-109 mg/dL / Hypoglycemia, DM, hypothyroidism, starvation, taking too much insulin or DM meds / Hyperglycemia, DM, hyperthyroidism, pancreatitis, pancreatic cancer
HgbA1C / 4.8-5.9% / Anemia, trauma with blood loss / DM, heart disease, renal failure, stroke, nerve damage
H/H / 14.0-17.5 g/dL 38-52% / hemolytic anemia, Iron, folate or B12 deficiency, bone marrow disorders, cancer, ulcers, renal failure / Dehydration, lung disease, CHF, Polycythemia vera, smoking, genetic conditions
MCV / 80-100 fL / Microcytic RBCs caused by iron deficiency anemia or thalassemias / Macrocytic RBCs from anemia caused by vitamin B12 or folate deficiency
MCH / 26-34 pg / Microcytic RBCs (mirrors MCV) / Macrocytic RBCs (mirrors MCV)
Iron (Fe) / 59-158 mcg/dL / Fe deficiency anemia / DM, liver and pancreas damage
Ferritin / 30-400 ng/mL / Fe deficiency / Hemochromatosis, sideroblastic , hemolytic anemia
Vitamin B12 / 211-911 pg/mL / Vegans, pernicious anemia, terminal ileum removal, alcoholism, achlorhydria, Celiac’s disease, parasites, neuropathy, malnutrition / Myeloproliferative neoplasm, diabetes, heart failure, obesity, AIDS, severe liver disease
Folate / 5.4-24.0 ng/mL / Alcoholism, Chohn’s disease, ulcerative colitis, short bowel syndrome, inadequate absorption from gluten enteropathy, Celiac’s disease, pernicious anemia, parasites, neuropathy, malnutrition / Neurologic sequelae from masked vitamin B12 deficiency
Ca / 8.4-10.2 mg/dL / Hypocalcemia, osteoporosis, rickets, kidney disease / Hypercalcemia, breast and lung cancer
Phos / 35-129 unit/L / Alcoholism, diabetic ketoacidosis (after treatment), prolonged aluminum hydroxide containing antacids, malnutrition, overuse of diuretics, refeeding syndrome / Renal failure, liver disease, onset of diabetic ketoacidosis
Mg / 1.4-2.3 mg/dL / Intestinal malabsorption, diuretic meds, severe vomiting and diarrhea, kidney disease, DM, alcoholism, malnutrition, acute pancreatitis, refeeding syndrome / Renal failure, pts receiving too high Mg doses

References:

1. Lab Tests Online: A public resource on clinical lab testing from the laboratory professionals who do the testing. Labtestsonline.org. Published February 8, 2012. Updated April 3, 2014. Accessed October 25, 2014.

2. Hark L., Darwin D., and Morrison G. Medical Nutrition and Disease: A Case-Based Approach, 5th. Ed. Philadelphia, PA: Wiley-Blackwell; 2014: 80-92.

(Hint: save this information and use it for the nutrition database assignments)

1. When you reviewed charts, did you see any diet orders that were inappropriate? Why?
   Yes, this actually happens quite often. Yesterday there was a patient receivinghemodialysis three days a week and they were not on a renal diet. My preceptor called the MD and the diet order was changed today. At my first hospital, during clinical 1, the RDs caught many regular diet orders for patients with diabetes. Part of the assessment is checking lab values, so it is common for dietitians to find patients that should be switched to a diabetic diet based on their fasting glucose and HgbA1c values.
   
2. What common feedback, if any, did you receive from patients when you visited them on meal rounds? What was your response? Why are meal rounds important?
   My experience working as a diet tech has really helped me understand the possible accommodations and limitations that the kitchen can do for patients. Most often patients love the food, however sometimes they are quite disappointed. I had a patient recently complain that it is easier for her to drink the soup directly from the bowl, however she did not realize that there were chunks of chicken and vegetables and the pieces got caught in her throat. I offered to change her soups to pureed and put into a mug for easier drinking. She was ecstatic! Another patient complained that her she does not like the vegetables because they are too hard. I let her know that she can specify “soft” veggies when she orders her meals from now on. She was also ecstatic! I also make sure to do rounding for the patients on clear and full liquid diets. Since these patients are already extremely restricted, I try to give them as many options as possible. I let the kitchen know the specific flavors they prefer, kinds of broth or soup, coffee or tea and kind of milk. I have also received complaints about not receiving certain condiments from patients on a heart healthy or diabetic diet. I have told these patients that their doctor prescribed this diet for them so they can ask the MD about switching. I always give these patients on restricted diets the option to order food that is not on the menu. This strategy usually allows them to pick out something they will enjoy, while feeling happy that they are getting special treatment! Fresh fruit with cottage cheese and tuna or chicken salad sandwiches are always popular substitutions. Meal rounds are essential to connect with the patients to find solutions and ensure meal satisfaction. This is also the best opportunity to improve food service scores!
   
3. What difficulties, if any, did you have in:
   
4. Accessing medical records
   Cerner, the electronic medical record system, definitely has some glitches. For example, you have to keep readjusting the date to go back to see the big picture for lab values and measurements. Also the dates appear to go in the opposite direction. Another issue is once you are entering a note, you cannot go back into the chart to find information that you missedwhen taking notes on the paper cardex. You have to open a new chart, which can make your computer screen quite cluttered and confusing. Also, there is no way to find a list of all notes you have charted without going into each patient’s chart. This may be intentional though, for HIPAA purposes. Logistically, there are times when it is difficult to find an available computer (especially two in a row next to each other for me and my preceptor!)
   
5. Visiting patients
   Patient visits can be challenging due to interruptions from other medical professionals and family members. Also many times the patient is sleeping or unable to speak. There are also language barriers. Often times there is a contact phone number for a caregiver or loved one posted in the room, so I can call them to obtain relevant information regarding the patient’s health.
   
6. Writing notes
   The challenge to writing notes is carefully considering the language and whom to address. One preceptor explained that I should write my notes as if every patient could end up in a malpractice trial that I may be called to testify at! It is also important to make sure to use only approved abbreviations, for example RD must be written as R.D. and bowel movement must be written as b.m. Another challenge to writing notes is making sure that to cover all the details, relevant conversations must be appropriately documented.
   
7. What can you do to reduce these difficulties?
   

Based on observations of working in a large hospital, I think making a plan of action (to do list) each morning helps to overcome some of the difficulties stated above. First, it is important to organize and prioritize the list of patients to see, next do background research on the medical record before assessing the patient and writing notes. Next, map out the best way to visit patients based on which part of the hospital they are in. Chart as you go so you do not forget details about the patient visit. Also, it is important to be efficient when visiting with patients to make the best use of your time and hopefully avoid many interruptions. There is definite truth to the joke that patients are very busy when they are in the hospital, with all the procedures, therapy, medication administering, etc.! Lastly, it helps to organize daily productivity and make a list of anything that was not finished and needs to be done the next day.