Documentation
Could you recommend a publication that would have the standards of practice for nutritional care for reference?
It would depend on what types of standards you are looking for. There are many good sources available depending on your area of interest. For example, the American Medical Director's Association (AMDA) has guidelines for care of older adults in LTC settings: nutrition care, diabetes, hydration, pressure ulcers. The Agency for Health Care Research and Quality (formerly Agency for Health Care Policy and Research) has guidelines for pressure ulcers (CMS still uses this as the standard of practice even though it is from about 1998), and numerous other clinical guidelines. ADA, CD-HCF and DMA have standards of professional practice on their websites. ADA has various nutrition care standards including information on the Nutrition Care Process (Members Only section of the ADA website: http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/home_13838_ENU_HTML.htm and the ADA Evidence Analysis Library (Members Only at https://www.adaevidencelibrary.com/default.cfm). The American Diabetes Association has their 2007 Clinical Practice Recommendations available at http://www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp.
Dysphagia
The corporation that owns several LTC homes in New York State has dictated that we use only 3 diet consistencies: Regular, Mech Soft and Puree. No diets can be a combination of consistencies to eliminate any error. (They had a home with a choking incident during a state survey in which the resident was served an item of regular consistency that was supposed to be mech soft-the rest of the meal was puree). What do you think about not having any combination diets? The SLP's, + RD's in this corporation believe that it would be a violation of resident rights to require all items to be pureed even if the resident could tolerate 1-2 items of mech soft, but needed other items to be pureed. Question 2: What is your definition of Aspiration Precautions?
I understand the dilemma of the corporation. It seems that litigation related to dysphagia/aspiration is on the rise. However, as practitioners, we know that "one size does not fit all." Trying to fit each individual resident neatly into a regular, mechanical soft or puree diet is not always in the best interest of the resident. If the dietetics professional is working closely with the SLP and the dietary manager, and individualizing the diet therapy for each case, this would be considered as the best standard of practice available. The regulations tell us that we must provide care and services for each resident to reach their highest practicable level. Needlessly limiting someone to an overly restrictive diet would not allow them to reach their highest practicable level. (You should consider moving toward the National Dysphagia Diets rather than the current diets you are using. For more information on that subject, you can review some of the articles posted on this website, or consider purchasing our revised book, Dysphagia Diet Solutions in the publication section of this website). To answer your second question, we do not have a policy on aspiration precautions. In our facilities, this would typically come from the speech language pathologist, and we would work with them to comply.
I am a dietitian at a 50 bed skilled nursing facility. We have some problems with our nursing staff understanding the importance of following dysphagia diets for some residents. I have teamed up with our speech therapist to develop an inservice. We want them to understand why some residents need the special diet consistency and why it is important to follow the recommendations for safe swallowing techniques. Do you know where we can purchase this? I have read your article "It's Tough to Swallow" and I think it's very informative. What other suggestions would you have as far as education techniques for nursing staff?
You can do some simple exercises to demonstrate some key points to staff. Have them think of the last time they choked on food or fluid and how that felt. Or if they ever had a child or loved one choke on something and how scary it was when that person couldn't breathe. Here is an exercise that gets the point across quickly and simply: Have them tilt their heads back and swallow; then tilt their heads to the side and swallow; and then do a slight forward chin tuck and swallow. Ask which position was easiest for swallowing. This demonstrates importance of proper positioning. You can then discuss how people should be positioned for safe swallowing. We have an inservice, Food and Fluid Prep for Dysphagia, that might also be very helpful. It reviews some basic info about dysphagia and also goes into food presentation for dietary.
We are having problems in our LTC facility. The DTR or RD has always been able to downgrade a diet if a patient requested it. For example if they wanted ground meat we were able to change that without consent from anyone else. Now the DON states that we need a physician order and SLP consent. What is your take on this?
If it is an individual request is for something as simple as ground meat, I don't think that needs to be a physician order. However, questioning further to determine why they need ground meat might lead to discovering that there may be dysphagia problems requiring a SLP consult for further investigation and diagnosis. In our facilities, we discourage nursing or dietary from downgrading or upgrading consistency altered diets without a physician order. Years ago we had facilities that would change the diet from meal to meal--sometimes because it was quicker to feed someone a pureed diet when staff was short. The goal is to keep the individual on the highest level of consistency they can safely tolerate, so there must be checks and balances in place to assure the individual is receiving what they need.
Do you know if you count the full 240mL in a cup of a thickened liquid?
Great question! It depends on the type of thickener and beverage you are using. For thickeners using modified food starches (powders): Water content is unchanged by the thickener. You will start with 4 oz. water, and still have 4 oz. water after the powdered thickener is added, but the volume of the liquid will increase by the volume of the powder added. For pre-thickened liquids: Calculate the amount of water by subtracting the grams of CHO, protein and fat from the total weight of the serving; Ex. 4 oz orange juice = 120 mL/gms -15 gms CHO = 105 gms/mL water. For gel thickeners (xanthan gum): Over 80% of the weight is "free" water available for hydration; If you add the gel thickener to a beverage and drink it all, you get more "free" water than you started with. Studies indicate that people drink 30-40% more with a gel thickener. (The information on gel thickeners comes from Simply Thick's website).
Enteral Feeding
A LTC Physician recently ordered a "pleasure diet" for a tube fed individual who is NPO. The goal is to provide foods upon request from the individual for his pleasure. I can not find any standard of practice for this terminology. How have you handled this situation?
The term "pleasure diet" or "food for pleasure" has been in use for many years especially in long term care and hospice care. The NPO order on the chart should be removed and changed to "food for pleasure only as requested." I would caution you to work closely with the SLP, review the medical record thoroughly for the SLP's recommendations, the barium swallow results, current medical status and prognosis. If the individual is at end of life with a terminal diagnosis and is on hospice care, pleasure foods are appropriate--as long as the individual and family understand that they may choke or aspirate and develop pneumonia. Be sure the nursing staff and STNAs are trained to position the individual for safest swallowing, know what to do if the individual chokes, and offer only food in a consistency the individual can tolerate. If the person is not terminally ill, and the NPO order is there because the barium swallow indicated swallowing food/fluid by mouth was unsafe (due to risk of aspiration), you will want to have a discussion with the SLP, DON and physician to voice your concerns for safety and risk of harm/liability, and document your concerns.
How long should an NG tube be used to supplement nutrients safely, if the patient is at home?
There are many variables with NG feedings, so this is a very difficult question to answer not knowing any other details. In the nursing home setting we usually use the guideline of no longer than 6 weeks for an NG tube. If the person needs enteral feeding for longer periods of time we recommend a PEG tube. However, these people have access to 24 hour nursing care. With any NG or PEG tube feeding there are specific guidelines to help to keep the patient safe (positioning the head of the bed at a 30 to 45 degree angle to avoid aspiration, careful and safe handling of the tube feeding formula, care of the tube and the skin surrounding the tube, avoiding administration of meds through the tube unless very careful guidelines are followed, and many other guidelines for more information, refer to our Diet Manual. Regardless, the person should be carefully monitored by the health care team to assure adequate care, nutrition and hydration.
Fluids/Hydration
What items should be counted in a fluid restriction?
All fluids consumed are counted in millileters (mLs). 1 ounce = 30 mL, 4 ounces = 1/2 cup = 120 mL, 6 ounces = 3/4 cup = 180 mL, 8 ounce = 1 cup = 240 mL. Other items that liquefy at room temperature also need to be included such as milkshakes, ice cream, sherbet, jello, fruit ice, and popsicles. Soups, stews, fruits and vegetables (or anything else that contains liquid) should be drained prior to being served.
I am a diet tech in a nursing home. One of our doctors is telling me that a two-calorie/mL supplement is not considered a fluid but a food. I have a resident on a fluid restriction and he said the supplement is a food. Can you please give me some guidance?
Two calorie per mL products do indeed contain fluid and solids, but the majority is water: about 700 mL water per 1000 mL (or 70%). You would want to count 70% of the two calorie per mL product as fluid. If the person is receiving 8 ounces (240 mL) of a two calorie per mL product per day, they are actually receiving 166 mL fluid. You can find more specific information on the product's nutritional value at the manufacturer's website.
How do I know if a person is drinking enough fluids?
Individuals can be at risk for dehydration for a number of reasons including dementia, dysphagia, uncontrolled diabetes, medication, and/or refusal to drink fluids. Look for signs of dehydration: cracked lips, dry tongue, poor skin turgor, concentrated urine, dry skin, dry mouth, elevated body temperature, unplanned weight loss, and abnormal labs. The dietitian will assess the individual’s fluid needs and then work with the dietary manager and nursing to ensure adequate fluids are provided. The facility staff need to encourage individuals to drink the fluids provided. If you suspect that an individual is not consuming at least 6-8 glasses of fluid each day, a one to three day fluid intake study can be completed with interventions as appropriate according to the results of the study.
What would you suggest as a way to get started implementing dehydration prevention measures? For instance, if patients are getting 8 oz milk, 6 oz. juice and coffee/cocoa, plus soup, fruit etc. from meals (probably 1500 mL) how much would you suggest increasing at fluid pass? I do have concerns that our frail, elderly patients may fill up on juice, sugar-free beverage or water. What kind of a time line would you suggest? We would like to be sure that patients are receiving water before, during and after therapies as well.
I understand your concerns about residents filling up on fluids and not eating meals. It is a difficult dilemma. Many older adults do not even realize that they are thirsty, so it is very important to spread offerings of liquids throughout the day. Just as every individual is unique, every facility is different. Facility staffing and routines vary greatly, so it is difficult to give specific suggestions for each facility. However, some general ideas may be helpful. Breakfast trays generally include 8 oz. milk, 6 oz. coffee, and 6 oz. juice. That's 600 mL in the morning after a night long fast, and should get residents off to a good start. Lunch and Dinner meals usually provide another 4-8 oz. of milk, 6 oz. coffee, and 6-8 oz. of either water or juice at each meal. This adds another 16-22 oz. (480-660 mL), for a daily meal total of about 1080-1260 mL. (Of course you may have additional fluids in the form of soups, sherbet, ice cream, etc.) This is spread nicely between the three meals. Then it is just a question of how to provide the between meal fluids. Depending on timing of med-pass versus meals, you might offer extra fluids in between meals--around 10:00-10:30 AM and 2:30-3:00 PM might work nicely. If med-pass times are too close to meals, the facility might consider a "beverage cart" service at the above times. Volunteers or activity staff might assist with a beverage cart. If fluids are offered at med-pass, offer a minimum of 6-8 oz. of fluids (180-240 mL or 360-480 mL per day). This gives us a total of 1440-1740 mL. And then there is HS snack, which is often offered after residents have gone to bed. Another 8 oz. would bring the totals to 1680-1980 mL. Obviously, some individuals will need more, and some will need less. For those needing additional fluids, it is wise to specify when and how they should get it (whether on the tray or in between meals). Staff training is essential to assure that staff understand the importance of hydration. For more information on a great training tool, check out Hydration: It's a Splash Inservice.
Food-Medication Interactions
Do you have any information on the Vitamin A overload in the elderly with supplementation?
What level is appropriate?
The body takes in vitamin A in two forms: preformed (from meat and dairy products) and as carotenes, (from fruits and vegetables). After food is digested, preformed vitamin A enters the blood, from which it is later removed and then stored elsewhere in the body. As we age, our bodies gradually perform this function less and less efficiently. Therefore, the elderly do not tolerate preformed vitamin A as well as the young. In the elderly, vitamin A can build up in the blood and become converted to toxic compounds which can lead to problems such as demineralization, or weakening, of the bones. Studies have shown that as little as twice the RDA of vitamin A can have adverse effects. The Vitamin A requirement is 1000 mcg RE for Men and 800 mcg RE for women. Increased levels of retinyl esters as a result of over supplementation of Vitamin A may indicate vitamin toxicity or liver damage.
Heights and Weights
I have a question on obtaining heights on nursing home residents. Whose responsibility is it to obtain the height...a nurse or a dietitian? I have only known in the past of nursing obtaining the residents height as part of the nursing assessment along with weights. Prior to me there was a dietitian who measured the residents with a tape measure and now the staff thinks this is appropriate. I do not think this is appropriate and believe it is the nurse's responsibility to obtain height on admission and yearly.
You are correct. It is normally a nursing responsibility to obtain height upon admission and usually at least yearly thereafter. If you are in a nursing home setting, the MDS requires a new height measurement each year. We have inservices available on Taking Accurate Heights and Weights which might be helpful if you need to offer to train the staff on doing this correctly.
Do you have any strategies for motivating nursing in the LTC setting, to do monthly weights and re-weights (as appropriate), in a timely and accurate manner?
Training, educating, positive relationships and good communications are the best ways to keep staff motivated. Our Healthy Weights Manual (found at need new link) offers many excellent suggestions on getting accurate and timely weights. Having the support of the Director of Nursing and the Medical Director tends to make things go smoothly. Do you have a Weight Team meeting every week? Have you explained why getting weights are are so important? We have done inservices with fun prizes, contests between units for the fewest re-weighs, least weight lost and other things to keep staff motivated. Food always seems to work as a prize! Does staff have the forms and tools they need to get the weights? The most important thing is to keep them accountable for doing the job.
Menus/Therapeutic Diets
What are the menu guidelines for a LTC facility?
For SNFs and NFs, the federal government provides regulations and interpretive guidelines for menus and meal service. Ask your administrator for a copy of the federal nursing home regulations and interpretive guidelines. You will want to review F363 Menus and Nutritional Adequacy. You can also read the article related to this subject, found at need new link for the article on menu guidelinesAssisted living facilities are not regulated by the federal government. You will need to check your state ALF regulations to see if there are specific nutritional guidelines for your state. If you need assistance with menus, we do offer both nursing home and assisted living menus at a very reasonable price. Our 4 week cycle menus which include therapeutic diet extensions. Please feel free to view more information on our website at Need new link to menu/recipe packages
We are interested in your publication on liberalized diets. Can we use them for acute care? Can you provide us with the literature behind liberalizing diets?
The literature on liberalizing diets for older adults is covered well in the "Position of the American Dietetic Association: Liberalized diets for older adults in long-term care" published by ADA in 2007 and available online at http://www.eatright.org/cps/rde/xchg/ada/hs.sxsl/advocacy_adar0902_ENU_HTML.htm.
As my LTC facility is growing with temporary rehab people, I am rethinking changing to regular diets for diabetics. I want to rename it consistent carbohydrates (we still have NCS) but still offer diet desserts so diabetics who go home with education are aware of diet desserts that can be made. I have also had people who watch their diet and want diet desserts. I still want to keep NAS because my patients with CHF and renal disease still need it. I offer, but they can still choose. Other smaller facilities in our area have gone to all Regular, so my CDM wants to go to all Regular, but we are a much larger facility with a large rehab program. I want to continue to educate regarding therapeutic diets for those who are interested. I can not very well set an example with our menus being regular if someone wants to watch their Na or CHO. So, where is the liberalized diet going now? Do you still recommend regular diets for all?
I must say that even though I was a co-author on a previous liberalized diet position paper (and a reviewer on the last one), I never did recommend regular diets for all residents. The most liberalized plan I ever recommended was Regular, Mechanical Soft, Puree, and some form of diabetic diet (NCS, LCS in the past—now we use Consistent CHO). Liberalization is very appropriate for the older, frailer resident in a nursing home. However, I personally believe that many facilities are in the same situation as yours, caring for a growing number of younger people who have a fairly good prognosis and fairly long lives to live if they adapt a healthier lifestyle. With the obesity epidemic such as it is, I think we will continue to see increasing numbers of younger people for hip or knee replacements or health problems related to obesity. I believe the pendulum is swinging back to offering more therapeutic options for those who want/need to make some healthy adjustments to their diets (controlled calories, lower odium, lower fat, cholesterol, diabetic alterations, etc.) In order to meet the needs of the residents/patients we are seeing in LTC, I think we have to offer healthier food choices. Education is also going to continue to grow in importance for these more transient residents. We will need to step up to the plate to meet these new challenges. I think you are wise to fight the desire to go with regular diets for everyone regardless of need/desire of the individual. You might be interested in two publications that we offer that include copy ready diet instructions: Diet Instructions and The Obesity Challenge
Nutrient Needs Calculations/Body Weight
To estimate protein need for prevention of pressure ulcers for a patient with BMI 61, do you use adjusted body weight or other method?
There is no evidence based research for determining whether to calculate nutritional needs using current, adjusted, or ideal body weight in a person with a BMI this high. The important thing is to be consistent in how you do your calculations and be sure you are monitoring and altering nutrition interventions as appropriate. A written protocol for nutritional needs calculations is best. ADA has dropped the use of adjusted body weight from their Nutrition Care Manual as there is no evidence to stand behind it. I can share what we do as a group of practitioners (there are about 18 RDs in our practice). First, we always document what we used as the basis of our calculations (actual weight or IBW, and factor for calories, protein and fluids). This is built into our assessment and reassessment forms. For those who are grossly under weight, we tend to adjust up for protein. Generally, we use the IBW as the basis of the calculation, and we may also give a range using IBW and current weight again, always noting what we used as the basis of our calculations. For those that are morbidly obese, we tend to use a range based on IBW and current weight (being sure to document what we used as the basis of our calculations). If the morbidly obese person is malnourished or has a pressure ulcer, we tend to use current weight for protein calculation, with the thought being that we need to heal the wound (or reverse the protein calorie malnutrition) first and worry about the obesity issue later as appropriate. The most important thing is the nutrition interventions you implement to improve nutritional status--assuring appropriate interventions, and checking to see if they are working (and if not, altering them appropriately). In other words, it's not just about the calculations. If a person’s weight continues to change or pressure ulcer shows no signs of healing, interventions need to be adjusted (calculations may need to be adjusted as well).
What should we be using for Ideal Body Weight (IBW)? Also, our state RD suggesting we reevaluate the use of the Harris- Benedict formula for calculating energy needs. What is your opinion or practice?
We use the Hamwi method for calculating IBW (basically for females, 100# for the first 5 feet and 5# for each inch over; for males, 106# for the first 5 feet and 6# for each inch over), but apply the use of IBW carefully. We focus more on usual body weight and changes in body weight. Limited research indicates that the Harris Benedict equation is not accurate in the frail elder population. Mifflin St. Jeor appears to be more accurate, but still not proven in this population. Indirect calorimetry is the gold standard, but most of the available portable equipment does not work for individuals who have respiratory problems--and most facilities don't have this technology available. We have used 25/30/35 calories/kg to estimate weight: 25-28 calories/kg for normal weight people who want to maintain and 30-35 for those who have pressure ulcers or need to gain weight. These are just estimates of course, and we must carefully monitor weight and determine if interventions are effective. Most of the current formulas are not terribly accurate in the fragile elder population and the calculations are only worth so much. What's really important is the interventions and assessing whether they are appropriate and acceptable to each individual--and if they are working to resolve the nutritional problem.
Why do elderly people need to increase their calorie and protein intake during metabolic stress?
Individuals who are elderly and chronically ill, may be at higher risk for a dangerous stress response. The body's response to stress may be triggered by injury or infection, and this leads to increased catabolism (tissue breakdown) and loss of lean body tissue, which in turn leads to protein energy malnutrition and weight loss. When the stress response is triggered, it creates a hypermetabolic state which increases nutritional needs. This hypermetabolic state can cause weight loss. Significant unintentional weight loss creates loss of lean body mass (LBM). LBM makes up 75% of body weight and provides the majority of the body’s protein. Protein is critical for growth and maintenance, fluid and electrolyte balance, acid-base regulation, blood clotting, enzymatic functions, metabolism, and immune function. When the body has lost just 10% of its LBM there is a decrease in immune response with increased risk of infection. At 15% or more loss of LBM, various components compete for protein to replace losses, thus reducing the rate of wound healing and increasing weakness. At 30% loss of LBM, pressure ulcers may develop and healing response becomes non-existent. And at 40% LBM loss death may occur, usually due to pneumonia. During acute illness or trauma (injury, burns, wounds, major surgery, major infection such as sepsis, etc.) the body reacts to protect itself with an inflammatory response which increases the demand for additional energy and protein. This results in metabolic alterations that begin at the time of the injury or acute illness and continue until recovery or healing is complete. Counter-regulatory hormones are released which mobilize fatty acids, promote breakdown of glucose and breakdown of proteins to glucose for energy. Production of energy becomes increasingly dependent on proteins. Metabolic stress causes poor utilization of carbohydrate, protein and fat. Rapid breakdown of lean body mass also causes urinary loss of potassium, phosphorus and magnesium. Fat metabolism increases to create energy. This series of events results in an acute PEM in which albumin, transferrin, prealbumin and retinol-binding protein decrease. A negative nitrogen balance occurs due to rapid loss of lean body mass, and muscle wasting may be the ultimate result.
When a resident who is on enteral nutrition leaves the nursing home to go to the hospital and leaves at a certain weight and then comes back at a different weight, what weight do you use to calculate calories needed from enteral nutrition? The weight before they left or the weight when they returned from hospital?
We recommend that you use the current weight (weight when they returned) to calculate their needs for the enteral feeding. Just be sure that the weight you are using was obtained by your facility nursing staff. Do not use the hospital weight as their scales may be different. If there is a significant weight change from the time they left the nursing facility to the time they return, you need to document the significant weight change and what interventions you are doing to assure that the person returns to normal weight if that is the desired result. Obviously, if the person is underweight and has lost weight, you need to be sure that you are providing adequate calories via the enteral feeding.
Pressure Ulcers
Can you give me the direct link to CMS to find the reference to protein recommendations for pressure ulcer treatment?
The State Operations Manual Appendix PP (Surveyor Guidance) can be found at: http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. F314 Pressure Ulcer Investigative Protocol begins on page 177. F325 Nutrition and Therapeutic Diets begins on page 262.
What are the basic guidelines for nutrition intervention for pressure ulcers? What about long term use of zinc supplements for a patient with wounds. What do you recommend for a patient that has a persistent wound?
First assure that the patient is receiving adequate calories (30-35 cals/kg body weight/day) to be able to utilize the protein in the diet (protein sparing). Then be sure that the patient is receiving adequate protein (1.2-1.5 gms/kg body weight/day depending on severity of pressure ulcer or ulcers) and fluids (30-33 mls fluid/kg body weight/day plus additional fluids for incidental losses (if losses exist: diarrhea, vomiting, draining wounds, heated air fluidized bed, fever, etc.). A daily multivitamin/mineral supplement should be provided if a deficiency is confirmed or suspected. If you are confident that these items are in place, and the individual is actually consuming the calories, protein and fluids needed, then consider additional investigation to see if other deficiencies exist.
What is your protocol on Vitamin C and Zinc with pressure ulcers and the various stages?
We follow AHCPR (AHQR) guidelines: provide a multivitamin with minerals if deficiencies exist or are suspected (at any stage). Zinc may be lost from large wounds and from diarrhea and certain disease states such as Crohn's, celiac, short bowel syndrome, diabetes and AIDS. Zinc does play a role in cellular proliferation and protein synthesis. However excess zinc may interfere with wound healing (specifically collagen synthesis) as well as contribute to possible copper deficiency if used for a long period of time. The RDA for zinc is 15 mg for males and 12 mg for females, and the Upper Limit is 40 mg/day. Only request a zinc supplement if a zinc deficiency actually exists. Request zinc supplementation at a rate of 25-50 mg elemental zinc/day for 2 weeks, and then reevaluate to see if the zinc needs to continue (if it has had a positive impact on healing). Zinc is given as a short term intervention to avoid copper deficiency. Our CEU programs and clinical manual, MNT for Pressure Ulcers, are excellent resources for you to determine the best course of treatment for individuals with pressure ulcers.
Does arginine or glutamine fit into the plan of care for a person with pressure ulcers? IWhat amounts should be given? Is MVT with ZN discontinuted when healed or is it good practice to continue per lab reports/deficiencies? What amount of Zn/d? Amount of Vit. C? Vit. A? What do you consider the upper limits of vit. C in foods and/or supplements per day to assist healing yet not to give too much?
I would recommend that you first assure that the individual is receiving adequate amounts of calories and protein to meet calculated needs before adding any specialty product. Arginine and glutamine are single amino acids that have been found to have wound healing properties, but there is no evidence based research to support the use of arginine or glutamine with wound healing. Many practitioners use these products in practice and believe that they do have a positive impact on healing. However, no positive impact will be achieved if basic needs are not met first. MVI with zinc can be continued if the person is not consuming adequate amounts of nutrients in their diet or tube feeding. Zinc should not exceed 100% of USRDI. Vitamin A, and Vitamin C are safely given at 100% of USRDI. There is not solid research to prove that giving more than 100% is effective in promoting healing. For more detailed information, you might want to purchase our inservice CD-Rom on MNT for Pressure Ulcers, or take our on-line CEU program on MNT for Pressure Ulcers.
What do you do with vascular wounds? Do you treat them with the same protocol as pressure ulcers?
Most of the research I have done has been on pressure ulcers (they make up about 70% of all wounds seen in health care), not vascular wounds (less than 6% of elderly experience these—but a problem none-the-less). According to Mary Litchford (Advanced Practitioners Guide to Nutrition and Wounds), vascular wounds are usually caused due to venous hypertension, arterial insufficiency, neuropathy or a combination of these factors. It would be most important to treat the cause of the vascular wound. In addition, it would be important to determine whether the person is on corticosteroids which may suppress wound healing (megadoses of vitamin A during steroid therapy has been shown to cancel out the negative effects of corticosteroids on wound healing). My limited understanding is that unless there is adequate circulation, nutrients cannot reach the site of the wound. However, being the optimist that I am, and with limited research available on nutrition and vascular wounds, my recommendation would be: 1. Treat the cause (medically and nutritionally). 2. Provide the extra calories, protein and nutrients you would for a pressure ulcer. What little circulation gets to the site will nourish the areas well as provide optimum nutritional health to the individual. For additional information, consider Advanced Practitioners Guide to Nutrition and Wounds.
Could you tell me how to calculate/determine nutritional needs for the person with a deep tissue injury (DTI) form of pressure ulcer?
Calculate nutritional needs based on the assumption that it may be a stage III to stage IV pressure ulcer (assuming the worst possible wound). Current recommendations for nutrition interventions for pressure ulcers are to provide the following: 30-35 kcal/kg body weight ; 1.25-1.5 gm protein/kg body weight; 30-33 mL fluid/kg body weight; A multivitamin/minerals supplement if deficiency is confirmed or suspected; 25-50 mg elemental zinc if deficiency is confirmed (provide for 10-14 days and then reevaluate its effectiveness--limiting the length of time a person receives zinc to avoid a copper deficiency).
What is the result of long term zinc use?
High doses of zinc for long periods of time may lead to a lower concentration of plasma lipoproteins and decrease copper absorption. Decreased copper status may also inhibit the transport of iron and result in anemia. Although zinc-induced copper deficiency and the resulting anemia is serious, it occurs only after excessive zinc intake over a long period of time and is easily corrected by adjusting the intake levels of zinc and copper accordingly. Supplements of zinc and iron may also compete for absorption in the body. Long-term use may compromise immune functions.
Obesity/Weight Gain
What can we do to prevent weight gain in our facility?
Weight gain is a common problem in our society so we shouldn't be surprised when individuals who have decreased mobility have problems with weight gain. Although we want to make quality of life our first priority, there are some things we can do such as monitoring portion sizes and compliance with diet orders. You can also discourage weight gain through diet counseling and encouraging increased movement/exercise and non-food related activities.
How is obesity in older adults handled in LTC?
Frail older adults in long term care settings are susceptible to malnutrition, weight loss and dehydration due to multiple disease states, medications and treatments. LTC professionals are very prudent when it comes to addressing the obese older adult. In the case of a frail older adult, we generally do not encourage weight loss, but rather weight maintenance. Unless there is a very good reason to encourage an older person in LTC to lose weight, we do our best to avoid it. If there is a well justified reason for the person to lose weight, the RD would need to plan a careful weight loss program with a healthy diet and gradual loss of no more than 1-2 pounds per week. This would need to be care planned, and the resident would need to be closely monitored so that the program could be adjusted as needed to promote a healthy weight loss. There are no actual regulations related to obesity in LTC, but the regulations under F325 Nutrition, address unintentional weight loss issues. For more detailed information on obesity, refer to the Obesity in LTC article or The Obesity Challenge manual.
Unintentional Weight Loss/Significant Weight Changes
How does one determine avoidable versus unavoidable weight loss?
According to the Investigative Protocol for Unintended Weight Loss for nursing homes released in June 2008, Avoidable/Unavoidable failure to maintain acceptable parameters of nutritional status:
Avoidable - means that the resident did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: evaluate the resident's clinical condition and nutritional risk factors; define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.
Unavoidable - means that the resident did not maintain acceptable parameters of nutritional status even though the facility had evaluated the resident's clinical condition and nutritional risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.
How do we determine significant weight loss?
According to the Investigative Protocol for Unintended Weight Loss for nursing homes released in June 2008, suggested parameters for evaluating significance of unplanned and undesired weight loss are:
Interval Significant Loss Severe Loss
1 month 5% Greater than 5%
3 months 7.5% Greater than 7.5%
6 months 10% Greater than 10%
The following formula determines percentage of weight loss:
% of body weight loss = (usual weight - actual weight) / (usual weight) x 100
Based on analysis of relevant information, the facility identifies a clinically pertinent basis for any conclusions that a resident could not attain or maintain acceptable parameters of nutritional status.
As a dietitian at what point do you recommend the use of supplements?
We always recommend starting with food first, but if all the traditional approaches have been tried and failed (interdisciplinary team review, dining, assistance, favorite foods, fortified foods, socialization, etc.), then it is time to try supplementation. Supplementation can take many forms, from milkshakes or puddings, to 1 to 2.0 calorie per mL med-pass programs, and so on. Be sure the product chosen is one that residents will accept. Vary flavors and types of supplements to avoid flavor fatigue. Timing is also important. Studies actually show that supplements given 60 minutes prior to the meal have a positive effect on appetite. Some residents do better with smaller volumes given more frequently. In this case a med pass program using a 2.0 Calorie/mL product may work best. There are also more concentrated products available that are even higher in calories and/or protein per mL. For more great ideas on how to implement a system for avoiding unintentional weight loss in your facility, see the publication, Healthy Weights.
How can nursing and dietary most effectively work together to prevent weight loss and intervene appropriately when it occurs?
Preventing and treating weight loss has to be a team effort. I would recommend a multifaceted approach:
1. Education: Understanding the federal regulations, interpretive guidelines and survey protocols and sharing pertinent information with nursing and dietary staff. Do frequent inservice training with both nursing and dietary. Stress the importance of working as a team for the benefit of the residents.
2. Systems: Use the systems you already have in place. The MDS Roster Matrix can help you identify residents at risk (those who have already lost weight, those who are not eating well, those who have difficulty feeding themselves, etc.). Make sure you have a good weight tracking system in place, and that weights are accurate and timely. Be sure there is a good food intake monitoring system in place. Managers should "manage by walking around" at meal time--do mealrounds in the dining rooms and on the wings. Intervene, supervise and retrain staff as needed.
3. Communication: Have weekly meetings to discuss residents who may be at risk. A "Nutrition at Risk Committee" or "Weight Committee" that includes all pertinent members of the team should be included. Be sure that everyone on the team gets a copy of the weekly weight reports, the roster matrix, or other pertinent information. Use good communication tools--in writing, not just vocal messages. Use a communication book or other tools to assure that everyone has access to pertinent information regarding high risk residents.
4. Dining and Food: Maximize the dining experience by assuring that residents receive the food they like at the proper consistency; food that is served in a timely manner and is at the proper temperature. Train staff on hospitality service and customer service. Focus on making mealtime as positive as possible, offering residents as many choices as possible (where to eat, who to eat with, what to eat). Assure residents receive the assistance they need to eat the meal. Call all staff out at meal time and take a "hands on deck" approach to meals: all staff can pass trays, open packages, cut foods, pour liquids, and provide verbal cueing as needed. This frees the STNAs (CNAs) up to feed those residents who are totally dependent. Make the most of the food served by enhancing favorite foods. Add additional calories and protein to food served (create a super cereal, super soup, or power potatoes by adding margarine, half and half and other high calorie/high protein ingredients). Focus on providing food first.
For more great ideas, see our Healthy Weights manual.
Miscellaneous Clinical Questions
I have a patient who is lactose intolerant, but wants ice cream. Can she have it?
While most lactose intolerant patients are told to avoid milk and milk-based products, some patients are able to tolerate small amounts. The individual and family/physician should be consulted to review past history with dairy products and what type of reaction ingestion evokes. If approved, a small amount should be trialed, monitoring for intolerance or side effects. The care plan should be updated to reflect this change in the meal pattern.
Is there an article or tips for patients who are NPO during the holidays? Ideas to make them feel a part of the celebration without feeling bad about not eating?
If possible it would be best to ask the individual and/or family about how much involvement at holiday meals and activities he or she would want to have. Would the person want to come to all the meals and activities regardless of being NPO? Sometimes the socialization and sights and smells of the event are enough to make someone feel a part of the celebration. Does the person feel that even being around food would cause emotional distress because they do not eat or drink orally? Are there any other important parts of the celebration that the individual would get pleasure from? Music therapy, art therapy, massage therapy, stories, picture review, readers, visitors can all be scheduled while everyone else is at the meal to keep the individual occupied yet distracted from the meal. In hospice, sometimes our pharmacy will make drops that can be added to the tube feeding formula to provide some "taste" (upon belching mostly) such as chocolate, pumpkin spice, cherry etc. We have also used oral sprays that give the taste of a variety of foods-even turkey and steak for those who have strong desires to taste food again and can swallow their own secretions. Ask your pharmacist for a list of flavorings you can request and nursing can administer. This was a very good question but one that has no easy answers!