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Clinical Questions
How can I fortify/enhance my resident’s foods?
You can use commercial products that can be mixed into food or you can enhance calories & protein using foods from your kitchen.Try this program that provides approximately 1500 calories and 20 g of protein a day: For breakfast use 8 ounces half-and half in place of milk. Provide one tablespoon of margarine. Mix 1 T of corn syrup into their breakfast juice. At lunch provide 8 ounces whole milk, 1 T margarine, and juice with 1 T corn syrup mixed in. At 2:00 snack provide 1/2 cup pudding made with half-and half. For dinner give 8 ounces of whole milk, 1 T margarine, juice with 1 T corn syrup mixed in, and 1/2 c of ice cream. For HS snack provide 8 ounces of a homemade milkshake or a commercial milkshake.
 
What is the purpose of thickened liquids?
Thickened liquids are recommended by a speech therapist for patients at risk of aspiration due to swallowing difficulties. Liquids are thickened in order to slow the swallow and allow better control during the swallow phase. For patients with dysphagia (swallowing problem), thin liquids may move through the esophagus too quickly which causes choking and aspriation. The following consistencies may be ordered based on an individual’s needs: nectar-like, honey-like and spoon (pudding) thick.
 
I need an up-to-date Nutrition Assessment form for use in my facility. Do you have any tools available?
Our MNT Made Easy is a copy-ready assessment package. It includes laminated assessment, re-assessment, progress notes, MDS section K, and temporary Plan of Care forms that you may copy for use in your facility. You can also check out www.cdhcf.org for the ADA & CD-HCF Nutrition Risk Assessment.
 
Help! I work in a nursing home that has accepted a resident on TPN. I don't know how to calculate nor do I remember what labs to monitor and how to make recommendations. What resources do you have that can help me?
Our Diet Manual has step by step guidelines for TPN/PPN calculations. For more specific information, refer to ASPEN at www.clinutr.org.
 
I have a question regarding swallowing evaluations and the recommendations. I am in charge of groups home for mentally and physically challenged individuals. Unfortunately, often when these individuals are assessed-they are lumped into the “retarded” group and are assumed that the least textured diet or liquid is needed. I have several clients who were tolerating thin liquids from a cup and after have a swallowing evaluation by a speech therapist a nectar or honey consistency was recommended. My question is this- Can I as a dietitian recommend to continue a thin liquid- as it is tolerated in the home or do I need to follow the diet as recommended.
I understand your concerns, but the SLP is trained to determine safety of consistency of food and fluid for each individual. Best practice would be to follow the SLP's recommendations. If you think that certain individuals should be reevaluated, request that the SLP reassess their needs. A person's condition and/or ability to swallow can change over time, and it may be that they can tolerate a higher level of consistency. Going through the proper channels of referral will assure that the individual receives the level of consistency needed to maintain a safe swallow.
 
How much calcium should an individual take in each day?
The dietary reference intake (DRI) for calcium is: 19-50 yrs old = 1,000 mg/day . Over 50 years old = 1,200 mg/day. Food is the best source of calcium. Calcium rich foods include: milk, yogurt, cottage cheese, cheese, pudding, ice cream, soy milk, calcium-fortified orange juice and other calcium fortified foods. An older person should consume at least three servings of calcium rich foods daily.
 
How do you choose which tube feeding formula is appropriate for individual patients?
Primary factors to consider in selecting the most appropriate tube feeding formula are nutrients (caloreis, protein, carbs, fat, vitamins, and minerals), water, fiber, and special nutritional requirements. Special nutritional requirements may include malabsorption, pulmonary disease, diabetes, renal failure, AIDS, metabolic stress, increased protein requirements, or fluid restrictions. Route of feeding (NG tube, g-tube, j-tube) and bolus versus drip or pump use also may affect choice of feeding. Tolerance to the formula must be monitored and formula or route of feeding adjusted accordingly.
 
Can diabetic patients have ice cream, cake, and other sweets?
For diabetic diets, the total carbohydrate count is just as significant as monitoring the amount of simple sugar in the diet. The diets in LTC are becoming more liberalized due to weight loss and malnutrition concerns. Simple sugars such as ice cream, cake with no frosting, etc, are being incorporated as part of daily meal planning. The difference is that the portion is being controlled. Diabetic menus are following regular menu desserts by cutting the portion to 1/2 or leaving off icing from baked goods. In some cases regular supplements are appropriate when served in small quantities (3-4 oz portions). Monitor blood glucose levels and make diet modifications as needed. For more information, refer to ADA's position paper on liberalized diets at www.eatright.org or check with the American Diabetes Association at www.diabetes.org. The common practice is to liberalize the diet to increase acceptance of the meal. Most often No Concentrated Sweets diets are given, even at times regular desserts are given with half portions.
 
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 residents who also have decreased mobilty and quality of life issues 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 (this includes staff, families and residents). We can also discourage weight gain through diet counseling and encouraging exercise and non food related activities.
 
Mrs. Smith 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 resident and family/physician should be consulted to review the resident's 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.
 
As an RD who works for Hospice in Pa. and Delaware I need to give an in-service to our volunteers who go into our clients home to assist them and their families. Since they often feed our patients my concern is the risk of aspiration. I have a video which I will show them, however do you know where I can obtain information on proper positioning of the patient.
There is a free article posted on our website, with information on positioning. Go to the Resources section of this website.
 
What items should be counted in a fluid restriction?
All fluids that a resident drinks are counted in mL's. 1 oz = 30 mL, 4 oz. = 1/2 cup = 120 mL, 6 oz. = 3/4 cup = 180 mL, 8 oz. = 1 cup = 240 mL. Other items that liquefy at room temperature also need to be included such as broth, ice cream, sherbet, jello, fruit ice, and popsicles. Fruits and vegetables should be drained prior to being served.
 
How do I know if a resident is drinking enough fluids?
Our residents can be at risk for dehydration for a number of reasons. These include 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 resident's fluid needs to ensure adequate fluids are provided. Encourage residents to drink those fluids. If you suspect that a resident is not consuming at least 6-8 glasses of fluid each day, a one to three day fluid intake study should be completed with interventions as appropriate according to the results of the study
 
Today I encountered another nurse questioning fluid calculations on a patient with a G-tube. I was taught to include the free water in the formula as part of the fluids received. First calculate fluid needs. Then subtract the free water in the formula. Then subtract for automatic flushes and the amount left over can be divided among med passes. Overall question, am I correct in adding the free water from a formula as part of the fluids received?
Yes you are correct. Free water from the formula should be counted as part of total fluids. Free water is not equal to the total ccs of a formula. The manufacturer provides the percentage of free water in each formula. For example, let's say a resident needs 2000 cc a day. If the resident is getting 1440 cc a day, multiply 1440 cc by 0.85 and the total ccs of free water in the formula is 1224.
 
I am an RD in a LTC facility. I also provide inservices at AL. When I started one year ago, menus were already in place. However, I don't know if they meet any guidelines. Where can I find the guidelines so I can check our menus?
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 F563 Menus and Nutritional Adequacy. Assisted 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 http://www.beckydorner.com/mr.php
 
Do you use the dysphagia diets for those that only have chewing problems (not swallowing problems)? I guess some of us wonder about labeling a diet "dysphagia", when someone really does't have a swallow problem. Some people just like a mech soft diet (or even a pureed diet ) for ease of eating, or because their teeth are in poor condition. Should we call our mechanically altered diets something different than dysphagia level 1, 2 or 3, for residents who don't have dysphagia? What diet would you recommend for these residents, and do you have an easy chew type diet that we could add to our diet manuals?
I have pondered this myself, as many facilities are not yet on board with the NDD. The simple definition of dysphagia is "difficulty chewing and/or swallowing." As you know, chewing problems can certainly lead to swallowing problems. Even so, I think we may go ahead and add the Mechanical soft diet back into the diet manual the next time we revise it because so many facilities are still using it. For your menus, you could consider listing NDD1/Puree as the diet name, so that residents could have an order for either diet and still use the same puree diet. And then alter the diet order if the resident can tolerate more. For ex. If the resident can tolerate breads, they could order "Pureed diet with breads."
 
I am a dietary intern working with a University in Pittsburgh, and we are interested in your publication on liberalized diets. Can we use them for the 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 paper for which I was co-author: ”Position of the American Dietetic Association: Liberalized diets for older adults in long-term care, JADA, September 2002”. The paper is included with permission as part of our publication. Our publication also includes simple explanations, policies & procedures, inservices, sample letters for communications, forms, etc. to make the transition go smoothly for your institution. I do know of some hospitals that have gone to liberalized diets for their patients (mostly due to the fact that many patients do not eat well while in the hospital anyway). Liberalized diets in hospitals would look different that liberalized diets in a nursing home. But the book can really help you with all the details to implement.
 
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 many take coofee/cocoa at each meal, plus soup, fruit etc. from meals (probably 1500 cc) how much would you suggest increasing at fluid pass? 4 oz, 6 oz or more 2x or 3x daily or ??? I do have concerns that our frail, elderly patients may fill up on juice or sugarfree beverage or even water that is presented shortly after Med Pass when they have water and many take 60 cc of a 2.0 supplement. 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. Any suggestions that might help spread the fluids throughout the day would be greatly appreciated.
I understand your concerns about residents filling up on fluids and not eating meals. It is a difficult dilemma. Many of our older residents do not even realize that they are thirsty, so it is very important to spread offerings of liquids throughout the day. Just as every resident 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 cc 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. (480-660cc), for a daily meal total of about 1080-1260cc. (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 divide 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 would be ideal. If med-pass times are too close to meals, the facility might consider a "beverage cart" service at that time. Volunteers or activity staff might assist. If fluids are offered at med-pass, offer a minimum of 6-8 oz. of fluids (180-240 cc or 360-480cc per day). This gives us a total of 1440-1740cc. 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. Obviously, some residents will need more, and some will need slightly less. In the case of those needing additional fluids, it is wise to specify when and how they should get it (whether on the tray or in between meals).
 
I noticed that Becky Dorner is on the review group for the National Dysphagia Diet. I'm wondering if melted cheese (such as in an omelette, not cheese sauce) is allowed on the Dysphagia mechanically altered menu?
There is no specific guideline of where to place melted cheese on this level. I would suggest that it is up to your professional judgement. It depends on the food served in your facility, and how difficult it is to move around in the mouth and to swallow. For example, if you know that the cooks like to put a lot of cheese in the omelettes, and the cheese tends to be gooey and somewhat difficult to handle in the mouth and to swallow, I would leave it off the menu for the dysphagia mechanically altered diet. However, if you know that there is little cheese, it is well distributed and not difficult to swallow, I'd put it on. When it comes to a grilled cheese sandwich or similar melted cheese (pizza, etc.), I'd leave that off at this level also. (Of course, bread must be pureed or slurried and gelled at this level also). But soft macaroni and cheese is fine. Hope that helps a bit.
 
Recently, state surveyors have been focusing on care plans, specifically whether or not they have been updated between review dates. Do you have any guidelines for how quickly care plans should be updated, ie., changes in diets, wt. changes, etc. Also, do you recommend listing the specific diet/tf/supplement orders on cp approaches, or "diet as ordered" etc.?
In our company, we set the standard that whenever a nutrition assessment, re-assessment or progress note is done, the care plan is updated at the same time. This way, we are sure we don't miss anything important on the care plan updates. As far as updating between review dates, our standard is that we update minimum of once a month on any residents with significant weight changes, pressure ulcers or enteral feedings and any other high risk residents. For changes or updates related to the RD's recommendations, the dietary manager or a nurse could do the care plan update if you are not in the facility on a daily basis. (As long as they are just following up on your recommendations, and not doing a nutritional assessment and making recommendations themselves). Everyone does care plans differently, so it is difficult to say whether you should list the specific diet, enteral feeding order or supplement order. All of this information is noted elsewhere in the chart. Your care plans need to be consistent with how the rest of the interdisciplinary team does theirs--are they that specific with their care plans, or do they refer to other sections of the chart for details? The care plan should reflect that you really do know what is going on with the individual resident, and you are keeping up with changes (however, those specific changes could be noted elsewhere in the chart).
 
I have read your info on ways to increase fluids to prevent dehydration but I work in an assisted living facility where most of the residents walk w/ some kind of assistance. They don't want to increase their fluids because they don't want to have increased urination. They find it difficult to get to the bathroom since they are not completely independent. Do you have any suggestions?
That is a very difficult concern. Have you talked with the nursing staff about it? Are the residents cognitively alert so that you might share some tips with them on what to watch for if they are becoming dehydrated? Simple things like to watch the color of their urine--it should be as close to clear as possible. If residents are not getting any assistance to use the restroom, and they have a difficult time getting to the bathroom, you might talk with the facility staff/administration to see if the restrooms of individual residents need more handicap features to help residents to be independent. And some of these residents may need some extra protection in the form of absorbent pads or adult diapers to reduce any possible embarrassment. Also consider "sneaking" in some fluids by using popsicles, gelatin, finger gelatin, soups, sherbet, pudding, ice cream (especially if they need extra calories), etc.
 
I have a question regarding long term use of zinc supplements for a patient with wounds. I believe that zinc is only recommended for 3 months or less because it may cause a copper deficiency. What do you recommend for a patient that has a persistent wound. Should the zinc be stopped after 3 months or should the patient get a copper supplement also? If copper should be supplemented, what is the usual dosage and are there any side effects or problems associated with copper supplementation?
First assure that the patient is receiving adequate calories (30-45 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 (1.1-2.0 gms/kg body weight/day depending on severity of pressure ulcer or ulcers) and fluids (30-33 mls fluid/kg body weight/day plus another 10-15 mls/kg body weight per day if on an air fluidized bed). 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 resident is actually consuming the calories, protein and fluids needed, then consider additional supplementation. If the wound is a persistent stage III or a stage IV, consider additional supplementation with zinc. 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. Zinc intake levels are commonly reported to be low in the older adult diet. Supplementation with 25-50 mg elemental zinc/day (possibly in the form of Zinc sulfate) for a period of 2-3 weeks is considered standard practice by many. After 2-3 weeks, evaluate to see if it has had a positive impact. If not you may want to continue for another 2-3 weeks. If there is no positive impact on healing after 4-6 weeks, zinc would be discontinued (and should be discontinued after about 6 weeks anyway). As for copper, I have not seen any recommendations for supplementing with extra copper, so I would not currently advise it.
 
A LTC Physician recently ordered a "pleasure diet" for a tubefeeding resident who is NPO. The goal is to provide foods upon request from the resident 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. 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 resident is at end of life with a terminal diagnosis and is on hospice care, pleasure foods are appropriate--as long as the resident and family understand that the resident may choke or aspirate and develop pneumonia. Be sure the nursing staff and STNAs are trained to position the resident for safest swallowing, know what to do if the resident chokes, and offer only food in a consistency the resident can tolerate. If the resident is not terminally ill, is NPO 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, voice your concerns for safety and risk of harm/liability, and document your concerns.
 
In the past month, a physician has ordered for "salty snacks" to be provided for two residents in a LTC facility which I consult for. I believe the latest resident had a Na+ level of 131. Based on my knowledge of the difference between serum Na+ level and cellular Na+ levels, this would not be an appropriate method of increasing their Na+. Would you agree?
Normal serum sodium levels range from about 136-145 mEq/L or 136-145 mmol/L. Serum sodium level is a reflection of the relationship between total body sodium and extracellular fluid volume. A low sodium level is usually caused by one of the following: over-hydration, vomiting or diarrhea, SIADH (syndrome of inappropriate antidiuretic hormone secretion), sodium wasting renal disease, chronic diuretic use, liver disease, tissue injury, gastric suction, hyperglycemia, Addison's disease, or ascites. In addition to diuretic use, low sodium levels may also be caused by certain other drugs such as sulfonylureas, trimterene, and vasopressin. However, it can be caused by low intake. If this is the actual cause, then additional dietary sodium should be a good intervention. Most nursing facilities do not serve very low sodium diets, so this is probably unlikely. But you will want to investigate all the possibilities. According to Nutrition Care of the Older Adult,
 
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). In addition, we offer high vitamin C sources 3 times a day (at any stage). Some practitioners also offer 500-100 mg Vit. C for a short term intervention. If it is a persistant stage III or a stage IV area, we request zinc supplementation at a rate of 25-50 mg elemental zinc/day for two weeks. Then we reevaluate to see if it needs to continue (if it has had a positive impact on healing). Zinc is given as a short term intervention to avoid copper deficiency.
 
How does one determine avoidable versus unavoidable weight loss?
According to the Investigative Protocol for Unintended Weight Loss, "unintended weight loss is unavoidable if the facility properly assessed, care planned, implemented the care plan, evaluated the resident outcome, and revised the care plan as needed. If not, the weight loss is avoidable" and the facility would be cited under F325, the Nutrition tag.
 
As a dietitian at what point do you recommend the use of supplements?
If the traditional approaches have been tried and failed (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 calorie/mL products, 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.
 
I am utilizing information for policy/procedure for a dietary department at LTC center. I have a few questions: Does arginine fit into plan of care? If so, what stage(s) of ulcers and how long is arginine given? Amounts? 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/d? Vit. A/d? (calculate for mg/kg? Last, Arginine Resource drink has 260% (156) of rds/d). 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?
Arginine can fit into your care plan for individual residents. I would recommend that you first assure that the resident is receiving adequate amounts of calories and protein to meet calculated needs before adding any specialty product. Arginine is one single amino acid that has been found to have wound healing properties, but even it will not work if basic needs are not met first. As far as what stage and what amount to utilize with any specialty product, I would refer you to the specific manufacturer of the product. My assumption is that these products would be utilized for stage III or IV wounds. 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 listen to one of our teleseminars on MNT for Pressure Ulcers, or take our 4 hour CEU program on MNT for Pressure Ulcers. Information can be found at http://www.beckydorner.com/ceu-homepage.php
 
I am a diet tech in a nursing home. I have a doctor who is telling me that two-cal hn is not considered a fluid but a food. I have a resident on a fluid restriction and he said the supplement is a food. He told me to contact a RD at the hospital I figured you were better to ask.
Two Cal HN does in deed contain fluid and solids. It contains 700 mL water per 1000 mL of Two Cal HN (or 70%). You would want to count 70% of the Two Cal HN as fluid. If the person is receiving 8 oz. Two Cal HN per day, they are actually receiving 166 mL fluid. Hope this helps. You can find more information on the product's nutritional value at www.ross.com.
 
I've read your guidelines regarding pressure ulcers, are they the same for stasis ulcers? ie, kcals, protein, fluids?
My expertise is in the area of pressure ulcers, so I am not well versed in the area of stasis ulcers. By stasis ulcers, I assume you mean venous ulcers? Venous ulcers (one type of vascular ulcer) were formerly known as venous stasis ulcers. Chronic venous disease is the underlying cause of 95% of all leg ulcers. Chronic venous hypertension is the cause and also the reason they don't heal well. The underlying edema must be controlled to heal the ulcer. Venous ulcers can also be caused by underlying DVT. My very basic understanding is that if nutrients can get to the venous ulcer it may be helpful, but if the circulation is poor, then oxygen and nutrients have a harder time reaching the area to assist with healing. In addition, hydration is very important for extremity perfusion (blood flow to the tissue). So yes, nutrition plays a role in the healing of all wounds, but with all of the other underlying issues, if the nutrients cannot reach the wound in adequate amounts and if other negative factors exist, the wound healing will continue to be delayed. I'm not sure how much that helps, but another good resource is Mary Litchford's Advanced Practitioners Guide to Nutrition and Wounds. We carry her book if you need a good reference. We also have good resources for information on nutrition and pressure ulcers. Please let us know if we can be of help.
 
Do you have suggestions for the calculation of a residents intake in calories vs their calculated needs? I noted you use 30-35 cal/kg vs BEE; can you tell me why?
You have asked how to express a resident's intake in calories. This would be done through a calorie count for usually no less than 3 days. All foods and fluids are recorded and then calories and usually protein are calculated and an average of the three days is given. Estimated nutrient need is based on ht and wt (and age when using Harris-Benedict) to determine energy/fluid needs to maintain weight (or loose or gain) based on best practice guidelines. Most like to compare estimated nutrient need to current intake to determine if a person is at risk for over or under nutrition. Many use a percent eaten such as 75%, and state that the person's estimated nutrient needs of 1500 cal and 75 gram pro are met by eating 75% of the 2000 calorie diet that provides 80 grm pro. Our MNT made easy is a streamlined form that uses simple calculations such as 25 calories per kg for weight maintenence with + 500 cal for gain, -500 cal to lose as a base. The numbers are close to what you would get if you did the multiple calculations from the Harris-Benedict equation. This saves valuable consultant time.
 
We are having some issues in our nursing home about free water that is provided from enteral formulas. The director of nursing disagrees that this does not count towards a patient's water intake and therefore they should receive free water flushes to meet fluid needs. There is now a big concern that our patients will become dehydrated.
Free water in enteral formulas is just that-free water. It is to be considered a part of the daily fluid intake. Over hydration is also quite dangerous and the outcome can be fatal, especially in those with heart and/or renal and liver disease. If you provide total fluid needs through flushes without consideration of the enteral product fluid volume, you will be over hydrating your clients and will have dangerous outcomes. Free fluid volume accounts for approximately 80% of the total volume for most enteral formulas, with formula specific ones (renal, liver low volume needs) usually being less. Manufacturer's labels provide you with the exact details of the free fluid. The MDS asks for total volume of the formula and flush at this time, and this may be a source of the confusion for your nurse that is questioning your practice. Food that we eat daily are considered part of the total fluid input and contribute to our actual total daily fluid intake. In the tube fed person this is the same, except that the "solids" constitute a much smaller volume than orally fed persons. As the nutrition expert, you are correct in questioning this suggestion. For further support and information, your pharmaceutical/nutrition support provider should be contacted. They often will come to the facility and in-service nursing on the enterally fed person as a value added service.
 
In Long-Term Care what is the appropriate time for an inital screening/assessment/follow-up? Who does the screening nursing or nutrition?
This question could have so many answers! It is dependent upon the facility policy and procedure. Nursing may screen per set parameters that the facility has to refer high risk to the RD for immediate assessment. It may be the Dietary Manager that screens and makes referrals to the dietary professional. Some screen in 48 hours or less, other within 5 days. It may also depend on what state you are in, as well as any credentialing the facility holds such as Joint Commission Accredidation. All clients in LTC must be assessed for nutrition and hydration risk by the nutrition professional. In general the Dietary Manager would see the client in the first 24-48 hours for food preferences and desires, with the nutrition professional following based on risks and need. By the fifth day the nutrition professional generally completes the assessment, but no longer than the seventh day. Follow up would be at the 14th 30th 60th and 90th days. The nutrition professional is most often responsible for all clinical documentation and follow up. First check your state specific guidelines and then check facility specific protocols.
 
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 LTC dietetics professional 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.
 
I would like to know why elderly people need to increase their protein, vitamin and mineral intake during metabolic stress.
Individuals who are old and chronically ill, may be more at 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 develop and healing response is 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. Counterregulatory 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 is the ultimate result.
 
Could you recommend a publication that would have the standards of practice for nutritional care for reference?
It depends on what kinds of standards you are looking for. The American Medical Director's Association (AMDA) has guidelines for care of older adults in LTC settings: nutrition care, diabetes, hydration, pressure ulcers. Agency for Health Care Policy and Research (now Agency for Health Care Research and Quality) has guidelines for pressure ulcers (CMS still uses this as the standard of practice even though it is from about 1998). ADA, CD-HCF and DMA have standards of practice on their websites. ADA has various nutrition care standards including Available ADA MNT Evidence-Based Guides for Practice: http://www.eatright.org/cps/rde/xchg/SID-5303FFEA-B8B0E8F0/ada/hs.xsl/advocacy_pgwrk02-03_ENU_HTML.htm. The American Diabetes Association has standards of care also. There are many good sources available.
 
Hello, I attended one of your seminar Pressure Sores. I have a question with the table that was given that defines the calories and protein needs of Pressure Ulcers from Stage 1 to Stage 4. I was not sure if it was clarified when the teleseminar was held as I did not hear any discussion. My question is the table given out, does not indicate if we use Adj Weight for Obese patient or when IBW percentage is greater than 125%. I found the calories high and the fluids high when using the actual weight for obese patients. Do I use the adjusted weight or the actual weight for the calories, proteins and fluids for obese or overweight? Also what do you do if the resident is underweight. Do you still use actual weight or the kg IBW.
To answer your question, there is no evidence based research that I know of for determining whether to calculate nutritional needs using current, adjusted, or ideal body weight. The important thing is to be consistent in how you do your calculations. A written protocol is best. 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, IBW or adjusted weight, and factor for calories, protein and fluids). This is built in to our assessment and reassessment forms. We tend to adjust protein for those who are grossly under IBW range. 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 and always being consistent to follow the same procedure for every resident. 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 would tend to use current weight for protein calculation, with the thought being that we need to heal the wound (or reverse the PCM) first and worry about the issue overweight later if appropriate. Remember that the most important thing for a practitioner in LTC is what you do for the intervention 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).
 
We are having a dilemma that needs an expert like yourself. The corporation that owns several LTC homes in New York State has dictated that we use only 3 diet consistancies: Regular, Mech Soft and Puree. No diets can be a combination of consistancies 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). Now for my question, what do you think about not having any combination diets? I have done a thorough search and have not found any supportive documentation in favor or opposed. 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 need the main entree for example to be puree. 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. 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 have a patient who gets bolus feeds of Glytrol through a PEG plus a bolus of several ounces of prune juice Q AM. The prune juice keeps her very well regulated (better than meds did) but the caregiver now says that the tube looks “dirty” and has dark specs in it. (The nurse is going to assess to make sure it’s not dried blood or anything.) My question is: is there anything we can flush the tube with to better clean the prune juice out of it?
From everything I have read, tubes should be flushed with water only. Prune juice tends to be fairly thick and sticky. You might suggest that the caregiver mix the prune juice with an equal amount water, warm the prune juice and water to between 70-100 degrees (between room temperature and body temperature), and then administer it through the tube. Then flush the tube with 50-100 mLs of water to clear any residual from the tube. As long as fluids are not a problem for this individual, this might just solve the problem.
 
To estimate protein need for prevention of pressure ulcers with BMI 61, do you use adjusted body weight or other method?
There is no evidence based research that I know of for determining whether to calculate nutritional needs using current, adjusted, or ideal body weight. The important thing is to be consistent in how you do your calculations. A written protocol is best. 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, IBW or adjusted weight, and factor for calories, protein and fluids). This is built in to our assessment and reassessment forms. We tend to adjust protein for those who are grossly under IBW range. 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 would tend to use current weight for protein calculation, with the thought being that we need to heal the wound (or reverse the PCM) first and worry about the issue overweight later if appropriate. Remember that the most important thing for a practitioner in LTC is what you do for the intervention 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).
 
I am a RD at LTC facility in Michigan. We are determining the best practice to calculate protein and fluid needs in residents over 120% IBW or under 90%. We currently use actual body weight for kcal needs. Upon calculating for protein/fluid needs with actual body weight, the needs determined can usually never be met with the amount the resident would actually need to intake to meet those needs. Supplements to meet these needs seem unjustified due to the added kcals they would provide and the amount of food waste that would be created. We have looked at Adjusted Body Weight (Actual-Ideal X .25) for over IBW and IBW for under but would like documentation or protocols in use to justify these calculations. Is there any publications/protocols at all in place regarding protein/fluid needs of obese or underweight residents? Please direct me in the direction to research this dilema. If you feel actual is appropriate, how do you document the appropriateness the extra amount of kcals this provides for an already obese resident?
You might find this article helpful http://www.beckydorner.com/pdf/CalculatingNeedsFeb2005.pdf You can also visit the ADA Evidence Analysis Library or the ADA Nutrition Care Manual online. I have spent a great deal of time researching this. From what I can find, ADA dropped the adjusted weight calculation years ago as there was no evidence behind it.
 
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 for nursing and nutrition services staff. We want them to understand why some residents need the special diet consistency they are on and why it is important to follow the recommendations for safe swallowing techniques. We want to be able to cause an impact on the staff. Our speech therapist mentioned a device that can be put in the mouth and simulates dysphagia. Do you know where we can purchase it? 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?
I do not know of any device that simulates dysphagia, but you can do some simple exercises to show staff how difficult it can be. Simply have then tilt their heads back and swallow, and tilt their heads to the side and swallow, and then do a slight forward chin tuck and swallow. This will demonstrate importance of positioning as well. You can also 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 can be when you can't breathe. We have an inservice that might also be very helpful. It reviews some basic info about dysphagia and also goes into food presentation for dietary. The info can be found on our website at http://www.beckydorner.com/publications-details.html?id=51
 
Do you know if you count the full 240mL in a cupe of a thickened liquid?
Great question! It depends on the type of thickener and beverage you are using. Thickeners using starches (powders): Water content is unchanged by the thickener; Start with 4 oz. water, still have 4 oz. water, 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 OJ = 120 mL/gms -15 gms CHO = 105 gms/mL water. For gel thickeners (xanthan gum): Over 80% of the weight of a packet of SimplyThick is “free” water available for hydration; If you add SimplyThick to a beverage & drink it all, you get more “free” water than you started with. Studies indicate that people drink 30-40% more with a gel thickener.
 
At our nursing home,we are trying to determine if someone with an MD order for thickened liquids should have thickened liquids at the bedside and how best to provide that for the residents. Any suggestions? Should we be leaving the small pre-thickened liquids at the bedside?
We would suggest that you do provide thickened water or have some way of a between meal hydration pass for your residents on thickened liquids. If you purchase the thickened liquids you can buy the 64 ounce bottles for the bedside or on the medication cart to be given at each med pass (4 ounces or more). If you have a snack pass or hydration pass, thickened liquids should be offered to all with that order. The aseptic individual boxes are also available. Individual packets, cans of thickener on med carts are all options as well. If dietary provides all the liquids, thicken in pitchers for service and stock the nursing pantry areas so that thickened liquids are available at any time.
 
Do we have to put thickened liquids at the bedside for each resident with an order for thickened liquids?
You don't have to have it at the bedside if you provide hydration pass several times during the day to those on thickened liquid and you can prove that no less than 1500 mL were served to all residents. Water does not have to be cold and should not be poured over or served with ice. If you want water at the bedside it does not have to be chilled. Milk and juice in the aseptic boxes must be served at the appropriate temperature though.
 
As my LTC facility is GROWING with temporary rehab people, I’m 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’ve also had people who watch their diet and want diet desserts. I still want to keep NAS as CHF, renal 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’t very well set an example with our menus being regular if someone wants to watch their Na or CHO. So, where’s 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, M 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 other 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 (lower sodium, lower fat, cholesterol, diabetic alterations, etc.) In order to meet the needs of the “new” 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.
 
Is fluid requirements for an obese person with a pressure ulcer based on adjusted or ideal or real body weight, and do you have any evidence based guidelines to support this?
Each individual with pressure ulcers must be assessed individually regardless of weight status and MNT implemented based on the best course of treatment to restore optimal nutritional status. There is no evidence based research that we know of for determining whether to calculate nutritional needs using current, adjusted, or ideal body weight. It is important to be consistent in how you do your calculations. It is best that you include documentation about what you used as the basis of your calculations and your rationale. Our "MNT for Pressure Ulcers" is an excellent resource for you to determine the best course of treatment for individuals with pressure ulcers. It can be purchased on-line at www.beckydorner.com under the Clinical Care Strategies category.
 
What do you guys 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 (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’s Advanced Practitioner’s 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 area—as well as provide optimum nutritional health to the individual.
 
We are having problems in our LTC facility. The DTR or RD has always been able to downgrade a diet if a pt would like. For example if they wanted ground meat we were able to change that w/out 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 a resident request 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 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 resident on the highest level of consistency they can safely tolerate, so there do need to be checks and balances in place to assure the resident is receiving what they need. With litigation the way it is in LTC, it's better to be prudent.
 
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?
This is such a good question and one that we all struggle with. Training, educating and communications are the best ways to keep staff motivated. Our Healthy Weights Manual 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 biggest thing is to keep them accountable for doing the job.
 
I have a question on obtaining heights on nursing home residents. Whos responsiblity is it to the obtain the height of a resident...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 (old school) who used to work in my facility 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 nurses responsiblity 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. Information can be found here: http://www.beckydorner.com/publications.html?category=tr
 
Can you give me the direct link to CMS to find the reference to protein rec for pressure ulcer treatment? I have a medical director who says it doesn't help and has references(not given yet)to support it. In general, I am looking for the interpretive guidelines r/t nutrition as I couldn't find it under a recent CMS link.
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 F326 Therapeutic Diets begins on page 236. There is also information from AHCPR (now AHRQ) on pressure ulcers (the "purple book"). This is essentially where the guidelines for protein requirements originally came from. Even thought the document is old (around 1998-1999), it is still used as the practice standard for pressure ulcers. When F314 was revised, the reviewers agreed that the evidence based research was available to support the protein requirements.
 
I am an RD consultant who just started working in long term care and was needing your opinion on something. 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. Weight before they left or weight when they returned from hospital?
You would 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—their scales may be different. If it 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 resident is underweight and has lost weight, you need to be sure that you are providing adequate calories via the enteral feeding. New research available suggests the use of the Mifflin-St. Jeor equation for caloric calculation.
 
How long should an NG tube be used to supplement nutrients safely, if patient is at home with one inserted?
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 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). Regardless, the person should be carefully monitored by the health care team to assure adequate care, nutrition and hydration.
 
The RD suggested we change our policy on calculating IBWR. We are using the Hamwi Formula. She suggest we use the Bechman tables. What is your opinion? The state RD is also suggesting we reevaluate the use of the Harris- Benedict formula for calculating energy needs. Again what is your opinion or practice?
We also use the Hamwi method for calculating IBW, but apply the use of IBW carefully. We focus more on usual body weight and changes in body weight. Limited available research indicates that Harris Benedict is not accurate in our elderly fragile population. Mifflin St Jeor appears to be more accurate, but still not perfect. 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 for quite a few years: 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 our elderly population in NH 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.
 
Could you tell me how to calculate/determine nutritional needs for the person with 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 or suspected (provide for 10-14 days and then reevaluate its effectiveness--limiting the length of time a person receives zinc to avoid a copper deficiency).
 
We have issues in our facility on physicians documenting significant weight changes. Can you offer any specific suggestions on how I can approach this situation with them?
I am not sure if you mean the physicians are not writing a note on the weight loss in the monthly visit or if you are having problems with notification. The Investigative Protocol for Unintended Weight Loss found in the Long Term Care Survey (guidance to surveyors) describes the weight loss parameters that must be addressed. These are federal regulations. Tag F 157 "Notification of Changes" describes the notification process for all significant changes in health status. Tags F 326 and 326 defines significant weight loss and the requirements for addressing unintentional weight changes. Tag F 385 describes the requirements for physician services. Generally, the physician is not required to note the weight change. Some simply say "lost weight this month; put on a supplement". In the case of palliative care or hospice referrals a longer, detailed note may be given. The Dietitian or nutrition professional designee reassesses, documents, and intervenes on all significant weight changes as soon as possible (once discovered and no less than monthly thereafter) for continued monitoring until stable.
 
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.
 
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. Recent 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.
 
We are a community-based program for nursing-home eligible seniors and use a benchmark for weight-loss QA of 4% or fewer of participants. My understanding is this is standard for nursing homes, but we have been unable to locate a rationale for this benchmark. Do you have information on this?
According to CMS and the Quality Indicator data, the national average for weight loss in long term care facilities is 9% (of the long-term care residents in any given facility at the time of the survey). I have not heard of a benchmark of 4% that you mention in your e-mail. Perhaps you are referring to a 5% loss in 30 days as being significant so you are keeping 4% as a threshold for weight loss? A loss of 5% or more of body weight in one month is usually considered unhealthy (for example, a 150 pound person should not lose more than 71/2 pounds in one month). Too much weight loss can make a person weak, change how medicine works in the body, or cause the skin to break down which can lead to pressure sores. Too much weight loss may mean that the resident is ill, refuses to eat, is depressed, or has a medical problem that makes eating difficult (like weakness caused by a stroke). It could also mean that the resident is not being fed properly, their medical care is not being properly managed, or that the nursing home’s nutrition program is poor. To help prevent unhealthy weight loss, it is important that the resident’s diet is balanced and nutritious, and that staff spend enough time feeding people who can’t feed themselves. Sometimes it may be necessary for a person to lose weight for medical reasons. In these cases, the medical staff may plan in advance for the resident to lose weight on a special weight loss program, but the person should not lose more than 5% of body weight in one month.
 
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 peron feel that even being around food would cause emotional distress because they do not eat or drink orally?Are there any other important part 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 TF formula to provide some "taste" (upon belching mostly) such as chocolate, pumpkin spice, cherry etc. We have also used oral sprays that gives 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!
 
I am an RD in an LTAC facility and my question is patients with ostomies with lots of output besides following an ostomy diet with certain food limitations/restrictions are there any additional recommendations that you have?
Foods may need to be individualized. After 6-8 weeksthe regular diet can be resumed but new food introduction should be done slowlyand only one thing at a time. Tapioca, applesauce, boiled milk, bananas and rice are used after diet progression(clear, full, bland, low residue)with the usual gas forming/bulk producing foodsavoided until tolerance is established.
 
Should cranberry be avoided in the diet if patient is on Coumadin? I never worried about it in our LTC setting, since our juice is a cranberry cocktail. However, a consulting NP has told us to avoid ALL cranberry products for our coumadin residents. Any thoughts?
This varies greatly in long-term care facilities. Once the therapeutic level dose for the individual is set, as long as there are no huge dietary changes itshould be OK to give the 6 oz juiceon occasion. It would be best to let the Medical Director of the facility make the decision on this with a policy implemented.
 
I have a question regarding recording fluid intake in LTC. Should I count the calories, protien, v/Min as fluid intake? How far do you recommend recording fluid/water intake?
In LTC we look at total fluid in mLs with 1500 mL fluid provided to every resident daily. In general, meals provide about 360 mL at Breakfast, 480 mL at L & D with 120 mL at HS. The water provided with meds and in the water pitchers add to the totals. Water should be poured and offered at every meal and encouraged. Estimated fluid needs are individualized for disease states and conditions (CHF, Renal, Wounds etc.)but are generally at 25-30 mL per kilogram of current weight. It is not necessary to pull out fluids for actual weight with enterals/oral supplements unless you are looking at total free fluids (if it is being tube fed or the fluid balance is critical for some reason). Input/output recording in LTC is an estimate at best, and the individual would most likely be hospitalized if the fluid was that unbalanced. I would recommend always using total fluid volume in the LTC setting.