NUTRITIONAL ASSESSMENT AND DIET HISTORY

POLICY A Nutritional Assessment and Diet History will be completed for each resident according to State and Federal requirements. This assessment/history form should be initiated within 72 hours; however, it is desirable to visit each new resident within the first 24 hours of admission and diet history should be completed by the Dietary Manager within 7 days of admission. PROCEDURE 1. A written diet order is initiated by nursing and sent to Dietary with resident’s name, room number, diet order and any special requires on admission. This form is to be dated and signed by nursing. 2. The Dietary Manager completes a kardex card and tray card for each new resident and initiates the nutritional assessment and diet history. The new resident is identified on the Monthly Assessment Flow Sheet for the RD to review and complete at her next visit. 3. The Dietary Manager must visit the new resident to accurately complete the nutritional assessment and diet history with likes, dislikes, allergies and beverage preferences. 4. The Dietary Manager will complete all available information on form, date and sign. The reverse side of the form shall be used for the Dietary Manager to write an initial progress note. 5. The Monthly Assessment Flow Sheet is used by the Dietary Manager to notify the RD when the condition of a resident changes warranting a review. Example: Weight loss or gain, insertion of a feeding tube, dehydration, pressure sore development, poor intake, adaptive device evaluation, abnormal laboratory values, nausea, vomiting, diarrhea, etc. 6. The nutritional assessment will include appropriate clinical data as required: pertinent lab data, diagnoses, food-drug interactions, hydration status, and ideal body weight range, weight loss or gain percentages, if applicable, etc. If a resident receives a tube feeding or is at significant well as protein, fluid and other nutrient needs will be calculated by the RD on all residents receiving enteral feedings. 7. The Nutritional Assessment and Diet History should be completed in black ink and will remain a permanent part of the medical record. OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

DIETARY PROGRESS NOTES

POLICY The Dietary Manager will assist with the comprehensive assessment (MDS) on admission of each resident and complete the Nutritional Assessment and Diet History. Thereafter, a dietary progress note will be completed for each resident at least every 3 months just prior to the care plan review and as needed.

PROCEDURE 1. The dietary progress note is intended to be an update of the dietary information contained in the comprehensive assessment. The Dietary Manager will include pertinent information regarding progress toward care plan goals and will evaluate the effectiveness of approaches being implemented. This information, plus the nutritional assessment will be taken into the care plan meeting. Care plan dates specific for each resident are designated on the glue Quarterly Dietary Evaluation Form generated by OptimaSolutions. 2. The resident should be interviewed by the Dietary Manager before the dietary progress note is written. If limited information is available from the resident, family members or appropriate staff members can be good sources on information. 3. The blue Quarterly Dietary Evaluation form generated monthly by OptimaSolutions is to be used for the Dietary Manager’s progress notes. Documentation of change in diet order, admission to hospital, etc. may also be done on this form. The RD will utilize the Dietitian’s Progress Notes form for completing pertinent notes and nutritional reassessments. 4. If at any time a problem arises with the resident requiring the Dietary Manager’s attention, the Dietary Manager should make a notation in the dietary progress notes showing what occurred and what action was taken. If a significant change occurs in the resident’s condition, such as a diet change, substantial weight loss, insertion of a feeding rube, pressure sore development, etc., these changes should be noted as they occur. Dietary Progress Notes should be specific toward each individual resident and his/her needs. All notes are to be signed and dated.

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

OptimaSolutions

Date

Dietary Manager Progress Notes

Progress Notations, Other Recommendations Signature & Title

Patient Name

Room No.

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

COMPREHENSIVE CARE PLAN

POLICY An interdisciplinary care plan will be developed for each resident. Its purpose is: (1) to develop measurable objectives for the highest level of function the resident may be expected to obtain, and (2) to develop care directives to maintain the optimal health status when the resident is dependent on staff for needs. The comprehensive care plan for each resident must include measurable objectives and timetables to meet the resident’s medical, nursing and psyche social needs identified in the comprehensive assessment. The care plan is prepared by an interdisciplinary team that includes the attending physician, a registered nurse with the responsibility for the resident and other appropriate staff and disciplines. To the extent practicable, the participation of the resident’s family or legal representative is encouraged. The services provided or arranged by the facility must meet professional standards of quality; and be provided by qualified persons in accordance with each resident’s written plan of care. PROCEDURE 1.

Each discipline reviews all assessments and notes. The Dietary Manager interviews the resident and observes eating patterns, etc.

2.

Identify problems to be addressed from resident assessment protocol.

3.

Establish goals to resolve problems using measurable objectives and time table.

4.

Develop realistic interventions which will work towards reaching the established goals.

5.

The care plan must be completed within 7 days after the completing of the comprehensive assessment.

6.

The comprehensive care plan will reflect current standards of medical practice.

7.

Residents and families, if the resident wishes, will be invited to participate in the care plan conference. Participation and invitations will be documented.

8.

With periodic reassessments, care plans will be reviewed and revised according to need following the steps previously stated.

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

NUTRITIONAL REASSESSMENTS

POLICY Reassessments shall be performed when there is a significant change in the nutritional status of a resident. All residents will be reassessed on a yearly basis using the admission date as a guide.

PROCEDURE 1. The nutritional assessment and diet history will be used for all yearly reassessments. The Dietary Manager will initiate this using the admission date as a guide. The box marked “reassessment” shall be checked. 2. The yearly reassessment performed by the Dietary Manager will replace the quarterly progress note. The same process used for the admission assessment will be followed. The Dietary Manager shall indicate all yearly assessments on the Monthly Assessment Flow Sheet. If the Manager determines that a yearly assessment is also high risk by falling into one or more of the other categories on the Flow Sheet, these categories should be checked so that the RD can review the resident in detail; otherwise, all yearly assessments will be checked by RD to make sure they are complete and current. 3. Those residents identified at nutritional risk should be indicated on the Monthly Assessment Flow Sheet for the RD to assess. The Dietary Manager is to remember that a notation needs to be made in the progress notes showing the change that has occurred and what action has been taken thus far. 4. The RD will reassess the high risk residents and those identified with special needs by the Dietary Manager on the Dietitians Progress Notes form.

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

PROTOCOL FOR PRESSURE SORES

POLICY The nursing department will inform the Dietary Manager of skin problems, especially pressure sores and of the healing process as it occurs.

PROCEDURE A current list of skin problems should be provided to the Dietary Manager so that she/he and the Dietitian can properly assess these residents. Some areas of focus should include. 1. 2. 3. 4. 5.

Sufficient calorie intake Sufficient protein intake Sufficient fluid intake Sufficient vitamin and mineral intake (particularly Vit C and zinc) Pertinent lab values

Nursing and Dietary should work to follow through on any recommendations the dietitian makes to hasten healing or pressure sores. Supplemental feedings may be institutes for these residents per physician orders. Suggested supplements may include milkshake products or complete liquid products such as Ensure. When a resident is overweight, skim milk and vitamins can provide protein and other nutrients without causing excessive weight gain.

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

HYDRATION PROGRAM

RESPONSIBILITY Licensed Nurse, Nurse Aide, Dietary Personnel PURPOSE 1. 2. 3.

To provide adequate fluid for residents To encourage fluid intake To prevent dehydration

EQUIPMENT 1. 2. 3. 4.

Water pitcher, glass and tray at bedside Water provided with each diet tray at dinner and supper Other fluids or fluid substitutes such as sugar free drink, popsicles, or gelatin, as needed. Water with medication pass.

PROCEDURE 1.

Each resident is to have a water pitcher with fresh ice water at bedside, unless contraindicated. 2. Fresh ice water is to be passed on day and evening shift each day. 3. The water pitcher and glass are to be changed once every 24 hours and sent to dietary to be washed. If utilizing Styrofoam cups with lids, instead of pitcher and glass, they are to be discarded every 48 hours. 4. Offer each resident fresh drink when water is passes, unless contraindicated. 5. Offer fluids at least mid-morning, med-afternoon, before retiring at night, and early in the morning, unless contraindicated. 6. Encourage residents to drink all fluids on diet tray at mealtime, unless contraindicated. 7. Encourage residents to drink a full glass of water with each medication pass, unless contraindicated. 8. Residents whose fluid intake is poor should have alternative approaches, such as popsicles, gelatin, or sugar-free drinks offered to them. 9. Intake of fluids should be monitored on all residents with catheters, feeding tubes, or those with fluid restriction. “Force Fluids” also requires recording of intake. 10. A guideline for determining baseline daily fluid needs is to multiply the resident’s body weight in kg times 30cc, (or weight in pounds times 66cc), for those residents at risk for dehydration. OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

DOCUMENTATION 1.

Record intake and output for all residents with catheters, restricted fluids, tube feeding, or forced fluids. Total each 24 hours.

2.

Record any unusual pattern of fluid intake in Nurses Notes and/or monthly summary.

3.

Records any signs of dehydration noted in observing resident and the interventions used to overcome dehydration.

RESIDENT CARE PLAN 1.

Identify problem

2.

Establish goal with resident input.

3.

Develop approaches with responsible disciplines identified.

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

IDEAL BODY WEIGHT

POLICY The ideal body weight range for each resident will be calculated as part of the comprehensive assessment. PROCEDURE IBW range for adults is as follows: Females:

Allow 100 lbs for the first 60” (5’) of height. For each additional inch of height, add 5 lbs to this amount.

Males:

Allow 106 lbs for first 60” (5’) of height, then add 6 lbs for each additional inch.

The target weight range can be calculated by adding and subtracting 10%. Example: Female 5’2” (62”): IBW = 100 + 10 = 110 lbs IBW range = 90 – 110 lbs

IBW ranges in pounds: Height

Female

4’10 4’11 5’0 5’1 5’2 5’3 5’4 5’5 5’6 5’7 5’8 5’9 5’10 5’11 6’0 6’1 6’2

81-99 85-105 90-110 94-116 99-121 104-127 108-132 112-138 117-143 121-149 126-154 130-160 135-165 140-170

(58”) (59”) (60”) (61”) (62”) (63”) (64”) (65”) (66”) (67”) (68”) (69”) (70”) (71”) (72”) (73”) (74”)

Male

95-117 100-123 106-130 111-136 117-143 122-150 127-156 133-163 139-169 144-176 149-183 154-189 160-196 166-202 171-209

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net

ASSESSING RESIDENTS’ NEEDS FOR CALORIES, PROTEIN AND FLUIDS

POLICY The condition of a resident at nutritional risk may call for calculation of caloric, protein, and fluid needs. These calculations will be accomplished when needed. PROCEDURE Caloric needs for adults may be calculated using the Harris-Benedict Equation which takes the residents height, weight, and age into consideration. The BEE (Basic Energy Equivalent) is the amount of calories needed at rest multiplied by a nutritional risk or activity factor. Male BEE = 66 + (13.7xW) + (5xH) – (6.8xA) x factor Female BEE = 665 + (9.6xW) + (1.7 x H) – (4.7 x A) x factor W = Actual weight in Kg (Wt in Kg = weight in lbs divided by 2.2) H = Height in cm (Ht in cm = ht in inches x) A = Age in years Risk or activity factors: Use BEE x 1.2 for bed rest Use BEE x 1.3 for moderate risk or activity Use BEE x 1.5 for repletion, high risk or high level of activity Protein needs can generally be met with 1 gram of protein per kilograms of body weight daily. (Weight in pounds divided by 2.2 = protein need per day in grams.) High risk factors (ex. Decubitus ulcers) may increase protein needs which can be calculated by multiplying the basic need above by 1.5. EXAMPLE: A resident with Decubitus ulcers weighs 110 pounds. 110 divided by 2.2 = 50 grams protein (normal need) x 1.5 = 755 grams protein (with Decubitus ulcer). Fluid requirements are generally calculated as follows: Weight in kg x 30 = cc’s fluid needed per 24 hours. EXAMPLE: Resident weights 132 lbs. 132 divided by 2.2 = 60 kg. 60 kg x 30 cc/kg = 180 cc per 24 hours

OptimaSolutions ⋅ 210 S. 13th Street ⋅ Griffin, GA 30224 Phone (770)233-1159 ⋅ Fax (770)233-5138 Want to find out more about us? Visit our website! www.optimacare.net