Subject: Scope and Depth of Nutritional Care

AdvancedMeal Nutritional Services ______

Related Policy Nutritional Status Evaluation and Care Planning

I. Assessing for Level of Nutritional Risk

II. Guidelines for Nutritional Assessment

III. Nutrition Care Plan Review Guidelines

IV. Nutrition Documentation of Pressure Ulcers

V. Albumin Policy

Table 1 - Target Weight Ranges

Table 2 – Metropolitan Weight Tables

Table 3 – Assessment of Lab Values

Table 4 – Liquid Supplement Analysis & Therapeutic Supplementation Guidelines

Table 5 – BMI chart

Table 6 – Osmolality chart

Table 7 – Amputation chart

It is the policy of AdvancedMeal that we will operate our organization with the highest ethical standards and avoid placing our company and ourselves in a compromising position. AdvancedMeal has a “Zero Tolerance” for fraud and abuse.

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AdvancedMeal Nutritional Services ______Scope and Depth Purpose

The purpose of this document is to create a comprehensive standard of nutritional care for all residents. Included in this document are the criteria, forms and their applications, and policies related to providing this standard of nutritional care.

Another integral part of the nutrition standard of care is the information included in the AdvancedMeal Diet Manual.

Scope & Depth of Nutritional Care

I. Assessing for Level of Nutritional Risk

Each resident will be assessed by the RD and DT to determine the appropriate level of nutritional care to be provided. The following "Level of Nutritional Risk" shall be utilized to designate the level of care under the direction of the RD. The DT shall provide nutritional intervention for residents designated as moderate risk. The RD and the DT shall provide nutritional intervention for residents designated as a high risk. The designated level of care is indicated in the Nutrition Assessment. A change in level of risk may also be written in the Nutrition Progress Notes.

Levels of Nutritional Risk

High Nutritional Risk (HR)

Residents who exhibit 1 or more of the following indicators are considered at high nutritional risk: 1. Recent, unplanned weight loss of 5% in 1 month, 7.5 % in 3 months or 10% in 6 months 2. Tube feeding or TPN 3. Pressure ulcer/maceration, surgical incisions, non healing areas and other skin issues per RD discretion. 4. Serum albumin 2.7 g/dl or less / Prealbumin < 16 mg/dl 5. BMI less than 18.5. 6. Unstable renal/liver disease requiring diet intervention (beyond a sodium restriction). 7. Poor P.O. intake resulting in a progressive weight loss. 8. Poorly controlled blood sugars (i.e., consistently above 300 mg/dl) resulting in signs and symptoms of hyper/hypoglycemia.

If the resident does not meet the high-risk criteria exactly they may be considered high risk at the discretion of the DT and RD.

Once the high-risk assessment has been completed, follow-up should occur monthly unless otherwise determined by RD.

AdvancedMeal Nutritional Services ______II. Guidelines for Nutritional Assessment

Many components are considered in the assessment process. No one component will be used alone to assess nutritional status.

A.Objective Data: 1. Diet Order The diet ordered by the Physician.

2. Consistency The consistency of the diet provided will be based on the resident's ability to chew and/or swallow safely.

3/4. Chew/SwallowThe resident's ability to chew and swallow will be assessed by observation. If problems are noted consistency changes may be indicated and/or an evaluation by SLP.

5. Dentition Indicate if the resident wears dentures or if teeth are in poor repair.

6. Food Allergies All resident food allergies will be recorded and menus adjusted as needed. “NKFA” will be noted if none known.

7. Feeding Ability The resident's ability to feed themselves will be evaluated by observation.

8. Skin Integrity If a resident is admitted with a pressure ulcer; its stage and location will be noted. If there is question as to if skin impairment is pressure or not, it will be assessed by the RD until clarification can be obtained.

9. Bowel Regimen Indicate all bowel medications or nutritional interventions for residents who have a previous history or current problem with constipation and/or impactions i.e., unprocessed bran in their cereal, prune juice, additional fluids provided on their trays, etc.

10. Diagnosis/PMH A resident's past medical history plays a very important role in assessing their nutritional needs. The nutritional assessment will include a review of the Cumulative Diagnostic Index (CDI) or Physicians Active Problem List (PAPL), the hospital discharge summary and/or admission patient review instrument (PRI). All active diagnosis and inactive diagnosis that may impact nutrition will be listed in this section.

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AdvancedMeal Nutritional Services ______11. Medications It is well known that many medications may affect appetite, increase lethargy at meals, and impair selected nutrient absorption/elimination. The Nutrition Department will attempt to consider the effects of medications as much as possible. However, ultimately it is the Physician's responsibility to consider medication-nutrient interactions since he/she is the only individual who can order and/or adjust the resident's medications. The pharmacy will assist the Physician with this information.

12. Lab Values Many laboratory values can be used to assess nutritional status. On the nutritional evaluation the following labs may be recorded e.g., serum sodium, potassium, creatinine, blood urea nitrogen, glucose, albumin, as well as hemoglobin and hematocrit. It will be noted if the lab values are outside normal ranges based on the normal ranges of that specific lab test.

It is the position of the Nutrition Department that the Physician be responsible for evaluating abnormal lab values since the Physician has the advanced medical knowledge necessary to evaluate these lab values along with the diseases of the elderly.

If the lab sheet is signed by the Physician with no further analysis indicated by medical notes or orders for further testing, it will be assumed by the clinical nutrition staff that no further intervention is deemed necessary by the Physician. The Physician's responsibilities also include identifying and treating any residents with anemia. Dietary interventions for anemia will be proceeded with at the Physician's request.

13. Diet History Upon admission, a complete diet history will be obtained from the resident, the resident's family and or friends. Diet history includes but is not limited to: 1. Food and consistency intolerances 2. Preferences 3. Weight history 4. Special diets - home or hospital 5. Appetite/food consumption prior to admission

Number Date Supersedes Page of 600.005 A 1/3/12 1/3/11 5 25 AdvancedMeal Nutritional Services ______B. Nutritional Analysis: 14. Height/Age/Wt An accurate height is very important in the nutritional assessment of a resident. It influences the determination of the recommended weight and range and the calculation of energy needs. Reported heights are not always accurate, especially in the elderly population who may report height, as they knew it from years past and have since lost inches related to curvature of the spine. (Avg. loss of height is 2.9 cm in males, 4.9 in females). For this reason it is our intent to try to obtain an accurate height therefore, height shall be measured upon admission by the Nursing staff. If the resident is chairfast, bedfast, or has advanced spinal curvature such that an accurate height can not be obtained, an estimation of stature will be made from an arm span or knee height measurement. All heights will be recorded in inches only. It is recommended that heights be re-measured annually on each resident.

15. Weight Weight is another crucial measurement necessary for an accurate nutritional assessment. Upon admission the Nursing staff will obtain the resident's weight. It is recommended that at least 2 admission weights are obtained on 2 consecutive days to establish an accurate baseline. It is also recommended that weights be obtained weekly for the first month so a baseline is established. Weights should be done a minimum of monthly unless specified otherwise. The RD/DT shall review weights weekly, and address any 5# weight variation. A plan of action shall be documented in the nutritional note. This is to assure that weight concerns are addressed in a timely manner. An adjusted body wt may be used to calculate a resident’s nutrient needs if his/her BMI exceeds 35 for any age. . More often than not it is ideal to assess nutrient needs based on Actual Body Weight however, the resident’s age, overall health, and desires concerning weight change are taken into consideration

Obesity Adjustment:

Men: [(ABW-IBW)] x .38 + IBW Women: [(ABW-IBW)] x .32 + IBW

*** Ideal Body Weights (IBW) will be the upper end of Weight Range Goal using: 1) Target Weight Ranges for 60+ years 2) Metropolitan Weight Tables for ages 25-59 Frame size should be specified on assessment.

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AdvancedMeal Nutritional Services ______16. Body Mass Index (BMI) BMI = Weight in pounds x 703 (Height in inches x Height in inches) BMI chart should be used to avoid mathematical error. BMI chart should be used to avoid mathematical error. See Table 5

BMI estimation in amputees: See Table 7

Estimated Total Weight = actual weight / (1- missing limb portion %)

Using limb portion % in decimal form, example: 15% = .15, 5.9% = .059

Each resident with amputations will be individually assessed to determine the portion of the limb amputation to account for varying amputation locations, (i.e. AKA just above the knee VS mid-thigh or BKA just above ankle VS just below knee.

Height prior to amputation will be used as the height for those bilateral lower extremity amputees.

Each resident will have to be individually assessed using the clinician’s judgment to determine whether or not an increase in calorie needs is appropriate for each specific resident and their conditions.

Wt History The resident's weight history is an important indicator of the resident's current nutritional status. This weight history may be obtained from the resident, the hospital record, previous medical record and/or the resident's family or friends. An unplanned weight loss of 5% of body weight in one month, 7.5% in 3 months and/or 10% of body weight within a 6-month period shall be considered an indicator of high nutritional risk. An assessment of the reason for the weight loss (if possible) will also be included. Unplanned weight gains shall be individually assessed as to whether a nutritional problem exists.

Number Date Supersedes Page of 600.005 A 1/3/12 1/3/11 8 32 AdvancedMeal Nutritional Services ______17. Estimating Kilocalorie Requirements: Needs are calculated on actual or usual body weight. A. Harris - Benedict Formula: (Basal Energy Expenditure = BEE)

For men: BEE = 66 + (13.7 x W) + (5 x H) - (6.8 x A) For women: BEE = 655 + (9.6 x W) + (1.7 x H) - (4.7 x A)

W = present weight in kg (lbs divided by 2.2 = kg) H = height in cm (inches x 2.54 = cm) A = age in years Harris Benedict charts should be used for calculating the BEE to avoid mathematical errors.

B. Mifflin – St. Jeor This calculation to determine energy needs is often more accurate for those participants with a BMI over 30. Men: (9.99 x W) +( 6.25 x H) – (4.92 x A) + 5

Women: (9.99 x W) + (6.25 x H) – (4.92 x A) – 161

W = weight in kilograms H = height in centimeters A = age

Total kilocalorie requirements =

BEE x activity factor x injury factor Activity Factors: Confined to bed/wheelchair/gerichair = 1.2 Use of wheelchair (pushes self) or minimal use of walker = 1.3 Walks without aids or continuously walks with walker = 1.4

Number Date Supersedes Page of 600.005 A 1/3/12 1/3/11 9 32 AdvancedMeal Nutritional Services ______Injury Factors: Cancer...... ……….…...... …. 1.10 - 1.45 Wt. loss (5% 1 mo./10% 6 mos)...... … 1.3 - 1.5 Wound healing - i.e. decubs…...... … 1.1 - 1.6 Stage I 1.1 Stage II 1.2 Stage III 1.3 – 1.4 Stage IV 1.5 – 1.6 COPD exacerbation...... …...... ………….. 1.14 - 1.5 Symptomatic HIV/AIDS...... …………… 1.2 -1.3 (or 20-30% increase) Post operative ...…...... ………...1.00 - 1.2 Long bone fracture...... ………. 1.15 - 1.30 Extreme wandering or agitation…...... …….. +500-1000 kcals * If more than one injury factor is applicable, the higher factor range should be used, i.e., wound healing and cancer use 1.2 - 1.6 * Obesity and desired weight should also be considered before increasing calories. * The standard of 500-1000 Kcal/day to gain/lose 1-2 pounds per week may be applied when the resident desires weight change.

18. Estimating Protein Requirements:

Normal resident allow 1 gm protein/kg BW per day. For healthy resident < 51 yrs of age allow .8 gm protein/kg BW per day per DRI.

Protein needs should not be below RDA. Per 2002 DRI the following is suggested: Males – 56 gms/d Females – 46 gms/d

Protein needs in Malnutrition Condition Albumin Level Protein Requirement Mild degree 2.8 - Abnormal 1.1 - 1.2 gm/kg BW/day Moderate degree 2.1 - 2.7 1.2 - 1.5 gm/kg BW/day Severe <2.1 1.5 - 2.0 gm/kg BW/day

Normal Prealbumin levels may range around the 16 – 40 mg/dl range. Condition Prealbumin Level Protein Requirement Mild degree 10 -15 mg/dl 1.1 -1.2gm/kgBW/day Moderate degree 9 – 5 mg/dl 1.2 – 1.5 gm/kgBW/day Severe < 5 mg/dl 1.5 – 2.0 gm/kgBW/day

* Labs should be monitored to prevent protein overload * Consider other diagnosis before increasing protein * The facility’s lab reference range may also be used.

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To calculate specific pro/kg needs for pressure ulcers by stage use: Stage I = 1.25 - 1.5 Stage II = 1.25 - 1.5 Stage III, IV (small/non-draining) = 1.25 - 1.5 Stage III, IV (large, multiple wounds &/or draining) = 1.25 - 1.5

Consider number of wounds and various stages when considering protein needs. Consider other diagnosis and medical conditions when considering protein needs. Special care is given to fluid needs with protein 1.3gm/kg or higher in the elderly and may not be appropriate. Areas noted as Maceration will be treated the same as Pressure. If intact, assess at 1.1. If denuded, at 1.25. Residents with other non-pressure related wounds may also need additional protein for healing if they present with compromised intake or nutritional deficiency. Protein needs in Renal Failure Non-dialyzed (GFR below 25): 0.6 - 0.75 gms/kgBW/day (GFR 25 – 55) 0.8 gm/kgBW/day Hemodialysis 1.2 gms/kgBW/day Peritoneal dialysis 1.2 – 1.3 gms/kgBW/day

Pulmonary Disease (COPD) Moderate stress: 1.0-1.5 gm/kgBW/day

19. Estimation Fluid Requirements

Use the following to assess fluid needs: 1. General Guideline: 30 cc/kg.bw OR 1cc/kcal of estimated needs (often more appropriate goal in obese residents) 2. Acute CHF/ Renal failure = 20 - 25 cc/kg.bw 3. Fluid needs are increased at 35cc/kg for factors such as, infection, draining wounds, chronic constipation, Vomiting/diarrhea/fever that is not episodic, and protein requirements greater > 1.3 gms/kg BW.

Do not increase if resident is on fluid restriction or in acute CHF. **Do not recommend going below 1500 cc/d, unless clinical condition warrants this.

C. Assessment:

All pertinent information and the rationale for the nutritional plan of care will be summarized under this section. A comparison of estimated nutritional needs to the intake studies information is essential to assess the resident’s nutritional status. The assessment may also include the following information:

1. Reason for admission and where the resident was admitted from. 2. Any special feeding needs the resident may require such as special feeding techniques, required adaptive equipment and the rationale behind it. 3. Any social, physical or chemical impairment which may have an impact on nutritional status. 4. The resident's physical appearance i.e., cachectic. 5. Chewing and/or swallowing problems and their impact on the resident's nutritional status. 6. The appropriateness of the diet order and if their needs to be a change requested. 7. Any pertinent lab values which are a concern. 8. Any initiation or adjustment of nutritional supplements. 9. Discussion of resident's weight status and, if appropriate the need for further nutritional intervention. 10. Need for counseling/education regarding any issues of concern, deficiency, or non- compliance.

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AdvancedMeal Nutritional Services ______Assessing Residents on Tube Feedings Initial orders and changes in orders will be written by the RD and signed by the physician. Orders include type of feeding, flow rate, number of feedings, flush per 24 hours and criteria for aspirates. Monthly tube feeding update notes by the RD should include: current weight, new labs, tolerance to tube feeding, whether TF meets estimated nutritional needs, including fluids, and any changes to tube feeding. If resident is consuming food or fluids po, an assessment of po intake should also be done. Assessing Residents on TPN TPN orders will be written by the Physician. (See Facility Policy). The RD will assess TPN order to assure nutrient needs are met. The RD will monitor weights, labs and tolerance to TPN and follow up minimum of monthly.

D. Plan:

The nutritional care plan defines specific approaches and goals to meet the nutritional needs of the resident. ADA's nutrition care process for the profession has four steps - (1) nutrition assessment, (2) nutrition diagnosis, (3) nutrition intervention, and (4) nutrition monitoring and evaluation. Nutrition Diagnosis is a critical step between nutrition assessment and nutrition intervention. A nutrition diagnosis identifies and labels a specific nutrition problem that dietetics professionals are responsible for treating independently. It is this step in the nutrition care process that results in the nutrition diagnosis statement or PES statement composed of three distinct components: Problem, Etiology, and Signs or Symptoms. The ADA has identified and defined nutrition diagnoses/ problems for the profession of dietetics. This standardized language of nutrition diagnoses/ problems is an integral component in the Nutrition Care Process, a process designed to improve the consistency and quality of individualized patient/client care and the predictability of the patient/client outcomes.

The nutritional care plan interventions will also be reflected in the interdisciplinary care plan as needed.

If the resident is here for rehabilitation, information regarding the need for special feeding devices or feeding techniques, the need for homebound meals and the need for further outpatient nutrition counseling should be made prior to that resident's discharge.

The Resident Meal Tracker Profile will clearly show the plan to meet all assessed nutrient needs, including calories, protein, and fluid. Inability to do so and the reason for it, i.e. resident refusal, will be clearly documented as a non-compliance issue with efforts to over come this and meet the resident’s needs. This will also be documented on the IDCP.

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III. Nutrition Care Plan Review Guidelines Based on Clinical Assessment Form used at some locations. Those facilities using Electronic Medical Records should complete assessments in EMR templates using the following as a reference.

I. Top Section (Objective information) Fill in all blanks.

HS Snack - offer resident a snack, if they want it, write what they usually accept. If resident declines - just write "resident declines".

If a resident is demented and can not state his/her preferences write, "bulk snacks provided by Nursing".

Please include PO medications pertinent to nutrition.

Only address labs done in the past quarter or state "No labs since ______".

II. Yes/No Section

Average P.O. Intake - Average one week of solids consumption. If >75% answer YES. - If resident usually eats <75% answer is NO (it's still a concern) but note in the comments that this is the norm for this resident. - Note any recent changes in POC in comments.

Fluid Intake - If resident doesn't consume all/almost all liquids then answer is NO, 75% or > consumed is YES.

Non-Compliant of Diet/Plan - Answer YES if resident doesn’t follow diet or snacks appropriately. If this is YES then offer education/counseling that includes the non-compliance and potential risk to the resident. This will be documented in the assessment section.

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Weight Loss: - If resident has lost 5%/30 days or 10%/180 days then answer YES and specify details in comments. - Although not triggered in MDS, 7.5% weight loss in 3 months still should be assessed. - If resident has had a progressive weight loss, answer YES and document in comment section. - If weight is relatively stable then answer NO.

MD Ordered Weight Loss: - If there is an MD order for planned weight loss, check YES. - If no MD order for weight loss, check NO.

Swallowing Issues: - Answer YES if having problems eating present consistency served due to: -Loss of liquids/solids from mouth when eating or drinking -Holding food in mouth/checks when eating or drinking -Coughing or choking during meals or when swallowing medications - Answer NO if on an altered consistency but tolerating without any noted issues.

Issues feeding self - Answer YES if resident requires spoon-feeding, partial feeding, or excessive encouragement to feed self. - Specify use of adaptive equipment in comments.

BM problems - Answer YES if resident continues to be constipated or have diarrhea, despite interventions. Continue to list interventions in comments. This allows us to determine if our intervention is effective.

Skin Issues - Answer YES if resident has a pressure sore or other skin impairment reported in the Nursing Tissue Trauma Notebook. - In the comment section include location and present stage of any pressure sores.

Edema Noted - Answer NO if edema has been documented by M.D. or Nursing.

III. Plan - The Resident Meal Tracker Profile will clearly show the plan to meet all assessed nutrient needs, including calories, protein, and fluid. Inability to do so and the reason for it, i.e. resident refusal, will be clearly documented as a non-compliance issue with efforts to overcome this and meet the resident’s needs. This will also be documented on the IDCP

AdvancedMeal Nutritional Services ______IV. Nutrition Documentation of Pressure Ulcers/Impaired Skin

1 New in-house pressure ulcers/maceration must be documented by the RD within 3 days of notification of pressure ulcer.

2. New admission pressure ulcers/macerations/surgical incisions will also be noted on the admission screen with an intervention pending RD assessment.

3. Initial documentation will include: - Description of wound - Recent weight status - POC meals - Any pertinent labs - Protein/calorie/fluid needs - Level of nutritional risk - Nutrition care plan to heal ulcer

4. All residents with pressure ulcers must be assessed minimum of monthly. The RD/DT will check floor weekly for new ulcers.

5. The monthly pressure ulcer note will include: - stage and location of the ulcer, if applicable, stage changes in the past 30 days since charted - changes in the nutrition care plan - current weights and if there have been any weight changes - POC meals and/or supplements - current pertinent labs - need for an intake study - possible nutritional deficiencies - need for vitamins and minerals - any recently detected chewing/swallowing problems that may be affecting PO intakes - Status of blood sugar management in diabetic clients.

6. Existence and status of all pressure ulcers will be included on the Interdisciplinary Care Plan.

VITAMIN AND MINERAL SUPPLEMENTAION IN WOUND HEALING - Request Multivitamin/Mineral for Stage I and II wounds if intakes are inadequate. - For Stage III and IV wounds: Request Multivitamin/Mineral Request 500mg Vitamin C BID Request 220 mg Zinc Sulfate x 2 weeks for residents with suspected deficiencies.

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AdvancedMeal Nutritional Services ______V. Albumin Policy

Normal albumin values will be determined according to the age-specific Lab Reference Range. Frequency of lab values to determine albumin levels will be determined by the Physician. The RD or DT may request albumin levels when a change in this lab value would predict a significant change in the resident’s nutritional plan of care. While Albumin and PAB are good indicators of morbidity and mortality, they may not be good indicators of nutritional status. All factors should be taken into consideration and the RD should document any rationale as to why Albumin level may be altered.

An albumin level less that the reference range shall be addressed on the CCP along with an update addressing the decreased albumin with a nutritional plan of intervention.

An abnormal albumin level of 2.7 or < shall meet high-risk criteria requiring nutritional assessment by an RD.

The Diet Tech may ask the RD to review a resident’s albumin. The RD may decide that a resident’s albumin is within an acceptable range for that particular resident and further action is not necessary. Following the assessment the RD shall determine whether the resident is to be followed as “High Risk” or “Moderate Risk”. A note must be written stating that.

Prealbumin is a more sensitive marker for protein and or calorie deficiency and is more responsive to nutrition therapy. Prealbumin < 16 shall meet high- risk criteria.

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AdvancedMeal Nutritional Services ______TABLE 1 TARGET WEIGHT RANGES FOR 60 YEARS +

FEMALE SMALL MEDIUM LARGE 4'4" 76-86 84-94 4'5" 78-88 86-96 4'6" 71-81 80-90 88-98 4'7" 73-83 82-92 91-101 4'8" 76-86 85-95 94-106 4'9" 78-88 87-97 97-104 4'10" 80-90 90-100 99-109 4'11" 82-92 92-102 102-112 5'0" 80-100 94-110 100-120 5'1" 85-105 95-115 105-125 5'2" 89-109 100-120 111-131 5'3" 94-114 105-125 116-136 5'4" 98-118 110-130 122-142 5'5" 103-123 115-135 127-147 5'6" 107-127 120-140 133-153 5'7" 112-132 125-145 138-158 5'8" 116-136 130-150 144-164 MALE 5'3" 102-122 114-134 126-146 5'4" 107-127 120-140 133-153 5'5" 112-132 126-146 140-160 5'6" 118-138 132-152 146-166 5'7" 123-143 138-158 153-173 5'8" 129-149 144-164 159-179 5'9" 134-154 150-170 166-186 5'10" 139-159 156-176 173-193 5'11" 145-165 162-182 179-199 6'0" 150-170 168-188 186-206 6'1" 156-176 174-194 192-212 * Reference: "Long Term Care (LTC) Survey Training Manual" Department of Human Sciences 1986

Table 2

METROPOLITAN WEIGHT TABLES "IDEAL LOWEST MORTALITY WEIGHT" AGES 25-59.

Adjusted to inches. WOMEN / FRAME HEIGHT SMALL 20% MEDIUM 20% LARGE 20% 58" 102-111 133 109-121 145 118-131 157 59" 103-113 136 111-123 148 120-134 161 60" 104-115 138 113-126 151 122-137 164 61" 106-118 142 115-129 155 125-140 168 62" 108-121 145 118-132 158 128-143 172 63" 111-124 149 121-135 162 131-147 176 64" 114-127 152 124-138 166 134-151 181 65" 117-130 156 127-141 169 137-155 186 66" 120-133 160 130-144 173 140-159 191 67" 123-136 163 133-147 176 143-163 196 68" 126-139 167 136-150 180 146-167 200 69" 139-142 170 139-153 184 149-170 204 70" 132-145 174 142-156 187 152-173 208 71" 135-148 178 145-159 191 155-176 211 72" 138-151 181 148-162 194 158-179 215 MEN/FRAME

HEIGHT SMALL 20% MEDIUM 20% LARGE 20% 62" 128-134 161 131-141 169 138-150 180 63" 130-136 163 133-143 172 143-153 184 64" 132-138 166 135-145 174 142-156 187 65" 134-140 168 137-148 177 144-160 192 66" 136-142 171 139-151 181 146-164 197 67" 138-145 174 142-154 185 149-168 202 68" 140-148 178 145-157 188 152-172 206 69" 142-151 180 148-1160 192 155-176 211 70" 144-154 185 151-163 196 158-180 216 71" 146-157 188 154-166 199 161-184 221 72" 149-160 192 157-170 204 164-188 226 73" 152-164 197 160-174 209 168-192 230 74" 155-168 202 164-178 214 172-197 236 75" 158-172 206 167-182 218 176-202 242 76" 162-176 211 171-187 224 181-207 248

AdvancedMeal Nutritional Services ______Table 3

Assessment of Laboratory Values

Flexibility in reference ranges will vary depending on lab and facility practice.

The following laboratory values are the most commonly used to assess nutritional status. Reasons for high or low values are included.

Test Normal Values Some Implications Sodium Use reference range Low: severe burns, vomiting, Addison's disease edema, loss of (serum) bile, severe nephritis, over-hydration, (may cause delusional hyponatremia), diarrhea, some diuretics, starvation, adrenal insufficiency.

High: dehydration, inadequate fluid intake, perspiration, fever, diabetes insipidus, excessive loss of water (advanced renal disease, uncontrolled diabetes mellitus), excessive solute loading (high-protein, high-electrolyte feeding with inadequate water).

Potassium Use ref. Range Low: stress, surgery, uncontrolled diabetes, corticosteroids, (serum) some diuretics, vomiting, malabsorption, malnutrition, liver disease, alcohol abuse, diarrhea.

High: renal insufficiency, intestinal obstruction, Addison's disease, catabolism, and dehydration.

Glucose (Per medical Low: pituitary hypofunction, Addison's disease extensive liver (whole blood) director) disease, chronic renal insufficiency, and alcoholism.

High: Mild Elevation: advanced age (impaired glucose tolerance 140 mg.dL fasting and 140-199 mg/dL 2 h postprandial), diuretics (thiazide & loop), cirrhosis, stress, obesity, hyperthyroidism, corticosteroids, Cushing's disease. Moderate Elevation: 300-500 mg/dL, diabetes mellitus. Marked Elevation: >500 mg/dL ketoacidosis.

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AdvancedMeal Nutritional Services ______Test Normal Values Some Implications Blood urea (per medical Low: severe liver damage, low protein intake, impaired nitrogen director) absorption, over hydration, cachexia. (BUN)

High: excessive protein intake, infection, fever, catabolism, inadequate excretion due to impaired renal function, dehydration, vomiting diarrhea, myocardial infarction, shock, GI bleeding.

Creatinine Use reference range Low: muscular dystrophy, advanced cancer. (serum) High: impaired renal function, chronic nephritis, obstruction of urinary tract, oliguria, and muscle disease with acromegaly.

Albumin Use reference range Low: impaired hepatic synthesis (liver disease, stress, (serum) malnutrition, burns, nephrotic syndrome, over-hydration, pressure ulcers, spinal cord injury, tuberculosis, cancer.

High: dehydration, corticosteroid therapy.

Hematocrit Use reference range Low: anemia, hemorrhage, leukemia, cirrhosis, excessive fluid, (Hct) and hyperthyroidism.

High: dehydration, hemoconcentration.

Hemoglobin Use reference range Low: anemia (cause: deficiencies of vitamins C and B12, iron, (Hgb) folic acid, protein; also secondary to other diseases), low serum albumin, infection, catabolism, spinal cord injury, end stage renal disease, leukemia, poor intake of iron or intake of mainly non-heme sources, hyperthyroidism, cirrhosis, cancer, Crohn's disease, blood loss from peptic ulcer disease.

High: hemoconcentration, dehydration following blood replacement, liver disease.

AdvancedMeal Nutritional Services ______Test Normal Values Some Implications Calcium Use reference range Low: severe nephritis, malabsorption syndrome (may be (serum) related to drug therapy), vitamin D deficiency, hypoparathyroidism, osteomalacia.

High: immobilization, hyperparathyroidism, vitamin D intoxication, milk-alkali syndrome, cancer, renal calculi.

Phosphorus Use reference range Low: may occur in severe malnutrition esp. during re-feeding, (serum) aluminum antacid overuse.

High: renal disease, hypoparathyroidism.

 BUN/CR Ratio There are various factors that affect the BUN creatinine ratio. In older people, due to decreased muscle mass, the creatinine levels are low, thus, this leads to high BUN to creatinine ratio.

Considering this Serum Osmolality may be a better indicator of hydration status.  Osmolality may be calculated as a measure of hydration, as follows:

Osmolality = (2 x sodium) + (glucose/18) + (BUN/2.8) >300 indicates dehydration

See Table 6

Table 4 LIQUID SUPPLEMENT ANALYSIS

AdvancedMeal Nutritional Services ______Nutrient Milk Shake Sugar Free MS Ensure Plus Nepro Glucerna Shake 4 oz 4 oz 8 oz 8 oz 8 oz

Kcal 200 200 355 425 220 Protein (g) 6 8 13 19 10 Carbohydrate (g) 35 19 50 37.9 29 Fat (g) 4 10 11 22.7 8.6 Sodium (mg) 95 100 240 250 210 Potassium (mg) 180 170 440 250 370 230mg in Chocolate Phosphorous (mg) 200 170 250 Magnesium (mg) 100 50 100 Zinc ( mg) 3.8 6.4 3.8 Calcium (mg) 200 250 250 Iron (mg) 4.5 4.5 4.5 Selenium (mcg) 18 18 18 Vitamin A (I.U.) 1250 750 1750 Vitamin C (mg) 30 25 60 Riboflavin (mg) 0.43 .64 0.43 Thiamin (mg) 0.38 .56 0.38 Niacin (mg) 5 7.5 5 Vitamin D (I.U.) 100 20 100 Vitamin E (I.U.) 7.5 23 30 Vitamin B6 (mg) 0.5 2.0 1 Vitamin B12 (mcg) 1.5 2.3 3 Folic Acid (mcg) 100 250 200 Vitamin K (mcg) 20 20 20

Super Foods

AdvancedMeal Nutritional Services ______Super Cereal (5 oz) 340 Kcal, 6 gm Protein } } not appropriate Super Pudding (4 oz) 190 Kcal, 5 gm Protein } for residents on } a NCS diet. Super Cookie (1 ea) 194 Kcal, 6 gm Protein }

Super Potato (4 oz) 320 Kcal, 8 gm Protein

Therapeutic Supplementation Guidelines The risk for poor nutritional status increases with age. Some factors that can affect nutrition include changes in body composition, complex medical conditions and impairments in functional ability. Nutritional assessments will determine the need for additional supplementation in a resident’s diet. While

AdvancedMeal Nutritional Services ______supplementation can be beneficial, it is also important to encourage consumption of balanced meals. The following are guidelines for supplementation to assure that variety in a resident’s meal pattern is not limited. Although these are guidelines, the RD or DT will be responsible for determining which nourishments/ supplements are appropriate to meet a resident’s individual needs. The nutrition staff should individualize a plan of care specific to each resident’s nutritional needs. Guidelines to Increase Calories and Protein Steps are in the order that the interventions should be tried with the resident that has been identified to need increased calories and/or protein. Step Action Suggestions 1 Incorporate all food preferences Update likes and dislikes into meal pattern 2. Provide nutrient dense foods 1. Slender milk to whole milk into meal pattern 2. Donut in place of toast 3. Add peanut butter to toast 4. Add gravies 5. etc. 3. Add between meal snacks 4. Increase portion size of any 1. Double Egg portion * particular item that the resident 2. Increase milk from 4 oz. to 8 oz. tid. may consume. 3. Double Meat portion* 5. Try fortified foods 1. Foods Options: Super Cereal, Super Cookie, Super Potato, Super Pudding 2. Add only a few times per week. Increase frequency at needed. 3. Try one supplement at a time. 6. Liberalize Diet Order 2 gm. Sodium to No Added Salt 7. Liquid Products 1. Milkshakes (NSA if on NCS diet) a. 1st between meals 2. Use Ensure Plus if resident is lactose b. 2nd at meals as milk intolerant. replacement. This 3. Use Glucerna for NCS and lactose should be a last resort. intolerant. 8. Med Pass with increased calorie Use Two Cal HN. This will require an MD fluid order. Hs Pass often preferred since this does not interfere with meal times. 9. Clarify resident and/or family This is important if the residents advanced wishes related to alternative directive does not include this information. nutrition and/or hydration. See documentation example. * Suggested to increase protein

Documentation Guidelines for Increased Calories or Protein

1. All plans should be individualized for the specific resident. 2. Resident acceptance of the intervention should be monitored and documented. If the intervention is not workable for the resident, document why. 3. Resident acceptance of the intervention can be determined several ways: a. Nutrition professional observation b. Modified intake study or intake study

AdvancedMeal Nutritional Services ______c. Nourishment sheets 4. If any liquid supplement (milkshakes, Ensure Plus, etc.) are added at meals, document why in-between meal trial failed. 5. If advanced directive does not have information related to alternative nutrition and/ or hydration, the nutrition professional should address this. For example: “Recommend clarifying resident and/or family wishes regarding alternate means of nutrition support and/or hydration at this time due to (reason).”

Possible Options to Increase Fluid

Action Suggestions Provide fluids between meals Increase beverage portion size Use 8 oz. container in place of 4 oz. container. at meals. Provide water at meals Increase high-water content Foods: jello, canned fruit, salad, ice cream, soup at noon meal foods at meals Categorize foods as able (i.e. pudding as dessert) Keep water pitcher at beside Work with Nursing Increase fluid offered at med Work with Nursing pass from standard to a greater amount

Documentation Guidelines for Increased Fluid

1. All plans should be individualized for the specific resident. 2. Resident acceptance of the intervention should be monitored and documented. If the intervention is not workable for the resident, document why. 3. Resident acceptance of the intervention can be determined several ways: a. Nutrition professional observation b. Modified intake study or intake study c. Nourishment sheets 4. If fluid was increased due to an acute illness, when the resident has recovered the intervention may not be indicated anymore, and the fluid plan should be adjusted.

Number Date Supersedes Page of 600.005 A 1/3/12 1/3/11 28 32 Table 5

BODY MASS INDEX (BMI) AT SPECIFIC HEIGHTS AND WEIGHTS

Height Body Weight (Ib) (inches) 58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 69 128 135 142 146 155 162 169 176 182 189 196 203 209 216 223 230 236 243 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 (kg/m2)

Height Body Weight (Ib) (inches) 58 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258 59 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267 60 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276 61 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285 62 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295 63 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304 64 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314 65 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324 66 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334 67 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344 68 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354 69 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365 70 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376 71 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386 72 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397 73 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408 74 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420 75 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431 76 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443 BMI 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 (kg/m2)

Source: CA Rosenbloom, ed, Sports Nutrition: A Guide for the Professional Working with Active People (Chicago: American Dietetic Association, 2000), pp. 188-189.

Source: CA Rosenbloom, ed, Sports Nutrition: A Guide for the Profesasional Working with Active People Number Date Supersedes Page of 600.005 A 1/3/12 1/3/11 30 32 AdvancedMeal Nutritional Services ______

TABLE 6 Sodium Glucose BUN 120…….240 36 – 54……….3 1 – 2……..…1 152…….304 55 – 72……….4 3 – 5……..…2 73 – 75……….27 121…….242 73 – 89……….5 6 – 8……. 3 76 – 78……….28 153…….306 90 – 107………6 9 – 11……….4 79 – 81……….29 122…….244 108 – 126…….7 12 – 14…..5 82 – 84……….30 154…….308 127 – 144…….8 15 – 16…..6 85 – 86……….31 123…….246 145 – 162…….9 17 – 19…..7 87 – 89……….32 155…….310 163 – 180…….10 20 – 22…..8 90 – 92……….33 124…….248 181 – 198…….11 23 – 25…..9 93 – 95……….34 156…….312 199 – 216…….12 26 – 28…….10 96 – 98……….35 125…….250 217 – 234…….13 29 – 30…….11 99 – 100……..36 157…….314 235 – 252…….14 31 – 33…….12 101 – 103…….37 126…….252 253 – 270…….15 34 – 36…….13 104 – 106…….38 158…….316 271 – 288…….16 37 – 39…….14 107 – 109…….39 127…….254 289 – 306…….17 40 – 42…….15 110 – 112…….40 159…….318 307 – 324…….18 43 – 44…….16 113 – 114…….41 128…….256 325 – 342…….19 45 – 47…….17 115 – 117…….42 160…….320 343 – 360…….20 48 – 50…….18 118 – 120…….43 129…….258 361 – 378…….21 51 – 53…….19 121 – 123…….44 161…….322 379 – 396…….22 54 – 56…….20 124 – 126…….45 130…….260 397 – 414…….23 57 – 58…….21 127 – 128…….46 162…….324 415 – 432…….24 59 – 61…….22 129 – 131…….47 131…….262 433 – 450…….25 62 – 64…….23 132 – 134…….48 163…….326 451 – 468…….26 65 – 67…….24 135 – 137…….49 132…….264 469 – 486…….27 68 – 70…….25 138 – 140…….50 164…….328 487 – 504…….28 71 – 72… .26 133…….266 505 – 522…….29 165…….330 523 – 540…….30 134…….268 541 – 558…….31 166…….332 559 – 576…….32 135…….270 577 – 594…….33 167…….334 595 – 612…….34 136…….272 613 – 630…….35 168…….336 137…….274 169…….338 138…….276 170…….340 139…….278 171…….342 140…….280 172…….344 141…….282 173…….346 142…….284 174…….348 143…….286 175…….350 144…….288 176…….352 145…….290 177…….354 146…….292 178…….356

AdvancedMeal Nutritional Services ______147…….294 179…….358 148…….296 180…….360 149…….298 181…….362 150…….300 182…….364 151…….302 183…….366 Greater than 300 = dehydration Osmolality = (NAx2) + (Glucose/18)+ (BUN/2.8)

TABLE 7

Volume 95, Issue 2, Pages 215-218 (February 1995)

AdvancedMeal Nutritional Services ______Number Date Supersedes Page of 600.005 A 1/3/12 1/3/11 32 32 Clinical Assessment Policy References

American Diabetes Association, Inc., and the American Dietetic Association Exchange Lists for Meal Planning, 1995

Krause, M. and Mahan, L., 1992 Food, Nutrition and Diet Therapy, W.B. Saunders Co.

Niedert, K.C. December 2005. “Liberalization of the Diet Prescription Improves Quality of Life in Older Adults in Long-Term Care”, Journal of the American Dietetic Association 105:12 pp 1955-1965,

Niedert, K.C., Dorner, B. 2004, Nutrition Care of the Older Adult. 2nd Edition, American Dietetic Association.

Becky Dorner, RD, LD @2005 Becky Dorner and Associates, Medical Nutrition Therapy for Pressure Ulcers

2007 ASPEN Nutrition Support Core Curriculum Pages 170-172

ASPEN 2009 Journal of Parenteral and Enteral Nutrition, Vol 33, No 2, 122-167

Charney,P, Malone, A., 2004 ADA Pocket Guide to Nutrition Assessment, American Dietetic Association.

National Pressure Ulcer Advisory Panel www.NPUAP.org The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper

ADA Times May/June 2008 www.RD411.com www.nutritioncaremanual.org by the American Dietetic Association www.cnpp.usda.gov/dietaryguidelines.htm