Running Head: MULTIPLE DISEASE STATE NCP

Theresa Price Multiple Disease State Nutrition Care Plan The University of Southern Mississippi

MULTIPLE DISEASE STATE NCP SCRMC CLINICAL NUTRITION SERVICES NUTRITIONAL ASSESSMENT Part 1: Chart Note Chart Note 1: Patient information: Pt is a 57 y.o. female admitted with a condition the pt could not describe. Pt had altered mental status and labored breathing. PMH: COPD, DM , HTN, AKI, Metabolic alkalosis Reason for RD consult: Ventilator Dependency Current Diet Order: Regular diet is currently ordered, but will be discontinued per RD. Pt will be NPO with tube feeding. Pulmocare @ 45ml/hour will provide adequate nutrition for estimated needs. Supplements: Pulmocare @45ml/hr (goal rate) which provides 1620kcal and 67.6g pro Wt: 148.5lb Ht: 65in IBW: 120lb %IBW: 124% BMI: 24.7 Nutritional Needs: Energy:1494.5 (calculated per Ireton-Jones calculation) Protein:66g Fluid:1687ml Labs: Low: Co2-93, GFR-52 High:Ca-40, BUN-54, Cr-1.09, Glu-202 Pertinent medications: Protonix, Lovenox, Albuterol, Insulin. Nutritional Diagnosis: Inadequate intake RT current medical condition AEB enteral nutrition infusion at low rate until goal rate is reached. Recommendations/Plan of care: Continue current plan of care. Will monitor/evaluate: Will follow up and make nutrition recommendations as necessary.

MULTIPLE DISEASE STATE NCP

SCRMC CLINICAL NUTRITION SERVICES NUTRITIONAL ASSESSMENT Chart Note 2: Patient information: Pt is a 57 y.o. female admitted with end stage COPD. PMH: COPD, T2DM , HTN, and AKI. Reason for RD consult: Diabetic education. Current Diet Order: Mechanical soft diet. Supplements: Ensure (will be discontinued) Wt: 148.5lb Ht: 65in IBW: 120lb %IBW: 124% BMI: 24.7 Cancelled Ensure order due to elevated blood glucose levels, and pt reports adequate PO intakes. Nutritional Needs: Energy:1687.5-2025kcal Protein:66-81g Fluid: 2025ml Labs: Low: Cl-94, Ca-8.5, GFR-24 High:Co2-40, BUN-25, Cr-2.09, Glu-173 Pertinent medications: Protonix, Lovenox, Albuterol, Insulin, Prednisone, Spiriva. Nutritional Diagnosis: Impaired ability to prepare foods for diabetic lifestyle RT high level of fatigue AEB uncertainty regarding ability to obtain and prepare foods for carbohydrate counting. Food and nutrition related knowledge deficit RT lack of prior nutrition education AEB no prior knowledge, reports difficulty understanding the material, and relates concerns about previous attempts to learn the information. Recommendations/Plan of care: Encourage carbohydrate counting. Educate family PRN. Will monitor/evaluate: Will follow up and make nutrition recommendations as necessary.

MULTIPLE DISEASE STATE NCP

Education Session: Educated pt on diabetic diet modifications. The information provided was importance of carbohydrate counting, what is considered a carbohydrate, serving sizes, how many carbs to eat in a day, nutrition labels, and sample meal plans. Pt is not newly diagnosed with DM but feels very unsure of how to manage the DM by herself. She was anxious with current medical condition ("weak lungs, and high blood sugar"). Pt wished son was present for education since he takes care of her and does the cooking, encouraged pt to contact Nutrition Services if family arrived and wanted another education session. Pt exhibited understanding of the materials but also expressed concern of not being able to move around alone, prepare meals, or keep blood glucose levels at a normal level. Would like to educate family on dietary modifications if possible. Better compliance may be possible if family is involved with carbohydrate counting. Pt had a fair understanding of the material and fair compliance is expected. Pt was encouraged to contact Nutrition Services with any concerns or questions. RD is available as needed.

MULTIPLE DISEASE STATE NCP Part 2: Structured Abstract Citation: Burkow, T. M., Vognild, L. K., Ostengen, G., Johnsen, E., Risberg, M. J., Bratvold, A., Hjalmarsen, A. (2013). Internet-enabled pulmonary rehabilitation and diabetes education in group settings at home: A preliminary study of patient acceptability. BMC Medical Informatics and Decision Making, 13, 1-10. Retrieved from http://www.biomedcentral.com/1472-6947/13/133 Study Design: Class: Quality Rating: Research Purpose: This research is a population based descriptive study. This study classifies as a C report. No quality rating was found. The purpose of this research was to determine if patients with either Chronic Obstructive Pulmonary Disease (COPD) or Diabetes Mellitus (DM) could benefit from an at home online program to help rehabilitate COPD patients or educate DM patients. Participants included patients with Stage IV COPD who were over 40 years of age and patients with DM were over 35 years of age. Exclusion criteria included anyone under 40 without COPD and anyone under 35 without DM. Participants were recruited from healthcare workers at the outpatient facility. The participants were given written and oral information and provided written consent. The two groups were provided a educational demonstration at at first meeting, then were provided another education when the equipment was set up in their homes. The participants were interviewed and asked a series of questions about how they rated the acceptability of the programs. The interviews were recorded and translated into English from Norwegian. The participants in each group were asked their opinion on

Inclusion Criteria:

Exclusion Criteria: Description of Study Protocol

Data Collection

MULTIPLE DISEASE STATE NCP Summary: the following areas: general impression of the computer programs, group education, in-person start up meeting, supervised exercise training and exercise video, social aspect of the program, individual consultations and health diary, lunches and coffee breaks, and conserving energy. Blinding was not used in this study. There were 10 total participants with five participants in each group. The COPD participants ranged from 45-74 years of age and included two women and three men. Three participants lived close to the outpatient facility and two lived far from the facility. All participants from this group were retired and only two were non-computer users. The DM participants ranged from 35-74 years of age and included three women and two men. Three participants were retired, two lived close by the facility, and one participant was a non-computer user. No participant withdrew from the study, although one COPD patient had a hospital admission and was unable to participate for two weeks. Overall the participants showed a positive acceptance for the online programs. The participants accepted the group education online and enjoyed being able to hear from other people with the same situations. Seven of the 10 participants felt the in-person start-up meeting was useful. The supervised group exercise was only provided to the COPD group and participants expressed the videos were as good as being at the facility. The social aspect was brought up during the interview process some stated they did not like the social aspect due to lack of eye contact but others liked it because they felt as if they were communicating with others from inside their living room. Most participants felt the individual consultations were helpful and most wrote in the health diary. The participants reported enjoying the lunch and coffee breaks in order to discuss more informal topics. A COPD participants stated a point of conserving energy and how at home rehab and education can conserve energy if the patient is severely ill. This study included interview answers as data collection and no P values were calculated or available for report. Patients with either COPD or DM find at home online programs acceptable for rehabilitation and education sessions. Interviews concluded that participants had positive feedback after a six-week course. The findings from this research indicate that computer programs that

Description of Actual Data Sample:

Summary of Results

Author Conclusion:

MULTIPLE DISEASE STATE NCP provide pulmonary rehabilitation and diabetes education could be beneficial to patients who have a difficult time getting to the treatment facilities. The online computer programming may also provide social support and a sense of fellowship among participants. Review Comments: Limitations noted by the researchers included the use of a complex computer program, the use of a non-valid health tool in relation to health outcomes in the future, very small participant population, the recruitment of only one rehabilitation facility, the use of the same rehabilitation facility personnel to help participants with the computer program, and financial aspects with using the computer program. Another limitation noted was the lack of statistical testing to determine significance. A strength noted was that the researchers conducted a study on two disease states in one, when very little research has been done on these populations in regards to online rehabilitation and education.

MULTIPLE DISEASE STATE NCP Section 3: EAL and Article Summary for My Patient

Literature suggests that patients with Chronic Obstructive Pulmonary Disease (COPD) or Diabetes Mellitus (DM) may find online computer programs acceptable for pulmonary rehabilitation and self-management of diabetes with education (Burkow, et al., 2013). The research conducted by Burkow and colleagues (2013) was collected from 10 participants, five with COPD and five with DM, to determine the acceptability of online computer programs providing rehabilitation for COPD and education sessions for DM. The study conducted one-onone interviews with all participants to determine their opinion of acceptance on the programs. Overall the programs received a high level of positive feedback. The Evidence Analysis Library (EAL) conclusion statement concluded from four studies, that patients with COPD may have a more difficult time completing activities of daily living, especially those who are considered to be malnourished. If the patients are in a state of malnourishment they may have lower pulmonary function, more dyspnea, and lower nutrient intakes (Cochrane & Afolabi, 2004; Katsura, Yamada, & Kida, 2005; Monso et al., 1998; Odencrants, Ehnfors, & Grobe, 2005). Due to my patients poor pulmonary function and poor to fair expected compliance with the diabetic diet modifications, I recommend providing my patient with an online computer program to provide pulmonary rehabilitation and self management education for diabetes. With an online computer program my patient may benefit from energy conservation, pulmonary strength, and increase diabetes self-management techniques as well as increased self-efficacy.

MULTIPLE DISEASE STATE NCP References Burkow, T. M., Vognild, L. K., Ostengen, G., Johnsen, E., Risberg, M. J., Bratvold, A., Hjalmarsen, A. (2013). Internet-enabled pulmonary rehabilitation and diabetes education in group settings at home: A preliminary study of patient acceptability. BMC Medical Informatics and Decision Making, 13, 1-10. Retrieved from http://www.biomedcentral.com/1472-6947/13/133 Cochrane, W. J., & Afolabi, O. A. (2004). Investigation into the nutritional status, dietary intake and smoking habiets of patietns with chronic obstructive pulmonary disease. Journal of Human Nutrition and Dietetics, 17, 3-11. doi: 10.1046/j.1365-277X.2003.00478.x Katsura, H., Yamada, K., & Kida, K. (2005). Both generic and disease specific health-related

quality of life are deteriorated in patietns with underweight COPD. Respiratory Medicine, 99, 624-630. Doi: 10.1016/j.rmed.2004.09.017 Monso, E., Fiz, J. M., Izquierdo, J., Alonso, J., Coll, R., Rosell, A., & Monera, J. (1998). Quality of life in severe chronic obstructive pulmonary disease: Correlation with lunch and muscle function. Respiratory Medicine 92, 221-227. Retrieved from http://download.journals.elsevierhealth.com/pdfs/journals/09546111/PIIS0954611198900993.pdf Odencrants, S., Ehnfors, M., & Grobe, S. J. (2005). Living with chronic obstructive pulmonary disease: Part 1. Struggling with meal-related situations: Experiences among persons with copd. Scandinavian Journal of Caring Sciences, 19, 230-239. doi: 10.1111/j.14716712.2005.00345.x