In this LTC case study, we look at a real life patient with wounds. Start thinking about the MNT in part 1 and then continue here for part 2 where we write the note.
LTC Case Study part 2 - The Note
Case study part 2: The Note
This is part two of a case study review of a patient with wounds in long-term care. Check out part one for history on our patient and their clinical needs.
In this post, we’re talking about how to pull all the information we gathered in part 1 then write the note and PES statement for our patient.
Start Putting it Together
After a full review of everything in the readmission documents and in the EMR in part 1, it’s time to put it all together. You’ll be completing a new admission assessment and updating a care plan that addresses the key areas your patient struggles with.
As you start this process, there are three things you’ll ask yourself:
- What’s the most acute issue? This will be your PES statement.
- What will you do about it? These will be your interventions.
- Is there anything you’re missing that will help you better support your patient? This is where referrals for the medical team happen.
Let’s start answering these questions for your patient Mr. Jute.
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First, identify the most acute issue.
The most acute issue is always the one thing that needs to be managed right now. In a hospital setting, this is the one thing that will help your patient get discharged as quickly as possible.
However in LTC, your patient is an ongoing resident of the facility and they’re likely not leaving your care anytime soon.
This means the purpose of the most acute issue in long-term care settings is to support and improve quality of life. The goal here is not to have them discharged but to keep them as healthy and in your care (and out of the hospital) for as long as possible.
Quality of life might be improved by supporting a medical problem, improving comfort measures (particularly if your patient is on palliative or hospice care), or it can be something else entirely.
The way you make decisions about the interventions you’ll implement are likely focused on a bigger picture of who your patient is and what they need to remain generally healthy. You’ll look at who your patient is and what they want for themselves, how they’ve been progressing, and what they need nutritionally to improve their overall wellbeing.
What’s the most acute issue for your patient?
Did you miss part 1 where we talked about all the MNT? Catch up here.
Knowing what you know about your patient Mr. Jute, the most acute nutritional issue might take on a couple of forms. And depending on how you’re planning to manage your patient you might consider it to be:
- Multiple pressure injuries
- Significant and ongoing weight loss
- Poor appetite
- High risk for malnutrition
Sometimes (like in this CHF case study) you’ll see lots of individual issues happening in your patient making it tricky to pick and choose from to determine the most acute issue.
But with Mr. Jute, each of his issues overlap and likely play a significant role in the development of the others. This means if you choose one condition to prioritize in your assessment, you’ll also have to be clear about how it connects to each of the other issues.
Here’s a few examples how that might play out:
- Poor appetite and intake likely related to advanced age, recent UTI, depression 2/2 poor mobility and inability to self-manage cares due to chronic hip and knee pain
- Significant weight loss likely related to poor intake >1 yr, multiple non-healing pressure ulcers leading to increased nutritional needs
- Multiple pressure ulcers due to poor mobility with reliance on staff for ADLs 2/2 inability to self-manage cares with refusal to get out of bed, increased nutritional needs with poor intake <25% of both meals and ONS
Hopefully you noticed these sound a lot like PES statements. You’re going to use that later and make life a lot easier when it’s time to write a note and the assessment summary.
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Next, calculate estimated nutritional needs.
Before you move on to writing the completed intervention, you’re going to want to get a sense of your patient’s estimated nutritional needs. Although these are always going to be required in the formal assessments, it helps to know your patient’s goals as you’re developing their interventions.
Especially when you’re faced with multiple conditions that all directly relate to Mr. Jute’s ability to take in adequate nutrients.
You start with his CBW: 127 lb and his Ht: 58”.
A healthy BMI range for older adults is in the range of 27-31. However Mr. Jute currently has a BMI of 19.3, significantly lower than you would like for a man of his age.
You also know he was admitted at 177 lb with a healthy BMI of 27, but he’s been losing weight consistently. Combined with his multiple pressure injuries, recent infection and surgery, and limited intake this sets the stage for a new diagnosis of malnutrition.
Doing the math
You now know Mr. Jute needs both increased energy and protein to manage his malnutrition. And to calculate his nutritional needs you can do the math with any of these three weights as a starting point:
- CBW: 127 lb – much lower than you’d like
- UBW: 177 lb – pretty close to his goal BMI
- IBW: 154 lb – possibly more achievable than his UBW
With Mr. Jute’s ongoing weight loss and considering how hard it is for him to eat more than 25% of most meals, you choose his IBW of 70 kg as your starting point.
With increased needs that include a stage 4 pressure injury and insidious weight loss, you choose a caloric range of 30-35 kcal/kg and a protein range of 1.6-1.8 g protein. You considered increasing his protein to the upward range of 2 g/kg but with his current weight status and recent acute kidney injury, you’ve have considered this adequate.
Mr. Jute’s estimated nutritional needs come to:
2100-2450 kcal/day = 70 kg x 30 kcal and 70 kg x 35 kcal
112-126 g protein = 70 kg x 1.6 g and 70 kg x 1.8 g
2500 ml water/day = Rounded up energy needs
Looking for a little more help on doing this kind of math? Start here.
Next come the interventions.
Once you know what your patient’s most acute issues are and know the needed nutrient content of their diet, this is when you start figuring out how to improve those issues. These are what we consider your interventions.
Generally, in a LTC setting your interventions will include things like:
- The diet order you assign
- Any supplements, food additions, fortified foods you consider needed
- Any referrals your patient might need
- Education your patient could use to support health goals
Whatever you consider important for your patient, these interventions should align with the most significant nutritional issue you decide to highlight. They will become core elements in how you justify your recommendations and how you formulate your PES statement(s).
Interventions for Mr. Jute
Considering Mr. Jute’s most acute issues of poor intake, significant weight loss, and his multiple pressure injuries, here are some interventions that will serve them all:
- Liberalized regular diet
- Fortified cereal and potatoes daily + Magic Cup and chocolate pudding daily
- Encourage intake >50% of meals, snacks
- Encourage fluids at MedPass
- 15 g protein TID
- Recommend adding Vit C 500 mg/day + Zinc 220 mg/day x 2 weeks to support wound healing
- Consider addition of micronutrients arginine and glutamine to further improve wounds
- Update food preferences PRN
- Consider appetite stimulant to aid in meeting estimated nutritional needs
- Include malnutrition diagnosis
This list should make it clear how interwoven his nutritional issues are. None of Mr. Jute’s issues can successfully be managed without also managing the others. And when you provide support for one, you’re inherently supporting the others.
Need how these interventions link together to be a little more clear? Think about it like this:
- Managing his poor intake and supporting his weight loss, provides needed nutrients for wound healing.
- Wounds, especially those pressure ulcers that are deteriorating, can lead to malnutrition which is enhanced with poor intake.
- Decreased interest in getting up and having meals may further contribute to poor intake and weight loss, and be directly tied to the pain caused by his wounds.
- Significant weight loss and a high risk for malnutrition is intimately tied to his poor intake and his need for increased nutrients with his multiple wounds.
Knowing this, establishing your interventions for Mr. Jute is fairly straightforward.
Writing the note
This is what you’ve done so far.
- You’ve collected all relevant information about Mr. Jute.
- You’ve reviewed his time while he was in the hospital and you’ve established his current nutritional needs.
Now all that’s left is to pull that information together into a clear and concise assessment summary statement. And since Mr. Jute is a readmission who’s been out of your facility for an extended period of time, you’ll be writing what sounds like a new admission note.
Let’s put all the information we have together.
What the note might look like:
Resident is an 83 yo man readmitted s/p hospitalization x 1 month for UTI, acute kidney injury and stage 4 sacral PU debridement. PMH of CAD, HTN, osteoarthritis, depression. Continues with stage 4 sacral PU, R+L-heel stage 2 PU with wound care note on 4/16 prior to hospitalization. No edema noted, no new labs since readmit. Doxycycline in place s/p debridement.
Poor intake at 0-25% prior to hospitalization. Heart Healthy diet provided on readmit.
CBW: 127 lb, BMI of 19 underweight. Wt on 4/4: 133 lb, wt loss of 6 lb / 4.5% x 1 month, not significant. Wt on 1/5: 149 lb, wt loss of 22 lb / 14.8% x 6 months, significant. Insidious, significant wt loss noted x 1 year since admitting wt: 177 lb.
With poor intake, multiple wounds and ongoing wt loss with BMI <25, pt recommended for dx of malnutrition.
Diet changed to liberalized regular with fortified cereal and potatoes daily + Magic Cup and chocolate pudding daily at medusas and a half sandwich at HOS. Encourage intake >50% of meals, snacks. Encourage fluids at MedPass.
Recommend 15 g protein TID, Vit C 500 mg/day + Zinc 220 mg/day x 2 weeks to support wound healing. Consider addition of micronutrients arginine and glutamine to further improve wounds.
Consider appetite stimulant to aid in meeting estimated nutritional needs. Will follow intake, wt status, wounds, labs as avail. Will update food preferences PRN.
Maybe you don’t write your notes with paragraphs or using sentences. Maybe you prefer headings and bullet points without the background information that’s found in the rest of the note.
That’s works too. As always, it’s not the structure of the note. It’s the content.
Looking for a comprehensive review of how to write a nutrition assessment summary and all the information you never want to forget? Check out the Clinical Evaluation Power Pack right here
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Care plan and MDS click-thrus.
The last two components of clinical assessments in a long-term care setting will always be completing your patient’s care plan as well as the MDS section of the assessment.
Both will look different depending on the EMR system you’re using, and it will take a little getting used to whenever you start using a new system.
Care plans
The care plan will happen in two places. First, it’ll happen as an in-person meeting between the healthcare team and the patient and their family. This is where the patient and family get clarity on what specifics are happening to support the acute issues of your patient. You may or may not be included in these meeting.
Care plans are also completed in the EMR by each member of the health team. This is a centralized place where all information on each patient is kept and referenced during the in-person meetings. Here you’ll include all the interventions you’re both recommending and implementing for each resident you care for. If you make an adjustment in your patient’s interventions, you’ll also update this in the care plan.
Once that’s complete, you move on to the MDS.
MDS
MDS stands for “minimum data set” but what your facility really uses it for is to support insurance company billing by tracking each resident’s key health indicators for LTC. For the nutrition department this includes items such as weight change, swallowing ability, and diet order among others. Each MDS section is completed after the corresponding required assessment is also completed.
The MDS calendar is what dictates the dates on which the quarterly assessment and annual assessments are to be completed and is established when your patient is first admitted.
Looking for some help on both writing assessments and completing the MDS portion of the assessments in long-term care? Start with the Clinical Evaluation Power Pack
And That’s It!
Looking for a more in-depth walk through on how to start talking to this kind of patient? Start here to catch up on all the Clinical Case Studies done live every month. Bring your questions and join in the Q+A available after every live.
Want to read another case study? Check out this CHF case study. Start with part 1, then move on to part 2.
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Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.
