Knowing how to identify and then use the most acute nutritional issue in your assessments is one of the most important things you need to be able to do as a new dietitian. Keep reading for a list of tips that can keep you focused and on track.
Working With the Most Acute Nutritional Issue
Knowing how to identify and then use the most acute nutritional issue in your assessments is one of the most important things you need to be able to do as a new dietitian.
It’s also one of the trickiest things to wrap your head around and feel confident figuring out.
When you’re starting out it can be hard to filter out what’s important and what’s not so important. And then figure out how to identify the most acute issue.
But it’s also one of the most important things you need to be able to do as a new dietitian.
Why?
Because the most acute nutritional issue will be your primary focus whenever you’re working with a new patient. It’ll even be your number one priority when reassessing a previous one.
To help make this easier, this post will go over:
- Identifying the difference between an acute medical and an acute nutritional issue
- How to use the EMR to identify the most acute nutritional issue
- How to triage your patient’s multiple conditions
- Using the assessment summary to document the most acute issue
And because this is such a big topic, consider this post a great starting point on understanding how to work through the most acute nutritional issue.
Let’s get started.
What IS an acute issue?
An acute issue is anything health concern that begins suddenly and severely.
And it’s the suddenness and severity that makes these conditions such a priority for the health care team.
As an RD, you can narrow down the two types of acute issues you’re going to see as a clinical dietitian.
- An acute medical issue
- An acute nutritional issue
In clinical nutrition, not surprisingly, the acute issue you’re going to be paying most attention to is your patient’s acute nutritional issues.
Maybe this sounds obvious.
But figuring out the difference between what’s purely medical and what has nutritional implications can be really hard.
Medical Issues vs. Nutritional Issues
There’s almost always there’s going to be something significant happening with your patients. Some reason that drove them to seek medical care.
That reason is most likely the most acute issue.
It’s up to you to determine if that reason is purely medical or if there are nutritional implications.
Let’s get into the difference.
Medical Issues:
Think of a medical issue as anything the doctors or the medical team is taking primary responsibility for.
It’s also the issues that require ongoing medical interventions that have little or nothing to do with what you’re able to do as an RD.
This might include things like:
- Surgeries
- Medication management
- Exploratory or evaluative procedures
Anything that’s directly outside the dietitian scope of practice.
If you need to wait and see the outcome of something, that’s a great indication it can be prioritized as a medical condition.
Clinical Nutrition Issues:
A clinical nutrition issue very often springs from medical conditions. But these acute issues require support that is firmly within the scope of nutrition support.
This will include issues around:
- Weight management
- Intake ability and feeding needs
- Specific nutrient requirements
- Wound support
Something becomes a significant nutritional issue when it must be addressed immediately in order for your patient to be discharged as quickly as possible.
It’s up to you as the dietitian to figure out the most acute issue that can be directly improved with nutrition support.
Need help understanding what to look for and manage with your patients? Check out Clinical Bootcamp
The difference between an acute medical and acute nutritional issue
Because the most acute nutritional issue will be the primary focus of all the support you provide your patient while they’re under your care.
It’s not about doing exactly what the doctors do. You’re on the same team, but you aren’t there to do the same job.
You’re the dietitian and your scope of practice is firmly on nutrition support.
Which means you’ll be spending your time and attention on only what you can impact and manage through your nutritional care.
And your time is limited.
So the faster you’re able to identify what the most acute nutritional issue is, the easier it will be for you to assess your patient’s needs and provide the interventions available to you.
How can you use the EMR to figure out the most acute nutritional issue?
Here’s a few places in the EMR to start looking when you’re trying to identify the most acute nutritional issue.
It’s not an exhaustive list, but it will get you started.
#1: Weight status and significant weight changes
Use this to identify any risk of malnutrition, concerns around your patient’s intake, or indications there might be a change in status in the near future.
Pro Tip: Check past admissions (if they’re available) for longer-term weight trends and use it as another way to validate what your patient may tell you.
#2: Determine skin integrity or recent surgical interventions
Check the chart for any recent surgeries your patient might be healing from or any wound care notes with indications of pressure injuries that have been documented.
Pro Tip: Whenever you’re in doubt about skin integrity, make sure to ask nursing or a doctor for confirmation.
#3: Nutritionally relevant diagnoses
Take notes on every condition you see that has any type of nutritional implication. Then scan the chart for indications that condition is either well controlled or being actively managed.
Pro Tip: Sometimes well controlled means it’s not even mentioned. Sometimes actively managed means the labs are off.
#4: Nutritionally relevant altered labs
When you notice labs that are significantly altered and point in the direction of a clear nutrition issue, use this as a clear sign that there’s something significant happening (even if it’s not acute).
Pro Tip: Take note of the exact medical condition that you’ve noticed then use the chart to find additional notes that further discuss the condition.
Once you’ve come up with a list of everything that sounds like it has nutrition implications, it’s time to do a little triage. Because there’s a good chance a lot of the things on that list will be happening together.
Triage is how you’re going to figure out which nutritional concern is something that can wait until later (chronic or not-urgent) vs something that needs to be addressed and managed immediately (acute).
When you’ve filtered your list, you should have a much clearer idea of what’s acute, what’s chronic, what the medical team is focusing on, and what you need to focus on.
Need a little more help understanding the difference? Check out these Clinical Nutrition blog posts:
How to know which kind of issue it is?
The easiest place to start is to look at what the diagnosis is called or consider the state of the condition.
If it’s called CHRONIC (as in chronic kidney disease), it’s likely something that has ongoing management.
It’s also likely a chronic condition if there’s ongoing management that started long before your patient came to see you and will go on (unchanged) long after they’ve been discharged.
These stable and ongoing conditions are usually controlled with medications (like hypertension), also making it a chronic condition.
If you’re seeing this, it means there’s a good chance this is not your most acute issue.
Anything called ACUTE (as in acute kidney failure), is probably something the medical team is putting their full attention on managing.
An acute issue is something has the power to change the course of your patient’s overall health outcomes (like uncontrolled glucose or wounds).
And if that acute condition also has a nutritional element, then there’s a good chance you as the dietitian will also be directly involved in the management of that condition.
Sometimes, an ongoing chronic issue starts to worsen. Or something that was a non-issue suddenly develops.
This is when you might see something chronic transform into an acute issue.
There are many times when it will be super straight-forward, and you’ll be able to identify an nutritional acute issue a mile away.
Other times, it’s going to be a little harder to decide between two (or more) medical conditions that both appear to have very significant nutritional implications.
An easy example of this is a patient who has CKD stage 3 as well as multiple pressure injuries.
Another example might be someone with elevated glucose levels who also has indications of malnutrition or even inadequate intake.
What happens then? What do you do?
How do you decide between two significant and acute nutritional issues?
This is a big question.
But the short answer is this:
Think about all the acute issues that have nutritional implications. Then determine which one has the power to impact all other parts of your patient’s health.
Here’s two ways to think about it:
- Despite having nutrition implications, the medical team has to manage the most acute issues before you can provide support. HERE’S AN EXAMPLE: A newly admitted patient with DKA. Their diabetes (and likely their ability for NPO intake) needs nutritional support, but not until the medical team has stabilized the patient first.
- Supporting one nutritionally relevant condition has the power to support or improve other nutritionally relevant conditions. HERE’S AN EXAMPLE: A patient with CHF and malnutrition. Managing the malnutrition can improve multiple areas of your patient’s health, whereas focusing on the CHF will likely not improve the malnutrition
It’s always going to be a hard question to answer. But if you can figure out what acute thing is, your patient has a better chance at getting discharged sooner. And that’s going to be the most acute nutritional issue.
Still feeling lost? Clinical Bootcamp holds your hand and walks you through ALL the MNT you need to know to do clinical in the real world. Check out Clinical bootcamp here.
How to document the most nutritional acute issue?
There are two places you’ll be documenting on this issue.
And when you do, you’ll also need to justify why you consider it a primary issue and the recommendations you’ll make for it.
PES statements and the Assessment Summary
Let’s start with a few definitions:
PES statements are the Academy’s way of having you formally write out what the most acute nutritional issue is, along with your justification for why it’s so important.
The nutrition assessment summary section is where you can write whatever you want, however you want to write it. It also will include sections for interventions and monitoring.
Interventions is where you say WHAT the issues are, and what your plan is to manage them. Monitoring is where you talk about what you’ll pay attention to as you follow the outcomes of your interventions.
First place you’ll justify your recommendations: PES statements
Whether or not your facility requires you to document PES statements for each of your recommendations, these are really useful to be able to do.
Not because the language is really helpful. But because they force you into thinking specifically about what you’re doing and why you’re doing it.
And this is something you need to be able to do regardless of the words used to convey those thoughts.
PROBLEM: What is the most acute nutritional issue you’re focusing on in this patient?
ETIOLOGY: Where does this problem come from?
SYMPTOMS: How do you know this is really a problem? Justify the issue.
Second place you’ll justify your recommendations – Assessment Summary Section
The assessment summary is all about being able to say what you’re doing and why you’re doing it.
This is where you’ll be able to justify your recommendations more informally and present your patient’s goals outside of the more formal presentation of the PES statements.
More specifically, it’s in the assessment summary where you’re going to need to be able to say why you’ve decided that the most acute issue is actually, the most acute issue.
Every RD uses these summary sections in a different way.
Some are straight to the point, using bullet points with incomplete sentences and no punctuation. Others write out complete paragraphs with grammatically correct sentences and full explanations.
Either way, it’s here you can spell out the most acute issue as you see it – and your justification for it, in any way you’d like.
Looking for some more tips? Start here:
And That’s It!
This is a solid start on what the most acute nutritional issue is — and how to use it.
If you feel like you’ve got to start one place, make it the Acute Care Starter Guide. You’ll get your feet wet with a solid roadmap to clinical nutrition — and you can move forward with everything on this list as you need it.
Want even more to help in clinical?
Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.
