Tapping the experts for dietary education
Dietitians an integral part of management team
Diet plays a strategic role in disease management for patients with many chronic conditions. Health conditions such as high blood pressure, heart disease, and especially diabetes are all impacted by what people eat.
"Frequently, a patient's dietary changes are the foundations of the care of their disease or treatment. But if the diet alone doesn't work the physician can prescribe medications," says Denise Thornton, RN, MSN, CDE, patient education coordinator at Methodist Hospitals of Memphis (TN).
That's why it is important to identify when a dietitian should be asked to teach the diabetic patient or provide a nutritional assessment, Thornton says. Also, the Joint Commission on Accreditation of Healthcare Organizations mandates teaching by appropriate members of the health care team. At Methodist Hospitals, patients are referred to a dietitian for teaching if they are on a new diabetic diet, a new low fat/low cholesterol diet for heart disease, or a new renal diet.
In addition, if the admission assessment shows that a patient is having trouble following a prescribed diet, then a dietitian referral would be made. Teaching for diabetic patients who aren't on new diets often takes place in an inpatient group class that patients are invited to attend.
There also is information on the closed circuit television and in booklets. "Some people learn better by watching videos, some by reading, and some by verbal instruction. Others need all three methods," Thornton explains. That's why those that don't fit the criteria for a special consultation with a dietitian are given choices on how they wish to learn.
To set criteria for a dietary consultation, staff at Methodist Hospitals identified high risk, high volume, problem prone areas, says Thornton. "We selected cardiac and diabetes because they are high risk, and renal because of the high volume. Also, they are all chronic problems," she explains.
At Providence Alaska Medical Centers in Anchorage, floor nurses teach general nutrition and basic diet guidelines. However, if a diet is modified a dietitian does the teaching. "We think there is a skill set that dietitians uniquely possess," explains Janet McVey, RD, team leader for nutrition services at the medical center.
Dietitians are the experts, agrees Laura Dorr-Uyemura, RD, manager of nutrition services at City of Hope National Medical Center in Duarte, CA. Because dietitians are required to stay updated on nutritional information it makes sense to have them do the counseling sessions, she says.
"The floor nurse might introduce the basic concepts of a modified diet, but the dietitian will build on the information and individualize the diet to the person's lifestyle and preferences. He or she will basically translate the diet information into practical applications like menu planning, shopping, food preparation, serving, and storage as appropriate," Dorr-Uyemura explains.
Diet teaching is time-consuming, says Patsy Nevins-Plant, RD, LDN, clinical dietitian at Lexington (NC) Memorial Hospital. The first session is a lot of history and assessment and then the dietitian must work with the patient to create a plan, she explains.
Follow-up visits are helpful
Teaching is personal and detailed and difficult to complete on an inpatient basis when the patient often is too sick to learn. "I see them in the hospital and give them some information to take home. Then I try to schedule a follow-up visit," Nevins-Plant says.
At City of Hope, diet teaching begins when a modified diet is ordered by the physician. Most diet instruction involves a basic introduction to the principles of the diet with additional information added in increments. "Ideally, the patient should leave the hospital with survival skills that can then be fine tuned in the outpatient setting if necessary," Dorr-Uyemura says.
As lengths of hospital stays grow increasingly shorter, the number of outpatient visits for diet teaching has increased at City of Hope. Dietitians assess each patient and if they determine the patient needs more information or follow-up, they schedule an outpatient visit.
"[Dietitians at Providence Alaska] call patients about a week after discharge to schedule them for an outpatient diet consultation. We try to match the consultation with their doctor's follow-up visit," McVey says.
The initial consultation is about an hour, and patients are scheduled for follow-up visits as needed - at least once, but sometimes weekly or monthly if the patient is having trouble adhering to a modified diet.
Teaching depends on the patient and his or her lifestyle. "We don't have a 1,200 calorie diet," McVey says. Most materials are given to patients to help them make good choices. For example, they might receive information on the fat content of foods or a list of high sodium foods. Sometimes McVey has a patient circle the foods on a list they love to eat or that they eat more than once per week so they can see which items to cut back.
At City of Hope, dietitians also make sure that patients on special diets receive a source list so they can purchase items that aren't readily available in supermarkets, such as low-protein bread. The list has addresses and phone numbers of mail order companies, Dorr-Uyemura says.
While the contribution of the dietitian in the teaching process is vital, dietitians don't work in a vacuum. It's important to work with the nursing staff, says McVey. "We see bedside nurses as critical links in our teaching. They reinforce our teaching and notify us if the patient is still confused," she explains.
For more information on incorporating dietitians into the teaching plan, contact:
Laura Dorr-Uyemura, RD, Manager - Nutrition Services, City of Hope National Medical Center, 1500 East Duarte Rd., Duarte, CA 91010. Telephone: (626) 359-8111, ext. 2103. Fax: (626) 301-8165.
Janet McVey, RD, Team Leader - Nutrition Services, Providence Alaska Medical Centers, 3200 Providence Drive, Anchorage, AK 99508. Telephone: (907) 261-3046. Fax: (907) 261-4886.
Patsy Nevins-Plant, RD, LDN, Clinical Dietitian, Lexington Memorial Hospital, 250 Hospital Drive, P.O. Box 1817, Lexington, NC 27293. Telephone: (336) 248-5161, ext. 371. Fax: (336) 248-6141. E-mail: [email protected].
Denise Thornton, RN, MSN, CDE, Patient Education Coordinator, Methodist Hospitals of Memphis, 251 South Claybrook, Memphis, TN 38104. Telephone: (901) 726-8435. Fax: (901) 726-8638.
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