臨床營(yíng)養(yǎng)診療流程的建立與發(fā)展

1、標(biāo)準(zhǔn)化臨床營(yíng)養(yǎng)診療流程的建立與發(fā)展社會(huì)經(jīng)濟(jì)學(xué)因素：老年獨(dú)居、貧困、多食少動(dòng)等疾病本身加?。合摹⒏叻纸獯x、器官功能改變、心理障礙營(yíng)養(yǎng)不良由NUTRITIONAL CARE MANAGEMENT INSTITUTE 對(duì)美國(guó)20家國(guó)家級(jí)醫(yī)院中2485位病人的評(píng)估顯示：約有94.4%的病人處在營(yíng)養(yǎng)不良的危險(xiǎn)中，這些病人占居了95.5% 的總住院天數(shù)。影響器官功能的保持和修復(fù)：免疫力的降低 各種酶活性下降 創(chuàng)傷愈合延緩等住院費(fèi)用增加：并發(fā)癥發(fā)生率上升 死亡率增加 住院時(shí)間XX對(duì)住院病人進(jìn)行營(yíng)養(yǎng)狀態(tài)的篩查和評(píng)估是住院常規(guī)檢查的要求在營(yíng)養(yǎng)不良的住院病人中：感染和非感染性并發(fā)癥高26倍； 死亡率高24倍；

2、 住院費(fèi)用高75%臨床營(yíng)養(yǎng)治療的必要性 共用配方 單一方式臨床 單一配方 多種方式臨床營(yíng)養(yǎng)科 臨床營(yíng)養(yǎng)診療流程：個(gè)體化腸外營(yíng)養(yǎng)腸內(nèi)營(yíng)養(yǎng)治療膳食基本膳食（公共營(yíng)養(yǎng)）腸外營(yíng)養(yǎng)腸內(nèi)營(yíng)養(yǎng)治療膳食基本膳食（公共營(yíng)養(yǎng)）醫(yī)學(xué)營(yíng)養(yǎng)治療=配餐？NO??？代謝調(diào)整入院營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查營(yíng)養(yǎng)狀況評(píng)價(jià)制定營(yíng)養(yǎng)治療方案營(yíng)養(yǎng)治療方案的實(shí)施再評(píng)價(jià)更新營(yíng)養(yǎng)治療方案病人監(jiān)測(cè)終止?fàn)I養(yǎng)治療放棄營(yíng)養(yǎng)治療評(píng)估醫(yī)療環(huán)境國(guó)外臨床營(yíng)養(yǎng)診療流程的標(biāo)準(zhǔn)有風(fēng)險(xiǎn)病情變化達(dá)到預(yù)期目標(biāo)需在院治療不再需要治療向目標(biāo)邁進(jìn)Russell MK， Andrews MR. Nutr Clin Pract， 2002， 17（6）:384-391.無(wú)風(fēng)險(xiǎn)麥當(dāng)勞的標(biāo)準(zhǔn)化業(yè)務(wù)

3、流程麥當(dāng)勞手冊(cè)包含了麥當(dāng)勞所有服務(wù)的每個(gè)過程和細(xì)節(jié)業(yè)務(wù)流程標(biāo)準(zhǔn)化操作的成功案例一定要轉(zhuǎn)動(dòng)漢堡包，而不要翻動(dòng)漢堡包如果巨無(wú)霸做好后10分鐘內(nèi)沒有人買就一定要扔掉收款員一定要與顧客保持眼神的交流并保持微笑賣奶昔的時(shí)候應(yīng)該怎樣拿杯子、開關(guān)機(jī)器、裝奶昔直到賣出的所有程序步驟 Relationship Between Patient/Client/Group & Dietetics Professional - Nutrition Diagnosis Identify and label problem Determine cause/contributing risk factors Cluster

4、signs and symptoms/ defining characteristics Nutrition Assessment Obtain/collect timely and appropriate data Analyze/interpret with evidence-based standards Identify risk factors Use appropriate tools and methods Involve interdisciplinary collaboration Screening & Referral System Outcomes Management

5、 System Monitor the success of the Nutrition Care Process implementation Evaluate the impact with aggregate data Identify and analyze causes of less than optimal performance and outcomes Refine the use of the Nutrition Care Process AND NUTRITION CARE PROCESS2017 Document Nutrition Monitoring and Eva

6、luation Monitor progress Measure outcome indicators Evaluate outcomes Document Nutrition Intervention Plan nutrition intervention Formulate goals and determine a plan of action Implement the nutrition intervention Care is delivered and actions are carried out Document Document 國(guó)內(nèi)現(xiàn)有標(biāo)準(zhǔn)化流程患者入院進(jìn)行營(yíng)養(yǎng)篩查與評(píng)估

7、營(yíng)養(yǎng)正常營(yíng)養(yǎng)治療：個(gè)體化方案營(yíng)養(yǎng)治療效果評(píng)價(jià)患者出院營(yíng)養(yǎng)門診隨訪營(yíng)養(yǎng)診斷營(yíng)養(yǎng)監(jiān)測(cè)營(yíng)養(yǎng)風(fēng)險(xiǎn)/營(yíng)養(yǎng)不良程度衛(wèi)健委醫(yī)政司；中國(guó)醫(yī)師協(xié)會(huì)營(yíng)養(yǎng)醫(yī)師專業(yè)委員會(huì)，2009-2010NCP：一種標(biāo)準(zhǔn)化流程而不是提供標(biāo)準(zhǔn)化營(yíng)養(yǎng)診療。標(biāo)準(zhǔn)化的流程意味著使用連續(xù)的結(jié)構(gòu)和框架提供營(yíng)養(yǎng)診療MNT：標(biāo)準(zhǔn)化診療意味著所有的病患/客戶接受一樣的診療方案標(biāo)準(zhǔn)化診療個(gè)體化 & 標(biāo)準(zhǔn)化標(biāo)準(zhǔn)化流程歐美國(guó)家NCP中營(yíng)養(yǎng)師的作用包括:Nutrition screening and patient prioritizationAssessing nutritional statusIdentifying nutrition-related

8、 issuesPlanning and prioritizing care for the issuesImplementing the careDocumenting and CommunicationEvaluating the nutritional care outcomes11歐美指南ASPENAll patients screened within 24 hrs of admission; those at risk undergo nutrition assessmentSpecialized nutrition support should be initiated in pt

9、s with inadequate intake， or expected inadequate intake over 7 14 dESPENAll healthcare institutions should have a policy and specific protocol for identifying pts at nutritional riskAll pts should be screened upon admissionOutcome of screen should be linked to defined course of actionEN for all pts

10、not expected to be on full oral diet within 3 days營(yíng)養(yǎng)篩查工具 MNA NRS2002 MUSTSNAQ ANSTStep1 Nutrition assessment in the NCPFood/Nutrition-related historyFood and nutrient intake, usual diet, medications, food availability, knowledge/beliefs about food, physical activity levelAnthropometric measurementsH

11、eight, Weight, body mass index, growth velocity, circumferences etcBiochemical data, medical tests and proceduresLab data such as electrolytes, glucose, lipids, tests such as resting metabolic rate, abdominal x-rays etcNutrition-focused physical findingsSkin turgor and integrity, dentition, appearan

12、ce of subcutaneous fat/muscle mass etc Client historyMedical/surgical/family history/socialNutrition assessment another wayAAnthropometryBBiochemistryCClinical, functional, psychologicalDDietaryEEnvironmental, behavioral, social膳食調(diào)查24h膳食回顧必選，每次營(yíng)養(yǎng)狀況評(píng)價(jià)時(shí)食物頻率法可選體格檢查首次和以后每周營(yíng)養(yǎng)師身高、體重BMITSF、AMC、腰圍、臀圍每天查房營(yíng)養(yǎng)醫(yī)

13、師腹部體征、腸鳴音等營(yíng)養(yǎng)相關(guān)的其它癥狀和體征Step2 營(yíng)養(yǎng)診斷ADA 20111、攝入問題營(yíng)養(yǎng)平衡問題經(jīng)口或營(yíng)養(yǎng)支持?jǐn)z入問題容量攝入問題生物活性問題營(yíng)養(yǎng)素問題2、臨床問題功能問題生化異常體重問題3、環(huán)境與行為知識(shí)與信仰體育活動(dòng)與功能食物安全與途徑營(yíng)養(yǎng)診斷對(duì)已經(jīng)出現(xiàn)和可能演變呈營(yíng)養(yǎng)問題的狀況的識(shí)別和標(biāo)記營(yíng)養(yǎng)診斷不應(yīng)同醫(yī)學(xué)診斷相混淆隨著患者的反應(yīng)而改變。而只要疾病還沒治好其醫(yī)學(xué)診斷就是不變的分析營(yíng)養(yǎng)評(píng)估的數(shù)據(jù)和給營(yíng)養(yǎng)診斷定義術(shù)語(yǔ)讓評(píng)價(jià)效果的工作變得可行和可衡量Nutrition diagnosisPProblem-describes alterations in a patient/client

14、/group/communities nutritional statusE（E）Etiology-cause or contribution risk factorsSSigns or sympoms-defining characteristicsP-E-S format營(yíng)養(yǎng)診斷 vs 醫(yī)學(xué)診斷Medical DiagnosisNutritional DiagnosisDiabetesExcessive CHO intake r/t visits to Coldstone Creamery as evidenced by diet hx and high hs blood glucoseT

15、rauma and closed head injuryIncreased energy needs r/t multiple trauma as evidenced by results of indirect calorimetryLiver failureAltered gastrointestinal function r/t cirrhosis of the liver as evidenced by steatorrhea and growth failure舉例：營(yíng)養(yǎng)素?cái)z入問題熱量攝取過多熱量攝取足夠熱量攝取不足極度熱量限制碳水化合物攝取過多碳水化合物攝取偏低精制糖攝取過多中國(guó)營(yíng)

16、養(yǎng)診斷（草案）營(yíng)養(yǎng)的社會(huì)功能食物與營(yíng)養(yǎng)的知識(shí)缺乏不良的營(yíng)養(yǎng)態(tài)度尚未準(zhǔn)備好進(jìn)行飲食或生活形態(tài)的改變自我監(jiān)控不足無(wú)法確實(shí)執(zhí)行營(yíng)養(yǎng)相關(guān)建議不適當(dāng)?shù)氖澄镞x擇運(yùn)動(dòng)不足此刻沒有營(yíng)養(yǎng)相關(guān)問題舉例：體重過輕Step3：營(yíng)養(yǎng)干預(yù)針對(duì)性地用于改變個(gè)人、目標(biāo)人群或社區(qū)的營(yíng)養(yǎng)習(xí)慣，針對(duì)風(fēng)險(xiǎn)因素，環(huán)境條件或健康狀況方面進(jìn)行營(yíng)養(yǎng)調(diào)整的計(jì)劃要求： 基于科學(xué)原則和原理； 基于最可靠的實(shí)踐研究； 基于營(yíng)養(yǎng)診斷；營(yíng)養(yǎng)干預(yù)營(yíng)養(yǎng)干預(yù)旨在讓患者達(dá)到理想數(shù)值并提供治療策略，實(shí)施治療計(jì)劃:What?When?Where?How?*Based on the ESPEN definition. Lochs et al， 2006如何管理營(yíng)養(yǎng)不

17、良問題Early identification through a screening programme is key to effective management A care plan should be an integral part of the programmeA range of nutritional strategies can be used醫(yī)療膳食配制標(biāo)準(zhǔn)普通膳食特殊成分調(diào)整膳食經(jīng)口營(yíng)養(yǎng)補(bǔ)充PEGEPJnasogastric腸內(nèi)營(yíng)養(yǎng)管飼安全、簡(jiǎn)便、講求技巧腸內(nèi)營(yíng)養(yǎng)制劑意味著：推薦營(yíng)養(yǎng)素供應(yīng)腸外營(yíng)養(yǎng)Enteral preferredSurgery highest pe

18、rcentage of usePost-op bowel dysfunctionFistulas （pancreatic surgery & tertiary referral）Over used 7 days frequentWe do not say no! （just need to follow rules）Pre-op: uncommon腸外營(yíng)養(yǎng)支持途徑的建立靜脈切開插管胸前隧道Port中心靜脈置管經(jīng)外周靜脈植入中央靜脈導(dǎo)管腸外營(yíng)養(yǎng)配置室收集與展示Step4：營(yíng)養(yǎng)監(jiān)測(cè)與評(píng)價(jià)監(jiān)測(cè)數(shù)據(jù)或其它表格和計(jì)算機(jī)程序的監(jiān)測(cè)結(jié)果人體測(cè)量數(shù)據(jù)，生化數(shù)據(jù)，醫(yī)學(xué)測(cè)試和程序患者調(diào)查，前期測(cè)驗(yàn)，后期測(cè)驗(yàn)以及問

19、卷電話和郵件隨訪監(jiān)測(cè)與評(píng)估三過程第一步，包括檢查患者對(duì)NCP的了解和遵守情況，判斷干預(yù)措施是否得到切實(shí)執(zhí)行，是否改變了患者的習(xí)慣和狀況，判斷其它正面或負(fù)面的效果，搜集信息，了解未能遵守的原因，進(jìn)度不足的原因。第二步，評(píng)估效果，在這一步，查看與營(yíng)養(yǎng)診斷階段的體征和癥狀，營(yíng)養(yǎng)目標(biāo)，醫(yī)學(xué)診斷和效果，健康狀態(tài)的改變第三步是把當(dāng)前效果與前期狀態(tài)，干預(yù)目標(biāo)和參考標(biāo)準(zhǔn)做對(duì)比怎樣監(jiān)測(cè)?Nutrition Monitoring and Evaluation結(jié)局類型終點(diǎn)結(jié)局直接營(yíng)養(yǎng)結(jié)局臨床和狀況狀況結(jié)局以患者為中心的結(jié)局醫(yī)療資源的消耗 間接指標(biāo)結(jié)局患者營(yíng)養(yǎng)監(jiān)測(cè)營(yíng)養(yǎng)指標(biāo)周期膳食調(diào)查24小時(shí)食物回顧法食物頻率問卷法出

20、入量/DPI每月1-2次診斷需要每月1-2次人體測(cè)量握力、TSF、MAC體重/BMI每36月每1月生化指標(biāo)Alb、pre-Alb、HbTC、TG、Ca、P、MgCRP每1月每1月每3月6月人體組成測(cè)定LBM測(cè)定BIA、DEXA每3-6個(gè)月綜合評(píng)價(jià)SGA/MNA每3-6個(gè)月Step 5 營(yíng)養(yǎng)教育原則:Occurs at the bedside with family/support Focused on the “safety” or “survival skills”E.g. hypoglycemia， carbohydrates， potassiumRisk and benefits of

21、foods/eating patternsWritten material and food models for examplesSet up for ongoing outpatient counseling as appropriate* If no outpatient RD/Clinic to refer， inpatient RD must provide full counseling患者教育資料:5-6th grade reading level合理營(yíng)養(yǎng)干預(yù)的益處營(yíng)養(yǎng)支持 改善攝入改善營(yíng)養(yǎng)狀況減少醫(yī)療耗費(fèi)改善臨床結(jié)局改善功能在營(yíng)養(yǎng)干預(yù)啟動(dòng)前應(yīng)充分考慮患者的狀況與預(yù)后再行實(shí)施舉例

22、: 成人體重管理工具包內(nèi)容總論MNT 計(jì)劃表Summary Recommendations for AWMFlowchart of EncountersEncounter ProcessMNT文件Sample Referral Form for MNTInitial & follow-up MNT Progress NoteSample Case Study結(jié)局管理 Forms in Excel患者教育信息資源Executive SummaryClient Agreement for Care & Encounter ContractCan Dairy Help Control WeightL

23、ow-Carbohydrate Diets: Hype or Hope?Meals on the GoPortion DistortionWeight Control Meal Patterns病例: Initial and Follow-up Encounters Illustrates the Nutrition Care Process Uses new SL for Nutrition Diagnosis， Intervention， Mon臨床營(yíng)養(yǎng)的NCP舉例患者一般情況59 歲男性入院11月21日， 2010酒精毒品濫用，同性愛人體測(cè)量Ht: 1.73mWt: 99 kgBMI:

24、33IBW: 154%營(yíng)養(yǎng)評(píng)價(jià)既往病史:直腸癌HTN便秘左臂手術(shù)史營(yíng)養(yǎng)評(píng)價(jià)入院情況無(wú)排便1月下腹低位疼痛，10分剖腹探查術(shù)后腸腺癌轉(zhuǎn)移NGT placement結(jié)腸造瘺營(yíng)養(yǎng)評(píng)價(jià)（2）用藥史 腫瘤化療藥（因嚴(yán)重感染及便秘停用化療）抗生素 （Vancomycin， zosyn and levaquin）降壓藥西甲硅油思諾思（睡眠障礙）嗎啡鎮(zhèn)痛（PatientControlledAnalgesia） for pain relief實(shí)驗(yàn)室檢查L(zhǎng)abPt valueNormal rangeInterpretationALB2.13.5-5 g/Lw/inflammation, acute stress,

25、 malabsorption of proteinPAB816-35 mg/dLw/inflammation, burns, poor nutrition, aspirin toxicity, or liver diseaseBUN38-18 mg/dL malnut, malab, overhydration, low protein diet, hepatic failureTotal Protein6.36-8 g/dLWNLSodium141136-145 mEq/LWNLK+3.33.5-5.5 mEq/LK+ intake, trauma, stress, V/D, diureti

26、cs, malnut, hemolysis, fistula drainage, overhydrationAST295-40 IU/mLWNLALT334-36 IU/LWNLCRP20 mg/L1.0 mg/LHigh risk of cardiovascular dz實(shí)驗(yàn)室檢查（2）LabPt valueNormal rangeInterpretationMag1.81.8-3 mg/dLWNLHgb9.814-17 mg/dL malesAnemia, prol dietary def of iron, cancer, overhydration, protein-cal mal, r

27、enal or liver disease, sepsis, small bowel surg, gastrectomyHct6040-54% malesPolycythemia (body makes too many RBCs)MCHC32.731-35 g/dLWNLMCH28.826-32 pg concentration is 32-35%WNLMCV88.280-94 cu/umWNLRDW12.911-14%WNLWBC30 K/ul3.3-8.7 K/ulw/infection, systemic illness, inflamm, allergy, leukemia, tak

28、ing antibiotics or anti-seizure drugsCreatinine1.2 mg/dL0.7-1.2 mg/dL malesWNL營(yíng)養(yǎng)診斷 PES 攝入不足from parenteral nutrition r/t food and 營(yíng)養(yǎng)支持知識(shí)匱乏concerning appropriate formulation given for PN aeb inadequate volume/concentration compared to estimated needs of pt.實(shí)驗(yàn)室指標(biāo)異常 values r/t Albumin 2.1， PAB 8， BUN 3

29、.0， WBC 30， CRP 20， Hgb 9.8， and Hct 60 aeb pt NPO for 1 week水化狀態(tài)不佳 r/t pt NPO for 1 week with no IV fluids aeb scanty dark yellow urine干預(yù) &補(bǔ)充目標(biāo):攝入充足體重適當(dāng)增加營(yíng)養(yǎng)干預(yù) :監(jiān)測(cè)PN耐受性Monitor labs: PAB， BUN， Cr， WBC， H/H， Mg， Phos監(jiān)測(cè)血糖Q6h每日監(jiān)測(cè)體重變化監(jiān)測(cè)出入量教育PN相關(guān)知識(shí)營(yíng)養(yǎng)供給 TPN 配方Estimated Needs:Kcal: ABW 77 kg x 25-30 Kcal/kg = 1925-2310 Pro: ABW 77 kg x 1.0 1.2 g/kg = 77-92Patients estimated fluid need: 1925-2310 mLPatients needs were estimated using the ABW since the patient is 140