Sample Details
Subjects
Health & Medicine
Healthy Nutrition
Type
Report
Reviewed by
Dr. Olha Stoliarchuk
Pages
5
Words
1228
Updated:

New Resident Dietary Assessment and Care Planning Report

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Introduction

As a food and nutrition manager (FNM), I have studied different disciplines, such as dietetics, food safety, and quality care, which have provided valuable skills and knowledge in my career. These competencies have prepared me for a more practical role in my placement setting, where I participated in a new resident’s assessment process. Thus, this report will describe the approach used at my placement facility for developing and administering a dietary assessment for a new resident, alongside a summary of our preliminary discussion. Additionally, this paper will include a breakdown of all the steps and actions taken to document and implement this patient’s care plan and a discussion of the intended enhancements.

Process Used for Conducting New Patient/Resident Assessment

The placement setting where I work follows a standardized procedure when conducting assessments of new patients or residents. To initiate the process, the intake coordinator collects fundamental details about the patient or resident, such as their name, medical history, and the reason for their admission. Subsequently, the intake coordinator arranges a meeting between the care team members, including the food and nutrition manager, nurse, physician, social worker, physical therapist, and the patient or resident.

The objective of this meeting is to collect information about the individual’s current health condition, medical necessities, and dietary choices. Thereafter, the patient’s overall cognitive, physical, and emotional well-being is evaluated during this session, and pertinent data about their nutritional needs and dietary preferences are recorded. The section that follows summarizes my initial interaction with the new resident at the placement facility.

Initial Interaction with the New Resident

In my initial encounter with the new resident, I presented myself and elucidated my position as the food and nutrition manager. I inquired about the resident’s food inclinations and any food sensitivities or allergies. The resident, whom I shall identify as Mrs. B, was amicable and willing to share her dietary requirements. She stated that she was lactose intolerant and preferred a vegetarian diet. I noted her preferences and reassured her that we would collaborate to develop an appropriate regimen that catered to her nutritional demands and dietary limitations.

Steps Followed When Documenting and Implementing Mrs. B’s Care Plan

Mrs. B was admitted to our long-term care facility with various medical conditions, which necessitated a personalized care plan. As the Food and Nutrition Manager, my responsibility was to formulate and execute a dietary regimen that would aid in her medical requirements and simultaneously accommodate her inclinations. To accomplish this, it was essential to follow an appropriate care plan and work closely with other care team members, including nursing staff, physicians, and social workers (Spacey et al., 2021). Therefore, I collaborated with the care team to design a comprehensive regimen for Mrs. B that incorporated various elements.

The nursing staff performed a pivotal role in conducting the primary evaluation and collating relevant data about Mrs. B’s medical past and present health conditions. Concomitantly, the physician was consulted to offer medical supervision and make any required modifications to Mrs. B’s care regimen, considering her medical history and current health status. On the other hand, the physical therapist collaborated with Mrs. B to formulate an individualized exercise and mobility strategy that corresponded to her specific necessities and abilities (Spacey et al., 2021). The section below highlights different actions taken when devising and implementing Mrs. B’s care plan.

Therapeutic Diets

My team and I formulated a customized therapeutic diet for Mrs. B, as per her care plan, that addressed her specific health concerns, which consisted of diabetes, hypertension, and a history of heart disease. The objective of this diet was to promote her overall well-being and manage her symptoms proficiently. We used a standard form to record Mrs. B’s dietary specifications and tastes, incorporating any food allergies or intolerances. To ensure that her diet was nutritionally adequate and well-balanced, we devised a meal plan that included a wide range of food items from all food groups (Spacey et al., 2021). Additionally, we cooperated closely with the kitchen staff to ensure that Mrs. B’s meals were prepared in compliance with her dietary needs and preferences.

Seasonal, Sustainable, and Cultural Foods

When creating Mrs. B’s diet plan, we not only factored in her therapeutic diet but also considered her cultural heritage and individual preferences. We ensured that the food items we included in her diet were culturally fitting, personally desirable to her, and suitable for her health conditions. Furthermore, we integrated seasonal and sustainable food options into her meal plan, where applicable, to provide her with an assortment of wholesome and fresh choices.

Documenting a Care Conference and Health Conditions

To ensure Mrs. B’s care plan was comprehensive, we held regular care conferences with her and her family to assess progress and make any necessary adjustments. We employed a standardized health assessment form to document these conditions, including her medical background, current health status, and medications. By recording Mrs. B’s health conditions and culinary preferences, we produced a customized care plan that catered to her specific requirements. This approach proved effective in enhancing her overall health results and contributed to a positive experience during her stay in the placement setting.

Assessment Forms

In my capacity as the Food and Nutrition Manager, I employed several standardized assessment forms to document Mrs. B’s dietary requirements and needs. These forms were developed based on the best practices in the field of dietetics to obtain all the pertinent information regarding Mrs. B’s health and dietary needs, thereby ensuring that we had a complete comprehension of her situation. One of the assessment forms used was MGMT 271, which was specifically designed to document Mrs. B’s dietary requirements and preferences. Using this form allowed me to acquire a comprehensive understanding of her specific needs, thereby making it easier to craft a customized meal plan tailored to her unique requirements.

Menu Planning

After considering Mrs. B’s dietary preferences and nutritional requirements, I created a menu plan that included a well-balanced diet with an appropriate level of calories and nutrients. To guarantee that each meal met Mrs. B’s recommended daily nutritional intake, I employed a software program to calculate its nutrient content. The segment below summarizes the significant improvement in Mrs. B’s care and satisfaction that I was able to deduce in the placement setting.

Improvements in Resident Care and Satisfaction

From my experience, the care and satisfaction of residents improved in different ways based on the care plan we created for Mrs. B. Firstly, Mrs. B noted that because her meals were prepared according to her dietary preferences and nutritional requirements, she felt happier every time. She further mentioned that the care team made her feel less anxious and supported because we took the time to address her issues and respond to her inquiries. On the same note, we were able to identify potential dietary deficiencies that, if unchecked, could have had a detrimental effect on Mrs. B’s health.

Conclusion

As an FNM, my duties during patient/resident assessments usually involve collaborating with the care team to devise and execute personalized dietary plans that cater to the patient’s dietary predilections and nutritional requirements. This collaborative approach allowed me to enhance Mrs. B’s care plan while supporting her to attain nutritional objectives. Thus, based on my experience, adhering to evidence-based directives and optimal nutritional care techniques ensures that residents receive top-notch care that caters to their distinct dietary preferences and needs.

Reference

Spacey, A., Scammell, J., Board, M., & Porter, S. (2021). . Journal of Advanced Nursing, 77(6), 2774-2784. Web.

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