The Nutrition & COVID-19 Connection: Prevention, Nutritional Intervention, Treatment, Care & Documentation

Transcript

Michelle (00:00):

I’m Michelle Mabry, a clinical supervisor with nutritious lifestyles. I have the pleasure of introducing to you today, to Janet Mckee, the president and owner of nutritious lifestyles, which is a group of 180 dietitians chefs and CDMs that provide nutrition and food service consultations nationally. Janet specializes in adult and geriatric nutrition, nutrition for renal disease and pressure ulcers, and speaks nationally on nutrition for the healthcare and food industries. She is a board certified specialist in geriatric nutrition, as well as a diplomat with the American professional wound care association. Janet has important updates to share with us today to have aid and resident care during these challenging times. So without further ado, I’m going to turn the stage over to Janet now.

Janet (00:41):

Thank you, Michelle, for that warm welcome. So, unfortunately, as we know COVID is here and we really do not expect a vaccine within the next 30 days. Hopefully we’ll get one later this fall or the first of the year, but then we have to think about how long it will take to disseminate that. So as we go along, we do expect COVID to be continued in our nursing homes and behavioral clients. So the purpose of today’s consultation has to really look into what is going to be the plan of care to help these people avoid COVID and how can we be positive to provide nutritional care for them to survive and not only that post COVID but to thrive. So our objectives are to talk about different approaches to help our residents avoid getting malnutrition or losing weight, which sets them up for possible COVID infection. We will be able to identify five effects of COVID-19 that may affect nutritional status. For example, many people have massive diarrhea and GI distress. Other people are affected by respiratory distress. Some people not at all for either, we will be able to discuss how COVID and the key ground conditions that affect the diagnosis of COVID bring increased nutrient needs to the human body and how we might approach that food care planning.

Janet (02:26):

So we know that kind of it is here. We all know about COVID, but to summarize that we know that it’s highly contagious. We know it’s airborne. We do not believe it’s food borne. We know that many people do get a fever, some people do not. They also have respiratory tract syndrome, most of the time, about 75% of the time, they are COVID positive with symptoms and multi organ failure is huge for many people with GI distress, also it affects our ability to smell. So COVID 19 is much more likely to affect an individual that has diabetes, coronary artery disease, respiratory problems, cancer those all increased risk of diminishing unity and it also increases the risk of severe symptoms and fatality. Most of our residents have more or one of the above symptoms, our diagnostics and our residents truly are at risk for this.

Janet (03:40):

Here are the facts we have close to 6 million confirmed cases in the United States, 80,000 plus deaths, 50%, depending on who you read – one week, the wall street journal had 50% of the deaths are in the elderly in nursing homes. The next week it was 40%. So it varies, but the margin amount of fatalities are any compromised immunity client and the elderly point back 1% of COVID cases that are diagnosed end up to be fatalities. So we, many of us have been in long term care and behavioral care for many years and we all know that our goal is to truly keep our residents safe, the goal is talk about some ways to do this and avoid that infection and once they get it, how to treat them and do our part with the hydration and food administration to keep it healthy well-nourished and beat COVID, so COVID for one I can tell you is unpredictable.

Janet (04:48):

There’s no rhyme, there’s no reason it has short term effects and long term effects depending on the person. So I’m going to give you a personal example: my son Campbell, who’s 19, plays competitive basketball, on AAU, one of his teammates tested positive so we recruited and took our entire family to get tested. All of us were negative for the virus and antibodies except for Campbell. He tested positive, had no symptoms. He was placed and his antibodies were negative too so we retested in 10 day, we were all negative again for the virus and these were the types that were sent to a lab. So the accuracy was high reportedly and also our immunizations were negative. Again, with the exception of Campbell, his immunizations were negative. However, he did test positive once again for the virus. So completely asymptomatic, no sniffles, no fever, nothing. So of course the more we know, the more questions we have, there are people that had the virus in May of this year, that still the virus is having negative digestive problems with them. Some people have had organ issues. So after the fact, we really just don’t know for sure, the long term and short term effects of this virus so safety’s key to keep our residents safe.

Janet (06:39):

So prevention of COVID-19 in nursing and behavioral facilities, an ounce of prevention is worth a pound of cure. There are so many different ways that we can protect ourselves and our residents we need to be using protective wear for ourselves and also for residents and again, we worry a lot about our clients, our residents and our vendor partners and staff masks are needed, gloves are needed, protective eyewear is now required in many States. Again, the mucous cells, they’re on the outside of the inner eyelid, the lips so to speak they are susceptible if someone spews the air that a globule of the virus can enter through that system. Social distancing is a must following your policies and taking temperatures in the lobby and following the standards established by your facilities. The number one way to keep our residents safe is to practice infection control the social distancing that we discussed, the hand washing the pump of alcohol/the sanitizing agents that have a minimum of 60% alcohol to keep ourselves safe but it’s also equally important to keep our residents well-nourished and also hydrate. We know that people that are malnourished get infections, we know that people dehydrated, they don’t have the ability to flush viruses out of their nasal cavity so they seem to stay in there, the dry could be more friendly to bacterial and viral loads. So it’s important that we remember that they need to stay well nourished and healthy and it’s challenging because many of us know our residents have not seen a family member in literally months and they’re isolated, they’re lonely and being in an unsocial environment has had a negative effect on their appetites and in many cases, promoting weight loss. So malnutrition and dehydration reduces immunity. It’s a fact, if you lose even 3% of weight of an elderly individual in an unplanned, rapid fashion, it increases the risk of infections, but bacterial and viral,

Janet (09:30):

COVID has a lot of negative effects on nutritional quality of life, nutritional status and quality of life well, we know that it decreases intake. If you have an upper respiratory infection, it’s been in effect your intake, it causes under-nutrition acutely. It also can promote depression, in mobility for weakness, dehydration, for lack of feeling like drinking, declining strength reduction in lean body, mass, severe inflammation. This is an inflammatory disease process, involuntary weight loss unpredictably and most importantly, we don’t think about this, for months and months and months residents, young people and all people, many people that had COVID have taste disorders for long periods of time so your olfactory buds are little live tissues, they sort of look like a light bulb and when they are damaged, it can take months for them to restore. During this time, the food for these residents may truly taste like straw, edema, isolation, dysphagia. You lose 5% of your weight as an elderly person, your chance of dysphagia goes up 80%. Increase difficulty managing blood sugar for chronic diabetes, etc., GI distress, acute and long term, both nausea and vomiting, increased GERD and diarrhea. These are all consequences or potential consequences of COVID

Janet (11:19):

COVID causes an acute inflammatory state. So when that virus goes in through your nose, the nice part are your hands through your mouth. Know that it causes instantaneously inflammation. It’s an infection. It’s in a foreign body. So our body starts immediately trying to fight off the infection. Instead of our body making albumin, our body starts making C reactive protein and other negative phase reactive proteins. So then that infection stay has inflammation and what has happened according to our residents and our patients in the literature is a decreased appetite. Therefore increasing the risks of weight loss, therefore increasing nutritional racing declines. So we know that COVID is an infection. All infections are hypermetabolic, catabolic and febrile. And if they have a fever, you can increase. I believe it’s a 7.8 increase in percentage of calories. For every temperature degree, you are above 98.6. So that is significant. COVID-19 increases your calorie fluid and protein needs. Many healthy young people, including teens and youthful adults are COVID carriers. They are positive that they’re asymptomatic carriers. So when you involve yourself with a person that’s a carrier, they may be completely asymptomatic. However, you may be the unfortunate one that picks up this virus and depending on the person, it can even attack your cardiac muscle. So there’s receptor sites in the cardiac muscle that will accept this attachment of the virus.

Janet (13:30):

Our elderly people with chronic conditions are at high risk for COVID and especially increased with fatalities, diabetes, uncontrolled with elevated blood sugars consistently has a 254% increase in fatality rates. Coronary disease, upper respiratory infections, such as pneumonia cancer, immune compromise, such as HIV, obesity, COPD, UTI’s, and renal disease, such as those requiring dialysis. They all are high risk for death infection complications, these increase fatalities. So nutritious key, remember many of your clients and remote referrals from the EMR available, and we are truly a phone call away. So for you that are nutritious lifestyles customers, please make sure that you as DONs and you as CDs have the dietitian consult cell phone number and email address and for after hours calls, please call us at our toll free number if you need help with a tube feeding issue or menu change, whatever call at 877-894-0401.

Janet (14:58):

So most facilities who assess this as screens, our pattern at nutritious lifestyles is to do screens using validated screens, such as this snack, such as the MNA, such as the MUST, are done at all admissions, and really should be done on all positive 19 patients. Because for COVID we know that those patients are very, very, very much at risk. Here’s an example of the MNA, so the MNA is one validated tool. It has an 86% accuracy of validity, right? That’s pretty good. So start nutrition interventions ASAP on high risk triggered residents, including COVID. So those that are at risk or in our nutrition receiving dialysis triggered because they have a poor appetite. They poor scored like an, a very low score on the Gnostic. Don’t feel like you have to wait for the dietician to start your nutrition care plans. Whenever you have a nutritional diagnostic within 24 to 72 hours of admission to your facility, you really should have started a nutrition interim care plan here for those who identify problems.

Janet (16:28):

So here’s a care plan for weight loss, we provide these to all our clients, and here’s a sample of an interim plan of care. Again interim plans of care should be implemented as soon as possible after admission between 24-72 hours for nutritional problems. This particular problem is the person has COPD they are at nutritional risk. They have diabetes, they have poor intakes and had recent significant weight loss. So our goal for this particular patient is to maintain a weight of 150 to 155. So our approaches are to consult the dietitian, obtain food preferences, add fortified food, monitor weights and intakes. So this is just a sample. And again, our survey process requires inner nutrition plans of care as well as other nutrition plans of care to address issues, including examples that pressure ulcers. So we want to start these interventions that are feasible and simplistic after identifying high risk status by your dietary management team and your nursing staff.

Janet (17:47):

There’s no need to wait for the dietitian, their role is to conduct a comprehensive assessment and add in what the status that may have changed between you and them seeing them, but also to implement additional interventions. So we need to make sure that we have a COVID positive client or someone that’s very sick or a new admission that we have a system makes sure our registered dietitian our nutritious diet tech that’s registered completes a comprehensive timely assessment on all high risk patients that are LTPN is have pressure ulcers that are Hema dialysis, on internal feed, which is also called TUPE they’re high risk and need to be seen by a dietitian, all COVID residents should have screens and also be monitored for nutrition interventions. So our rule as the team is once that dietitian or diet technician completes that assessment, we need to make sure that it’s done timely and those recommendations are in order. If the dietitian recommends fortified foods and they don’t get done, that’s an ineffective intervention that when the state comes and checks the tray line and there’s no fortified foods as there’s continued weight loss, it can result in an IJ, which we do not want that for you or for our residents. So we need to think about our assessment and look and see what’s going on and look for things the dietitian may have missed that we may have found out about by looking at, for example, depression based on the social services. So we know that we need to look at respiratory status. That’s the dietician solving that could have been in need of respiratory therapists that could have gotten a fever that could be shorter breath that could have developed because dehydration causes acute kidney failure.

Janet (19:59):

Maybe they didn’t eat well. They were discharged from our facility or back two days later with acute kidney injury that was attributed to dehydration. Are they all isolation, trays people, isolation, trays tend to eat less. Socialization causes us as humans to eat more. That’s why they call from, I believe it’s a week before Thanksgiving to January 1st, the holiday ten. So approximately people that are challenged to stay away from party foods. Many of them will gain 10 pounds over that period of time looking at their weight loss history poor appetites, dysphagia, again if someone comes in and is already weak and they get COVID and they lose a couple of pounds then they may or may not be able to swallow it very well or feed themselves because of declining hand strength, think about their taste. Maybe they’re not eating nothing and need to have enhanced food taste such as fortified foods, because their ability to taste is declined and really who would really mind if a diabetic had cake, we have insulin, let them eat and enjoy their food and get those calories in them. The lack of socialization, how does that affect intake? That intake the lack, when you have COVID, it weakens you, it causes lean body mass wasting. Did it reduce that said individual’s ability to feed themselves? Have they lost strength? Look at your PT and OT notes. If they’ve lost strength a lot of times it is related to weight loss. Read those notes and it’ll tell you a lot and of course COVID is associated with weakness. Here’s a sample assessment note that RD or in DTR, Mr. Van Loon is a 78 year old man with vascular dementia/Alzheimers, muscle weakness. He was currently a resident at Gentle Brook assisted living. Mr. Van Loon was discharged because they don’t take COVID patients there and he is positive for COVID-19, his intake is nearly 30% on average, his weight is 150, his height is 5’8, he’s had weight loss of 10% in the last two weeks, he leased 2100 calories at 85 grams of protein and 2000 CCS of fluid daily. On 30% it is clear he’s not meeting his needs on his regular no added salt diet. Additionally, when the dietitian saw him, she noted that his hand strength, he could not grasp her hand and hold it tightly for five seconds, which is a classic sign of muscle weakness and declining muscle mass. So Mr. Van Loon is struggling eating his meals independently in the middle of the meal he’s just tuckered out and at the end of meals, Mr. Van Loons is at the risk for nutritional declines and continued involuntary weight loss due to poor intakes in the acute diagnostic of COVID 19, the resident has complained to said dietitian and dietary manager that the food tastes like straw.

Janet (23:39):

So the dietitian recommended for the food service director to either pick up the initial food preferences or come back and revise them, refer to occupational therapy, to look at the need for adaptive equipment or restorative dining or assistance at meals offering 2 high calorie, high protein snacks because the intake, it will be an adequate or intake such as whole chocolate milk and vanilla cookies, such as cookies with milk or chocolate milk with a slice of pound cake, fortified soup and potato cycle lunch. So Monday you have fortified soup, Tuesday you have potatoes, Wednesday you have a different fortified soup and stuff, and throughout the week. Weekly weights, so our role is to take those recommendations and implement a plan of care or revise the current plan of care as clinicians in the facility as dietitians, but also as dietary managers and DONs. We all should be working together on the plan of care. So here’s the sample care plan. This would be a nutritional issue that’s related to acute COVID, so risk due to COVID-19 is positive. You had a positive test, poor intakes, taste declines and weight loss so our goal is to maintain 50% to 75% intakes. We’re going to consult the dietitian, monitor intake, weights, add fortified food, have 2 high high calorie, high protein snacks and we’re going to obtain and continue to honor the food preferences. That’s the solid care plan that absolutely has to be done by the 21st day post admission.

Janet (25:32):

So what we should be doing, even if a COVID person is not losing and is COVID positive, we need to be doing weekly weights. We need to use our EMR to identify those clients that are eating poorly. We need a red flag system to help them because we don’t want them to lose weight and we don’t want to address the poor intake after the fact of weight loss but before to catch it before the weight loss occurs. So visit your residents on your rounds, visit them and you can look at residents many times and tell they’re emaciated or losing weight. Their face looks like Jed Clampett’s dog on the Beverly Hillbillies and their face is all loose and heavy. Poor intakes are obvious if you’re doing a lunch rail, facial washing, weak handshake again, your strength is in your hands and it’s the first to go when malnutrition starts, skin condition, looking at feeding needs, collaboration with OT and ST and restorative diet reviewing ADL’s refer residents to the RD/NDTR as needed, ASAP when somebody is COVID. So you got the assessment that we gave you, but what else could we do? Well as a team, let’s chat, that’s the purpose of care planning and communication can we liberalize the diet more. Does it really matter if someone who has, COVID-19 lost 10 pounds if they eat a piece of bacon or if they add extra salt to their plate? Can we look at using enhanced flavor foods? For example, if everything tastes like straw, you might want to give an extra high calorie dessert, which a lot of people will be able to taste sweets, but nothing else. So look at fortified foods, always honoring the food preferences, comfort foods are big and inexpensive right now, macaroni and cheese goes over very, very well.

Janet (27:41):

It’s a starch and protein, easy to chew and very tasty and again, you’ll see more and more people converting to lots of mashed potatoes, softer noodles, spaghetti, and meatballs, shepherds pie, spaghetti pie. You’ll want to make sure that there’s good communication with the RD or the NDTR referrals would be an EMR process or telephonically visit the residents, aroma therapy. Many studies have shown, and I’ve seen it myself that around with therapy with meals as little as activity time can definitely help improve one’s appetite. These people get exhausted from feeding themselves a whole meal, perhaps a consideration would be to have five to six small meals a day. So for example, have small portions and 2 heavy snacks, like chocolate milk and more dunes at three o’clock to the tune of 250 calories at that meal and then they can have cereal and milk and banana, another couple hundred calories at night.

Janet (28:57):

Sometimes their fluid and their food consistency needs to be changed. If you’re too weak to eat, you’re probably too weak to cut your own food. Perhaps your meal needs to be slash mechanical saw, and certainly collaborating with the recap team and your peers. So for the nursing home industry, in my opinion, and also in any other dietician and physician’s opinion, diet should be a four letter word. We want to keep our residents weight on them. We want to make those people happy. They have a huge amount of time that they have been in a nursing home without a lot to do sometimes and so we want to make meals exciting. Specialization is important and it is positive as possible. The blood cholesterol, low fat, low sodium, diabetic, none of those diets have shown to have any positive outcomes on the elderly.

Janet (30:01):

So as we said before, many clients tell me that their food tastes like straw. So overcoming the taste straw, can we add extra fat? So for once in our life, we’re going to focus on adding more fat, not less are we adding liberal salt because you lose your ability to taste salt. If your elder person gets COVID, are we using spices or we use sugar to dice that food or make it spicy. Are we using cost-effective menu alternatives in foods that wake up the taste buds with experience using flavor, flavor enhancers like gravy, margarine, spices, Rosemary basil, lemon pepper, sugar, thyme, and yes MSG, unless you have an allergic reaction to MSG is a great flavor enhancer chili and cinnamon. So enhanced foods are the way to go for COVID-19 and people losing weight, you get a lot of bang for your buck.

Janet (31:06):

You get increased protein, increased calories, and increased fat intake. You can use half and half and whole milk versus low fat milk to boost those calories. You can use protein powder. For example, you can add to keep your costs down. You can make a pudding from a mix and use powdered milk in the product to beef up your protein content. eggs, meat patties. High calorie desserts. The elderly tend to love sweets, and when they have lost their tastes during COVID it has been explained to me that some of these sweet, soft desserts like peanut butter pie, that’s a cool product cream cheese product and a peanut butter mix powdered sugar mix product. It’s very soothing to them. That pairs flavor. That’s why Kentucky fried chicken made their sandwich this way, this past summer in may, it flew off the shelves. It was fabulous.

Janet (32:10):

The biscuits had fat in it, the fried chicken had fat. That frankly, it was a great flavor, butter and margarine carry flavor, pie crust carry flavor, gravies carrier flavor again, fat is a flavor carrier. So use it liberally to forget weight loss for COVID. You can use half and half the recipes in place of milk. So if you look at this, this is potatoes that are made with half and half mashed potatoes and a chicken type soup. I’m sorry, tomato soup. It has a half and half addition to it versus water. So a cup of milk has 103 calories and 8-9 grams of protein. A cup of half and half has 320 calories and 8 grams of protein. So are approximately 300% bang for the buck using that. I can have fortified foods of your recipes, your snack patterns, your foods increase your power. Raise, increase your protein because these people need it, but they’re so weak. They may not be able to consume large volumes of food. So we’ve got to pack those calories and protein in very small volumes.

Janet (33:30):

Think outside the box, look at your, we provide these to all our customers. Look at your recipe. Reinhardt, Cisco PFG boots. They all have fortified recipes. This is a particularly fortified recipe for peanut butter cookies. So if you see them as graham crackers which are easy, add a mixture of to a smooth consistency and like a scoop of number 16 and bake it off. So those have 150 calories for one more cookie and two grams of protein compartment that would be chocolate, whole milk, 108 calories, eight grams of protein, 330 calories, 10 grams of protein. It’s an exceptional snack. So we can always take our recipes and fortify them. You can look and see that they have different things. So these menus that help fortify them at least once a day to provide some of those delicious fortified products, such as the fortified oatmeal.

Janet (34:35):

We always as clinicians, dietary managers, DON’s and RDS need to make sure we know what the needs are. Reading the chart and looking at intake. So if someone needs 2,400 calories a day and we are only able to give them or they are able to consume 50%. That is only going to be anywhere to a thousand to 1200 calories clearly would not meet their needs. Extra protein calories are needed that this person may not be able to take a lot of volume. They regular diet for most of the programs is around 2,400 calories and 85 grams of protein review the RD/NDTR assessment compared the intakes, meals and menus and close the gap between needs and intakes, the medical nutrition balance, make your snacks, high calorie, high protein, a quarter sandwich, which I call lady finger, you can get between a slices of a sandwich for like a pimento sandwich or a peanut butter sandwich, ice cream, yogurt, milk, and sugar cookies, power pudding, which is using, um, you’re going to use half and half and then add powder milk to that and boost your calorie and protein count of your pudding.

Janet (35:59):

You also can use a brownie and chocolate or plain milk. So there’s many different ways to use high protein, high calorie snacks. Again, many people cannot eat a lot at one time because they just frankly get winded for shortness of breath. So it might be a consideration to give them a brownie in the afternoon and maybe a lady finger, which will be two strips of peanut butter and jelly, or either pimento cheese sandwich and whole chocolate milk or plain milk at night, boosting those calorie intakes with less volume. So again, a lot of COVID clientele, they simply cannot consume three large meals a day. Our stomach can only haul 24 ounces or so a day is that normal human being. And a lot of times I am told that COVID has negative GI distress and causes the person a potential feeling of gas and nausea and fullness.

Janet (37:03):

So adding five to six small things a day, small portions, that meal, powerful nutritional snacks, for example, the peanut butter cookie and the chocolate milk, 330 calories and lots and lots of protein to support skin healing and COVID recovery success. Making your food a fortified food program is certainly not going to hurt anybody with extra butter and powdered milk in a soup like cream tomato, look at your bread program. It’s great to have a soup kettle and bread program, and lots of buttery sauces to go with that grid who wouldn’t like honey and butter on a piece of corn bread and tomato cream of tomato/basil soup. Aroma therapy can be used by therapy to have an Otis Mayer cookie machine and that fills the entire facility with smell. This is very appetizing. Socialization is important at meals.

Janet (38:11):

So an example of how you might use a soup cart in a dining area would be to see Mrs. Jones take the soup cart up to the four tops you visit with them. We have tomato soup, and let’s say the other cream of tomato soup. she’s frail. She weighs 90 pounds and we also have a salad. So your CNA, if she’s on the red napkin program can say Mrs. Jones, Would you like the tomato soup today? And guess what? We’ve got honey, cornbread and I have butter. Would you like me to pre-butter it for you? We have delicious, great punch. So it is up to be 720 calories and she eats 50% of that. I would be a static because that’s a great meal, a hundred pound female. Remember for females, you can take their weight times 10-12. Well, that’s how many calories they need a day, unless I have a credible validity that increases your calorie needs.

Janet (39:17):

So a lot of these frail elderly people, by fortifying their meals, you can get a lot in them with less volumes. So that’s really key. Aromatherapy benefits us all. Have you ever walked in a nursing home instead of smelling Brussels sprouts, smell biscuits? So when we’re making those products, let’s keep the dining rooms open. Let’s keep the smell. Let’s think about putting Otis’ spunkmeyer machine in activities or the lobby. Let’s look at doing dessert carts and with piping hot coffee with the smell, let’s look at soup carts and looks, look at buns being hot and available with the odor coming in the dining room area, dessert carts are great and to keep your costs down in your dining area, you can always have a fortified cookie for those on that need those extra calories attracted dessert carts can make your food cost go down. Can you use it for leftovers? You can get this particular ice cream cookie has 500 calories and 4 grams of protein, and it looks beautiful. You can have cobblers. You can have cake, you can have sheet cake, all relatively inexpensive products that we can doctor up and add more calories and protein, and then boost the calorie intake with very small volumes of food.

Janet (40:49):

As clinicians we know that people eat with their eyes, we do. So we encourage you to work with your food service directors and your team and your nursing department, and make sure our food is presented in the most attractive way possible. So which plate would you eat? Would you like to have pure red rice? And even though it’s for pureed fish, which is like grayish, brownish, tan, maybe, and then light tan, no color varierty or had you rather have a plate that has fried chicken strips, matched potatoes or rice and asparagus or green beans. Lots of color variety. Remember we all eat with our eyes, not just our mouth. by providing low calorie, I’m sorry, low calorie and high calorie beverages. It can be a really, really positive way of getting extra calories in individuals. So it’s very, very easy to get dehydrated.

Janet (42:05):

When we get elderly, our kidneys are not able to tell our brain that you need to drink. So we need to flip us those fluids, push, push, push fluids. We can do that with residents that have inadequate intakes by making it taste good, high calorie, low costs, beverages, fruit punches, tea with sugar, grape punch, kool aid type beverages lemonade punches in those all in eating adequate fluid intakes can help reduce falls infections by keeping our bodies healthy. So patients that need thickened liquids, and we need to pay special attention to them and really make sure that they do get enough fluids and enough calories. One, 8 oz glass of lemonade has 120 calories. Again, looking at all calorie sources to keep that weight up. Here’s your punch, another product and only costs 3 cents. A lot of bang for a very small buck. o, and I’m giving a class in the near future on this and that everybody will be able to attend that. One of the biggest issues that we’re getting concerns about is the lack of socialization in dining rooms. You know, where you’re being so careful when we appreciate them to avoid COVID. But one of the main concerns about getting COVID is isolation. So people that are isolated, they still don’t want to eat meals. Mealtime traditionally is a socialization time. So how can we make our dining programs, social events by using plexiglass? So people can sit together and be safe by giving them choices that create a positive music atmosphere by making it a fun cinco de mayo meals, Tuesday tacos, lots of different ways to make those theme meals a tie in day country, fried chicken day, lots and lots. Look at calendars. They have all kinds of days like ice cream, holiday garnish plates.

Janet (44:36):

You don’t want white on white on white plates. So if you have fried chicken, mashed potatoes, you have green beans and you have a curl of an orange on there. That’s very, very attractive. Making sure that the OT is seeing those people that need adaptive equipment. If we’re providing it on the tray, we’re care planning, making sure that someone is in the dining room manager on duty, encouraging the staff to make sure they’re doing what they do. Again, inspect and don’t expect having any conversations with those individual residents. How are you doing what’s going on? You miss your family? I understand. Let me give you an extra piece of that cobbler and let’s make that better for you music in the dining room. MOD means manager off duty. I’m a big advocate for our people to do what you inspect, never what you expect.

Janet (45:35):

So here’s the example of an attractive dining room, right now they’re in the far corner, there is a table over there with a plexiglass, making sure all your food looks really good. And if you look at that cupcake only took some premade cookies, a couple of chocolate chips, and it also is a plain yellow sheet cake batter dumped into a cup, come back down iced the next day and look at what you have. Same thing for this brownie, very attractive. Say your leftovers. If you have leftover bread, make your bread pudding from it. If you have extra things that are leftover from bread, bread pudding, if you have other things such as leftover pudding and leftover cake make parfait . So use those leftovers frequently and healthily to make these residents excited about what they’re eating. So this slide was provided to me by our staff and I wanted to thank them for providing this information to help us make those foods for isolation, because we have facilities that have had up to 60 people COVID positive.

Janet (46:54):

So what did we do? Well, we were using isolation and the cups & plates. So Darren Dewitt, Johnny Dean and Eric Jones have a culinary background and also are RDS that work with nutritious lifestyles. They top their hot food with aluminum foil. They have found that increased heat retention, casseroles, like for example, in a casserole increases heat retention, batch cooking. Keep cold in your cold containers, hot in hot, avoid soggy food by using portion cups for your sausage, personalize that tin with the name and a smiley face. They will appreciate that. That is the way of socializing with them. Even though you can’t see that, use baggy/Ziploc and put ice in it for cold items on the cart, use garnishing more for those isolation trays again, they don’t get to get out of their room and see people add pops of color. Excuse me, add an orange wedge, a slice with mellon, pickle wedge, pickle spear, lots, and lots of opportunities. a slice of beef, slice of spiced apple rings use fresh herbs, use shredded cheese and bacon bits on potatoes and soups Desserts, you could easily make a short sheet cake for 10 bucks to serve most of the nursing time. Put a cool whip topping on it and put a chocolate chip for two and you get a great dessert or drizzle with sauce and sauces and condiments using squeeze bottles.

Janet (48:43):

So we can make some of our puree foods and also soup foods of the day. We can save our leftover chicken piece of beef, etc. Daily. After the trayline, instead of throwing out one chicken breast, we can freeze it. We can puree it. We can add it to the soup for those COVID-19 residents’ benefit. We can save leftovers from the day before to offer alternatives for our residents. Everyone likes choice, even someone that may not be eating that well, it may improve the content of their meals in their cohort intake. If you give them the option to choose, everyone wants choices in life. Create a high calorie high value, nutritionally dense snack rotation, alter your menus to get the very, very best retention on foods for hot and cold. You can go to unit trays, use aesthetic appeal, color, Temperatures and shapes at meals, especially isolation trays, try to put your mind on how you would accept the tray and make sure you would be one you would want to eat from there. A lot of negative factors would COVID, especially now. Some of the states are opening up to visit and surveys by the way, but a lot of these patients, they don’t understand COVID and the staff don’t understand it either and it causes a great amount of anxiety send that referral to social services so she can work with the physician and that patient owns the increased activity. Staying busy, et cetera.

Janet (50:34):

At any point, if a resident cannot eat COVID or not COVID and is losing weight, for example, maybe they’re on the ventilator and their throat is so sore that they can’t swallow. You immediately need to refer that to STD RD, et cetera so get them involved. If any point a resident cannot eat is losing what develops a pressure ulcer. You need to reach out to your RDN immediately or DTR. We are there for you. We all have cell phone numbers and we can be contacted electronically as well by an email. Does the resident, as we’re going through this COVID experience, have they lost weight? Can they feed themselves or do they need help. If they do, help them recommend that they’d be seeing OT or ST to assist them in meeting their nutritional needs, individual plans of care should be based on the rest and what they need and what they want.

Janet (51:42):

We are all different. Some people with or without COVID, want four things a day. That’s okay. We’re all different. We’re not cut out of the same clothing bottle. So again, COVID can fatigue and we individuals may need frequent hydration and texture changes. They may get COVID on Monday, be on a regular diet then be constipated and weak by Thursday if they need a mechanical soft. So that is a constant change in communication is key with nursing, the RD, DTR, a speech pathologist and occupational therapists. We’ve got to look at what they need and close those gaps to get good nutrition, to keep them healthy. We need to focus on our interventions being feasible. We need to monitor for outcomes. If you do an intervention, they’re still losing weight then that can rethink the intervention, try something different, doing new plans of care based on the problems that we’re revising old plans of care, if you will, based on updates and changes and the acceptance, the interventions and changes and goals and approaches. COVID is not a team approach. Again, hand sanitation, masks, sanitizing, and disinfecting the kitchen areas are important. We are working together as a team, food service, RD, NDTR dietary manager, CDN nursing rehab, OT, PT. The physicians are their delegated nurse practitioner or physician’s assistant and social. This is truly a team disease, team problem.

Janet (53:31):

Remember nutritious lifestyles is a click or call away. We are here for you. Please reach out to Logan Stackhouse at the above email. If you need anything we can help you with cost control, helping with survey preparation. We are here from you. If you need to get information about your city, use Michelle Mabry to be available to you at the email address and my name is Janet McKee again, I thank you for your time and I value the opportunity to work with you. Thank you.