Sunshine Terrace Semester Project

Written by: Lea Palmer

Step 1: Make a nutrition treatment plan for a group of residents

Patients (Highest to lowest risk factors)

SH: sepsis, UTI, respiratory failure (check calorie needs), obesity, gout, acute kidney
failure, lymphedema, difficulty walking; BMI:
HG: heart failure, difficulty walking, muscle weakness, hypertension, obesity, edema,
osteoarthritis
VM: difficulty chewing/ swallowing, difficulty walking, osteoarthritis
TG: spinal injury, cognitive issues, Parkinsons Disease
WK: fractured ischium, difficulty walking, muscle weakness, epilepsy
Patient Interview notes:
Low High Risk

WK:
Disabilities: Difficulty walking, uses wheelchair
Allergies: None
Dx: closed fracture of ischium, aftercare for healing traumatic fractions, difficulty in
walking, muscle weakness, atherosclerosis, leukocytosis, epilepsy, obsessive behaviors
Appearance: good HEENT, no sores
Dietary:
o Bfast: pancake, sausage, cream of wheat, coffee, peach juice, etc.
o Lunch: Normal Diet
o Dinner: Cheeseburger, spaghetti, or pizza
o % PO: 100
Social: loves to read. Doesnt do a lot of group activities
Nutritional Needs: bone nutrition, limited physical activity improvement
RD needs:
TG:
Allergies: None
Dx: clos ex dorsal vertebra w/o metion sp cord injury, cognitive functional issues,
Parkinsons Disease
 Disabilities: In a wheelchair- clos ex dorsal vertebra w/o metion sp cord injury, cognitive
functional issues, Parkinsons disease
Appearance: hunched over
Social: likes to spend time in community area,
Dietary
o % PO: 75
Nutritional Needs: bone nutrition, limited physical activity improvement

VM:
Allergies: Cinnamon
Disabilities: Hard of hearing, needs a walker, has difficulty chewing hard things, and
needs to chew a lot before swallowing
Allergies: Cinnamon
No nutritional knowledge on osteoarthritis
Hx of smoking
Appearance: good HEENT, hunched shoulders, no edema, dry skin, missing some
teeth, no dentures
Dietary:
o Bfast: 2 slices bread, bacon, coffee (doesnt taste as good), mush, milk, juice,
water
o Lunch: mashed potatoes with gravy, (was given BBQ chicken but sauce was too
strong to eat)
o Dinner: Normal diet
o Goes out to lunch room to eat most of the time
o % PO: 75
Food Preferences: loves yogurt, ice cream bars, not many options.
Social: has a dog at home, very family oriented
Typical Day:
o 10 or 10:30: exercise in room, up & down hall, relax, every afternoon/ morning
o Afternoon 2-3x: goes for a walk, but gets unnoticed and CNA comes in saying
she needs to be more active.

Nutritional Needs: bone nutrition, limited physical activity improvements

HG:
Allergies: cherries
Dx: chronic diastolic heart failure, difficulty walking, muscle weakness, unspecified
myalgia & myositis, unspecified hypertension, obesity, esophageal reflux, osteoarthritis,
pure hyperglyceridemia, chronic lower edema, hypercalcemia, high fall risk.
Disabilities: difficulty walking,
Social: Both times I went in to talk to her, she was out
Dietary:
o % PO: 100%
Nutritional Needs: heart healthy diet, weight loss to help with obesity, limited physical activity
improvements

SH:
Allergies: None
Dx: Severe Sepsis w/o septic shock, UTI, chronic respiratory failure, morbid obesity,
gout, acute kidney failure, lymphedema
Disabilities: difficulty walking
Social: out with family both times
Dietary:
o %PO: 100
Nutritional Needs: higher protein needs r/t sepsis, weight loss to help with gout and obesity
improvements
RD: supplements, group activity work

OT:
pool only available for rehabilitation, PT/OT only happens when decline shows, restorative
therapy/ music therapy/ rec therapy available for preventative.

Similarities between residents: difficulty walking, muscle weakness, osteoarthritis, obesity

Other considerations: SH with kidney failure
Nutritional Needs (related to bone health):
Dietary- teaching importance of protein and calcium and bone health
Physical therapy- building up strength in joints
 CNA- recording daily improvement ratings on both physical progression and mental
motivation.
Activities- coordinate activities each month to emphasize the importance of nutrition and
bone health.
Other Nutritional Needs:
Respiratory Failure: monitor and evaluate calorie needs
Lymphedema and obesity: group exercise classes, one one one exercise training,
weight loss program
Chewing/ Swallowing difficulty: follow-up with speech language pathologist for therapy if
not doing so already.

Nutrition Plan:
Mission:
Building bones project will target residents with bone related problems and will involve a series
of activities, educations, and supplements.

Objectives:
To increase knowledge among residents on nutrition related to bone health
To build confidence and motivation in each resident throughout physical therapy
Increase access and awareness of Calcium, Vitamin D, and protein.
Create a support group approach to bone health involving basic activities, lessons, etc.

Reason for need:

Many residents at Sunshine Terrace are experiencing osteoporosis and some

sarcopenia, which are typical degenerative diseases when it comes to aging (Gaffney). The
prevalence and progression of these degenerative diseases increase fall, and even mortality
risk, and should be addressed. Factors to be addressed include nutrition, physical therapy and
support systems.

Nutrition: Some major nutritional components to bone health include protein, vitamin D, and
calcium. Among the elderly, protein is not consumed in sufficient quantities. Protein is a key
factor, however, in bone and muscle health and density. In addition to insufficient intake, the
aging process also takes a toll on absorption, which decreases the amount of protein actually
absorbed even more so. One study showed that elderly individuals consuming 1g/kg body
wt/day were able to maintain protein status (looking at protein serum and upper arm mass). A
10-year longitudinal study found that when elderly individuals consumed 1.2-1.7g/kg/day, they
were at less risk of health problems than individuals consuming .8 g/kg/day. (Gaffney) Another
component is Vitamin D. Vitamin D allows calcium to be absorbed into the bones. Vitamin D
deficiencies have become more common because of the increased use of sunscreen and less
exposure to the sun. (HOLLICK) Elderly, especially those in nursing homes are at a really high
risk for deficiency because they are mostly confined to the indoors. Vitamin D isnt available in
many foods so it is important to address to an elderly individual of whom is living in an assisted
living facility and doesnt spend much time outdoors. Calcium is a third important component of
bone health. Calcium is key to strengthening and building up bone tissue. Without these
components bone tissue begins to metabolize causing osteoporosis and risks related to that.
Currently at Sunshine Terrace, my assigned residents are all experiencing some form of
bone disease and do not have known access or knowledge allowing them to improve their
situation. The snack basket available consists of chips, fudge, cookies, granola bars, ritz
crackers, and chex mix but does not provide any healthy protein-dense snacks. The residents
need education and access for bone healthy options. Following are my plans to address the
needs.

Plans to address needs: Building Bones Project

Objective 1: Increase knowledge among residents on nutrition related to bone health
I will go to each resident and educate them on protein, calcium, and Vitamin D in regards
to bone health and give them the Building Bones Challenge.

Objective 2: Build confidence and motivation in each resident throughout physical therapy
During education w/ patient, discuss the importance of physical therapy on strengthening
the muscles around joints and bones.

Objective 3: Increase access and awareness of Calcium, Vitamin D, and protein

Talk to kitchen RD about ordering high protein foods for a Protein Power Basket in
addition to the regular snack basket on each floor. (See if there will be access to a fridge
on each floor for cold items) Have CNAs offer snacks to every resident daily.
o Room temp items: Protein Bars, high protein shakes, Gosners white and
chocolate milk, honey roasted peanuts
 o Cold: individual cottage cheese cups, string cheese, Greek Yogurt cups, Gosners
milk
Have CNAs offer each patient to assist them outside for 15 minutes each day for extra
Vitamin D
Change out designated room lights with UVB lights and inform residents that they can go
sit in the room for 15-20 minutes for an extra boost of vitamin D.

Objective 4 : Create a support group approach to bone health involving basic activities, lessons,
etc
Present to activities director ideas for a monthly bone health activity. Ideas include:
o Protein Shake taste testing (have residents vote on their favorite and have those
available on each floor in Protein Power snack basket)
o Bone Health Seminar
o Discussion group (allow residents to discuss bone health challenge to help
motivate them to continue- this can be done every other month with other
activities in between)
o Got Milk? Day (have an activity to show how drinking milk can help someone get
enough calcium and Vitamin D, have it themed a day on a dairy farm and have a
dairy farmer come talk to them about the nutrition of milk)
o Soak in the Sun: Take everyone outside for 15-30 minutes a snack and a lesson
on Vitamin D and the sun. Challenge them to go outside at least 15 minutes each
day.
o Jeopardy- Teach a short lesson about bone health (incorporate physical therapy,
vitamins, food, etc) and then play a game of jeopardy to test their knowledge
o Skit night: Have an RD, nurse, physical therapist, and kitchen staff member put
on an entertaining skit and emphasize bone health in an entertaining way.
o Dining to have healthy bones: In the dining hall go around and give out little
informational cards on bone health. Talk to residents about what foods they are
eating, and how those play a role nutritionally.

Sources:
Gaffney-Stomberg E, Insogna K, Rodriguez N, Kerstetter J. Increasing Dietary Protein Requirements in
Elderly People for Optimal Muscle and Bone Health. Journal of the American Geriatrics Society.
2009;57(6):1073-1079. doi:10.1111/j.1532-5415.2009.02285.x.

Holick M. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and
cardiovascular disease. The American Journal of Clinical Nutrition. 2004;80(6). Available at:
http://ajcn.nutrition.org/content/80/6/1678S.full. Accessed February 26, 2016.

Step 2: Initiate your nutrition care plan

Why isnt your plan in place at the facility already?

I talked to Sue Rock and she let me know that nurses are able to come pick up items
from the kitchen that could be part of that Protein Power Basket. The problem is
communication to the residents on availability. Educating the residents on protein
sources and letting them know that they can order protein snacks will really be
beneficial with the Building Bones Challenge
Do you think your plan would work at other facilities? Why or why not?
I think that this program is simple but beneficial to any facility. Having an initial one on
one education with the resident followed by group activities and emphasizing protein
snacks and milk will really help.
How could you work to get your plan implemented?
1. Talk to Sue about ordering protein snacks for a protein basket.
2. The next step would be to educate residents on bone health nutrition so that they
have an awareness of options, give bone challenge.
3. Talk to activity director about having an activity group with a building bones
emphasis, making sure to let residents know especially if they have osteoporosis.
What partners would you need?
Sue Rock- Kitchen RD- She can help me implement a Protein Power Snack basket
Cory Funk-Activities Director- Can coordinate Building Bones Activities on a monthly
basis.
Maintenance manager- Can start ordering a few UVB light bulbs for certain rooms
CNAs- first line promoters of protein, calcium, and vitamin D
What benefits would there be to the institution for using your plan?
If an institution incorporates this program the common deficiencies of calcium, Vitamin
D, and protein among elderly adults will be addressed and hopefully improved. The plan
is simple enough that it would not take much to implement, but would be very beneficial
to the residents whether or not they have bone problems.

Step 3 & 4: Review and Evaluation

Building Bones Project
Over the course of the three visits plus a couple extra days, I was able to assess
five patients and begin to implement a good majority of my Building Bones project. It
provided the beginning stages of meeting the bone health challenge needs of the
residents, but did not address the other problems. I feel that with more time and
planning, all of the issues could be addressed but the limited amount of time restricted
the magnitude of intervention. One barrier I expected was lack of support from the
facility, but everyone that I talked to about the program were fully on board with it.
For the first step of the assignment, I went in and talked to my assigned
residents. I was never able to meet with a couple of them because they were always
gone during the hours that we were at Sunshine Terrace, but I still was able to get some
critical information based off of their medical file. For the assessments I looked at the
basic information that I would look at for any nutritional assessment including
anthropometrics, medication lists, clinical observations, dietary, and any extra
information. I then categorized and prioritized the nutritional needs with every resident.
The group of residents that I assessed all had some form of bone degeneration issues
and I knew that bone health would be a problem for most elderly individuals, so I
decided that bone health would be a good focus for my project.
The Building Bones project had several aspects in order to reach needs more
fully. I started with one on one counseling and discussed bone health with the assigned
residents. I gave them a building bones challenge handout to help motivate them to
increase protein intake. I feel that the idea behind the challenge has some potential, but
there is a need for more education and support before it will really impact the residents.
The residents I talked to didnt seem to have a strong interest in the handout, but they
also didnt seem to understand the association between nutrition and bone strength. I
feel that if there were a few group activities addressing bone health, and possibly
targeting different residents initially, the challenge would be more successful. Residents
such as those in the rehab wing, who are actively trying to recover so they can go home
might be at a higher level of motivation to try the challenge.
The second part of the project that I was able to start involved the initiation of the
Protein Power basket. The nurses and kitchen manager were all excited about this
idea because it provided better access to residents. We ended up finding out that foods
such as cottage cheese were already available in the kitchen, there just wasnt any
communication on the availability to the residents for snack time. Sue was able to have
cottage cheese portioned out in the mornings to be brought to one of the wings as a test
run. This is just a start, but hopefully with time, the nurses will be able to add to the
Protein Power basket.
The third part of the project that I was able to start was the monthly building
bones activity. I feel this was probably the most successful part of the project, and much
of that had to do with how willing the activities director was to start the program. The
recreational therapy department is always looking for new ideas for activities, especially
to those relating to healing and health, so this project was perfect for that situation. Cory
Funk, the activities director, was able to meet with me during spring break and discuss
my ideas and the options that we had. He asked me to plan an event for April and
based off of what I did, he would continue the events in the following months. For the
event, I created a protein power presentation, and did a protein drink taste-testing
portion. I first came up with an outline and supply list that Cory was able to obtain (see
attached). I then created a presentation that discussed the building bones project, the
benefits of protein, how to obtain protein, how much protein they should eat, and
information on each protein drink they were going to taste test. The four drinks I chose
included the eggnog Ensure made in the facility kitchen, high protein chocolate Boost, a
homemade chocolate peanut butter protein shake, and a homemade Black forest cherry
protein shake. On the day of the event, I came in early to help prepare the shakes. I
then went with the activities director assistant to find residents who were awake and
willing to go to the protein drink taste-testing event. We had only about six residents
attending because it was a Saturday morning, but it still turned out to be a success. The
presentation and taste testing turned out really well and a couple of the residents
showed interest in protein so they were asking several questions throughout the event.
After the taste testing, and taking the residents back to their rooms, the activities
staff took the leftover samples around to different rooms so that more people were able
to try the different shakes and hopefully ask a couple questions about them. I felt that it
was such a great experience that I asked Cory if I could do the events for the summer
before I leave for Salt Lake, and he was more than willing to give me that opportunity.
For the future events, I will plan a time during the week when more residents are
available. I had to do a Saturday morning event for the protein drink taste testing due to
time constraints, but having a time during the week will really help with the turnout
numbers.
Overall, creating and implementing parts of the Building Bones Project was such
a great experience. Not every part was fully implemented, but I was able to take the first
step for each thing that I planned. Chronic issues such as bone degradation are
problems that take time to fix, especially in an elderly population. By taking small steps,
however, the residents might be able to really benefit from the interventions, and make
changes for themselves. This project helped me learn skills required implementing
intervention-based programs, and it was really exciting. The most rewarding moment
was after all the planning and implementation and then one of the residents asked
simple questions about protein with a genuine interest in bone health. That was the first
step to her making a change in her life, and I hope that she will. I also hope that over
time, the idea of bone health will be more prominent throughout sunshine terrace.
Appendix:
Building Bones Project
Month: April
Topic: Protein Drink Taste Testing

Building Bones Project Objectives:

Objective 1: Increase knowledge among residents on nutrition related to bone health
Objective 2: Build confidence and motivation in each resident throughout physical therapy
Objective 3: Increase access and awareness of Calcium, Vitamin D, and protein
Objective 4: Create a support group approach to bone health involving basic activities, lessons,
etc.

Event Objectives:
Objective 1: Increase awareness and understanding of protein benefits through a fun taste
testing activity.

Outline of event:

10:00 Introduce topic with slide show presentation- challenge

10:30 Introduce protein drinks and taste testing
10:45 Go through each drink
11:00 Announce winner of the protein drink
11:15 Concluding remarks

Preparation:
Purchase four protein drinks that Sunshine Terrace would be willing to purchase in
bulk in the future
o Talk to Sue?
Purchase sample size cups or use 1.5 oz portion cups from kitchen
Prepare Slide Show/ presentation.
Reserve room for demonstration
Create fliers for event
Advertise to residents
Recruit 4 people to help serve protein drinks
Set up tables for residents to sit at

After Event:
Clean up event area
Have the winning protein drink ordered for the wings
When each wing gets their supply, have them portion out sample cups to all the
residents so they can sample the new addition to their protein basket
 Protein Drink Taste Testing Preparation

Drinks (2 oz sample sizes): 40 oz or about 5 cups total of each

1. In-House Ensure

2. Chocolate Peanut Butter shake

Ingredients Amount Needed Directions
Chocolate Protein Powder #1 4 scoops Blend up until smooth
Whole Milk 2 cups
Banana 2
Creamy Peanut Butter cup
Ice cubes 2 cups

3. Black Forest Protein Shake

Ingredients Amount Needed Directions

Chocolate Protein Powder #2 4 scoops Blend up until smooth
Whole Milk 2 cups
Banana 2
Frozen Dark sweet cherries 2 cups
Ice Cubes 2 cups

4. Vanilla Carnation high protein drink (or even high Protein Boost drink):
http://www.walmart.com/ip/Carnation-Breakfast-Essentials-High-Protein-Classic-
French-Vanilla-Complete-Nutritional-Drinks-8-fl-oz-6-
count/44886190?action=product_interest&action_type=title&item_id=44886190&p
lacement_id=irs-106-
m2&strategy=PWVAV&visitor_id&category=&client_guid=a85717fc-0ad3-4c3a-
a570-
7b11e2f57797&customer_id_enc&config_id=106&parent_item_id=47088942&pare
nt_anchor_item_id=47088942&guid=9d9a1d64-5c3e-4f11-862c-
f81ce110ffcb&bucket_id=irsbucketdefault&beacon_version=1.0.1&findingMethod=p
13n
We Need:

For recipes:
5 cups/ 40 oz of in house Ensure
Carnation high protein drinks or Boost high protein drinks
Whole Milk
4 bananas
Creamy peanut Butter
Ice
Frozen Dark sweet cherries
2 chocolate protein powders

Other:
Dixie cups or small portion cups for testing
Tables for everyone to sit at
Blender
Pens for everyone
Screen to put a PowerPoint up on/ computer
MIC and sound system
Trays or cart to bring portion cups out on

Prep for event:

Prepare drinks
Portion into sample cups and put on a cart or trays
Set up PowerPoint
Put handout/ cards at each place setting

Event:
10:00 Introduce topic with slide show presentation
10:30 Introduce protein drinks and taste testing
10:45 Announce winner of the protein drink/ closing remarks
 Building Bones Challenge
Protein, Calcium, and Vitamin D are all so important when it
comes to strong healthy bones, joints, and muscles. Take
the challenge and strengthen your bones for a stronger,
healthier, and happier lifestyle!`

Protein Points Goal: __________________

Power Protein (20+ grams): 4 points

Beef
Chicken Breast
1 cup Edemame/Soybeans
Fish Fillet
Pork

High Protein (10-20 grams): 3 points

cup Cottage Cheese
Protein Shake
1 cup Oatmeal
Tuna Sandwich

Medium Protein (5-10 grams): 2 points

Cup Yogurt
Large Handful of Peanuts
2 Tablespoons Peanut butter Cup Beans
1 Egg
1 Pack Peanut Butter Crackers
1 Cup milk

Good Sources of Calcium Good Sources of Vitamin D

Yogurt, Orange Juice, Milk, Spend 15 min a day outside!
Salmon, Turnip Greens,
Milk, Yogurt, Fish, and Eggs
Cottage Cheese, Breakfast
Cereal and Broccoli