Use of Standing Orders for Care of Renal Patients

Practical Aspects

Use of Standing Orders for Care of Renal Patients Linda McCann, RO*

S

ATELLITE Dialysis Centers, Inc. is a nonprofit, multiunit outpatient dialysis provider in Northern California that uses an *Nutrition Services Coordinator, with thanks to M. Aaron, RD, J. Boccanfuso, RD, S. Brooks-Schulke, MS, RD, S. Belanger, RD, E. Emery, MS, RD, K. Hansen, RD, F. Tootel/, MS, RD, and M. Torres, RD, Satellite Dialysis Centers, and M. Mayfield, MS, RD, EI Camino Dialysis, Mountain View, CA. Address correspondence and reprint requests to Linda McCann, RD, Satellite Dialysis Centers, 585 Glenwood Ave, Menlo Park, CA 97025. © 1991 by the National Kidney Foundation, Inc. 1051-2276/91/0104-0005$03.00/0 Patient Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

adaptation of the standing-order format. The use of standing orders by renal dietitians (RDs) facilitates the routine care of renal patients. A standing order (Fig 1) outlining the routine care that can be delivered by the dietitian under the physician's direction is placed in the chart for each patient. General guidelines for care are given allowing the dietitian flexibility to adapt the patient's treatment-yet remain within the parameters of the patient's medical treatment for which the physician is legally responsible--without contacting the physician for every change. PatientlD #

POLICY:

Nephrologists authorize RDs to initiate nutritional interventions according to approved standing orders.

PURPOSE:

To provide timely and consistent nutritional care for the patient.

PROCEDURE: The RD may write orders within the guidelines of standard orders, which will be accepted and implemented like a physiCian verbal or telephone order. The written order will then be sent to the MD to co-sign for legal and communication purposes. AUTHORIZATIONS INCLUDE: 1. DIET ORDERS-within accepted practice and determined by individual patient needs including concurrent medical problems, urine output, fluid balance, serum chemistries: a .. 8-1.5 gm/protein/kg body weight b. 20-50 calories/kg body weight c. 1-4 g sodium d. 2-4 g potaSSium e. 15 mg/ g protein dietary phosphorus f. 0-2,000 mg calcium (dietary and supplements) 2. NUTRITIONAL SUPPLEMENTS a. Protein b. Calories c. Vitamins 1) Renal formulas 2) B-complex plus C at RDA levels and folic acid (400 fJog-1 mg/d) d. Minerals 1) Calcium 2) Zinc 3) Oral iron EXCEPTIONS:

3. Calcitriol or vitamin D per unit treatment procedures* 4. Phosphate binders per unit treatment procedures 5. Initiate IDPN needs assessment a. Quality patient per Medicare reimbursement protocol 6. Kinetic modeling a. Initiate request for pre- and post-BUN b. Model patient on current therapy c. Model patient for alternate therapy d. Present data to MD 7. Over-the-counter fiber-laxative products per unit treatment procedures 8. Nutritional education plans/priorities a. RD will consult with other members of team to educate regarding dietary needs and reinforce education for patients taking into account 1) Patient's education level 2) Family support 3) Ethnic background 4) Language spoken 5) Ability to understand 6) Food preferences

MD will notify RD/head nurse of exceptions to these orders MD Signature

Date

EXCEPTIONS: FIGURE 1. PhysiCian's standing orders for the RD. MD, physician; RDA, Recommended Dietary Allowance; IDPN, interdialytic parenteral nutrition; BUN, blood urea nitrogen. *, "Per unit treatment procedures" refers to the individual parameters developed for each treatment component. (Modified and reprinted with permission from Satellite Dialysis Centers, Inc., Menlo Park, CA.)

Journal of Renal Nutrition, Vol 1, No 4 (October), 1991: p 187

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