Learning Outcomes
By the end of this section, you should be able to:
- 9.4.1 Evaluate a nutritional plan for its effect on hematological wellness.
- 9.4.2 Modify a nutritional plan to promote hematological wellness.
Evaluating Client Readiness to Follow a Nutritional Plan
Assessing a client’s readiness to change their nutritional lifestyle requires a collaborative conversation. The nurse should emphasize the direct link between iron-deficient anemia, their current eating habits (craving ice and lack of iron-rich foods) and their recent symptoms. Evidence-based research has shown that clients are more likely to engage in healthy behavior if they believe that their symptoms and complications will negatively affect their lifestyle (Lee & Chung, 2021). Often the only motivator prompting change is the presence of unpleasant symptoms. The next step is for the client to reflect on how they feel about change and what they need to be successful. At this point, the focus should shift to providing additional nutritional knowledge, such as specific dietary needs, and establishing the client’s desire to achieve change. The use of a scoring scale can be helpful, asking questions such as
- “How important is it to you to make this change, on a scale of 0 to 10 with 10 being extremely important?”
- “How confident are you that you can make this change, on a scale of 0 to 10 with 10 being extremely confident?”
The nurse must keep in mind that this is not a static process, and the focus must remain on a shared decision-making conversation (National Lipid Association, 2021).
Making Connections
As previously stated, the client who makes connections between food choices and hematologic wellness is more likely to intentionally change nutritional habits. According to the Transtheoretical Model (TTM), change occurs as a series of steps aligned with the client’s degree of motivation (Nakabayashi et al., 2020; Lee & Chung, 2021). This model has been widely used for health education interventions and more recently applied to nutritional interventions, specifically. The model includes five stages: precontemplation, contemplation, preparation, action, and maintenance. Figure 9.5 depicts this model, applied to the scenario in this chapter’s unfolding case study.
The nurse’s role is to raise a consciousness that empowers the client to recognize there are more positive outcomes than negative to this nutritional modification. The benefit of using the TTM in practice is its applicability in all settings, adaptability to different nutritional needs, flexibility, and cost-effectiveness (Nakabayashi et al., 2020).
An important assumption to the effectiveness of the TTM is the client’s nutritional health literacy, as it relates to hematological wellness. Clients with low-to-moderate nutritional literacy are likely to have poor self-management skills and communication with health care providers (Zhong et al., 2020). Client education targeted at enhancing nutritional knowledge is an important point for nursing intervention. In Ms. Foster’s case, she has identified a lack of knowledge regarding iron-rich foods; therefore, the nurse should incorporate information about iron-rich foods into the decision-making conversations with Ms. Foster.
Evaluating the Effectiveness of a Nutritional Plan
According to TTM, maintenance of the behavior change takes 6 months to achieve. In the case of a nutrition-related hematologic disease, the client will need to be evaluated at more frequent intervals due to the serious potential consequences of untreated blood disorders. The nurse should be aware that pharmacologic interventions vary in their onset and duration of action. Correcting long-term nutritional deficiencies is a process. Some medications are dosed according to the extent of the blood abnormality and require intermittent laboratory analysis for dose modifications. For instance, ferrous sulfate has a dose range that is different for infants and children versus adults and is based on the severity of anemia using hemoglobin and symptoms as determinants. It is recommended to check hemoglobin every 3 weeks during the first month of treatment for potential dose modifications. The nurse should provide anticipatory guidance to the client in terms of frequency of return visits, what will be evaluated at each visit, and what changes or symptoms the client should expect. The client is likely to remain motivated if they can identify signs of improvement, even outside of actual visits with their health care team.
Modification of the Nutritional Plan
The final phase of any change plan is to make modifications based on the evaluation outcome, remembering that change is a dynamic, cyclic process. Use of motivational interviewing with open-ended questions will assist the client in recognizing self-efficacy. Bringing the focus back to hematologic wellness and the potential consequences the client faces if untreated, while praising the successful change, is key. The nurse should re-address the previously established goals and look for opportunities for improvement. In Ms. Foster’s case, the nurse would consider the following questions:
- What iron-rich foods have you incorporated into your diet?
- How often do you consume each food? What serving size do you consume?
- How do you rate your level of fatigue and shortness of breath over the past week, compared with before you started iron replacement 3 weeks ago?
- What barriers do you have to obtaining access to iron supplements and food items?
Unfolding Case Study
Part D
Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up from Case Study Parts A, B, and C.
After discussing Ms. Foster’s symptoms in relation to her anemia, Grant reviews iron replacement therapy, including the importance of taking iron with a citrus beverage such as orange juice to aid in iron absorption. He informs Ms. Foster that most insurance companies will not cover the cost of iron replacement as it can be purchased over the counter. Grant further offers to search her local pharmacy website to determine the cost and formulations available. He provides a written client education handout on iron deficiency anemia as well as instructions for Ms. Foster to call her PCP for a follow-up appointment in 3 weeks. Grant then discusses several foods that are iron rich (Table 9.4) and helps Ms. Foster identify 3 food items that she feels she can incorporate into her daily diet. Ms. Foster’s daughter repeats the items needed to initiate this plan and offers to take her mother to the store before returning home. Ms. Foster reminds her daughter that she has groceries delivered every other week but will increase to a weekly delivery to ensure fresh or frozen spinach availability daily. At this point, Grant asks Ms. Foster the following: “How confident are you that you can make this change, on a scale of 0 to 10, with 10 being extremely confident?”
| Food Item | Serving Size | Iron Content |
|---|---|---|
| Tofu | ½ cup | 3 mg |
| Kidney beans | ½ cup | 2 mg |
| Beef liver | 3 oz | 5 mg |
| Canned white beans | 1 cup | 8 mg |
| Boiled lentils | ½ cup | 3 mg |
| Fortified breakfast cereal | ½ cup | 18 mg |
| Potato, baked, flesh and skin | 1 medium size | 2 mg |
| Tomatoes, canned, stewed | ½ cup | 2 mg |
Ms. Foster reports a confidence level of 8, vocalizing her motivation to actively participate in her grandson’s wedding in 3 months. Grant feels confident that he and Ms. Foster have developed a solid plan in a collaborative manner. He provides Ms. Foster with a copy of the plan and educational materials and recommends she ask her PCP for a referral to a registered dietitian to help with meal planning. He adds the nursing care plan to Ms. Foster’s electronic medical record to ensure that her PCP’s office will have access during the follow-up appointment.