Nutrition Care ProcessKNH 411

Relationship Between

Patient/Client/Group & Dietetics

Professional

-

Nutrition Diagnosis Ø Identify and label problem Ø Determine cause/contributing risk

factors Ø Cluster signs and symptoms/ defining characteristics

Nutrition Assessment Ø Obtain/collect timely and appropriate data Ø Analyze/interpret with

evidence - based standards

Ø

Ø Identify risk factors Ø Use appropriate tools

and methods Ø Involve

interdisciplinary collaboration

Screening & Referral System

Outcomes Management Sys tem

Ø Monitor the success of the Nutrition Care Process implementation

Ø Evaluate the impact with aggregate data Ø Identify and analyze causes of less than

optimal performance and outcomes Ø Refine the use of the Nutrition Care

Process

ADA NUTRITION CARE PROCESS AND MODEL

Ø Document

Nutrition Monitoring and Evaluation Ø Monitor progress Ø Measure outcome indicators Ø Evaluate outcomes Ø Document

Nutrition Intervention Ø Plan nutrition intervention · Formulate goals and

determine a plan of action Ø Implement the nutrition intervention · Care is delivered and actions

are carried out Ø Document

Document

ADA’s Nutrition Care Process Steps

Nutrition AssessmentNutrition DiagnosisNutrition Intervention Nutrition Monitoring and

Evaluation

Nutrition Assessment (Definition)“A systematic process of obtaining, verifying, and

interpreting data in order to make decisions about the nature and cause of nutrition-related problems.”Lacey and Pritchett, JADA 2003;103:1061-1072.

Nutrition Assessment ComponentsGather data, considering

Dietary intake; consequences of condition; physical, psychological, behavior conditions; knowledge, readiness to change, potential for change

Compare to relevant standardsWhat is normalWhat can you do to fix

Identify possible problem areasADIME (anthroplymetrics, biochemical,

clinical, dietary intake)

Nutrition Assessment: Critical ThinkingObserve Verbal and nonverbal

Determining appropriate data to collectLook at key aspects

Selecting assessment tools Distinguishing relevant from irrelevant dataOrganizing data

Figure out what client needs and implement Determining when problems require referral

ADA’s Nutrition Care Process Steps

Nutrition AssessmentNutrition DiagnosisNutrition Intervention Nutrition Monitoring and

Evaluation

Nutrition Diagnosis Nutritional problem

Diagnose problems associated with disease

Names and describes the problem What are you going to do to solve?

Problem may already exist, or may be at risk of occurring

Not a medical diagnosis

Nutrition Dx Domains: IntakeDefined as “actual problems related to intake of energy,

nutrients, fluids, bioactive substances through oral diet or nutrition support (enteral or parenteral nutrition)

Class: Calorie energy balance (weight gain)Class: Oral or nutrition support intake

Post operation (type of diet)

Class: Fluid intake balance Renal patients

Class: Bioactive substances balance Metabolic, someone missing an enzyme

Class: Nutrient balance Deficiencies

Nutrition Dx Domains: ClinicalDefined as “nutritional findings/problems

identified that relate to medical or physical conditions

Class: functional balance Physical or mechanical condition

Class: Biochemical balanceAbility to metabolize nutrients

Class: weight balanceChronic weight changes

Nutrition Dx Domains: Behavioral-Environmental

Defined as “nutritional findings/problems identified that relate to knowledge, attitudes/beliefs, physical environment, or access to food and food safety

Class: knowledge and beliefsState of the disease

Class: physical activity, balance and functionHow they get around/function

Class: food safety and accessEconomic status

Nutrition Diagnosis Components

Problem – diagnostic label Etiology – cause, contributing risk factor Signs/Symptoms

Signs – observable and measureableSymptoms – what the subject feels/expresses

(objective)

Nutrition Diagnosis Components Problem

Describes alterations in pt’s nutritional statusDiagnostic labels Impaired Altered Inadequate/excessive Inappropriate Swallowing difficulty

Nutrition Diagnosis Components

Etiology Related factors that contribute to problem Identifies cause of the problemHelps determine whether nutrition intervention will

improve problemLinked to problem

Nutrition Diagnosis Components Etiology

Excessive calorie intake related to regular consumption of large portions of high-fat meals

Swallowing difficulty related to stroke

Nutrition Diagnosis Components

Signs/Symptoms Evidence Linked to etiology

Nutrition Diagnosis Components Etiology

Excessive calorie intake “related to” regular consumption of large portions of high-fat meals as evidenced by diet history and weight status

Swallowing difficulty related to stroke as evidenced by coughing following drinking of thin liquids

Nutrition Diagnosis Excessive calorie intake “related to” regular consumption of large portions of

high-fat meals “as evidenced by” diet history & 12 lb wt gain over

last 18 mo

Nutrition Diagnosis ComponentsFood, nutrition and nutrition-related

knowledge deficit R/T lack of education on infant feeding practices as evidenced by infant receiving bedtime juice in a bottle

Altered GI function R/T ileal resection as evidenced by medical history and dumping syndrome symptoms after meals

Nutrition Diagnosis Components

Nutrition Diagnosis Statement should be:

clear, concisespecific related to one problemaccurate based on reliable, accurate assessment

data

Nutritional vs Medical DxMedical Diagnosis Nutritional Diagnosis

Diabetes Increased blood glucose, increased carbohydrate intake

Trauma and closed head injury

Total nutrition supportHydration, increased energy needs

Liver failure Blood glucose stability (insulin)s/s- increased blood glucose levels

Nutritional vs Medical Dx

Medical Dx Nutritional Diagnosis

Obesity Take in more calories than burningLack of access to food

Dependence mechanical ventilation

Excessive energy intakeLoading with carbohydrates

Anorexia nervosa Decreased caloric intakeUndesirable food choicesSeen by diet history and weight history

ADA’s Nutrition Care Process Steps

Nutrition AssessmentNutrition DiagnosisNutrition Intervention Nutrition Monitoring and

Evaluation

Nutrition Intervention Definition

“Purposely-planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, a target group, or population at large.” – Lacey and Pritchett, JADA 2003;103:1061-1072

Directed at the etiology or effects of a diagnosis

Create a plan for the patient

Intervention Objectives

Should be patient-centered Must be achievable

Must be measureable, quantifiable, have a goal/endpoint Stated in behavioral terms Pt and counselor must establish goals together

Everyone working with the patient must agree on the plan What will the patient do or achieve if objectives met

Intervention Objectives Problem 1: Involuntary weight loss

Objectives: 1. increase calorie intake

X calories divided into six small meals 2. gain 10 pounds in one month

Give plan and how to acheive

Intervention Objectives Problem 2: Inadequate protein-energy intake 2° poor

appetiteObjectives:

1. Eat foods high in protein

2. Eat X meals with X amount of protein

Nutrition Intervention

Intervention translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives.

Interventions should be specificWhat, when, how

Nutrition Intervention Problem 1: Involuntary Weight loss

Intervention: (plan of action)1. Instruct client on options (educate patient)

2. Gradually introduce plan

3. Introduce supplement

4. Plan for implementing and measuring

Nutrition Intervention

Problem 2: Inadequate protein-calorie intake 2° poor appetite Intervention:1. nutrient-dense foods

2. Introduce to socialization

ADA’s Nutrition Care Process Steps

Nutrition AssessmentNutrition DiagnosisNutrition Intervention Nutrition Monitoring and

Evaluation

Nutrition Monitoring & EvaluationComponents

Evaluate outcomes

Compare current findings with previous status, intervention goals, and/or reference standards

Be specific

What gets Measured?Nutrition

Monitoring and Evaluation

Types of Outcomes

End-result outcome(follow-up visits)

• Direct nutrition outcomes • Clinical and health status outcomes • Patient/client-centered outcomes• Healthcare utilization

Intermediate-result outcome(first client visit)

Nutrition Goals and ObjectivesAre necessary in order to evaluate Should be achievableShould be directly or indirectly related to nutrition

careHow effective was your plan?

NCP Example: Acute CareNutrition AssessmentMedical hx: 72 y.o. female admitted with

decompensated CHF; heart failure team consulted; has been admitted with same dx x 2 in past month; meds: Lasix and Toprol; current diet order: 2 gram sodium; has lost 5 pounds in 24 hours since admission; Output > input by 2 liters

Nutrition history: has been told to weigh self daily but has no scale at home. Does not add salt to foods at the table. Noticed swollen face and extremities on day prior to admission. Day before admission ate canned soup for lunch and 3 slices of pizza for dinner; does not restrict fluids; has never received nutrition counseling

NCP Example: Acute CareNutrition Diagnosis1. Fluid intake concerns relate to dietary

discretion and indicated by patient2. Excessive sodium intake of foods eaten by

diet history3. No previous nutrition education as

evidenced by patient results4. Not self-monitoring, not weighing self

NCP Example: Acute CareNutrition Intervention1. low sodium diet2. go to senior center for assistance3. attend nutrition programs4. get scale5. limit fluids

NCP Example: Acute CareMonitoring and Evaluation1. Get scale- weight log2. Get vitals3. Food log