Nutrition Care Process in template for emailing updatedcyprusconferences.com/conferences/CYDA2012/presentation_pdf/Jane... · Nutrition Care Process Jane McClinchy 2nd Dec 2012 Jane

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Nutrition Care Process

Jane McClinchy

2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 1

Learning outcomesAt the end of the session, you should be able to:

• Describe the main steps of the NCP

• Be able to write a nutrition diagnosis

• (note I will not be covering groups)

2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 2

Content

• Explore why a process is needed in

dietetics

• Look at the stages of the Process

• Workshop with case studies


Time Activity 13.00 Introduction to the process13.45 Workshop 14 30 Feedback14.30 Feedback 15.00 Finish


Need for a process

• Uncertainties in health care funding• Electronic health records• SNOMED:SNOMED:• Systematized Nomenclature of Medicine


EFAD competencies Dietetics process and professional reasoning• 3.1 Meet the needs of clients in complex situations related to health, social

situations and the environment. Clients may be individuals, groups, organisations or populations

• 3.2 Implement the Dietetic process, including screening, assessment, identifying needs, formulating goals, planning, implementing interventions and evaluating outcomes, in order to enable client choice.

• 3 3 Implement theories and models nutritional and activity analysis in order3.3 Implement theories and models, nutritional and activity analysis in order to integrate reasoning related to the dietetic process with client need. (This guides the selection and provides best possible practice for individuals and groups).

• For the Clinical Dietitian• 3.4 Make a dietetic/nutrition related diagnosis.• 3.5 Treat and counsel a client/patient using special dietetic/nutritionally

modified products.

• European Federation of the Associations of Dietitians (EFAD) and Thematic Network DietitiansImproving Education and Training Standards in Europe (DIETS) (2009) European Dietetic Competences and their Performance Indicators attained at the point of qualification and entry to the profession of Dietetics retrieved from http://efad.topshare.com/iextranet/1468/5/0/70


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Different processes in useSOAP BDAP ABCDE

SPPNDP NCP

Subjective Background A, B, C, D, E

A, B, C, D, E

Objective Data

Assessment Assessment Summary Nutritional diagnosis

Nutritional diagnosisdiagnosis diagnosis

Plan Plan Plan Plan intervention

Plan and deliver intervention Deliver

intervention Monitor Monitoring

and Evaluation

Evaluation

Others?2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 7

Process- pros and cons

Pros• Problem solving-scientific

• Provides security

Cons• Less flexible

• May mask creativityy

• Sequential/cyclical

• Patient centred

y y

• ? The unexpected

• Not patient centred


Barriers

• Lack of knowledge• Time• Need for training and support• Difficulty in determining nutritional

diagnosis statements

• Ferguson et al. (2012) Personal communication


Benefits of using a process?Using a process leads to:

• Consistent quality of practice• Evidence of professional clinical decision

making• Autonomy of practice• Autonomy of practice• Consistent record keeping and therefore

improved care • Key step in determining and measuring

outcomes of dietetic care • Can be used to promote the profession

• (Source BDA 2012)2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 10

Structural framework

• ‘…which helps us to inform what the [nutritional] diagnosis is, which helps to inform what intervention we’re going to plan which helps us inform whatplan, which helps us inform what outcomes we’re going to consider’ (FG2-P1)

• (Aylesbury and McClinchy, 2012 in press)


MDT Communications

• ‘…that we’re efficient, precise and concise and methodical in what we write…I think it is an important part of MDT communications’ (FG3-P1)( )

• ‘what’s important in terms of the profile of the profession is that what’s written is concise and neat and to the point…doctors want the nitty gritty’ (FG1-P1)

•


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Transfer of patients between..

‘when patients are transferred…you get the notes with the patient sometimes it can take a while trying to figure out what thea while trying to figure out…what the intervention has been whereas if it was all standardised…it would be more focussed’ (FG2-P4)


Monitor/

Assessment

Nutritional

The NCP follows the

steps…

evaluate Diagnosis

Plan Implement intervention


NCP 14

The spiral

2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 15 2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 16

Nutrition assessment in the NCP …Food/Nutrition-related history

Food and nutrient intake, usual diet, medications, food availability, knowledge/beliefs about food, physical activity level

Anthropometric measurements

Height, weight, body mass index, growth velocity, circumferences etcg y,

Biochemical data, medical tests and procedures

Lab data such as electrolytes, glucose, lipids, tests such as resting metabolic rate, abdominal x-rays etc

Nutrition-focused physical findings

Skin turgor and integrity, dentition, appearance of subcutaneous fat/muscle mass etc

Client history Medical/surgical/family history/social2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 17

Nutrition assessment –another way …

• Anthropometry • Biochemistry• Clinical functional psychological• Clinical, functional, psychological • Dietary• Environmental, behavioural, social

• Critical thinking 2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 18

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• The RD determines the relevant data• Compare these to an individualised goal

or standard • Eg nutritional intake is…• Estimated nutritional requirements q

• And therefore defines the nutritional related problem in the form of a nutrition

diagnosis


Nutrition diagnosis


Nutrition diagnosis

• Identification of an actual occurrence, risk of, or

potential for developing a nutritional problem

that a dietitian is responsible for treating p g

independently or of leading the strategy to

manage.

• PAS statement (PES in USA)


Nutrition diagnosis

P-A-S format (P-E-S USA)

• Problem - (diagnostic label) describes alterations in a

patient / client/group/communities’ nutritional status

• (A)etiology - cause or contribution risk factors

• Signs or symptoms - defining characteristics

Problem related to (A)etiology as evidenced by

Signs/symptoms


Nutrition diagnosis

P-A-S format

• Problem - (diagnostic label) describes alterations in a

patient / client/group/communities’ nutritional status

Note UK spelling AetiologyAmerican spelling Etiology

• (A)etiology - cause or contribution risk factors

• Signs or symptoms - defining characteristics

Problem related to (A)etiology as evidenced by

Signs/symptoms


p g gyIn USA PES statement

Nutrition diagnosisPAS statement

Problem

Diagnostic termIn USA

Related to

(A)etiology

Factors identified in

As evidenced by

Signs and Symptoms

Measureable


In USA standardized terminology Must be nutritional ie not medical diagnosis& resp for treating independently

identified in assessment: potential intervention should be linked to this.Should be able to resolve the problem by addressing the aetiology

Measureable parameters that are monitored and evaluated for improvement

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Nutrition diagnosis example

Overview:

Obesity caused by consumption of high energy snack

foods as evidenced by weight gain, BMI, diet history


Overview:




Problem?


Problem:




Aetiology?


Aetiology:




Sign or symptom?


Signs or symptoms:





P for nutritional Problem

Intake• Too much or too little of a food or nutrient compared to

actual or estimated needs High energy intake

Nutrition diagnosis

Clinical• Nutrition problems that relate to medical or physical

conditions

Behavioural-environmental• Knowledge, attitudes, beliefs, physical environment,

access to food or food safety

High energy intake

Obesity

Limited exercise 2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 30

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P for nutritional ProblemIntake• Too much or too little of a food or nutrient compared to

actual or estimated needs• E.g.

Nutrition diagnosis

g

• Energy balance

• Macro nutrients

• Micronutrients-vitamins/minerals

• Types of foods e.g. fruit and veg/ energy dense foods

• Fibre/alcohol



Clinical• Nutrition problems that relate to medical or physical

conditions

Nutrition diagnosis

• E.g.

• Functional (of the GI tract) swallowing/appetite/diarrhoea

• Biochemical e.g. lab values (LDL/HbA1c),

• Weight gain/loss, over or under



Behavioural-environmental• Knowledge, attitudes, beliefs, physical environment,


Nutrition diagnosis


• E.g.• Need for knowledge/Not ready to make changes• Physical activity-inactivity/self-feeding difficulty• Limited access to food


A for Aetiology,

• Links to intake, clinical, behavioural issues

Nutrition diagnosis

• Consider if there is a potential intervention that

would address and therefore resolve or improve

the problem and/or cause?


A for Aetiology must link to a potential intervention

Intake• Too much or too little of a food or nutrient

Advice about appropriate foods

Nutrition diagnosis

Clinical• Changes in nutritional requirements because of a clinical

condition

Behavioural-environmental• Uncertainty Limited knowledge, attitudes, beliefs, physical

environment/activity, access to food or food safety

Advice about appropriate foods

Advice to change behaviour 2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 35

Change in nutrition prescription

A for aetiology or cause-some more examplesIssue Cause InterventionIntake Choosing too

much/not enough/ Education/setting goals/making

Nutrition diagnosis

ginappropriate foods/fluids

g gappropriate foods/fluids available

Clinical Increased nutritional requirements

Increase in nutritional prescription

Behavioural Uncertainty about what foods to eat

Advice/information/goal setting


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• Clinical problems and aetiologies must be nutritional

Issue Cause Intervention

Clinical Increased nutritional Increased energy

Nutrition diagnosis

requirements (patient with infection)

prescription

Stroke e.g. ?

Diabetes e.g. ?


• Clinical problems and aetiologies must be nutritional

Issue Cause InterventionClinical Increased nutritional

requirements (patient with Increased energy prescription

Nutrition diagnosis

infection) Stroke e.g. Impaired movement of food /fluid from mouth to stomach

Texture modified diet

Diabetes e.g. change in ability to metabolise refined carbohydrate

Low GI diet


Signs or symptoms:

• How do you know

• Must link to the information you collected on your assessment

Nutrition diagnosis

• Must link to the information you collected on your assessment

• Then consider whether the signs and symptoms are specific

enough that you can measure

• A, B, C, D, E


Now complete the following for a patient whose

problem was an excessive oral intake:

• P What’s the problem ?

Nutrition diagnosis

• A Why is this happening ?

• S How do we know a problem exists ?


Excessive oral intake


could be excessive intake of energy dense foods such

Nutrition diagnosis

as…







Nutrition diagnosis

as…


could be lack of knowledge



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Nutrition diagnosis

as…




could be high BMI, diet history


Nutrition diagnosisExcessive oral intake



as…




could be high BMI, diet history

ND=Excessive intake of energy dense foods caused by a lack of knowledge as evidenced by high BMI, diet history


• More than one?

• Focus on the most pressing problem

• Prioritise towards the one relating to intake as this is

Nutrition diagnosis

likely to be more specific to your role

• Agree with patient and health care team


Nutrition Care Process

Quiz


Nutrition Care Process Quiz

• Which are not part of the Nutrition Diagnosis

• Assessment

• Signs and symptoms

• Medical diagnosis

• Problem

• Aetiology



• Which are not part of the Nutrition Diagnosis

• Assessment x

• Signs and symptoms

• Medical diagnosis x

• Problem

• Aetiology


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Which is a nutrition assessment?

• 8kg weight loss over the past 4 months• 8kg weight loss over the past 4 months

• Oral nutrition supplement prescribed because

intake <75% of estimated needs

• Excessive fat intake



Which is a nutrition assessment?

• 8kg weight loss over the past 4 months• 8kg weight loss over the past 4 months

• Oral nutrition supplement prescribed because

intake <75% of estimated needs

• Excessive fat intake



Which is the right order for the nutritional diagnosis

SAPSAP

APS

PAS



Which is the right order for the nutritional diagnosis

SAPSAP

APS

PAS


Getting to intervention…

… from assessment

ViaVia

nutrition diagnosis


Definition of intervention

• A nutrition and dietetic intervention is a set of activities and

associated resources which are used to address the

identified nutrition and dietetic diagnosis.

• Note: all interventions are planned with the communities, service

users and carers who are the recipients of the intervention. This

client centred approach is a key element in developing a realistic

plan that has a high probability of positively influencing the outcome.


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What is an intervention?

•

Food and/or nutrient delivery Oral diets, enteral and parenteral nutrition, supplements, feeding assistance, feeding environment, nutrition-related medication management


medication management Nutrition education Basic education on content and

survival skillsNutrition counselling Theoretical, cognitive,

behaviour based counselling for self-efficacy and self management

Coordination of nutrition care Team meetings, referral to experts or outside agencies

Intervention

• Planning• Implementation


Components of the PlanComponent Definition Links with

NDOutcomes measurable and specific Signs and

symptomsIntermediate goals

which will achieve the outcomes

Problem

Plan provision of food Aetiology


Plan provision of food, provision of nutrition support, education package, counselling, coordination of care, social marketing campaigns, food availability, food shopping and cooking skills

Aetiology

Planning nutrition intervention Outcomes Examples (use info from S&S)

Anthropometric change

Weight, MUAC, waist:hip ratio

Biochemical indicators Lab values, indicators of nutritional status

Clinical/symptoms Clinical status, complications, symptom scales

Environmental/behavioural/ Social

Client-focussed outcomes: quality of life, client identified outcomes, satisfaction, self-efficacy, self-ural/ Social identified outcomes, satisfaction, self efficacy, selfmanagement, functional ability

Behavioural Food related behaviour, physical activity

Psychological Self-efficacy, self management, mental health state

Healthcare utilisation and cost outcomes

Medication changes, special procedures, planned/unplanned clinical visits, preventable hospitalisations, length of hospitalisation, prevent or delay nursing home admission 2nd Dec 2012 58Jane McClinchy University of Hertfordshire

NCP

Planning nutrition intervention Goals

Area Examples:

Diet and nutrition goals (changes)

Reduced energy intake by 600 kcalsReduce fat intake


(changes) Reduce fat intake

Environment/behavioural/social Increase physical activity by 30 minutes 5 times per week

Plan -designed to meet the outcomesand goals

Plan Examples

Dietetic prescription for an individual

Xx kcals reducing dietXxmls of xx feed at xx mls per hourHigh protein and high energy diet

Education plan for an individual Specifics of education e.g. which foods are


or group high or low in fat

Community programme or health community strategy

Exercise prescription scheme Fruit in schools

Behavioural strategies and counselling

Use of SMART goal setting Food diary

Motivational intervention Motivational interviewing

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Problem Caused by

Evidenced by

Intake: Energy balanceEnergy intake greater than expenditure

caused by reduced activity

as evidenced by weight gain

Intake: Food

Plan Intervention Implementation Intervention

Outcome: weight maintained at xxGoal? Plan?

Outcome:

Planning links with ND

Intake: Food intakeExcessive intake of energy dens e foods

Lack of knowledge about appropriate foods

Diet history and patient reporting

Clinical: ObesityOverweight

Excessive energy intake

High BMI

Outcome: Patient will choose lower energy foodsGoal?Plan?

Outcome: weight loss 05.-1 kg per weekGoal?Plan?2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 61

Problem Caused by

Evidenced by




Intake: Food


Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week Outcome:







High BMI

Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription


Problem Caused by

Evidenced by




Intake: Food


Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 min 5 x per week Outcome:







High BMI



Problem Caused by

Evidenced by




Intake: Food


Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week Outcome:







High BMI



Nutrition intervention -implementation

Activities

• Communication and negotiation

• Education

• Collaboration with other health care professionals

• Use of behavioural change strategy or approach e.g. use

of SMART goals

• Use of educational tool e.g. diet sheet/food models


Diagnosis:Patient is obese caused by excessive energy intake of 25% above estimated requirements as evidenced by raised BMI and diet history

Interventions• Diet information • Sample meal plan with

600 kcal energy deficit • Smart goals enabling

Nutrition intervention – implementation

Intervention planning:Outcome : 0.5-1 kg loss of weight per week Goal: Consume 600 Kcal less Plan: 600 kcal energy deficit diet prescription

achievement of 600 kcal energy deficit

• Agree ‘episode of care’ and review timescale


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Nutrition intervention -implementation

Collaboration with other health care professionals

• Information for carers

• Asking Nurse to weigh

• Ward staff implement food record chart

• MDT home visit team implement


Problem Caused by

Evidenced by




Intake: Food


Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week

SMART goal on the length/frequency of a specific exercise

Outcome:

Link with intervention






High BMI

Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods

SMART goals on selection of lower energy foods

Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription

SMART goals enabling 600 kcal energy deficit


Nutrition monitoring and review

Definition:• The review and measurement of the client, group or

population’s nutritional status at planned intervals with regard to the nutrition diagnosis, intervention plan, goals and outcomes

Components:• Check understanding or compliance• Determine if the intervention is being implemented as

prescribed• Obtain evidence that the plan is/is not changing

behaviour, nutrition or health status• Identify other positive or negative outcomes


Nutrition monitoring & review

Review and measurement of status at scheduled times

Nutritional diagnosis Plan ImplClinical: ObesityOverweight


High BMI

a pG: weight loss 05.‐1 kg per weekP: 600 kcal energy deficit

SMART goals enabling 600 kcal energy deficit



• For the patient what will you measure or monitor?



• Or ABCDE

Parameter What will you measure?AnthropometryAnthropometry

Biochemistry

Clinical

Dietary

Environmental


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Evaluation

DefinitionSystematic comparison of current findings against previous

status, intervention goals and outcomes

To enable for example decisions about p• Discharge• Continuation of intervention• Reassessment


Monitor/

Assessment

Nutritional

The NCP follows the

steps…


evaluate Diagnosis

Plan Implement intervention

Sample NCP statementAssessment Diet weight, phys activity

Nutritional diagnosisPatient is obese caused by excessive energy intake of 25% above estimated requirements as evidenced by raised BMI and diet history

Planning intervention Outcome: weight loss 05.-1 kg per week Outco e e g t oss 05 g pe eeGoal: 600 kcal energy deficit Plan: Dietetic prescription and education

Implementation of intervention SMART goals enabling 600 kcal energy deficit

Monitoring Review weight, diet, understanding , patient acceptability

Evaluation against original outcome measure and decision about the future

Jane McClinchy University of Hertfordshire NCP 752nd Dec 2012

Workshop

Spend 15 mins on each activity• ND ‘fill in the blanks’ sheet• Writing a NCP statement case 1a or 1b• Your own action plan for implementing the

NCP in your work

• 14.30-15.00 Feedback • 15.00 Finish 2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 76

Feedback


NCP 77

Weight loss • Problem• Inadequate energy Intake (or could have food

intake) • Aetiology (Cause)Aetiology (Cause)• Energy intake not meeting needs to prevent

weight loss(food refusal-could be a meal/specific food items/snacks)

• Signs (Objective)/Symptoms (Subjective)• Xkg lost in y days, low BMI


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• Problem• Self –feeding difficulty (behavioural)• Aetiology (Cause)• Impaired ability to place food in mouth (spillage• Impaired ability to place food in mouth (spillage

of ____ % during meals)• Signs (Objective)/Symptoms (Subjective)• • X kg weight loss in Y days/ Rapid weight loss• • Advanced stages of Parkinson’s/MS/

Excessive shaking of hands2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 79

• Low Iron, HgB/HCT• Signs and symptoms-low haemoglobin• Abnormal Lab Values• Aetiology-change in ability to eliminate by products of

metabolism/metabolise/absorb• Diabetes• Problem-Inconsistent carbohydrate intake• Tube Feeding• Signs Symptoms -X kg lost in y days• Dysphagia• Aetiology- Impaired movement of food/fluid from mouth

to stomach• Problem-Inadequate food/beverage intake


Nutritional diagnosis P-Energy and protein intake below estimated requirements A-Increased requirements and reduced appetiteS-Medical notes report sepsis, weight loss 4% and food record chart shows intake of 600 kcals and 20g protein


Intervention Planning Outcome: Maintain current weight of 72 kgPatient reports improved appetiteGoal: Increase nutritional intake initially by 600 kcals and 24g proteinPlan:Plan: High protein, high energy diet including prescription of oral nutritional supplements which provide 600kcals and 24g proteinImplementation SMART goal with patient on consumption of ONSWork with nursing staff on help with menu selections (favourite foods to help with appetite) 2nd Dec 2012 Jane McClinchy University of Hertfordshire

NCP 82

Monitoring Monitor appetite and weightEvaluationIntake will be lower than requirements initially, so increase energy prescription once appetite has improved


Learning outcomesAt the end of the session, you should be able to:

• Describe the main steps of the NCP

• Be able to write a nutrition diagnosis


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Feedback

• Implementation of NCP• Try to use PAS• SMART goals• Step wise approach• Try to see the problem first• Identify the most important problem•


Further reading

Resources on the Academy of Nutrition and Dietetics http://www.eatright.org/

Search Nutrition Care Process and a number of accessible pdfs are available

Resources on the BDA website are available to members only:

BDA (2012) Model and Process for Nutrition and Dietetic Practice

http://members.bda.uk.com/profdev/profpractice/modeldieteticpractice/index.ht

ml


Documents

Nutrition Care Process in template for emailing updatedcyprusconferences.com/conferences/CYDA2012/presentation_pdf/Jane... · Nutrition Care Process Jane McClinchy 2nd Dec 2012 Jane