Skipper Article (2)

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Support Line December 2007 Volume 29 No. 6

Abstract

The Nutrition Care Process (NCP)was accepted by the dietetics professionin 2003 and is being implemented in allsettings where dietitians provide directpatient care. Standardized terminologyis being developed to describe theactivities of registered dietitians (RDs)within each of the four steps of the NCP:Nutrition Assessment, NutritionDiagnosis, Nutrition Intervention, andNutrition Monitoring and Evaluation.RDs providing nutrition support tocomplex or critically ill patients havequestions about how to apply the NCPand standardized language to theirpatients. This article provides a briefoverview of the NCP and a case illus-trating how standardized language canbe applied to a postoperative intensivecare unit (ICU) patient whose coursechanges over time.

Introduction

The NCP is a four-step approach tonutrition problem solving and care thatis designed to guide and illuminate thework of RDs. Since its adoption by thedietetics profession in 2003, three of thefours steps of the process — diagnosis,intervention, and monitoring andevaluation — have been elaborated inbook form (1). Standardized terminol-ogy describing nutrition diagnosis wasintroduced in 2005 (2). A second bookthat included nutrition diagnosis andintervention terminology was releasedin 2006 (3). A third book, InternationalDietetics and Nutrition TerminologyReference Manual, which includes themonitoring and evaluation step of theNCP, was released in 2007 (4).

Many RDs are familiar with the NCP,and some are incorporating standardizedlanguage into medical record documen-tation. As a result, nutrition supportdietitians have questions about how toapply the NCP to critically ill patientsreceiving enteral (EN) and parenteral

nutrition (PN). The dynamic nature ofthe critical care unit and sheer volumeof data that RDs incorporate into thedecision making process presentchallenges in identifying the nutritiondiagnosis, describing the intervention,and determining the monitoring andevaluation using the standardized lan-guage of dietetics. The purpose of thisarticle is to illustrate how the nutritiondiagnosis, intervention, and monitoringsteps of the NCP can be applied to acritically ill patient.

Background

Standardized or controlled vocabular-ies are used in medicine and nursing todescribe diagnosis and treatment forthose within and outside the medicalprofession. Examples of controlledvocabularies familiar to dietitians includethe Common Procedure Terminology(CPT) and the International Classifica-tion of Diseases (ICD-9) terminologiesdeveloped for use by physicians (5,6).Nurses may use one of several standard-ized languages, and physical therapistshave also developed a controlledvocabulary to describe their patientcare activities (7,8). All of these termi-nologies ultimately should combine toidentify the contributions of healthprofessionals within the electronicmedical record. The InternationalDietetics and Nutrition Terminology isbeing developed to identify the uniquecontributions of RDs within theuniversal electronic medical record.

Controlled vocabularies serve severalimportant purposes besides their rolein meeting the federal mandate forelectronic medical records. The termsand codes are easily incorporated intolaws and regulations. Because they areuniform descriptors, they may facilitateproductivity, efficacy, and reimbursementdata collection. In educational settings,controlled vocabularies are used toorganize information presented tostudents. In the clinical environment,standardized language facilitates clear,

consistent documentation of caredelivered, communication betweenhealth-care professionals, and continuityas patients move from one location toanother. Such vocabularies clearlydistinguish the unique activities ofeach profession, thereby reducing theopportunities for miscommunication,overlapping activities, and interprofes-sional conflict.

Widespread implementation of theNCP and use of standardized languagealso should aid benchmarking datacollection and may serve as the basisfor identifying homogenous populationsfor research. A standardized approachto describing care is especially valuableto RDs working in nutrition supportwhere the multifaceted nature of thedata evaluated may be underappreciatedby those who focus on the number ofpatients seen rather than the complexityof care delivered.

Nutrition Diagnosis

The most unique feature of the NCPis the nutrition diagnosis. The 60nutrition diagnosis terms and definitionswere developed to describe nutritionproblems that can be treated indepen-dently by the dietitian (4). Thus, theyare distinct from the terms physiciansuse to describe medical diagnoses.However, RDs and physicians use asimilar process of diagnostic reasoningto derive diagnoses from their respectivedomains (9). Like medical diagnoses,nutrition diagnostic terms have a specificdefinition; unique etiologies, signs,and symptoms; and a code numberthat may be used for linking to data inan electronic medical record. Unlikemedical diagnoses, nutrition diagnosestypically resolve following interventionby the dietitian.

Once the RD “makes” a nutritiondiagnosis, the term is incorporatedinto a nutrition diagnosis statement orPES statement composed of three parts:a problem (P), etiology (E), and signsand symptoms (S) (Table 1). Within

Applying the Nutrition Care Process: Nutrition Diagnosis and Intervention Annalynn Skipper, PhD, RD, FADA

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the PES statement, the diagnosis is a nutrition problem that will resolvewith the dietitian’s intervention. Theetiology is the “root” cause of thenutrition problem. It may be improvedor eliminated with the nutritionintervention. The signs and symptomsare monitored by the dietitian to deter-mine progress toward resolving thenutrition diagnosis. For example, thenutrition support dietitian may calculatethe carbohydrate intake of a criticallyill patient with hyperglycemia, rule out excessive carbohydrate intake as anutrition diagnosis, and suggest theneed for an increased insulin dose.

Diagnosing nutrition problems andwriting a PES statement that is bothcorrect and meaningful is a rigoroustask. It involves validating assessmentdata, clustering and comparing signsand symptoms to develop differentialdiagnoses, and systematically eliminatingthem until a diagnosis is derived fromthe signs and symptoms.

Nutrition Intervention

The nutrition intervention is definedas a specific action that remedies anutrition diagnosis and consists of twocomponents: the plan and the imple-mentation. The first step in planningnutrition intervention is the nutritionprescription. The prescription is based

on best available evidence and theclinical judgment of the RD. It is notthe current nutrition order, but ratheran individualized statement of the needsof the patient at a given moment intime. In critically ill patients, thenutrition prescription may be adjustedfrequently as medical diagnoses (e.g.,acute renal failure, hepatic encephalopa-thy), treatments (e.g., surgical procedures,medications), and the patient’s condition(e.g., wound healing, weaning fromthe ventilator) change.

An example of a nutrition prescriptionfor a critically ill patient might be assimple as 1,800 kcal and 65 g protein.It might be expanded to include specificamounts of fat, vitamins, minerals,fluids, and bioactive substances. Ideally,the nutrition prescription is based onthe latest evidence-based standards, butwhere data are lacking, the RD appliesclinical judgment and institutionaltradition to the nutrition prescription.

The RD implements one of 13nutrition interventions that are designedto reduce the gap between the patient’scurrent and ideal intake. Each nutritionintervention consists of a definition, aunique number, and a reference sheetdescribing the details of the interventionand usual application. Nutrition supportdietitians are strongly identified withenteral and parenteral nutrition (NC-2),

which they individualize to meet thenutrition prescription by manipulatingformula volume and composition.Nutrition support dietitians may alsoprescribe medical food supplements(ND-3.1) and participate in nutrition-related medication management (ND-6). The purpose of the nutritionintervention ultimately is to correctthe nutrition diagnosis, remove theetiology, or reduce the signs andsymptoms.

Nutrition Monitoring andEvaluation

The monitoring and evaluation stepof the NCP is defined as the reviewand measurement of the patient/client’sstatus at a scheduled or preplannedfollow-up point with regard to thenutrition diagnosis, intervention/plansgoals, and outcomes (1). Evaluation isthe systematic comparison of currentfindings with previous status, interven-tions, goals, or a reference standard.Almost 50 monitoring and evaluationstrategies have been identified in thenutrition monitoring and evaluationstep of the NCP. Effectiveness of theintervention is monitored by changesin the signs and symptoms listed in thePES statement. In Table 1, the inter-vention (potassium supplementationND-3.2) should resolve the nutritiondiagnosis and can be monitored usingthe sign (serum potassium level) in thePES statement.

For critically ill patients or othersreceiving nutrition support, the diag-nosis may resolve, but the monitoringand evaluation portion of the NCPcontinues for the duration of thenutrition intervention. The monitor-ing and evaluation step incorporateschanges from baseline in biochemicaland medical tests, anthropometricdata, intake and output, and otherfamiliar nutrition support monitoringparameters. Thus, the fourth step ofthe NCP incorporates the familiarcomponents of the nutrition supportdietitian’s assessment in a moresystematic approach that enablesmeasurement of nutrition outcomesand ultimate demonstration of theRD’s effectiveness.


(Continued on page 16)

Table 1. General Format for the Three-part Nutrition DiagnosticStatement (PES Statement) With a Sample Statement

General Formatproblem (P) related to etiology (E) as evidenced by signs and symptoms (S)

Sample PES statement(P) Inadequate intake of potassium (NI 55.1) related to (E) increased urinarylosses with amphotericin B administration, as evidenced by (S) declining serumpotassium levels.

Sample Nutrition PrescriptionIncrease potassium intake to 2 mEq/kg each day.

Sample Nutrition Intervention Mineral (potassium 40 mEq/day) supplements (ND-3.2) as needed to maintainserum potassium levels within normal limits.

Sample Nutrition Monitoring and EvaluationMonitor potassium intake (FI-6.2); serum potassium level (S-2.2)

Note: The (P), (E), (S) and numbers for the nutrition diagnostic term (NI 55.1),nutrition intervention term (ND-3.2), and nutrition monitoring and evaluation terms (FI-6.2 and S-2.2) are included for the convenience of the reader; they are not necessarily recorded in the medical record.

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Application

The NCP is designed for use withindividual patients as well as groups andpopulations. The remainder of thisarticle illustrates how the NCP andstandardized language may be appliedover several days. The case is presentedusing the assessment, diagnosis, inter-vention, monitoring, and evaluation(ADIME) format. Table 2 containsgeneral guidelines for incorporatingkey features of the NCP into somepopular documentation formats. Theexamples of chart notes also containdiagnostic, intervention, and monitor-ing and evaluation terms from theInternational Dietetics and Nutrition

Terminology Reference Manual (4).These terms should not be adaptedor modified because they are designedto describe and capture the RD’sactivities related to the NCP.

The following case provides anexample of how the standardizedlanguage of dietetics and the ADIMEformat can be used for medical recorddocumentation. The author appreciatesthat some RDs would provide a muchmore detailed note, while others wouldlimit their documentation to informationunavailable elsewhere in the medicalrecord. The intent is not to specify alevel of detail, but to provide sufficientdetail to describe the case. The inter-ventions and monitoring and evaluation

parameters selected reflect the author’spersonal practice philosophy, whichincludes an evidence-based approachto patient management. Of course,nutrition support practice varies widelyand others might use a different approachto problems presented. The reader isencouraged to set aside differences inopinion on how the patient is managedand focus on how the standardizedterminology may be applied.

Case

HF is a 27-year-old previouslyhealthy male who was admitted to theintensive care unit (ICU) followingemergency surgery for a rupturedappendix. He weighed 82 kg onadmission and was at ideal weight forhis height of 6 ft 1 in. His temperaturewas 100.4°F, and his white blood cellcount was elevated (14×103/mcL) onadmission. Other laboratory findingswere unremarkable. On hospital day 2,HF was being weaned from the ventila-tor and expected to transfer out of theICU later in the day. The intravenous(IV) fluids of D5.45 saline were run-ning at 125 mL/h. Because all patientsadmitted to the ICU are automaticallyseen by an RD, a note must be enteredinto his medical record before thepatient is transferred to the floor.Cumulative patient data are shown in Table 3.

Initial Assessment and Diagnosis As part of the initial assessment, the

RD reviewed the medical record forbiochemical data, the results of medicaltests and procedures, and anthropomet-ric measures. Because HF was on aventilator, the food/nutrition andclient history was limited to a briefconversation with family members,who stated that he was eating welluntil 2 days prior to admission. Giventhe elevated blood glucose value, theRD inquired about a history ofdiabetes, which was negative.

Nutrition Diagnostic Reasoning

The RD reviewed the assessmentdata and compared the findings withpotential nutrition diagnoses. Becauseof the elevated blood glucose value,the RD evaluated the dextrose contentof the IV fluids and determined that it


Table 2. General Guidelines for Incorporating the Nutrition CareProcess Into Six Common Documentation Formats

ADIME PGIE A = Assessment P = ProblemD = Diagnosis or Diagnosis or

PES* statement PES* StatementI = Intervention G = Goal

Nutrient Prescription Nutrient PrescriptionNutrition Intervention I = InterventionGoal Nutrition Intervention

M= Monitoring GoalE = Evaluation E = Evaluation

SOAP DARS = Subjective D = DataO = Objective Diagnosis or A = Assessment PES* Statement

Diagnosis or A = ActionPES* Statement Nutrient PrescriptionNutrient Prescription Nutrition Intervention

P = Plan Goal Nutrition Intervention R = ResponseGoal

PIE DAR-OP = Problem D = Data

Diagnosis or Diagnosis or PES* Statement PES* Statement

I = Intervention A = ActionNutrition Intervention Nutrient Prescription

E = Evaluation Nutrition Intervention Goal

R = ResponseO = Output

*PES=Problem, Etiology, Signs and Symptoms where Problem is a diagnostic term andEtiology, Signs and Symptoms are derived from the corresponding reference sheet forthe diagnostic term.

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was likely insufficient to contribute tohyperglycemia. The elevated bloodglucose concentration appeared to be atransient stress response followingsurgery, and the RD confirmed thatthe surgeons had addressed the hyper-glycemia by ordering insulin coverage.Because the hyperglycemia was notnutrition-related, the dietitian ruledout excessive carbohydrate intake (NI-53.3).

Clearly, HF was well nourished. TheRD did not identify any significantnutrition problems except that he wasNPO. However, the patient wouldhave a diet ordered in time for theevening meal. In this case, the RDcould simply decline to diagnose anutrition problem by recording the

data from the nutrition assessment,then writing “the patient has nonutrition diagnosis at this time.” Thisstatement would be substantiated bypublished guidelines that clearly statethat a previously healthy patient couldeasily tolerate up to 7 days withoutnutrient intake (10). However, theruptured appendix made HF a candi-date for postoperative complications,and a return to the ICU was a reason-able expectation. Because HF hadbeen eating well prior to admissionand had been NPO for less than 24hours, the RD diagnosed inadequateprotein-energy intake (NI-5.3),primarily because the definition of thediagnosis refers to changes in physiologicneeds of short or recent duration (3).

Determining the Nutrition Prescription

The nutrition prescription conciselystates individualized recommendeddietary intake. It is based on currentreference standards and dietary guide-lines adjusted for the patient’s healthcondition and nutrition diagnosis (3).The level of detail for the nutrientprescription can be adjusted based onthe patient’s condition as well as practicestandards, institutional convention, andclinical judgment. Thus, the require-ments for lipid, carbohydrate, andindividual nutrients could be specifiedas needed. For HF, the RD based thecalorie and protein prescription onpublished standards (10). The recentlyreleased evidence-based guideline forcritically ill patients also could be used,


Table 3. Cumulative Patient Data From Admission Through Hospital Day 10

Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital HospitalDay 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10

CHEMISTRY

Sodium (mEq/L) 135 134 132 132 130 132 133 133 137 135

Potassium (mEq/L) 3.4 4.1 4.8 3.2 4.4 3.9 3.7 4.6 4.7 4.6

Chloride (mEq/L) 111 113 102 103 101 102 100 100 99

Carbon dioxide (mEq/L) 17 17 23 21 20 18 17 18 19

Blood urea nitrogen (mg/dL) 21 24 26 25 31 37 46

Creatinine (mg/dL) 0.8 0.7 1.1 1.2 1.5 1.7 2.0

Blood glucose (mg/dL) 184 136 237 140 132 125 145 130 136

Magnesium (mEq/L) 1.9 2.1 2.4 1.6 1.7 1.6 1.2 1.4 1.8 2.0

Phosphorus (mg/dL) 4.3 4.2 4.0 3.9 4.0 4.1 4.2 4.0 3.8 2.6

Calcium (mg/dL) 8.1 7.9 8.0 7.8 7.6 8.1 8.2 8.0 7.9 7.8

Intake and Output

Weight (kg) 83 86 87 94 96 100 99 98 97 97

Intake (L) (all sources) 5.1 3.4 7.8 4.7 3.0 3.6 2.8 2.4 2.4 2.4

Output (L) (all sources) 1.8 2.0 1.0 1.6 1.6 2.5 3.1 3.0 3.0 1.6

MEDICATIONS

Vancomycin 1 g q12 h IV • • • • • • • • •

Insulin drip (titrate to keep blood glucose <150 mg/dL) • • • • • •

Propofol 20 mcg/kg/min IV • • • • •

Amphotericin B 50 mg qd IV • • • • • •

IV=intravenous

(Continued on next page)

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especially if a long-term ICU stay wasanticipated (11).


The nutrition intervention is designedto treat the nutrition diagnosis or its

etiology. In this case, inadequate protein-energy intake will be alleviated with a general diet (ND-1), which will beordered as soon as the patient is weanedfrom the ventilator. Once the diet isordered, the dietetic technician regis-

tered (DTR) can verify that the patientis eating and report any identifiedproblems to the RD. Table 4 illustratesa sample initial note in the ADIMEformat that incorporates the nutritiondiagnosis, prescription, nutrition


Table 4. Initial Note Hospital Day 2

NUTRITION ASSESSMENT

Biochemical Data, Medical Tests and Procedures Anthropometric MeasurementsWNL except blood glucose of 184 mg/dL and WBC Ht. 6'1"; current weight is 86 kg; up fromof 10,000 cells/mm3 82 kg on admission.134 | 111 | 21 /4.1 | 17 | 0.8 \

184

Physical Exam Findings Food and Nutrition HistoryEating well prior to admission; no known nutrient

Deferred modifications. Currently NPO; receiving D5.45 saline at 125 mL/hr providing 510 calories and 210 mEq Na. I&O + 6 L since admission.

Client HistoryMedical history: negative for diabetes. Surgical history: appendectomy for ruptured appendix last PM. Per MD, patient towean from ventilator and transfer from ICU today. Regular diet to be ordered on extubation.

NUTRITION DIAGNOSIS

#1 Problem Inadequate calorie and protein intake (NI-5.3)___________________________________________________Etiology related to insufficient GI access__________________________________________________________________Signs/Symptoms as evidenced by calorie intake 35% of required and no protein intake ___________________________

#2 Problem______________________________________________________________________________________________Etiology ______________________________________________________________________________________________Signs/Symptoms _______________________________________________________________________________________


NUTRITION INTERVENTION

Nutrition PrescriptionThe patient/client’s individualized recommended Intervention #1 Order general diet (ND-1)_________dietary intake of energy and/or selected foods or Goal (s) Adequate PO intake_______________________nutrients based upon current reference standards and dietary guidelines and the patient/client’s Intervention #2__________________________________health condition and nutrition diagnosis. (specify) Goal (s)_________________________________________

General diet providing 2,050 calories and 100 grams Intervention #3__________________________________of protein.________________________________________ Goal (s)__________________________________________________________________________________________

NUTRITION MONITORING AND EVALUATION

Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL#1 Energy intake (F1.1.1) _________________________ #1 Consumes >2,000 kcal/day______________________#2 Protein intake (FI-5.2.1)_______________________ #2 Consumes >90 grams of protein per day___________#3_______________________________________________ #3 _____________________________________________

Note: Terms in bold text are drawn directly from the International Dietetics and Nutrition Terminology Reference Manual. They are definedwithin the language and should not be modified. The codes (numbers in parenthesis) are included for the convenience of the reader, butit is not necessary to include them in the medical record.

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intervention, and monitoring andevaluation.

Follow-up on Hospital Day FourHF was transferred to the floor as

planned, but on hospital day 3, histemperature reached 102°F, and hecomplained of abdominal pain. Thatafternoon, he underwent small bowelresection for ischemic necrosis. Resultsof the operation included a temporarydiverting ileostomy. His ileocecal valveand colon were intact, with about 200cm of small bowel in continuity andthe remaining segment excluded bythe diverting colostomy.

On hospital day 4, the RD foundthat HF weighed 94 kg. His skin waswarm and dry to the touch, and he had+2 pedal edema. Bowel sounds wereinaudible, and an ileostomy bag was inplace, but there was no drainage.Nasogastric (NG) tube output wasabout 100 mL over the previous 8-hour shift. Ventilator settings wereintermittent ventilation of 24 breaths/min, FiO2 of 80%, and 6 cm of posi-tive end-expiratory pressure. The max-imum temperature was 100.6°F. Bloodcultures were positive for Staphylococcusepidermis and Escherichia coli. He wasreceiving D5.45 lactated Ringer at 125 mL/hr. Vancomycin and ampho-tericin B were started postoperatively.An insulin drip was started accordingto unit protocol, and a multiplevitamin infusion was ordered.


The RD recognized that HF haddeveloped sepsis, according to thewidely used criteria of the AmericanAcademy of Chest Physicians (12), andconsidered a second nutrition diagnosis:increased nutrient needs (NI-5.1) (3).However, the definition of increasedneeds is “increased need for a specificnutrient compared to established ref-erence standards.” Because there wasno evidence that HF required morecalories or protein than specified inreference standards for a critically illpatient with sepsis, that diagnosis wasrejected (13).

The RD noticed a marginally lowserum sodium concentration, butquickly rejected inadequate mineralintake (sodium) (NI-55.1) because HF

had a cumulative input and output thatwas positive by almost 15 L, no extra-ordinary sodium losses, and a sodiumintake from his IV fluids in excess ofhis requirements (3,10). The RDattributed the hyponatremia to thecumulative input and output, whichresulted from medically necessary IVfluids administered during surgery andthe postoperative stress response. Sheelected to monitor the serum sodium,which she knew would normalize withpostoperative diuresis. She suggestedon rounds a reduction in the currentIV fluid rate, documented the positivecumulative input and output in theassessment, and adjusted the nutritionintervention to reflect the need formaximally concentrated formula.

The RD also noticed the sharpincrease in serum glucose concentrationand evaluated HF for a diagnosis ofaltered nutrition-related laboratoryvalue, glucose (NC-2.2) (3). However,the carbohydrate intake of 150 g (1.2 mg/kg/min) was far below therecommended maximum of 472 g (4 mg/kg/min per day) (14), and thisdiagnosis was ruled out. A diagnosis ofexcessive carbohydrate intake (NI-53.2)was ruled out for the same reason. Theelevated blood glucose was attributedto impaired glucose metabolism com-monly seen in sepsis, and the amountof insulin administered via a continuousinsulin infusion (insulin drip) wasincreased per unit protocol.

The RD also noticed the magnesiumvalue of 1.6 mg/dL. She evaluated thepatient’s recent magnesium intake andnoted that HF had not receivedmagnesium supplementation sinceadmission. He was asymptomatic, butlikely had increased urinary losses ofmagnesium associated with ampho-tericin administration, which wouldcontinue for several more days. TheRD added inadequate mineral intake(magnesium) (NI-55.1) to the list ofdiagnoses because HF had a lower-than-recommended intake based onphysiologic needs, which is consistentwith the diagnostic criteria for inade-quate mineral intake. She spoke withthe surgeon, who ordered 2 g ofmagnesium sulfate IV to correct the intake deficit.


Consistent with unit protocol and an evidenced-based guideline, the RDcontinued to restrict HF to 14 to 18 kcal/kg/day for the first week in theICU (15). During the second week, theRD might recalculate energy require-ments based on the Penn State Equation:(HB (0.85)+VE(33)+Tmax(175)-6433),as recommended in the evidence-basedguide for critically ill patients (16).This information would be incorpo-rated into the nutrition prescription.

In this setting, the RD had obtainedclinical privileges to place the feedingtube and write orders for EN and PNand monitoring if consulted by thephysician to do so. The RD reviewedthe assessment data and developed aplan of care with the surgeons. Thedecision was made to initiate a smallbowel feeding tube because the NGsuction would interfere with gastricfeedings. In another patient, the RDmight have placed an NG tube basedon recent evidence denying a clearadvantage of small bowel over NGfeeding (11). The RD selected a stan-dard formula with the highest possibleprotein content to balance the dextrosecalories from the IV fluids and the fatcalories from the propofol. Additionalprotein could be added if the propofoland IV fluids continued. The RD didnot select an immune-enhancing formulabecause such formulas are not recom-mended for routine use (15). Table 5shows a sample nutrition progress note.

Follow-up on Hospital Days Eightand Ten

On hospital day 8, HF weighed 98 kg.His blood glucose values were withinthe acceptable range established by theteam managing his blood glucose andinsulin. However, his renal functionwas declining, consistent with hisclinical course of sepsis and antibioticadministration. His IV fluids were0.45 saline at 80 mL/hr. Enteral feed-ings were held because he had 2 L ofliquid stool in a 24-hour period. Stooloutput had decreased sharply sincecessation of feeding 8 hours earlier. Thephysicians attributed the stool outputto the length and/or condition of his


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Table 5. Follow-up Note for Hospital Day 4


Biochemical Data, Medical Tests and Procedures Anthropometric MeasurementsLabs: Ht. 6'1"; current weight is 94 kg; up from132 | 102 | 21 / 82 kg on admission. 82 kg is dosing weight.3.2 | 23 | 0.8\

237

calcium: 7.8; phosphorus: 3.9; magnesium: 1.6

Physical Exam Findings Food and Nutrition History+ 2 edema of lower extremities Diet NPO; 24 hour I&O + 4 L. NG tube to intermittent suction Cumulative I&O + 14.6 L. No bowel sounds Receiving D5.45 saline at 125 mL/hr. and propofol Ileostomy without drainage at 10 mL/hr providing 774 calories & 210 mEq Na.T max 100.6

Client HistoryMedications: vancomycin, amphotericin B, propofol, insulin drip, potassium chloride; multiple vitamin infusion. Bowelresection last PM with diverting ileostomy; intact ileocecal valve and colon.

NUTRITION DIAGNOSIS

#1 Problem Inadequate protein-energy intake (NI-5.3)______________________________________________________Etiology related to insufficient GI access__________________________________________________________________Signs/Symptoms as evidenced by calorie intake 35% of required and no protein intake ___________________________

#2 Problem Inadequate mineral intake (magnesium) (NI-55.1) _______________________________________________Etiology related to magnesium losses with amphotericin_____________________________________________________Signs/Symptoms as evidenced by serum magnesium of 1.6 mg/dL ____________________________________________



Nutrition PrescriptionThe patient/client’s individualized recommended Intervention #1 Dietitian will insert enteral feeding dietary intake of energy and/or selected foods or tube (ND-3.1)___________________________________nutrients based upon current reference standards Goal (s) Enteral access_____________________________and dietary guidelines and the patient/client’s health condition and nutrition diagnosis. (specify) Intervention #2 Dietitian will initiate enteral feedings

with standard 2 kcal/mL feeding at 25 mL/hr when tubeBased on 82-kg dosing weight, permissive underfeeding placed (ND-2) and decrease IV fluids accordingly______with 2 kcal/mL feeding at 25 mL/hr to provide 1,230 kcal Goal (s) Optimum nutrient intake by 10 PM today _____and 55 g protein in minimal volume. Supplement vitamins, minerals, and electrolytes to meet needs._________________ Intervention #3 Dietitian will order enteral nutrition___________________________________________________ monitoring protocol_________________________________________________________________________________ Goal (s) Identify feeding intolerance_______________________________________________________________________________________________________________________ Intervention #4 Recommend 2 g of Mg sulfate IV as ___________________________________________________ discussed with surgery________________________________________________________________________________ Goal (s) Replete serum Mg_________________________


Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL#1 Enteral access (FI-3.1.1) _________________________ #1 Placement confirmed by radiograph ______________#2 Enteral formula (FI-3.1.2)________________________ #2 Recorded intake of 25 mL/hr of feeding___________#3 Energy intake (F1.1.1) ___________________________ #3 Recorded intake of 25 mL/hr of feeding___________#4 Protein intake (FI-5.2.1) _________________________ #4 Recorded intake of 25 mL/hr of feeding___________#5 Total carbohydrate intake (FI-5.3.1)_______________ #5 Carbohydrate intake from all sources <472 g/day____

For dietitians without privileges to insert the feeding tube, order the formula, and provide the monitoring protocol, the wording“Recommend post-pyloric feeding tube, etc.” may be substituted.

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remaining bowel and recommended thatfeedings be held. The RD recognizedthat HF had altered gastrointestinal(GI) function (NC-1.4), but also con-tinued to have inadequate intake fromenteral/parenteral nutrition (NI-2.3).The RD could revise the PES statementfor the inadequate enteral/parenteralintake to include altered GI functionas an etiology. However, the alteredGI function was the nutrition diagnosisdriving a change in therapy, and twoseparate diagnoses were recorded.

The RD and the surgeons were con-cerned that HF had suboptimal intakefor most of the 8 days since admission.In some instances, the feeding wouldbe held and subsequently restarted.However, in light of this patient’sdeteriorating condition, marginal GIfunction, and an accumulating caloriedeficit, the decision was made to startPN and reinitiate enteral feedings astolerated. The surgeons changed thecentral line, and the RD ordered 1 L of PN containing 60 g amino acids(0.7 g/kg) and 200 g (1.6 mg/kg/min)dextrose to be administered over 24hours daily with electrolytes, decreasedpotassium, and increased acetate toaccommodate declining renal function.She ordered a 250-mL bottle of 20%lipids to be administered as an IV riderover 12 hours daily. She planned toincrease the feeding to goal the follow-ing day and checked to ensure thatlaboratory tests were ordered formonitoring. Sample follow-updocumentation is found in Table 6.

On hospital day 10, HF weighed 97 kg.The RD had decreased his IV fluids to20 mL/hr and increased his PN to goalthe day before. Despite declining renalfunction, phosphorus concentrationsdeclined from 4.0 to 2.6 mg/dL. Hisstool output had slowed to 1 L/24 hr.Blood glucose control was acceptableon the insulin drip. If blood glucosevalues remained below 150 mg/dL, thesurgeons would consider administeringoctreotide for the diarrhea, but PNwas scheduled to continue until thediarrhea was better controlled.


The inadequate EN and PN hasresolved with the achievement of goal

feedings. Inadequate mineral intake(magnesium) resolved with ongoingmagnesium supplementation in thePN. Altered GI function persisted. Thedecline in serum phosphorus valuessuggested to the RD the possibility ofan altered nutrition-related laboratoryvalue (phosphorus) (NC-2.2) (3).However, she rejected the diagnosisbecause the decrease in phosphorusconcentrations likely representedrefeeding hypophosphatemia, which isnot included in NC-2.2. The diagnosisalso could have been inadequate mineralintake (NI-55.1) (phosphorus). How-ever, the RD selected imbalance ofnutrients (NI 5.5) to describe moreprecisely the relationship betweenphosphorus and carbohydrate. Afterdiscussion with the surgeons, the RDsupplemented the PN with an additional20 mEq of sodium phosphate andanticipated resolution of hypophos-phatemia the next day (Table 7). TheRD also informed the nurse of anincrease in dextrose intake and thepotential for an increased insulinrequirement.

On hospital day 14, HF was stableand weaned off the ventilator. A generalhealthful diet was ordered (ND-1),and HF was transferred out of the ICUto the care of another RD. The ICURD signed off and transferred care tothe RD on the floor (RC-2).

Conclusion

The NCP is a four-step problem-solving process that can be used toidentify nutrition problems that theRD can treat independently. The stan-dardized language is used to describenutrition diagnoses, interventions, andmonitoring and evaluation. The NCPand standardized language aredesigned for use by RDs caring forpatients or clients of all ages and levelsof complexity. Critically ill patientswith myriad intercurrent medical andnutritional problems present chal-lenges in applying the NCP that canbe overcome with clear thinking thatclusters detailed information used tomanage critically ill patients. TheNCP and standardized language ofdietetics is designed to describe thenutrition problems that the RD can

identify and document nutrition-related problems and their resolution.The anticipated result is improvedcommunication with other profession-als, increased visibility of the dietitian’srole, and clearer documentation of thedietitian’s unique contribution topatient care.

Readers are encouraged to log in to the DNSlistserve to discuss this article with the author.

Annalynn Skipper, PhD, RD, FADA, hasmore than 25 years experience as a nutritionsupport dietitian. She is an author andconsultant in Oak Park, Ill.

References1. Lacey K, Pritchett E. Nutrition care

process and model: ADA adopts roadmap to quality care and outcomesmanagement. J Am Diet Assoc. 2003;103:1061–1071.

2. Nutrition Diagnosis: A Critical Step inthe Nutrition Care Process. Chicago, Ill:American Dietetic Association; 2005.

3. Nutrition Diagnosis and Intervention:Standardized Language for the NutritionCare Process. Chicago, Ill: AmericanDietetic Association; 2006.

4. International Dietetics and NutritionTerminology Reference Manual. Chicago,Ill: American Dietetic Association; 2007.

5. American Medical Association. CPT®

2007 Professional Edition. Chicago, Ill:American Medical Association; 2007.

6. American Medical Association. AMAPhysician ICD-9-CM 2007, Volumes 1 &2. Chicago, Ill: American MedicalAssociation; 2007.

7. NANDA International. NursingDiagnosis: Definitions and Classification2005-2006. Philadelphia, Pa: NANDAInternational: 2006.

8. American Physical TherapyAssociation. Guide to Physical TherapistPractice. 2nd ed. Fairfax, Va: AmericanPhysical Therapy Association; 2003.

9. Bowen JL. Educational strategies topromote clinical diagnostic reasoning.N Engl J Med. 2006;355:2217–2225.

10. A.S.P.E.N. Board of Directors and theClinical Guidelines Task Force. Guide-lines for the use of parenteral and enteralnutrition in adult and pediatric patients.JPEN J Parenter Enteral Nutr. 2002;26(suppl):1SA–138SA.

11. Critical Illness Evidence-BasedNutrition Practice Guideline. Availableat: http://www.adaevidencelibrary.com/topic.cfm?cat=2799. AccessedNovember 20, 2006.

12. Bone R, Balk R, Cerra F, et al.Definitions for sepsis and organ failureand guidelines for the use of innovativetherapies in sepsis. The ACCP/SCCM


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Physical Exam Findings Food and Nutrition History+ 2 edema of lower extremities Feedings held for 2 L stool output. Diet NPO; 24 hour+ NG tube to drainage I&O – 1.4 L; Cumulative I&O +16.6 L; 0.45 saline at

80 mL/hr. Propofol at 10 mL/hr. Total intake over last24 hours is approximately 400 kcal & 150 mEq Na

Client HistoryMedications: vancomycin, amphotericin B, propofol, insulin drip.

NUTRITION DIAGNOSIS

#1 Problem Inadequate intake from enteral nutrition infusion (NI-2.3)________________________________________Etiology related to feeding intolerance____________________________________________________________________Signs/Symptoms as evidenced by intake less than needs______________________________________________________

#2 Problem Altered GI function (NC-1.4)___________________________________________________________________Etiology related to bowel resection_______________________________________________________________________Signs/Symptoms as evidenced by 2 L stool output that declined when enteral feedings discontinued________________



Nutrition PrescriptionThe patient/client’s individualized recommended dietary Intervention #1 Initiate parenteral nutrition (ND-2)___intake of energy and/or selected foods or nutrients Goal (s) 1 L of PN containing 60 g amino acids andbased upon current reference standards and dietary 200 g dextrose over 24 hours. Administer 250 mL of guidelines and the patient/client’s health condition 20% lipids over 12 hours separately with reducedand nutrition diagnosis. (specify) potassium (20 mEq) and increased (maximum)

acetate relative to baseline._________________________1.5 L PN providing 100 g of protein and 340 g of dextrose over 24 hours daily with an IV rider of 250 mL of 20% lipids Intervention #2 Order parenteral nutrition daily over 12 hours. Electrolytes to meet baseline needs are monitoring protocol______________________________80 mEq Na, 30 mEq K, 20 mmol phosphorus, 10 mEq Goal (s) Identify feeding intolerance_________________calcium, 8 mEq Mg (with 1/3 chloride and 2/3 acetate).Will also give 10 mL MVI, 3 mL trace elements, and Intervention #3__________________________________40 mg famotidine daily_______________________________ Goal (s)____________________________________________________________________________________________NUTRITION MONITORING AND EVALUATION

Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL

#1 Parenteral access (FI-3.1.1) ______________________ #1 Parenteral access patent_________________________#2 Parenteral formula (FI-3.1.2)_____________________ #2 Parenteral formula administered as ordered________#3 Parenteral formula rate/schedule (FI-3.1.5)________ #3 Parenteral formula administered as ordered________#4 Energy intake (F1.1.1)___________________________ #4 Parenteral formula contains 1420 calories__________#5 Protein intake (FI-5.2.1)_________________________ #5 Parenteral formula contains 60 g/protein__________#6 Total carbohydrate intake (FI-5.3.1)_______________ #6 Carbohydrate intake from all sources <472 g/day____

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14. Wolfe R, O'Donnell T Jr, Stone M,Richmand D, Burke J. Investigation offactors determining the optimal glucoseinfusion rate in total parenteral nutrition.Metab Clin Experiment. 1980;29:892–900.

15. Kattelmann KK, Hise M, Russell M,Charney P, Stokes M, Compher C.Preliminary evidence for a medicalnutrition therapy protocol: enteral

feedings for critically ill patients. J AmDiet Assoc. 2006;102:1226–1241.

16. Frankenfield D, Smith J, Cooney R.Accelerated nitrogen loss after traumaticinjury is not attenuated by achievementof energy balance. JPEN J ParenterEnteral Nutr. 1997;21:324–329.




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Physical Exam Findings Food and Nutrition History+ 2 edema of lower extremities NPO; Receiving PN as ordered. 24 hour I&O + 0.8 L; + NG tube to drainage cumulative I&O + 15.2; 0.45 saline at 20 mL/hr

provides 35 mEq/day of Na

Client HistoryVancomycin, amphotericin B, propofol, insulin drip.

NUTRITION DIAGNOSIS

#1 Problem Inadequate intake from enteral nutrition infusion (NI-2.3) has resolved_____________________________Etiology______________________________________________________________________________________________Signs/Symptoms _______________________________________________________________________________________

#2 Problem Altered GI function (NC-1.4)___________________________________________________________________Etiology related to bowel resection_______________________________________________________________________Signs/Symptoms as evidenced by 2 L stool output, which declined when enteral feedings discontinued ______________

#3 Problem Imbalance of Nutrients (NI-5.5) _______________________________________________________________Etiology related to insufficient phosphorus to balance carbohydrate intake ______________________________________Signs/Symptoms as evidenced by a decline in serum phosphorus level__________________________________________


Nutrition PrescriptionThe patient/client’s individualized recommended Intervention #1 Dietitian will order 1.5 L of PN with dietary intake of energy and/or selected foods or 65 g amino acids and 340 g dextrose over 24 hoursnutrients based upon current reference standards daily with 250 mL of 20% lipids daily plus additional and dietary guidelines and the patient/client’s acetate and reduced potassium.______________________health condition and nutrition diagnosis. (specify) Goal (s) PN to meet goal needs as BUN corrects______

1.5 L parenteral nutrition providing 100 g of protein and Intervention #2 Dietitian will order parenteral340 g of dextrose over 24 hours daily with an IV rider of nutrition monitoring protocol_______________________250 mL of 20% lipids daily over 12 hours. Electrolytes to Goal (s) Identify feeding intolerance_________________ meet baseline needs are 80 mEq Na, 30 mEq K, 20 mmol phosphorus, 10 mEq calcium, 8 mEq Mg (with 1⁄3 chloride Intervention #3 Dietitian will increase the phosphorus and 2⁄3 acetate), 10 mL MVI, 3 mL trace elements, and in the PN to 39 mmol_____________________________40 mg famotidine daily _______________________________ Goal (s) Serum phosphorus level of 4.0 mg/dL___________________________________________________________


Indicator, e.g., self-monitoring ability Criteria, e.g., intake amount, mg/dL#1 Parenteral formula rate/schedule (FI-3.1.5) ________ #1 I&O sheet reflects PN administered as ordered_____#2 ________________________________________________ #2 Serum phosphorus within normal limits___________#3 ________________________________________________ #3 ____________________________________________

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