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