nutrition care process briefer cp orientation

7/30/2019 Nutrition Care Process Briefer CP Orientation

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RelationshipBetween

Patient/Client/Group& Dietetics

Professional

-

Nutrition Diagnosis

Identify and label problem

Determine cause/contributing risk

factors

Cluster signs and symptoms/defining characteristics

Nutrition Assessment Obtain/collect timely and

appropriate data

Analyze/interpret with

evidence - based standards

Identify risk factors Use appropriate tools

and methods Involve

interdisciplinarycollaboration

Screening& Referral

System

OutcomesManagement System

Monitor the success of the Nutrition Care

Process implementation

Evaluate the impact with aggregate data

Identify and analyze causes of less thanoptimal performance and outcomes

Refine the use of the Nutrition Care

Process

ADA NUTRITION CARE PROCESS AND MODEL

Document

Nutrition Monitoring andEvaluation

Monitor progress

Measure outcome indicators

Evaluate outcomes

Document

Nutrition Intervention

Plan nutrition intervention Formulate goals and

determine a plan of action

Implement the nutrition intervention

Care is delivered and actionsare carried out

Documen t

Document


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ADAs Nutrition Care

Process Steps

Nutrition Assessment

Nutrition Diagnosis


Nutrition Monitoring and Evaluation


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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.


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Components Gather data, considering

Dietary intake

Nutrition related consequences of health and disease

condition Psycho-social, functional, and behavioral factors

Knowledge, readiness, and potential for change

Compare to relevant standards

Identify possible problem areas


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Nutrition Assessment: Critical

Thinking Observing verbal and non-verbal cues to guide

interviewing methods

Determining appropriate data to collect

Selecting assessment tools and procedures andapplying in valid and reliable ways

Distinguishing relevant from irrelevant data

Organizing data to relate to nutrition problems

Determining when problems require referral


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ADAs Nutrition Care

Process Steps


Nutrition Diagnosis




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Nutrition Diagnosis

Nutritionalproblem that the dietitian is

responsible for treating

Names and describes the problem

Problem may already exist, or may be atrisk of occurring

Not a medical diagnosis Type 2 diabetes = medical diagnosis

Excessive carbohydrate intake resulting in elevated

blood glucose levels = nutrition diagnosis.


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Nutrition Dx Domains: Intake

Defined as actual problems related tointake of energy, nutrients, fluids, bioactivesubstances through oral diet or nutrition

support (enteral or parenteral nutrition) Class: Calorie energy balance

Class: Oral or nutrition support intake

Class: Fluid intake balance Class: Bioactive substances balance

Class: Nutrient balance


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Nutrition Dx Domains: Clinical

Defined as nutritional findings/problems identifiedthat relate to medical or physical conditions

Class: functional balance (change in physical or

mechanical functioning with nutritionalconsequences)

Class: Biochemical balance: change in capacityto metabolize nutrients as a result of

medications, surgery, or as indicated by alteredlab values

Class: weight balance: chronic weight orchanged weight status when compared with

usual or desired body weight


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Nutrition Dx Domains:

Behavioral-Environmental

Defined as nutritional findings/problems

identified that relate to knowledge,

attitudes/beliefs, physical encironment, or

access to food and food safety

Class: knowledge and beliefs

Class: physical activity, balance and

function

Class: food safety and access


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Nutrition Diagnosis Components

Problem (Diagnostic Label)

Etiology (Cause/contributing risk

factors) Signs/Symptoms (Defining

characteristics)

Signs = objective data = observable,measurable changes

Symptoms = subjective data = changes pt

feels and expresses


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Nutrition Diagnosis

Components Problem (Diagnostic Label)

Describes alterations in pts nutritional status

Diagnostic labels Impaired (nutrient utilization)

Altered (GI function)

Inadequate/excessive (calorie intake)

Inappropriate (intake of types of carbohydrate)

Swallowing difficulty


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Etiology (Cause/Contributing Factors)

Related factors that contribute to problem

Identifies cause of the problem Helps determine whether nutrition

intervention will improve problem

Linked to problem by words related to

(RT)

Note: etiology may not always be clear


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Etiology (Cause/Contributing Factors)

Excessive calorie intake (problem) related

to regular consumption of large portions of

high-fat meals (etiology) Swallowing difficulty (problem) related to

stroke (etiology)


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Nutrition Diagnosis

Components Signs/Symptoms (Defining

characteristics)

Evidence that problem exists

Linked to etiology by words as evidenced

by


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Etiology (Cause/Contributing Factors) Excessive calorie intake (problem) related

to regular consumption of large portions

of high-fat meals (etiology) as evidencedby diet history and weight status

Swallowing difficulty (problem) related to

stroke (etiology) as evidenced by coughing

following drinking of thin liquids (signs andsymptoms)


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Nutrition Diagnosis

Excessive calorie intake (P)

related to regular consumption of large

portions of high-fat meals (E)

as evidenced by diet history & 12 lb wt

gain over last 18 mo (S & S)


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Nutrition Diagnosis

Components Food, nutrition and nutrition-related knowledge

deficit (P) R/T lack of education on infant

feeding practices (E) as evidenced by infant

receiving bedtime juice in a bottle (S) Altered GI function (P) R/T ileal resection (E) as

evidenced by medical history and dumping

syndrome symptoms after meals (S)


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Nutrition Diagnosis Statement should be:

clear, concise

specific

related to one problem

accurate related to one etiology

based on reliable, accurate assessment

data


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Nutritional vs Medical Dx

Medical Diagnosis Nutritional Diagnosis

Diabetes Excessive CHO intake r/t visits to Coldstone Creamery

as evidenced by diet hx and high hs blood glucose

Trauma and closed

head injury

Increased energy needs r/t multiple trauma as

evidenced by results of indirect calorimetry

Liver failure Altered gastrointestinal function r/t cirrhosis of the liver

as evidenced by steatorrhea and growth failure


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Nutritional vs Medical Dx

Medical Dx Nutritional Diagnosis

Obesity Excessive energy intake r/t lack of access to healthy food

choices (restaurant eating) as evidenced by diet history

and BMI of 35.

Dependence mechanical

ventilation

Excessive energy intake r/t high volume PN as evidenced

by RQ >1

Anorexia nervosa Undesirable food choices r/t history of anorexia nervosa

and self-limiting behavior as evidenced by diet history

and weight loss of 5 lb


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ADAs Nutrition Care

Process Steps


Nutrition Diagnosis Nutrition Intervention



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Nutrition Intervention Definition

Purposely-planned actions designed withthe intent of changing a nutrition-relatedbehavior, risk factor, environmental

condition, or aspect of health status for anindividual, a target group, or population atlarge.

Lacey and Pritchett, JADA 2003;103:1061-

1072

Directed at the etiology or effects of adiagnosis


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Intervention Objectives

Should be patient-centered Must be achievable

Stated in behavioral terms, quantifiable

terms Pt and counselor must establish goals

together

may involve other members of health careteam

What will the patient do or achieve ifobjectives met


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Problem 1: Involuntary weight loss

Objectives:

1. Pt will stop losing wt and begin to gain wt

slowly, to a target wt of 145# 2. Pt will modify his diet to increase intake to

meet calorie and protein needs


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Problem 2: Inadequate protein-energy intake

2 poor appetite

Objectives:

1. Pt will attend senior center for lunch dailyto improve socialization and calorie intake

2. Pt will include nutrient-dense foods in his

diet


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Intervention translates assessment data

into strategies, activities, or interventions

that will enable the patient or client tomeet the established objectives.

Interventions should be specific:

What? When?

Where? How?


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Problem 1: Involuntary Weight loss

Intervention:

Pt will try to eat three meals a day plus bedtimesnack

Pt will include at least one nutrient-dense supplement

per day in his diet

Pt will increase energy intake to 1800 kcal per day,complete 3-day food record for analysis of adequacy


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Problem 2: Inadequate protein-calorieintake 2 poor appetite

Intervention: Pt will include nutrient-dense foods with meals,

especially when appetite is minimal

Patient will begin meal with nutrient-dense foods,

follow with others Pt will attend senior center for lunch daily to

improve socialization/appetite


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ADAs Nutrition Care

Process Steps


Nutrition Diagnosis Nutrition Intervention



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Nutrition Monitoring &

Evaluation

Components

Evaluate outcomesCompare current findings

with previous status,

intervention goals, and/or

reference standards


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What gets Measured?Nutrition

Monitoringand Evaluation

Types of Outcomes

End-result outcome

Direct nutrition outcomes

Clinical and health status outcomes

Patient/client-centered outcomes

Healthcare utilization

Intermediate-result outcome


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Nutrition Goals and Objectives

Are necessary in order to evaluate the

effectiveness of nutrition care

Should be achievable and based on

scientific evidence

Should be directly or indirectly related to

nutrition care


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NCP Example: Acute Care


Medical hx: 72 y.o. female admitted with decompensatedCHF; heart failure team consulted; has been admitted withsame dx x 2 in past month; meds: Lasix and Toprol; currentdiet order: 2 gram sodium; has lost 5 pounds in 24 hourssince admission; Output > input by 2 liters

Nutrition history: has been told to weigh self daily but has noscale at home. Does not add salt to foods at the table.

Noticed swollen face and extremities on day prior toadmission. Day before admission ate canned soup for lunchand 3 slices of pizza for dinner; does not restrict fluids; hasnever received nutrition counseling


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Nutrition Diagnosis Excessive sodium intake r/t frequent use of canned

soups and restaurant foods as evidenced by diethistory

Knowledge deficit r/t no previous nutritioneducation as evidenced by frequent use of highsodium convenience foods and inability to namehigh sodium foods

Excess fluid intake r/t dietary indiscretions asevidenced by diet hx and current fluid status

Self-monitoring deficit r/t lack of access to scale asevidenced by patient self report


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Excessive sodium intake: Patient will attendSenior Feeding site that provides low sodium

meals; Patient will implement survival skills lowsodium diet principles and attend heart failurediet program in heart failure clinic

Self-monitoring deficit: Patient will obtain free

home scale from CHF case manager; will limitfluids to 2 liters/day per instructions in HeartFailure Clinic if adherence to low sodium dietdoes not achieve appropriate fluid balance


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Monitoring and Evaluation

Patient will weigh self daily and keep log;

report to heart failure case manager if

weight 2 lb in 24 hours

Patient will bring 3 day diet record to heart

failure clinic for review by dietitian

Heart failure case manager will track

hospital readmissions over 12 months

nutrition care process briefer cp orientation

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