Presented  by:  

Sarah  Lippman  Sharon  Pokorny  Cindy  Salazar  Lucy  Ta  Peer  Nutri<on  Counseling  Spring  2013  

 NUTRITION  CARE  PROCESS        (NCP)  

What  Is  The  Nutri.on  Care  Process  And  Model?    

•  A  systema.c  method  that  allows  nutri.on  professionals  to  provide  pa.ents  with  quality  care.  

•  Intended  to  be  used  as  framework  to  guide  Registered  Die..ans  in  providing  consistency  in  care  and  predictability  of  outcomes.  

•  Provides  structure  for  research  and  data  collec.on  and  a  standardized  language.  

Nutri.on  Care  Process  Steps  

1.  Assessment:  nutri.onal  health  status  

2.  Diagnosis:  interpret  data    

3.  Interven.on:  develop  a  plan  of  ac.on  

4.  Monitor/Evaluate:  monitor  the  effec.veness  of  the  plan  

ADA  NUTRITION  CARE  PROCESS  AND  MODEL  

Step  1:  Nutri.on  Assessment  

•  The  founda.on  of  the  Nutri.on  Care  Process    

•  Necessary  to  iden.fy  the  cause  and  significance  of  nutri.on  related  problem  

How  Nutri.on  Professionals  Collect  Data  

�From  individuals:  •  Directly  from  pa.ents  through  interview  •  Through  observa.ons  and  measurements  •  Medical  records  •  Referring  health  care  provider    �From  popula.on  groups:  •  Data  from  surveys  •  Administra.ve  data  sets  •  Epidemiological  or  research  studies  

Categories  of  Nutri.on  Assessment  Data  

Food and nutrition-related history •  Food intake, nutrition and health awareness and

management, physical activity and exercise, and food availability.

Biochemical data, medical tests and procedures •  Include laboratory data (e.g., electrolytes, glucose,

lipid panel, and gastric emptying time).

Anthropometric measurements •  Include height, weight, body mass index (BMI),

growth rate, and rate of weight change.

 Categories  of  Nutri.on  Assessment  

Data    Nutri.on-­‐focused  physical  findings  

•  Include  oral  health,  general  physical  appearance,  muscle  and  subcutaneous  fat  was.ng  

Client  history  •  Include  medica.on  and  supplement  history,  social  history,  medical/health  history,  and  personal  history.  

Cri.cal  Thinking  in  Nutri.on  Assessment  

• Helps  o Determine  appropriate  data  to  collect  and  the  need  for  addi.onal  informa.on  

o Select  assessment  tools  and  procedures  o Apply  assessment  tools  in  valid  and  reliable  ways  o Dis.nguish  relevant  and  important  data  o Validate  the  data  

Step  2:  Nutri.on  Diagnosis/Problem  

• Cri.cal  step  between  nutri.on  assessment  and  nutri.on  interven.on  

•  Involves  using  standardized  terminology  for  iden.fying  and  labeling  the  specific  nutri.on-­‐related  problem  that  nutri.on  professionals  are  responsible  for  trea.ng  independently  

• Different  than  a  medical  diagnosis  which  describes  a  disease  or  pathology  of  organs  or  body  systems  (e.g.,  diabetes)  

Nutri.on  Diagnosis/Problem  

•  Three  domains:  1.   Intake  –  related  to  intake  of  energy,  nutrients,  fluids,  or  

bioac.ve  substances  through  oral  diet  or  NS  (EN  or  PN)    2.   Clinical  –  includes  nutri.onal  findings/problems  iden.fied  

as  related  to  medical  or  physical  condi.ons  

3.   Behavioral-­‐Environmental  –  includes  iden.fied  nutri.onal  findings/problems  that  relate  to  knowledge;  a^tudes/beliefs;  physical  environment;  access  to  food,  water,  or  nutri.on-­‐related  supplies;  and  food  safety  

Nutri.on  Diagnosis/Problem  

Medical  or  Nutri.onal  Diagnosis?  • High  cholesterol  •  Swallowing  difficulty  • Diabetes  •  Elevated  fas.ng  glucose  • Altered  GI  func.on  •  Excessive  fat  intake  • Disordered  ea.ng  pabern  

Nutrition  Diagnosis/Problem  •  It  is  summarized  into  a  structured  sentence  named  the  nutri.on  diagnosis  statement  or  the  PES  statement  because  it  is  comprised  of  a  problem  (P),  e.ology  (E),  and  signs  and  symptoms  (S).  

 •  The  generic  format  is:  

 Nutri.on  related  problem  (P)  related  to…  e.ology  (E)  as  evidenced  by…  signs  and  symptoms  (S)  

Nutri.on  Diagnosis/Problem  (P)  Problem  (nutri.on  diagnosis  label)  –  describes  altera.ons  in  the  pa.ent/client’s  nutri.onal  status    (E)  E<ology  (cause/contribu.ng  risk  factors)  –  are  those  

 factors  contribu.ng  to  the  existence  or  maintenance  of  the  nutri.on  related  problem    (S)  Signs/Symptoms  (defining  characteris.cs)  –  consist  of  objec.ve  (signs)  and/or  subjec.ve  (symptoms)  data  used  to  determine  if  the  pa.ent/client  has  the  nutri.on  diagnosis  specified    

Nutri.on  Diagnosis/Problem  

A  well-­‐wriben  PES  statement  should  be:  

•  Simple,  clear,  and  concise  

•  Specific  to  the  pa.ent/client  • Related  to  only  one  nutri.on-­‐related  problem  

• Related  accurately  to  the  e.ology  • Based  on  reliable  and  accurate  nutri.on  assessment  data  

Nutri.on  Diagnosis/Problem  Examples  of  PES  statements:    

1.  Excessive  fat  intake  related  to  limited  access  to  healthful  op.ons  and  poor  nutri.on  knowledge  as  evidenced  by  serum  cholesterol  level  of  230  mg/dL  and  patent’s  self  reported  food  intake  .  

 2.  Involuntary  weight  loss  related  to  poor  oral  food  and  

beverage  intake  as  evidenced  by  15-­‐lb  loss  in  3  months.    3.  Excessive  energy  intake  related  to  poor  food  choices  as  

evidenced  by  a  BMI  of  31.  

   

Nutri.on  Diagnosis/Problem  Evalua<ng  the  PES  statement  (P)  –  Can  the  problem  be  resolved  by  the  nutri.on  professional?  Use  the  nutri.on  diagnosis  from  the  intake  domain  as  that  one  is  the  most  specific  to  the  role  of  the  R.D.    (E)  –  Is  the  e.ology  chosen  the  “root  cause”  of  the  problem  which  can  be  addressed  with  a  nutri.on  interven.on?  If  not,  can  the  interven.on  lessen  the  signs  and  symptoms?    (S)  –  Can  the  signs  and  symptoms  be  monitored  (measured/evaluated)  to  indicate  if  there  is  improvement  with  the  nutri.on  diagnosis?      Overall  Does  the  nutri.on  assessment  data  support  the  nutri.on  diagnosis  with  the  e.ology  and  signs  and  symptoms?    

Step  3:  Nutri.on  Interven.on  Purposefully  planned  ac.ons  intended  to  posi.vely  change  a  nutri.on  related  behavior,  environmental  condi.on,  or  aspect  of  health  status  for  an  individual,  target  group,  or  community.    Purpose:  resolve  or  improve  the  iden.fied  nutri.on  problem  

•  How  are  Nutri.on  Interven.ons  determined?  o Interven.on  strategies  are  selected  based  on  nutri.on  diagnosis  and  e.ology  o Eg.  Change  nutri.onal  intake,  nutri.on-­‐elated  knowledge  or  behavior,  access  to  services  etc.  

o Interven.on  goals  provide  a  framework  for  monitoring  progress  and  measuring  outcomes  

Nutri.on  Interven.on  Domains  •  Each  domain  defines  classes  of  nutri.on  interven.on  strategies  based  on  specific  terms  necessary  for  medical  record  documenta.on,  billings,  communica.on,  and  research  

•  More  than  one  nutri.on  interven.on  may  be  simultaneously  implemented  as  part  of  the  pa.ent  plan  

1.  Food  and/or  Nutrient  Delivery  •  Individualized  approach  for  food/nutrient  provision,  

including  meals/snacks,  EN/TPN,  supplements  2.  Nutri<on  Educa<on  •  Formal  instruc.on/training  on  management/modifica.on  of  

food  choices  and  ea.ng  behavior  in  order  to  impart  knowledge  to  pa.ents  on  maintaining  or  improving  health  

 

Nutri.on  Interven.on  Domains  3.  Nutri<on  Counseling    •  A  suppor.ve  process,  characterized  by  a  collabora.ve  counselor-­‐pa.ent  rela.onship,  to  set  priori.es,  establish  goals,  and  create  individualized  ac.on  plans  that  foster  responsibility  for  self-­‐care  to  treat  exis.ng  condi.ons  and  promote  health  

4.  Coordina<on  of  Nutri<on  Care  •  Consulta.on  with,  referral  to,  or  coordina.on  of  nutri.on  care  with  other  health  care  providers  that  can  assist  in  trea.ng  or  managing  nutri.on-­‐related  problems  

Nutri.on  Interven.on  Reference  Sheets  •  Developed  for  each  nutri.on  interven.on  

•  Includes  nutri.on  interven.on  label,  defini.on,  descrip.ve  details,  and  nutri.on  diagnosis  for  which  it’s  commonly  associated  

•  Designed  to  assist  food  and  nutri.on  professionals  with  consistent  and  correct  u.liza.on  of  the  nutri.on  interven.ons  

Components  Nutri.on  Interven.on  1.   Planning  •  Priori.ze  nutri.on  diagnoses  

•  Nutri.on  interven.on  è  e.ology  (PES)  •  Consult  AND’s  EBNPG  &  other  prac.ce  guides  •  Determine  pt-­‐focused  expected  outcomes  for  each  nutr  dx  •  Confer  with  pa.ent/family  members/caregivers  •  Define  nutri.on  interven.on  plan,  strategies  •  Define  .me,  frequency  of  care  •  ID  resources  needed  2.   Implementa<on:  Ac<on  Phase  •  Communica.on:  nutri.on  care  plan  •  Carrying  out  plan  

Nutri.on  Prescrip.on  •  Essen.al  component  of  the  interven.on:  concisely  state  individualized  recommenda.ons  (based  on  reference  standards,  dietary  guidelines,  pa.ent’s  ND.  

o Use  assessment  data:  PES;  evidence,  policies,  and  procedures;  pa.ent  preferences.  

•  Nutri.on  Rx  è  interven.on  selec2on,  or  implementa.on  o  IDs  specific  interven.on  strategies  o è  pa.ent-­‐focused  goals  -­‐  Clear,  measureable,  achievable,  <me-­‐defined  -­‐  Essen.al  in  order  to  measure  the  quan.fiable  and  qualifiable  impact  of  interven.on    

 

Step  4:  Nutri.on  Monitoring  and  Evalua.on  

•  IDs  important  measures  of  change/pt.  outcomes  relevant  to  the  ND  &  interven.on:  how  to  measure  and  evaluate  outcomes.  

•  Purpose:  evaluate  efficacy  of  nutri.on  (pa.ent  mee.ng  goals?)  § Reassessment  to  ID  if  the  nutri.on-­‐related  problem  s.ll  exists;  evaluate  the  progress    

§ Progress  assessed  by:  comparing  specific  markers,  nutri.on  care  indicators  to,  science-­‐based  standards,  baselines  

o Contributes  to  body  of  literature  quan.fying  effec.veness  of  nutri.on  interven.ons  

Nutri.on  Monitoring  and  Evalua.on:  Defini.ons  

•   Monitoring:    o  Preplanned  review,  measurement  of  selected  nutri.on  care  

indicators  relevant  to  defined  needs,  nutri.on  diagnosis,  nutri.on  interven.on,  outcomes  

•   Evalua<on:    o  The  systema.c  comparison  of  findings  with  previous  status,  

nutri.on  interven.on  goals,  effec.veness  of  nutri.on  care,      reference  standard  

•   Nutri<on  Care  Outcomes:    o  Results  of  nutri.on  care  directly  related  to  nutri.on      

diagnosis  goals  of  interven.on  plan  •   Nutri<on  Care  Indicators  (NCI):    

o  Markers  –  measured,  evaluated  to  determine  effec.veness    of  nutri.on  care  

Nutri.on  Care  Outcomes  •  Food/Nutri.on-­‐Related  History  o Food  and  Nutrient  Intake;  Food,  Nutrient  Administra.on,  Medica.on/Supplement  Use;  Knowledge/Beliefs/A^tudes;  Behavior;  Factors  Affec.ng  Access  to  Food  and  Food/Nutri.on  Related  Supplies;  Physical  Ac.vity  and  Func.on;  and  Nutri.on  Related  Pa.ent-­‐Centered  Measures  

•  Biochemical  Data,  Medical  Tests,  and  Procedures  o Lab  data  and  tests  •  Anthropometric  Measurements  o Height;  Weight/History;  BMI;  Growth  Pabern  Indices/%  Ranks  •  Nutri.on-­‐Focused  Physical  Findings  o Findings  from  an  evalua.on  of  body  systems,  muscle  and  subcutaneous  fat  was.ng,  oral  health,  suck/swallow/breath  ability,  and  affect  

Nutrition  Monitoring  and  Evaluation:  Components  

•   Monitor  Progress:      §   Check  pa.ents  understanding/compliance      §   Determine  if  interven.on  is  being  implemented      §   Provide  evidence:  interven.on  is/is  not  working  §   ID  other  +/-­‐  outcomes  §   Gather  informa.on  (lack  of  progress?)  §   Support  conclusions  with  evidence  

•   Measure  Outcomes:    §   Select  the  NCI(s)  to  measure  outcomes(s)  §   Use  standardized  NCIs  to  ñ  validity  &  reliability  

•   Evaluate  Outcomes:    §   Compare  data  with  Rx/goals,  reference  standards  §   Evaluate  impact  of  all  interven.ons  on  overall  pa.ent  health  

outcomes  

Nutri.on  Monitoring  &  Evalua.on:  Documenta.on  

Quality  documenta<on  for  nutri<on  monitoring  and  evalua<on  include:  •  Date  and  .me  •  Indicators  measured,  results,  and  method  for  obtaining  •  Criteria  to  which  the  indicator  is  compared  •  Factors  facilita.ng  or  hindering  success  •  Other  posi.ve  or  nega.ve  outcomes  •  Future  plans  for  nutri.on  care,  nutri.on  monitoring,  and  follow-­‐up  or  discharge  

Data  Sources  and  Tools:  •  Pa.ent  ques.onnaires  •  Surveys  •  Pretests/Posbests  •  Pa.ent  interviews  

•  Anthropometric  measurements  •  Biochemical/medical  test  results  •  Food  and  nutri.on  intake  tools    

NCP  Example  #1  Nutri<on  Assessment  •  Medical  hx:    -­‐  72  year  old  female  admibed  with  decompensated  CHF  -­‐  Admibed  two  .mes  in  the  past  month  with  the  same  dx    -­‐  Meds:  Lasix  and  Toprol    -­‐  No.ced  swollen  face  and  extremi.es  on  day  prior  to  admission  

-­‐  Has  lost  5  lbs.  in  24  hrs  since  admission  -­‐  Output  >  input  by  2  L    

 

 

NCP  Example  #1  Nutri<on  Assessment    •  Diet  hx:    -­‐  Was  told  to  weigh  herself  daily  but  has  no  scale  at  home  -­‐  Does  not  add  salt  to  foods  at  the  table    -­‐  Ate  canned  soup  for  lunch  and  3  slices  of  pizza  for  dinner  the  day  before  admission    

-­‐  Usually  goes  out  to  eat  at  restaurants  -­‐  Does  not  restrict  fluids  -­‐  Has  never  received  nutri.on  counseling  -­‐  Current  Diet  Order:  2  g  Na  

NCP  Example  #1  

Nutri<on  Diagnosis  •  Excessive  sodium  intake  as  related  to  consump.on  of  canned  soup,  pizza,  and  restaurant  foods  as  evidenced  by  diet  history.  

•  Lack  of  nutri.on  knowledge  as  related  to  never  seeing  a  nutri.on  counselor  as  evidenced  by  excess  consump.on  of  high  sodium  foods.    

NCP  Example  #1  Nutri<on  Interven<on  •  Excess  sodium  intake:  -­‐  Teach  pa.ent  how  to  read  nutri.on  label  to  avoid  high  Na  foods    

-­‐  Abend  Senior  Feeding  Sites  where  they  serve  low  Na  foods  -­‐  Abend  heart  failure  diet  program    •  Lack  of  nutri.on  knowledge:    -­‐  See  an  RD  weekly  or  bi-­‐weekly  at  the  heart  failure  clinic    -­‐  Compliance  with  diet        

NCP  Example  #1  Monitoring  and  Evalua<on  •  Pa.ent  should  weigh  herself  daily  and  keep  track  in  a  log;  report  to  heart  failure  case  manager  if  pa.ent  weigh  2  pounds  or  more  in  24  hours  

•  Pa.ent  should  keep  track  of  diet  by  wri.ng  3  day  diet  logs  to  show  to  the  RD  for  review    

 

NCP  Example  #2  Nutri<on  Assessment  •  Medical  hx:    -­‐  70  year  old  male  admibed  for  cardiac  bypass  surgery  -­‐  History  of  hypertension,  thyroid  dysfunc.on,  asthma,  prostate  surgery    

NCP  Example  #2  Nutri<on  assessment  •  Diet  hx:    -­‐  Has  lost  weight  without  trying  and  has  been  ea.ng  poorly  for  several  weeks  before  admission,  leading  to  referral  to  the  RD  for  nutri.on  assessment.    

-­‐  Caloric  intake:  1,200kcal/day    -­‐  Meals:  irregular  throughout  the  day;  drinks  coffee  frequently    •  Personal  hx:  -­‐  Lives  alone  at  home  -­‐  Lost  his  wife  3  months  ago  -­‐  Rarely  sits  down  to  a  cooked  meal  in  the  past  6  months    

NCP  Example  #2  Nutri<on  Diagnosis    •  Involuntary  weight  loss  as  related  to  irregular  meals  throughout  the  day  as  evidenced  by  a  consump.on  of  1,200  calories  a  day.    

 

NCP  Example  #2  Nutri<on  Interven<on  •  Involuntary  weight  loss:  -­‐  Modify  diet  to  include  adequate  calories  and  protein    -­‐  Nutrient  and  caloric  dense  foods  to  prevent  weight  loss  and  promote  weight  gain    

NCP  Example  #2  Monitoring  and  Evalua<on  •  Monitoring  will  include  weekly  weight  measurements  and  nutrient  intake  analyses    

•  If  nutri.on  status  is  not  improving,  such  as    weight  records  and  goals  not  being  met,  he  needs  to  be  reassessed  and  develop  new  goals  and  create  plans  for  new  interven.ons    

   

References  Academy  of  Nutri.on  and  Diete.cs.  (2013).  Interna.onal  Diete.cs  &  Nutri.on    

 Terminology  (IDNT)  Reference  Manual:  Standardized  Language  for  the  Nutri.on    Care  Process  (4th  ed.).  Chicago,  IL.  

   American  Diete.c  Associa.on.  Frequently  Asked  Ques2ons  Regarding  the  Nutri2on    

 Care  Process  and  Model  (2008).  Retrieved  November  2,  2009    from  www.eatright.org  

   Bueche,  J.,  Charney,  P.,  Pavlinac,  J.,  Skipper,  A.,  Thompson,  E.,  Myers,  E.  (2008).  Nutri.on    

 care  process  and  model  part  I:  The  2008  update.  Journal  of  the  American    Diete2cs  Associa2on,  113-­‐117.  Retrieved  November  13,  2010  from    

hbp://www.eatright.org/HealthProfessionals/content.aspx.?id=7077&terms=NCP      Mahan,  L.K.,  &  Escob-­‐Stump,  S.  (2012).  Krause’s  Food  and  the  Nutri.on  Care  Process  (13th    

 ed.).  St.  Louis,  MO.      Nutri.on  Care  Process:  Diagnosis,  Interven.on,  Evalua.on,  and    Monitoring.  Retrieved    

 from  www3.uakron.edu.