Nutrition Care ProcessKNH 411

RelationshipBetween

Patient/Client/Group & Dietetics

Professional

-

Nutrition DiagnosisØ Identify and label problemØ Determine cause/contributing risk

factors Ø Cluster signs and symptoms/

defining characteristics

Nutrition AssessmentØ Obtain/collect timely and

appropriate dataØ Analyze/interpret with

evidence- based standardsØ

Ø Identify risk factorsØ Use appropriate tools

and methodsØ 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 dataØ Identify and analyze causes of less than

optimal performance and outcomesØ Refine the use of the Nutrition Care

Process

AND NUTRITION CARE PROCESS AND MODEL

Ø Document

Nutrition Monitoring and EvaluationØ Monitor progressØ Measure outcome indicators Ø Evaluate outcomesØ Document

Nutrition InterventionØ Plan nutrition intervention• Formulate goals and

determine a plan of actionØImplement the nutrition intervention• Care is delivered and actions

are carried outØDocument

Document

AND’s Nutrition Care Process Steps

� Nutrition Assessment

� Nutrition Diagnosis

� Nutrition 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 Components

� Gather data, considering

� Compare to relevant standards

� Identify possible problem areas

Nutrition Assessment: Critical Thinking

� Observe

� Determining appropriate data to collect

� Selecting assessment tools

� Distinguishing relevant from irrelevant data

� Organizing data

� Determining when problems require referral

ADA’s Nutrition Care Process Steps

� Nutrition Assessment

� Nutrition Diagnosis

� Nutrition Intervention

� Nutrition Monitoring and Evaluation

Nutrition Diagnosis

� Nutritional problem

� Names and describes the problem

� Problem may already exist, or may be at risk of occurring

� Not a medical diagnosis

Nutrition Dx Domains: Intake

Defined 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

� Class: Oral or nutrition support intake

� Class: Fluid intake balance

� Class: Bioactive substances balance

� Class: Nutrient balance

Nutrition Dx Domains: ClinicalDefined as “nutritional findings/problems

identified that relate to medical or physical conditions

� Class: functional balance

� Class: Biochemical balance

� Class: weight balance

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 beliefs

� Class: physical activity, balance and function

� Class: food safety and access

Nutrition Diagnosis Components

� Problem

� Etiology

� Signs/Symptoms� Signs � Symptoms

Nutrition Diagnosis Components

� Problem � Describes alterations in pt’s nutritional status� Diagnostic labels� Impaired� Altered

� Inadequate/excessive

� Inappropriate � Swallowing difficulty

Nutrition Diagnosis Components

� Etiology � Related factors that contribute to problem� Identifies cause of the problem� Helps determine whether nutrition intervention will

improve problem� Linked 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 Components

� Food, 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, concise

� specific

� related to one problem

� accurate

� based on reliable, accurate assessment data

Nutritional vs Medical Dx

Medical  Diagnosis Nutritional  Diagnosis

Diabetes

Trauma  and  closed  head  injury

Liver  failure

Nutritional vs Medical Dx

Medical  Dx Nutritional  Diagnosis

Obesity

Dependence  mechanical  ventilation

Anorexia  nervosa

AND’s Nutrition Care Process Steps

� Nutrition Assessment

� Nutrition Diagnosis

� Nutrition 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

Intervention Objectives

Should be patient-centered� Must be achievable

� Stated in behavioral terms

� Pt and counselor must establish goals together

� What will the patient do or achieve if objectives met

Intervention Objectives

� Problem 1: Involuntary weight loss� Objectives:� 1.� 2.

Intervention Objectives

� Problem 2: Inadequate protein-energy intake 2° poor appetite

� Objectives:

1.

2.

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 specific

Nutrition Intervention

� Problem 1: Involuntary Weight loss� Intervention:1.

2.

3.

4.

Nutrition Intervention

� Problem 2: Inadequate protein-calorie intake 2° poor appetite� Intervention:1.

2.

3.

AND’s Nutrition Care Process Steps

� Nutrition Assessment

� Nutrition Diagnosis

� Nutrition Intervention

� Nutrition Monitoring and Evaluation

Nutrition Monitoring & EvaluationComponents

Evaluate outcomes

Compare current findings with previous status, intervention goals, and/or reference standards

What gets Measured?Nutrition  Monitoring

and  Evaluation

Types  of  Outcomes

End-­result  outcome

•Direct  nutrition  outcomes  

•Clinical  and  health  status  outcomes  

•Patient/client-­centered  outcomes

•Healthcare  utilization  

Intermediate-­result  outcome

Nutrition Goals and Objectives

� Are necessary in order to evaluate

� Should be achievable

� Should be directly or indirectly related to nutrition care

NCP Example: Acute Care

Nutrition Assessment

� Medical 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 Diagnosis

1.

2.

3.

4.

NCP Example: Acute CareNutrition Intervention

� 1.

� 2.

� 3.

� 4.

NCP Example: Acute Care

Monitoring and Evaluation

1.

2.

3.