The Nutrition Care Process Chapter 21

© 2004, 2002 Elsevier Inc. All rights reserved. Nutrition Care Process n Assess nutritional status. n Analyze data to identify nutritional needs. n Plan and prioritize nutritional care objectives to meet these needs. n Implement strategies necessary to meet the objectives. n Evaluate the nutritional care outcomes. n Assess nutritional status. n Analyze data to identify nutritional needs. n Plan and prioritize nutritional care objectives to meet these needs. n Implement strategies necessary to meet the objectives. n Evaluate the nutritional care outcomes.

© 2004, 2002 Elsevier Inc. All rights reserved. Nutrition Care Process

© 2004, 2002 Elsevier Inc. All rights reserved. Nutrition Care Process –cont’d

© 2004, 2002 Elsevier Inc. All rights reserved. Nutrition Care Process –cont’d

© 2004, 2002 Elsevier Inc. All rights reserved. Patient/Nutrition Care Process n Admission n MD orders: PE, Dx, PMHx, Diet order, Labs, Tests/Procedures, Consults, Meds RN Assessment: Ht, Wt, I/Os, Vitals, PO, FPG, Allergies, GI Status, Feeding ability/Dentition, Wounds n Nutrition Screen: Age, Dx, Diet Rx, Anthros, Labs, Oral intake, GI, Meds n Admission n MD orders: PE, Dx, PMHx, Diet order, Labs, Tests/Procedures, Consults, Meds RN Assessment: Ht, Wt, I/Os, Vitals, PO, FPG, Allergies, GI Status, Feeding ability/Dentition, Wounds n Nutrition Screen: Age, Dx, Diet Rx, Anthros, Labs, Oral intake, GI, Meds

© 2004, 2002 Elsevier Inc. All rights reserved. Nutriton Assessment Gather & evaluate/analyze data Update screen info from MR Interview pt/family D/w staff Document assessment & plan SOAP, PIE, DAR, Narrative Paper vs. computer chart

© 2004, 2002 Elsevier Inc. All rights reserved. n Implement Strategies (Interventions) –Education, Referrals, Food Preferences, snacks/supplements n Nutrition F/U Assessments –Evaluate outcomes, Document assessment, –Implement further strategies PRN n Implement Strategies (Interventions) –Education, Referrals, Food Preferences, snacks/supplements n Nutrition F/U Assessments –Evaluate outcomes, Document assessment, –Implement further strategies PRN

© 2004, 2002 Elsevier Inc. All rights reserved. Nutritional Assessment n The process by which the nutritional status of an individual is determined n Usually includes dietary history and intake data, laboratory data, clinical examination and health history, anthropometric data, and psychosocial data n The process by which the nutritional status of an individual is determined n Usually includes dietary history and intake data, laboratory data, clinical examination and health history, anthropometric data, and psychosocial data

© 2004, 2002 Elsevier Inc. All rights reserved. Nutritional Screening Information

© 2004, 2002 Elsevier Inc. All rights reserved. Nutrition Screening and Assessment Tool Courtesy Carolinas Medical Center, Charlotte, N.C.

© 2004, 2002 Elsevier Inc. All rights reserved. Development of a Plan for Nutritional Care n Prioritize problems n Client and counselor must jointly establish achievable goals n Express objectives in behavioral terms n State objectives in quantifiable terms n Prioritize problems n Client and counselor must jointly establish achievable goals n Express objectives in behavioral terms n State objectives in quantifiable terms

© 2004, 2002 Elsevier Inc. All rights reserved. Implementation of Nutritional Care n Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives. n Interventions should be specific: —What?—When? —Where?—How? n Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives. n Interventions should be specific: —What?—When? —Where?—How?

© 2004, 2002 Elsevier Inc. All rights reserved. Evaluation of Nutritional Care n Evaluate care provided n Review plan frequently n Reassess plan—may be new needs n Identify any new needs n Formulate a new nutritional care plan n Evaluate care provided n Review plan frequently n Reassess plan—may be new needs n Identify any new needs n Formulate a new nutritional care plan

© 2004, 2002 Elsevier Inc. All rights reserved. Nutritional Care Record n Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives

© 2004, 2002 Elsevier Inc. All rights reserved. Care Record Courtesy St. John’s Hospital, Springfield, Ill.

© 2004, 2002 Elsevier Inc. All rights reserved. Documentation Style n DAP (diagnosis, assessment, plan) n PIE (problem, intervention, evaluation) n PES (problem, etiology, symptoms) n IER (intervention, evaluation, revision) n HOAP (history, observation, assessment, plan) n SAP (screen, assess, plan) n SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions) n SOAP (subjective, objective, assessment, plan) n DAP (diagnosis, assessment, plan) n PIE (problem, intervention, evaluation) n PES (problem, etiology, symptoms) n IER (intervention, evaluation, revision) n HOAP (history, observation, assessment, plan) n SAP (screen, assess, plan) n SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions) n SOAP (subjective, objective, assessment, plan)

© 2004, 2002 Elsevier Inc. All rights reserved. SOAP Notes S: Subjective n Info provided by patient, family, or other n Pertinent socioeconomic, cultural info n Level of physical activity n Significant nutritional history S: Subjective n Info provided by patient, family, or other n Pertinent socioeconomic, cultural info n Level of physical activity n Significant nutritional history

© 2004, 2002 Elsevier Inc. All rights reserved. SOAP Notes—cont’d O: Objective n Factual, reproducible observations n Diagnosis n Height, age, weight—and weight gain patterns n Lab data n Clinical data (nausea, diarrhea) n Diet order n Medications O: Objective n Factual, reproducible observations n Diagnosis n Height, age, weight—and weight gain patterns n Lab data n Clinical data (nausea, diarrhea) n Diet order n Medications

© 2004, 2002 Elsevier Inc. All rights reserved. SOAP Notes—cont’d A: Assessment n Interpretation of patient’s status based on subjective and objective info n Evaluation of nutritional history n Assessment of laboratory data and medications n Assessment of diet order n Assessment of patient’s comprehension and motivation A: Assessment n Interpretation of patient’s status based on subjective and objective info n Evaluation of nutritional history n Assessment of laboratory data and medications n Assessment of diet order n Assessment of patient’s comprehension and motivation

© 2004, 2002 Elsevier Inc. All rights reserved. SOAP Notes—cont’d P: Plan n Diagnostic studies needed n Further workup, data needed n Medical nutrition therapy goals n Recommendations for nutritional care P: Plan n Diagnostic studies needed n Further workup, data needed n Medical nutrition therapy goals n Recommendations for nutritional care

© 2004, 2002 Elsevier Inc. All rights reserved. Basic Hospital Diets

© 2004, 2002 Elsevier Inc. All rights reserved. Basic Hospital Diets —cont’d

© 2004, 2002 Elsevier Inc. All rights reserved. Soft Diet

© 2004, 2002 Elsevier Inc. All rights reserved. Clear Liquid Diet

© 2004, 2002 Elsevier Inc. All rights reserved. Full Liquid Diet

© 2004, 2002 Elsevier Inc. All rights reserved. Full Liquid Diet –cont’d

© 2004, 2002 Elsevier Inc. All rights reserved. Nutritional Care of the Terminally Ill Patient n Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients. n Dietary restrictions are rarely appropriate. n Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients. n Dietary restrictions are rarely appropriate.

© 2004, 2002 Elsevier Inc. All rights reserved. Palliative Care n Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently

© 2004, 2002 Elsevier Inc. All rights reserved. Discharge Planning Discharge documentation includes n Summary of nutritional therapies and outcomes n Pertinent information such as weight, lab results, dietary intake n Potential drug-nutrient interactions n Expected progress or prognosis n Recommendations for follow-up services Discharge documentation includes n Summary of nutritional therapies and outcomes n Pertinent information such as weight, lab results, dietary intake n Potential drug-nutrient interactions n Expected progress or prognosis n Recommendations for follow-up services

© 2004, 2002 Elsevier Inc. All rights reserved. Discharge Planning Courtesy University of Washington Medical Centers, Seattle.

© 2004, 2002 Elsevier Inc. All rights reserved. Nutrition Care Process n See Appendix 56

© 2004, 2002 Elsevier Inc. All rights reserved.