1. ADA NUTRITION CARE PROCESS AND MODEL
Screening
& Referral
System Ø
Identify risk factors Ø
Use appropriate tools
and methods Ø
Involve
interdisciplinary
collaboration
Nutrition Diagnosis Ø
Identify and label problem
Nutrition Assessment Ø
Determine cause/contributing risk Ø
Obtain/collect timely and
factors
appropriate
data Ø
Cluster signs and symptoms/ Ø
Analyze/interpret with
defining characteristics
evidence -
based standards Ø
Document Ø
Document
Relationship
Between
Patient/Client/Group
Nutrition Intervention
&
Dietetics Ø
Plan nutrition intervention
Professional
Formulate goals and
determine a plan of action Ø
Implement the nutrition intervention
Nutrition Monitoring and
Care is delivered and actions
Evaluation
are carried out - Ø
Monitor progress Ø
Documen t Ø
Measure outcome indicators Ø
Evaluate outcomes
Over the next few slides we will look at the steps and systems of the Nutrition Care Process and Model. Since this slide doesn’t project well, please refer to your handout of the diagram of the Nutrition Care Process and Model though out the next few slides.
The model is intended to depict the relationship with which all of these components overlap, interact, and move in a dynamic manner to provide the best quality nutrition care possible. Ø
Document
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

2. ADA’s Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The 4 quadrants around the core represent the four steps of the nutrition care process: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals.
Even though each step builds on the previous one, the process is not linear. Critical thinking and problem solving will frequently require that dietetics professionals revisit previous steps to reassess, add, or revise nutrition diagnoses; modify intervention strategies; and/or evaluate additional outcomes.
The first step we’ll look at is the Nutrition Assessment

3. 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:

4. Nutrition Assessment 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

5. Nutrition Assessment: Critical Thinking
Observing verbal and non-verbal cues to guide interviewing methods
Determining appropriate data to collect
Selecting assessment tools and procedures and applying in valid and reliable ways
Distinguishing relevant from irrelevant data
Organizing data to relate to nutrition problems
Determining when problems require referral

6. ADA’s Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The 4 quadrants around the core represent the four steps of the nutrition care process: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals.
Even though each step builds on the previous one, the process is not linear. Critical thinking and problem solving will frequently require that dietetics professionals revisit previous steps to reassess, add, or revise nutrition diagnoses; modify intervention strategies; and/or evaluate additional outcomes.
The first step we’ll look at is the Nutrition Assessment

7. Nutrition Diagnosis
Nutritional problem that the dietitian is responsible for treating
Names and describes the problem
Problem may already exist, or may be at risk of occurring
Not a medical diagnosis
Type 2 diabetes = medical diagnosis
Excessive carbohydrate intake resulting in elevated blood glucose levels = nutrition diagnosis.

8. 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

9. Nutrition Dx Domains: Clinical
Defined as “nutritional findings/problems identified that relate to medical or physical conditions
Class: functional balance (change in physical or mechanical functioning with nutritional consequences)
Class: Biochemical balance: change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered lab values
Class: weight balance: chronic weight or changed weight status when compared with usual or desired body weight

10. 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

11. 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

12. Nutrition Diagnosis Components
Problem (Diagnostic Label)
Describes alterations in pt’s nutritional status
Diagnostic labels
Impaired (nutrient utilization…)
Altered (GI function…)
Inadequate/excessive (calorie intake…)
Inappropriate (intake of types of carbohydrate)
Swallowing difficulty

13. Nutrition Diagnosis Components
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

14. Nutrition Diagnosis Components
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)

15. Nutrition Diagnosis Components
Signs/Symptoms (Defining characteristics)
Evidence that problem exists
Linked to etiology by words “as evidenced by”

16. Nutrition Diagnosis Components
Etiology (Cause/Contributing Factors)
Excessive calorie intake (problem) “related to” regular consumption of large portions of high-fat meals (etiology) as evidenced by diet history and weight status
Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing following drinking of thin liquids (signs and symptoms)

17. 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)

18. 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)

19. Nutrition Diagnosis Components
Nutrition Diagnosis Statement should be:
clear, concise
specific
related to one problem
accurate – related to one etiology
based on reliable, accurate assessment data

20. 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

21. Nutritional vs 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

22. ADA’s Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The 4 quadrants around the core represent the four steps of the nutrition care process: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals.
Even though each step builds on the previous one, the process is not linear. Critical thinking and problem solving will frequently require that dietetics professionals revisit previous steps to reassess, add, or revise nutrition diagnoses; modify intervention strategies; and/or evaluate additional outcomes.
The first step we’ll look at is the Nutrition Assessment

23. 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:
Directed at the etiology or effects of a diagnosis

24. 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 care team
What will the patient do or achieve if objectives met

25. Intervention Objectives
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

26. Intervention Objectives
Problem 2: Inadequate protein-energy intake 2° poor appetite
Objectives:
1. Pt will attend senior center for lunch daily to improve socialization and calorie intake
2. Pt will include nutrient-dense foods in his diet

27. 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:
—What? —When?
—Where? —How?

28. Nutrition Intervention
Problem 1: Involuntary Weight loss
Intervention:
Pt will try to eat three meals a day plus bedtime snack
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

29. Nutrition Intervention
Problem 2: Inadequate protein-calorie intake 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

30. ADA’s Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The 4 quadrants around the core represent the four steps of the nutrition care process: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals.
Even though each step builds on the previous one, the process is not linear. Critical thinking and problem solving will frequently require that dietetics professionals revisit previous steps to reassess, add, or revise nutrition diagnoses; modify intervention strategies; and/or evaluate additional outcomes.
The first step we’ll look at is the Nutrition Assessment

31. Nutrition Monitoring & Evaluation Components
Evaluate outcomes
Compare current findings with previous status, intervention goals, and/or reference standards
The third sub step is to evaluate the outcomes.
It’s not just adequate to measure outcomes, but we need to determine what difference was made with the nutrition intervention.
By looking at nutrition monitoring and evaluation in the 3 different sub steps, we can begin to see some of the immediate outcomes that can be incorporated into our practice. This can make it easier for practitioners to begin tracking data over time.

32. Intermediate-result outcome
What gets Measured?
Nutrition
Monitoring
and Evaluation
Types of Outcomes
Direct nutrition outcomes
Clinical and health status outcomes
Patient/client-centered outcomes
Healthcare utilization
During the nutrition monitoring and evaluation step, there are several types of outcomes we measure.
The 4 types of outcomes are listed on the slide. Examples of direct nutrition outcomes that we can access and track over time include the client’s behavior change, food or nutrient intake changes, improved nutritional status, or knowledge gained.
Clinical and health status outcomes include laboratory values, weight, blood pressure, risk factor profile changes, signs and symptoms, clinical status, infections, and other complications.
Client-centered outcomes on the other hand include quality of life measures, satisfaction, self-efficacy, self-management, and the client’s functional ability.
And finally, healthcare utilization and cost outcomes include items such as medication changes, special procedures, planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, or the prevention or delay of nursing home admission.
We also measure this data for immediate results-- in the short term such as the first visit with the client, as well as measure long-term results, such as the end of our MNT visit with the client or year 2 follow-up visits.
Intermediate-result outcome
End-result outcome

33. 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

34. 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

35. NCP Example: Acute Care
Nutrition Diagnosis
Excessive sodium intake r/t frequent use of canned soups and restaurant foods as evidenced by diet history
Knowledge deficit r/t no previous nutrition education as evidenced by frequent use of high sodium convenience foods and inability to name high sodium foods
Excess fluid intake r/t dietary indiscretions as evidenced by diet hx and current fluid status
Self-monitoring deficit r/t lack of access to scale as evidenced by patient self report

36. NCP Example: Acute Care
Nutrition Intervention
Excessive sodium intake: Patient will attend Senior Feeding site that provides low sodium meals; Patient will implement survival skills low sodium diet principles and attend heart failure diet program in heart failure clinic
Self-monitoring deficit: Patient will obtain free home scale from CHF case manager; will limit fluids to 2 liters/day per instructions in Heart Failure Clinic if adherence to low sodium diet does not achieve appropriate fluid balance

37. NCP Example: Acute Care
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