Nutrition Care Process Practical Applications

Nutrition Care Process Practical Applications
Andrea Maher RD, LD Alicia Aguiar MS, RD, LD

Functional changes (swallowing, GI) Altered lab data
International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, Second Edition Functional changes (swallowing, GI) Altered lab data Altered body weight Behavioral/Environmental

Why should I learn NCP Process?
Promotes critical thinking to treat current and pertinent nutrition problems Determines a nutrition diagnosis that drives the care plan Utilizes a vocabulary to describe the dietitian’s process within and outside the profession Affirms via documentation that the nutrition diagnosis has been resolved

Why should I learn NCP Process?
If we can name it We can do it We can teach it We can measure it We can improve it We can get paid for it Annalynn Skipper, PhD, RD, FADA, author and consultant

Step 1: Nutrition Assessment
Method in which we obtain, verify and interpret data needed to identify nutrition related problems. Determines whether a nutrition diagnosis exists The PES statement is then derived from the synthesis of information from the nutrition assessment data

Step 1: Nutrition Assessment
Mark page 11 of your pocket guide: “Assessment”

Step 2: Nutrition Diagnosis
Mark page 139 of your pocket guide: “Diagnosis”

Nutrition diagnosis are categorized under 3 domains Intake (page 139) Clinical (page 140) Behavioral-Environmental (page 140) Currently, 60 nutrition diagnosis identified In the LTC setting, the Intake domain will be used most frequently

Step 2: Nutrition Diagnosis, cont.
The dietitian is responsible for treating independently No right or wrong nutrition diagnosis—some are more appropriate than others When faced with equally good choices from different domains (Intake, Clinical or Behavioral-Environmental) choose Intake Intake domain more likely to be caused by a nutritional etiology and have a nutrition directed intervention It is interesting to have a group of RDs read a case study and then brainstorm using the SNL. You quickly find that the language may be standardized, but we do not all think alike. There is room for individual planning. The PES statement is used to succinctly describe the target for the intervention we provide. Our standardized language is not static. A mechanism is in place for periodic review of the terminology to ensure that it reflects dietetics practice. Future changes to the diagnoses/problems and the worksheets are expected as this standard language evolves. We are encouraged to submit new terms or suggest changes to approved terms. P 268…

Medical Diagnosis Disease/pathology of specific organs or body systems Does not change as long as the condition exists Ex: Diabetes Nutrition Diagnosis Problem related to nutrition that RD can influence Changes as the resident’s response changes Ideally, with nutrition intervention, diagnosis is resolved Ex: Excessive CHO intake A nutrition diagnosis is not a medical diagnosis.

The dietitian is responsible for treating independently No right or wrong nutrition diagnosis—some are more appropriate than others When faced with equally good choices from different domains (Intake, Clinical or Behavioral-Environmental) choose Intake Intake Domain more likely to be caused by a nutritional etiology and have a nutrition directed intervention It is interesting to have a group of RDs read a case study and then brainstorm using the SNL. You quickly find that the language may be standardized, but we do not all think alike. There is room for individual planning. The PES statement is used to succinctly describe the target for the intervention we provide. Our standardized language is not static. A mechanism is in place for periodic review of the terminology to ensure that it reflects dietetics practice. Future changes to the diagnoses/problems and the worksheets are expected as this standard language evolves. We are encouraged to submit new terms or suggest changes to approved terms. P 268…

The dietitian is responsible for treating independently No right or wrong nutrition diagnosis—some are better than others When faced with equally good choices from different domains (Intake, Clinical or Behavioral-Environmental) choose Intake Intake Domain more likely to caused by a nutritional etiology and have a nutrition directed intervention It is interesting to have a group of RDs read a case study and then brainstorm using the SNL. You quickly find that the language may be standardized, but we do not all think alike. There is room for individual planning. The PES statement is used to succinctly describe the target for the intervention we provide. Our standardized language is not static. A mechanism is in place for periodic review of the terminology to ensure that it reflects dietetics practice. Future changes to the diagnoses/problems and the worksheets are expected as this standard language evolves. We are encouraged to submit new terms or suggest changes to approved terms. P 268…

Components: Problem – (Nutrition Diagnosis) Etiology – cause or contributing risk factors Signs or symptoms –objective and/or subjective data used to determine whether the resident has the nutrition diagnosis specified. The etiology explains why the problem exists. The signs and symptoms are proof of the problem.

Problem – related to – Etiology – as evidenced by – Signs or symptoms Always remember: The etiology explains why (ask Why 5 times) the problem exists. The signs and symptoms are proof of the problem.

Problem – related to – Etiology – as evidenced by – Signs or symptoms E.g. page 194 Inconsistent carbohydrate intake (NI-5.8.3) related to nutrition-related knowledge deficit concerning appropriate timing of carbohydrate intake as evidenced by wide variations in blood glucose levels, dx IDDM, frequently skips breakfast meal.

Step 2: Nutrition Diagnosis – PES Statements
Problem – related to – Etiology – as evidenced by – Signs or symptoms E.g. page 217 Altered nutrition-related laboratory values (NC-2.2) related to kidney dysfunction as evidenced by abnormal BUN, Cr and K+ levels, hemodialysis, preference for fresh fruits, poor patient knowledge of modified diet.

Step 3: Nutrition Intervention
Mark page 261 of your pocket guide: “Intervention”

Used to remedy a nutrition diagnosis Intended to change a nutrition-related behavior, environmental condition or aspect of nutritional health Always collaborate interventions with the resident and other health care providers Resident response may lead us to revise our intervention Carry out and communicate plan of care Document if resident chooses to not follow an intervention

Organized into four domains Food and/or Nutrient Delivery page 261 Nutrition Education page 262 Nutrition Counseling page 262 Coordination of Care page 262 In the LTC setting, the Food and/or Nutrient Delivery domain will most frequently be used

Step 4: Nutrition Monitoring and Evaluation
See page 11 of your pocket guide: “Monitoring and Evaluation” uses the same terms as the “Assessment” except for those indicators that are shaded.

Determines the amount of progress made to reach the specified goal(s) Specific outcomes that can be measured and compared to previous data or reference standards, e.g. Weight or BMI Laboratory values

Organized in five domains Food/Nutrition-Related History Outcomes page 11 Anthropometric Measurement Outcomes page 13 Biochemical Data, Medical Tests, and Procedure Outcomes page 13 Nutrition-Focused Physical Finding Outcomes page 14 Comparative Standards page 15 In the LTC setting, the Food/Nutrition-Related History Outcomes and Anthropometric Measurement Outcomes is likely to be used more frequently

Case Study #1 Background Information
1/22/09: Resident A is a 99 yo female with depression, lactose intolerance and recently dx gastroenteritis. She reports her appetite isn’t good lately. Meal intake records also show a decline. She feeds herself, A&O x 3. Ht- 61”, Wt 1/20= 120.8#, ↓10% (14#) x 30 days and ↓16% x 180 days. Diet: General, ground meat. Nursing has just moved her to the ADR for cuing and supervision.

Case Study #1 Step #1- Prioritize Assessment Problems- What is the most immediate problem? Step #2- Nutrition Diagnosis Verify the problem→ confirm the appropriate one

Case Study #1- Is there a nutrition dx?
□ No nutrition diagnosis at this time □ Proceed to nutrition diagnosis below Nutrition Diagnostic Codes NI-1.4 Inadequate energy intake NC-1.1 Swallowing difficulty NI-1.5 Excessive energy intake NC-1.2 Chewing difficulty NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 Underweight NI-3.2 Excessive fluid intake NC-3.2 Involuntary weight loss NI-5.1 Increased nutrient needs NC-3.3 Overweight/obesity NI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gain NI Inadequate protein intake NB-1.7 Undesirable food choices NI Inconsistent carbohydrate intake NB-3.2 Inability to manage self-care NI Inadequate fiber intake NB Self-feeding difficulty NI-5.9/5.10 Inadequate vitamin/mineral intake (specify) Problem: Etiology: Signs/ Symptoms:

Nutrition Diagnostic Codes
Case Study #1 □ No nutrition diagnosis at this time □ Proceed to nutrition diagnosis below Nutrition Diagnostic Codes NI-1.4 Inadequate energy intake NC-1.1 Swallowing difficulty NI-1.5 Excessive energy intake NC-1.2 Chewing difficulty NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 Underweight NI-3.2 Excessive fluid intake NC-3.2 Involuntary weight loss NI-5.1 Increased nutrient needs NC-3.3 Overweight/obesity NI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gain NI Inadequate protein intake NB-1.7 Undesirable food choices NI Inconsistent carbohydrate intake NB-3.2 Inability to manage self-care NI Inadequate fiber intake NB Self-feeding difficulty NI-5.9/5.10 Inadequate vitamin/mineral intake (specify) Problem: Etiology: Signs/ Symptoms:

Case Study #1 Step #1- Prioritize Assessment Problems- What is the most immediate problem? Step #2- Nutrition Diagnosis Verify the problem→ confirm the appropriate one Inadequate food and beverage intake (pg 146) (definition)- Oral food/beverage intake that is less than established reference standards or recommendations based on physiological needs

Case Study #1 □ No nutrition diagnosis at this time □ Proceed to nutrition diagnosis below Nutrition Diagnostic Codes NI-1.4 Inadequate energy intake NC-1.1 Swallowing difficulty NI-1.5 Excessive energy intake NC-1.2 Chewing difficulty NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 Underweight NI-3.2 Excessive fluid intake NC-3.2 Involuntary weight loss NI-5.1 Increased nutrient needs NC-3.3 Overweight/obesity NI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gain NI Inadequate protein intake NB-1.7 Undesirable food choices NI Inconsistent carbohydrate intake NB-3.2 Inability to manage self-care NI Inadequate fiber intake NB Self-feeding difficulty NI-5.9/5.10 Inadequate vitamin/mineral intake (specify) Problem: Inadequate oral food and beverage intake Etiology: related to p.o. intake less than calorie expenditure Signs/ Symptoms: as evidenced by depressed meal intake, significant wt loss of 10% in 30 days and 16% in 180 days, resident verbalizes decreased appetite

Case Study #1 Step #1- Prioritize Assessment Problems- What is the most immediate problem? Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance Step #3- Nutrition Intervention- aimed at “fixing” the etiology

Nutrition Intervention
Case Study #1 Nutrition Intervention Nutrition Prescription: Recommend ~1500 kcal and 48 grams protein from meal and planned snacks to meet nutrient needs Interventions: See Care Plan □ Yes. □ No. [X] Meals/Snacks: Add Super Cereal, provide whole milk each meal, add pm ice cream, HS pudding [ ] Food Supplements: [X] Vit/Min: Rec MVI/mineral [ ] Feeding Assistance: [ ] Nutrition Education: [ ] Coordination of Care (Refer to): [ ] Enteral Nutrition:

Case Study #1 Step #1- Prioritize Assessment Problems- What is the most immediate problem? Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance Step #3- Nutrition Intervention- aimed at “fixing” the etiology Step #4- Monitoring and Evaluation

Monitoring/Evaluation
Case Study #1 Monitoring/Evaluation [X] Food intake: Monitor meal/snack pattern [X] Acceptance of cuing from nursing [ ] Nutrition quality of life responses [ ] Behavior [X] Lab Data: □ Hgb A1C □ Glucose, casual X Albumin □ Other: [X] Weight- screen weekly for changes [ ] Med use: [ ] Other: Follow up: □ 7 days □ 1 week X 1 month □ Quarterly X Monitor with MDS Inform physician/family of significant wt change.

Case Study #2 Background Information
You are informed when you arrive at the facility a week later (1/29/09) that this same resident from case study #1 has developed a stage II pressure area on her L/buttock (3 cm diameter). Wt 1/27=116#, down 4# from last week.

Case Study #2 Bring your PES statement(s) forward to begin your note
Collect supporting data Document the status of your problem, e.g. Resolved Improved Need to adjust intervention or nutrition Rx if problem is not improving NCP continues until problem is resolved

Case Study #2 1/29/09 Nutrition Dx: Inadequate oral food and beverage intake related to p.o. intake less than calorie expenditure/energy needs for healing as evidenced by depressed meal intake, significant wt loss, new stage II pressure area on L/buttock. Interventions- Nutrition Rx: Recommend ~1600 kcal and 57 grams protein from meal, planned snacks and supplement to meet nutrient needs. Continue current interventions, see care plan. Add: Med Pass supplement BID (ND-3.1.1) for additional 240 kcal, 10 gm protein. Recommend Vit C 500 mg (ND-3.2.3) to promote wound healing. Monitor/Evaluation: Monitor skin status monthly/prn (PD 1.1.8), Monitor weight weekly (AD-1.1.2), Monitor meal/snack patterns (FH ), Monitor albumin level as ordered (BD-1.11). Notify family/physician of significant weight changes. RD signature

Transitioning charting to NCP format
You do not need to change the style of your charting format Narrative Just include standard language terms in your sentences SOAP S= Assessment terminology O= Data documented elsewhere in chart or data documented by the dietitian A= Nutrition Diagnosis, written as a PES statement P= Nutrition Prescription and Intervention. Monitoring indicators and evaluation criteria also go here.

Case Study #3- Annual assessment
Background Information 4/06/09: Resident B is a 95 yo female with dx HTN, constipation, severe low back pain, GERD, advanced cancer. He is on hospice care. Feeds himself then staff finish. Ongoing poor appetite. Ht- 60”, Wt 4/09= 92#, ↓8% (9#) x 30 days and ↓21% x 180 days. Diet: Pureed. House supplement 60 mL TID

Case Study #3 □ No nutrition diagnosis at this time □ Proceed to nutrition diagnosis below Nutrition Diagnostic Codes NI-1.4 Inadequate energy intake NC-1.1 Swallowing difficulty NI-1.5 Excessive energy intake NC-1.2 Chewing difficulty NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 Underweight NI-3.2 Excessive fluid intake NC-3.2 Involuntary weight loss NI-5.1 Increased nutrient needs NC-3.3 Overweight/obesity NI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gain NI Inadequate protein intake NB-1.7 Undesirable food choices NI Inconsistent carbohydrate intake NB-3.2 Inability to manage self-care NI Inadequate fiber intake NB Self-feeding difficulty NI-5.9/5.10 Inadequate vitamin/mineral intake (specify) Problem: Etiology: Signs/ Symptoms:

Case Study #3 □ No nutrition diagnosis at this time □ Proceed to nutrition diagnosis below Nutrition Diagnostic Codes NI-1.4 Inadequate energy intake NC-1.1 Swallowing difficulty NI-1.5 Excessive energy intake NC-1.2 Chewing difficulty NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 Underweight NI-3.2 Excessive fluid intake NC-3.2 Involuntary weight loss NI-5.1 Increased nutrient needs NC-3.3 Overweight/obesity NI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gain NI Inadequate protein intake NB-1.7 Undesirable food choices NI Inconsistent carbohydrate intake NB-3.2 Inability to manage self-care NI Inadequate fiber intake NB Self-feeding difficulty NI-5.9/5.10 Inadequate vitamin/mineral intake (specify) Problem: Increased nutrient needs Etiology: related to increased demand for energy Signs/ Symptoms: as evidenced by significant wt loss trend of 8% (9#) x 30 days and 21% x 180 days, cancer, hospice care

Case Study #3 Nutrition Intervention Nutrition Prescription: Recommend continue current pureed diet and supplement as tolerated by resident for comfort measures Interventions: See Care Plan □ Yes. □ No. [X] Meals/Snacks: Cont current pureed diet, provide snacks as tolerated [X] Food Supplements: Cont supplement [ ] Vit/Min: [X] Feeding Assistance: Mouth care after meals/prn [ ] Nutrition Education: [X] Coordination of Care (Refer to): Hospice [ ] Enteral Nutrition:

Case Study #3 Monitoring/Evaluation [X] Food intake: Monitor meal/snack pattern [ ] Acceptance of [X] Nutrition quality of life responses [ ] Behavior [ ] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other: [X] Weight- screen monthly/prn for changes [ ] Med use: [ ] Other: Follow up: □ 7 days □ 1 week X 1 month □ Quarterly X Monitor with MDS

Case Study #4- Initial assessment
Background Information 4/06/09: Resident C is an 86 yo male with dementia. He has a good appetite per meal intake records. He feeds himself with set up assist. A&O x 2 with confusion. Ht- 68”, Admit wt 4/09= 162#, no significant wt changes found, UBW= 170# per spouse Diet: Mechanical Soft During mealtime observation you notice that he has difficulties keeping the food on his plate- spilling food on himself.

□ No nutrition diagnosis at this time □ Proceed to nutrition diagnosis below Nutrition Diagnostic Codes NI-1.4 Inadequate energy intake NC-1.1 Swallowing difficulty NI-1.5 Excessive energy intake NC-1.2 Chewing difficulty NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 Underweight NI-3.2 Excessive fluid intake NC-3.2 Involuntary weight loss NI-5.1 Increased nutrient needs NC-3.3 Overweight/obesity NI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gain NI Inadequate protein intake NB-1.7 Undesirable food choices NI Inconsistent carbohydrate intake NB-3.2 Inability to manage self-care NI Inadequate fiber intake NB Self-feeding difficulty NI-5.9/5.10 Inadequate vitamin/mineral intake (specify) Problem: Self-feeding difficulty Etiology: related to impaired cognitive ability Signs/ Symptoms: being provided foods that may not be conducive to self-feeding, dropping of food from untensil, dx dementia

Case Study #4 Nutrition Intervention Nutrition Prescription: Provide adaptive equipment to facilitate independent eating Interventions: See Care Plan □ Yes. □ No. [ ] Meals/Snacks: [ ] Food Supplements: [ ] Vit/Min: [X] Feeding Assistance: Provide Adaptive Equipment, Encourage finger foods [X] Coordination of Care (Refer to): OT [ ] Enteral Nutrition:

Case Study #4 Monitoring/Evaluation [X] Food intake: Monitor meal intake [ ] Acceptance of [ ] Nutrition quality of life responses [X] Behavior: Fatigue/ability to feed self [ ] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other: [X] Weight- screen monthly/prn for changes [ ] Med use: [ ] Other: Follow up: □ 7 days □ 1 week □ 1 month X Quarterly X Monitor with MDS

No nutrition diagnoses

No nutrition diagnoses, cont.
What do you do if there is not a nutrition diagnosis? The nutrition diagnoses describe actual problems, not “potential for” or “at risk for” concerns Potential/at risk concerns would be recorded in the resident’s care plan (per NCP Long Term Care Toolkit)- if you decide if you still want to care plan without a nutrition diagnoses You still need to set up Monitoring and Evaluation for follow up reassessment

No nutrition diagnoses, cont.
Skip to Step #4- Monitoring and Evaluation [X] Food intake: Monitor meal/snack pattern [ ] Acceptance of [ ] Nutrition quality of life responses [ ] Behavior [X] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other: as available [X] Weight- screen weekly x 4 wks [ ] Med use: [ ] Other: Follow up: □ 7 days □ 1 week □ 1 month X Quarterly X Monitor with MDS

Nutrition Reassessment, e.g. Qtr Review
When completing a reassessment, we determine progress of the goal Positive Outcome Obtained Continue Plan of Care Resolve Problem Status quo Continue Plan of care Change Intervention Decline

Nutrition Care Process- Where do we go from here?
Get the resources you need to get started Practice writing PES statements and using the assessment terminology Review current systems of documentation in your facilities Develop changes in systems, if needed Communicate to key stakeholders in your facility Implement the Nutrition Care Process Evaluate progress and get feedback

Andrea Maher RD, LD

Nutrition Care Process Practical Applications

Similar presentations

Presentation on theme: "Nutrition Care Process Practical Applications"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Nutrition Care Process Practical Applications

Similar presentations

Presentation on theme: "Nutrition Care Process Practical Applications"— Presentation transcript:

Similar presentations

About project

Feedback