1. Nutrition Care Process KNH 411

2. Relationship Between Patient/Client/Group & Dietetics Professional - Nutrition Diagnosis   Identify and label problem   Determine cause/contributing risk factors   Cluster signs and symptoms/ defining characteristics Nutrition Assessment   Obtain/collect timely and appropriatedata   Analyze/interpret with evidence-based standards   Identify risk factors  Use appropriate tools and methods  Involve interdisciplinary collaboration Screening & Referral System Outcomes Management System  Monitor the success of the Nutrition Care Process implementation  Evaluate the impact with aggregate data  Identify and analyze causes of less than optimal performance and outcomes  Refine the use of the Nutrition Care Process ADA NUTRITION CARE PROCESS AND MODEL  Document Nutrition Monitoring and Evaluation  Monitor progress  Measure outcome indicators  Evaluate outcomes  Document Nutrition Intervention  Plan nutrition intervention  Formulate goals and determine a plan of action  Implement the nutrition intervention  Care is delivered and actions are carried out  Document Document

3. ADA’s Nutrition Care Process Steps Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

4. 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.

5. Nutrition Assessment Components Gather data, considering: dietary intake, nutrition related causes of health and disease condition, psycho-social reasons and behavioral reasons and functional (disability), knowledge base and readiness to change and potential change Compare to relevant standards Identify possible problem areas

6. ASSESSMENT: ABCD A  height, weight, BMI, wait to hip and tricep skinfold weight change B  biochemical data- albumin (protein status, long ½ life), pre-albumin better marker, hemoglobin and electrolyte & hydration, glucose, lipids (cardio concern) C  clinical information D  dietary intake- supplements, etc.

7. Nutrition Assessment: Critical Thinking Observe: verbal and nonverbal ques Determining appropriate data to collect: only record key information ex) diabetes  insulin Selecting assessment tools Distinguishing relevant from irrelevant data Organizing data Determining when problems require referral

8. ADA’s Nutrition Care Process Steps Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

9. Nutrition Diagnosis Nutritional problem: high blood glucose, weight gain, PO intake, etc. Write down what you are going to solve Names and describes the problem Problem may already exist, or may be at risk of occurring Not a medical diagnosis

10. 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 1: Calorie energy balance- obesity Class 2: Oral or nutrition support intake- post operation Class 3: Fluid intake balance- renal Class 4: Bioactive substances balance- metabolic event Class 5: Nutrient balance- anemia

11. Nutrition Dx Domains: Clinical Defined as “nutritional findings/problems identified that relate to medical or physical conditions Class: functional balance- changes in physical that affect nutrition, ex) stroke, elderly Class: Biochemical balance- change in capacity to metabolize nutrients: medication, surgery, changes in lab values Class: weight balance- changes in weight may mean more

12. 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- new diabetic Class: physical activity, balance and function Class: food safety and access- socioeconomic status

13. Nutrition Diagnosis Components Problem  related to Etiology  as evidenced by : cause or risk factors (excess or not enough) Signs/Symptoms Signs : objective data Symptoms : subject of data, what patient feels and expresses EXAMPLE: excessive calorie intake related to large high fat meals

14. Nutrition Diagnosis Components Problem Describes alterations in pt’s nutritional status Diagnostic labels Impaired Altered Inadequate/excessive Inappropriate Swallowing difficulty

15. 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

16. Nutrition Diagnosis Components Etiology Excessive calorie intake related to regular consumption of large portions of high-fat meals Swallowing difficulty related to stroke

17. Nutrition Diagnosis Components Signs/Symptoms Evidence Linked to etiology

18. 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

19. 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

20. 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

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

22. Nutritional vs Medical Dx Medical DiagnosisNutritional Diagnosis DiabetesIncreased blood glucose level Trauma and closed head injury IV hydration TPN- long term PPN- short term Increased energy needs RT trauma as evidenced by increase in weight Liver failureBlood glucose stability Lack of glucose production RT liver failure as evidenced by blood glucose levels

23. Nutritional vs Medical Dx Medical DxNutritional Diagnosis ObesityIntake energy balance RT obesity, lack of intake of healthy foods, as evidenced by weight, BMI, diet history Dependence mechanical ventilation IV carb intake RT high volume carb intake in TPN Anorexia nervosaDecreased intake RT history of anorexia and self limiting behavior as evidenced by weight and diet history

24. ADA’s Nutrition Care Process Steps Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

25. 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

26. 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

27. Intervention Objectives Problem 1: Involuntary weight loss Objectives: 1. increased caloric intake, be very specific 2. high protein high calories: x amt. of times x amt. of calories GOAL  to gain ten pounds in one month

28. Intervention Objectives Problem 2: Inadequate protein-energy intake 2° poor appetite Objectives: 1. Patient will eat nutrient dense foods with high amt. of protein 2.X amt. of calories x amt. of times a day

29. 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 Should answer: what, when, where, and how

30. Nutrition Intervention Problem 1: Involuntary Weight loss Intervention: 1. Limiting fluids 2. Obtain scale 3. Nutrient dense foods 4. Patient will attend social lunch

31. Nutrition Intervention Problem 2: Inadequate protein-calorie intake 2° poor appetite Intervention: 1. 2. 3.

32. ADA’s Nutrition Care Process Steps Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

33. Nutrition Monitoring & Evaluation Components Evaluate outcomes Compare current findings with previous status, intervention goals, and/or reference standards

34. 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

35. Nutrition Goals and Objectives Are necessary in order to evaluate Should be achievable Should be directly or indirectly related to nutrition care

36. 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

37. NCP Example: Acute Care Nutrition Diagnosis 1.Fluid intake concerns RT dietary indiscretion AEB diet hx 2. Knowledge deficit related to no previous nutrition education AEB 3. Self monitoring deficit RT lack of access to scale AEB patients

38. NCP Example: Acute Care Nutrition Intervention 1. limiting fluids 2. obtain scale 3. 4.

39. NCP Example: Acute Care Monitoring and Evaluation 1. Next clinic visit check BP 2. Have her weigh themselves 3.