The Nutrition Care Process

1. The Nutrition Care Process Allie Hanson Concordia College Moorhead, MN

2. Be able to clearly explain the Nutrition Care Process Be able to describe in your own words the 4 steps in the Nutrition Care Process Be able to write a clear and concise Nutrition PES Statement Be able to develop nutrition related chart notes Objectives

3. Nutrition Care Process (NCP): Defined • A systematic problem solving method developed by the ADA that dietetic professionals use to think critically, make decisions addressing nutrition-related problems, and provide safe, effective, highly qualified nutrition care

4. Other Key Definitions • Nutrition Care Plan • A formal statement of the nutrition goals and interventions prescribed for an individual using the data obtained from a nutrition assessment. The plan, formulated by an interdisciplinary process, should include statements of nutrition goals and monitoring parameters, the most appropriate route of administration of specialized nutrition support (oral, enteral, and/or parenteral), method of nutrition access, anticipated duration of therapy, and training and counseling goals and methods • Nutrition Screening • A process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated

5. Providing Nutrition Care • Nutrition Intervention • Specific set of activities and associated materials used to address a (nutrition-related) problem • Strategies and focus of care based on status of health

6. Nutrition Care • Evaluating nutritional status • Biological • Ex. Male, Female, age • Lifestyle • Ex. Smoking, Drinking, Eating Breakfast • Environment • Ex. Wages, Transportation • Systems • Ex. Health Care System, Education System

7. Purpose of Providing Nutrition Care • Influence and change the factors that contribute to an imbalance in nutritional status and thus restore an improved state of nutritional health • Registered Dietitians are highly qualified to provide nutrition care

8. ADA’s Standardized Model of Care • Nutrition Care Process • American Dietetic Association’s standard process • Systematic process to make decisions • Provides a standardized language for documentation and communication • 62 terms, known as the Nutrition Diagnostic Terminology, are used to clearly describe specific types of nutrition problems that contribute to a person’s nutritional imbalance

9. ADA’s Standardized Model of Care • Four steps of the Nutrition Care Process: • Nutrition Assessment • Nutrition Diagnosis • Nutrition Intervention • Nutrition Monitoring and Evaluation

10. The Nutrition Care Process Model • Central Core • Relationship between the client and the dietetics professional or team of dietetic professionals • Important to develop trust and communicate effectively with others • Essential that the client be actively involved in the care whenever possible • Individualized and Client focused • Outer Rings • Outermost rings = environmental factors that have an impact on the ability of the client to receive and benefit from the interventions of nutrition care • Inner Ring = strengths that dietetic professionals bring to the nutrition care process • Supportive Systems • Screening and referral system • Identifies those individuals or groups who would benefit from nutrition care provided by dietetic professionals • Outcomes management system • Used to evaluated the effectiveness and efficiency of the entire NCP process when nutrition care is provided to a number of patients

12. Steps in the Nutrition Care Process • Step 1: Nutrition Assessment • A very systematic process of obtaining, verifying, and interpreting data in order to make decisions about the nature and cause of nutrition related problems • Ongoing, dynamic process involving not only initial data collection, but also continual reassessment and analysis of a clients needs and conditions • Provides data to accurately describe nutrition problems and facilitate the formulation of a nutrition diagnosis at the next step of the NCP • Provides a means to reevaluate the nutrition program as a part of nutrition monitoring and evaluation • Focuses on the understanding the wide variety of factors • Data gathered during the assessment step are also used to describe the severity of the problem

13. Steps in the Nutrition Care Process • Step 1: Nutrition Assessment (cont.) • Obtain and verify appropriate data • Varies depending on a number of factors such as practice setting or the individual’s/group’s health status • Cluster and organize assessment data • In a meaningful way that relates to specific types of nutrition problems • Evaluate the data using reliable standards • Important that data be linked to specific types of problems • Important that information be compared to reliable standards or ideal goals • Data includes anthropometrics, laboratory, clinical, history, etc.

14. Steps in the Nutrition Care Process • Step 2: Nutrition Diagnosis • Identification and descriptive labeling of an actual occurrence of a nutrition problem that dietetics professionals are responsible for treating independently • The missing link between nutrition assessment and nutrition intervention • A nutrition diagnosis, in contrast to a medical diagnosis, is written in terms of client problem for which nutrition-related activities provide the primary intervention • Focus on nutrition issues that may be consequences of or contribute to diseases • Also address behaviors that impact food choices

15. Steps in the Nutrition Care Process • Step 2: Nutrition Diagnosis (cont.) • Nutrition Diagnostic Terms • Intake Domain –nutrition problems that are related to intake, energy, nutrients, fluids, and bioactive substances through oral diet or nutrition support • Labels such as inadequate, excessive, or inappropriate are used • Clinical Domain –nutrition problems that are related to medical or physical conditions • Include problems in swallowing, chewing, digestion, absorption, and maintaining appropriate weight • Behavioral-Environmental Domain – problems that are related to knowledge, attitudes/beliefs, physical environment or access to food, and food safety

16. Steps in the Nutrition Care Process • Step 2: Nutrition Diagnosis (cont.) • PES Statement • Problem, etiology, signs/symptoms • Format used in the NCP to write a nutrition diagnosis • Clarifies a specific nutrition problem and logically links the nutrition diagnosis to nutrition intervention and to monitoring and evaluation • (P) – diagnostic label, describes in a general way an alteration in the nutritional status • Words commonly used: excessive, inadequate, inappropriate • (E) – factors that contribute to the cause or existence of a particular problem • (S) – defining characteristics obtained from the subjective and objective nutrition assessment data

17. Steps in the Nutrition Care Process • Step 2: Nutrition Diagnosis (cont.) • PES Statement • Generally stated in the following manner: • The problem (p) due to the etiology (e) as evidenced by the signs and symptoms (s). • Example: • Patient has involuntary weight loss (p) due to inadequate energy intake (e) as evidenced by eight pounds weight loss within 4 weeks (s).

18. Steps in the Nutrition Care Process • Step 2: Nutrition Diagnosis (cont.) • PES Statements – How do I get there? • Evaluate nutrition assessment using critical thinking • Identify the problem(s) • State them each clearly and singularly • Focus on those that can be treated by nutritional intervention • Describe the signs and symptoms • Explore the etiology or cause • Again focus on a nutrition-related cause Not medical diagnosis

19. Steps in the Nutrition Care Process • Step 2: Nutrition Diagnosis (cont.) • PES Statement – How do I evaluate? • Ask yourself appropriate questions • Ex. Can the dietetics professional impact, improve, or resolve the nutrition problem? • Relationship to other steps: • Signs and symptoms become basis for setting ideal and measurable goals (step 3) and outcome measures (step 4)

20. Steps in the Nutrition Care Process • Step 3: Nutrition Intervention • Involves both planning and implementing • A specific set of activities and associated materials used to address the problem • Purposefully planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, target group, or the community at large • Dietetic professionals work not only with other health care professionals, but also with the client, family, or caregiver to create a realistic plan with a good probability of working • Client-driven process is key

21. Steps in the Nutrition Care Process • Step 3: Nutrition Intervention (cont.) • Sub Steps • Prioritize the Nutrition Diagnosis • Arrange problems in the order of importance and urgency for the client • Identify Ideal Goals and Patient-Focused Expected Outcomes • Ideal Goals – science based values intended to control or improve specific health conditions • Expected Outcomes – the desired change(s) to be achieved over time as a result of nutrition intervention • Implement the Nutrition Intervention

22. Steps in the Nutrition Care Process • Step 4: Nutrition Monitoring and Evaluation • Determine the degree to which progress is being made and whether or not the client’s goals or desired outcomes of nutrition care are being met • Much more than merely “watching” what is happening • Requires an active commitment to measuring and recording the appropriate outcome indicators relevant to the nutrition diagnosis’ signs and symptoms • Progress should be: • 1. Monitored • 2. Measured • 3. Evaluated on a planned schedule

23. Steps in the Nutrition Care Process • Step 4: Nutrition Monitoring and Evaluation (cont.) • Sub Steps • Monitor Progress • Determining that the goals and outcomes that are anticipated by the client and the dietetics professionals are indeed occurring • Monitor, measure, evaluate on a planned schedule • Measure Outcomes • Data is collected over time • Nutrition, clinical and health status, patient/client centered, and health care utilization • Evaluate Outcomes • To determine what changes have occurred as a result of the nutrition intervention • Comparing the current findings with the previous signs and symptoms • Create outcome management system • Contribute to the body of evidence-based research

24. Documentation • Ongoing process to support the steps of the NCP • Standardized language now part of NCP improves both written and oral communication among members of the health care team as well as communication with the patient • Should be Relevant, Accurate, and Timely • Variety of Formats are acceptable: • SOAP notes • Focus notes • PIE • ADIM – what is laid out by the NCP • ADA would like to be using this • Electronic Medical Records

25. SOAP Note Format • Subjective (S) • Patient information or data collected from the patient or caregiver • Have no proof of • Objective (O) • Empirical information, information drawn from physical tests and medical staff observations that are of consequence to the patient’s nutritional status • Have proof of • Assessment (A) • Nutrition diagnosis or interpretation of the patient’s nutrition problems • PES Statement • Plan (P) • An outline of interventions necessary to treat each nutrition problem • What you plan to do

26. ADIM Note Format • Organized to reflect the Nutrition Care Process • Assessment (A) • Relevant data about the patient’s condition • Diagnosis (D) • PES Statements listed and prioritized • Intervention (I) • Documentation of the specific treatment goals and expected outcomes, interventions, and response of the client • Monitoring and Evaluation (M) • Documentation of progress toward goals • Factors that are facilitating or hampering progress • Changes in the client’s level of understanding or behavior • Future plans for care

27. Trivia Game!

28. What does the medical abbreviation a.c. mean? • Before meals

29. What is the nutrition care process? • A systematic problem solving method developed by the ADA that dietetic professionals use to think critically, make decisions addressing nutrition-related problems, and provide safe, effective, highly qualified nutrition care

30. What are the steps of the nutrition care process? Briefly describe each step. • Nutrition Assessment (A) • Relevant data about the patient’s condition • Nutrition Diagnosis (D) • PES Statements listed and prioritized • Nutrition Intervention (I) • Documentation of the specific treatment goals and expected outcomes, interventions, and response of the client • Nutrition Monitoring and Evaluation (M) • Documentation of progress toward goals • Factors that are facilitating or hampering progress • Changes in the client’s level of understanding or behavior • Future plans for care

31. What does the medial abbreviation FH mean? • Family History

32. What does the medical abbreviation b.i.d. mean? • Twice a day (bis in die)

33. What is the nutrition care plan? • A formal statement of the nutrition goals and interventions prescribed for an individual using the data obtained from a nutrition assessment. The plan, formulated by an interdisciplinary process, should include statements of nutrition goals and monitoring parameters, the most appropriate route of administration of specialized nutrition support (oral, enteral, and/or parenteral), method of nutrition access, anticipated duration of therapy, and training and counseling goals and methods

34. What does the medical abbreviation NPO mean? • Nothing by Mouth

35. How should an error be corrected in the medical record? • Should not be erased. Draw a line through it and write error over it, put correct info, date of correction, and signature.

36. Where would the following statement fall in a SOAP note (subjective, objective, assessment, or plan)? Results of a laboratory test performed at the hospital. • Objective

37. What does the medical abbreviation SOB mean? • Shortness of breath

38. Where would the following statement fall in a SOAP note (subjective, objective, assessment, or plan)? Patient-centered and measurable overall treatment goal. • Plan

39. What are measurable goals? • Clear and concise measurable goals that specify an outcome that can be assessed. It is a target measure.

40. What is a screening process? • A process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated

41. What does the medical abbreviation cc mean? • This medical abbreviation is prohibited by JCAHO (Joint Commission on Accreditation of Healthcare Organizations) • Means cubic centimeters, use ml instead

42. What does the medical abbreviation c mean? • With (cum)

43. Where would the following statement fall in a SOAP note (subjective, objective, assessment, or plan)? Calculated energy intake from observed food intake by the client at the hospital. • Objective

44. What does the medical abbreviation Hx mean? • History

45. What is a nutrition assessment? • An analysis of an individual’s nutrition status incorporating both subjective and objective data, including information on diet, psychosocial parameters, education, and motivation

46. What does the medical abbreviation R/O mean? • Rule out

47. Where would the following statement fall in a SOAP note (subjective, objective, assessment, or plan)? Usual body weight and dietary intake information given by the client. • Subjective

48. Where would the following statement fall in a SOAP note (subjective, objective, assessment, or plan)? Dietitian’s evaluation of the nutritional status. • Assessment

49. Where would the following statement fall in a SOAP note (subjective, objective, assessment, or plan)? Recommendations by the dietitian for the physician’s approval. • Plan

50. Miss J.S. is a 43-year-old woman coming to the St. Mark’s Regional Diabetes Center to meet with you for an initial nutrition interview. Miss J.S.’s height is 5’4”. She tells you that her weight has always been stable (around 160 lb), but that a year ago she started to become ill. At the interview, you measure her weight to be 140 lb. You find in her medical record that she was diagnosed with breast cancer 12 months ago. (Number 12, pg 228) • What is her usual BMI? • 27.3