1. Diagnosis, Intervention, Evaluation, and Documentation

2. 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

3. Nutrition Assessment Leads to 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

4. Nutrition vs Medical Dx
Nutrition Diagnosis
Diabetes
Excessive CHO intake related to evening visits to Coldstone Creamery as evidenced by diet hx and high hs blood glucose
Trauma and closed head injury
Increased energy expenditure related to multiple trauma as evidenced by results of indirect calorimetry
Liver failure
Altered gastrointestinal function related to cirrhosis of the liver as evidenced by steatorrhea and growth failure

5. Nutritional vs Medical Dx
Nutrition Diagnosis
Obesity
Excessive energy intake related to lack of access to healthy food choices (restaurant eating) as evidenced by diet history and BMI of 35.
Dependence mechanical ventilation
Excessive energy intake related to high volume PN as evidenced by RQ >1
Anorexia nervosa
Inappropriate food choices related to history of anorexia nervosa and self-limiting behavior as evidenced by diet history and weight loss of 5 lb

6. PES Statement Problem: nutrition diagnosis label
Etiology: the focus of the intervention
Signs and symptoms: change when nutrition problems are successfully treated; the focus of monitoring and evaluation

7. Problem (Diagnostic Label)
Falls into three general domains:
Intake (NI)
Excessive or Inadequate intake compared to requirements
Clinical (NC)
Medical or physical conditions that are outside normal
Behavioral/environmental (NB)
Knowledge, attitudes, beliefs, physical environment, access to food, food safety

8. Etiology 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

9. Etiology Etiology (Cause/Contributing Factors)
Excessive energy intake (problem) “related to” regular consumption of large portions of high-fat meals (etiology)…
Swallowing difficulty (problem) RT recent stroke (etiology)…
Involuntary wt gain RT decrease in exercise…

10. Diagnostic Labels Can Be Problems or Etiologies
Inadequate energy intake (NI-1.4) related to food-nutrition knowledge deficit (NB-1.1)
Food-nutrition knowledge deficit (NB-1.1) related to lack of previous nutrition education
Involuntary weight loss (NC-3.2) related to inadequate energy intake (NI-1.4)
Inadequate oral food-beverage intake (NI-2.1) related to swallowing difficulty (NC-1.1)

11. Signs and Symptoms Signs/Symptoms (Defining characteristics)
Evidence that problem exists
Linked to etiology by words “as evidenced by”
Evaluation and monitoring of effectiveness of intervention is done by reviewing signs and symptoms

12. Nutrition Dx with S/S Excessive energy intake (NI-1.5) (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 (Signs)

13. Nutrition Assessment Identifies Etiology and S/S
Problem: excessive energy intake
Etiology: reviewing the diet history, we learn that
Patient eats in fast food restaurants 2x day
Patient supersizes portions because it’s a bargain
Patient has only 15 minutes for lunch

14. PES Statement Excessive energy intake P
Related to eating frequently in fast food restaurants E
As evidenced by BMI of 30 and diet history S

15. Etiology Guides Intervention!
The clinician determines what the intervention is by looking at the root cause of the nutrition problem.
If the cause of excessive energy intake is eating frequently in fast food restaurants, how would you intervene?

16. Signs and Symptoms Direct Intervention and Evaluation
Intervention/ Eval P
Excessive energy intake E
RT eating frequently in fast food restaurants
Intervention: Counsel patient about best choices in fast food restaurants (C-2.4) S
As evidenced by BMI and diet history
Eval: Recheck weight (S-1.1.4) and diet history (BE ) at next visit

17. PES Statements
Excessive fat intake (NI-5.6.2) related to high intake of fried foods and bakery goods as evidenced by diet history and hyperlipidemia
Excessive energy intake (NI-1.5) related to high intake of fried foods and snack items as evidenced by diet history and BMI
Food/nutrition related knowledge deficit (NB-1.1) related to lack of education on cholesterol lowering diet as evidenced by history and patient self-report

18. Nutrition Diagnosis Statement Should Be
Clear, concise
Specific
Related to one problem
Accurate – related to one etiology
Based on reliable, accurate assessment data

19. Evaluating Your PES Statement
There are no right or wrong PES statements
But some are better than others

20. Evaluating Your PES Statement
Can the RD resolve or improve the nutrition diagnosis?
Can your intervention address the etiology and thus resolve it or improve the problem?
Or can your intervention address the signs and symptoms?

21. Evaluating Your PES Statement
Ex: Inadequate energy intake related to decreased taste perception as evidenced by diet history, medical dx and weight loss of 10 lb. during cancer tx
Cannot treat the etiology (decreased taste perception) but can treat S&S by recommending foods with stronger flavors

22. Evaluating Your PES Statement
Altered nutrition-related labs related to GI bleed as evidenced by medical hx and decreased hgb/hct in medical record
Labs likely won’t improve until GI bleed is addressed; the etiology is not a nutritional deficit
CAN address inadequate intake of iron, copper, B12, protein, etc.

23. Evaluating Your PES Statement
When all things are equal and there is a choice between two nutrition diagnoses from different domains, consider the Intake domain diagnosis as the one more specific to the role of the RD
Instead of Altered nutrition-related labs related to GI bleed as evidenced by medical hx and decreased hgb/hct in medical record
Consider Inadequate intake of iron (NI ) related to increased needs due to GI bleed as evidenced by medical history, blood count, diet history, and serum ferritin

24. Evaluating Your PES Statement
Will measuring the signs and symptoms tell you if the problem is resolved or improved?
Ex: If nutrition dx is excessive energy intake, can do another diet history at next visit and see if intake has changed; can also check weight

25. NCP Example: Long Term Care
85 y.o. resident of LTC facility has lost >10% weight in the last 6 months
Medical workup negative
Oral supplement is ordered but patient continues to lose weight
Nutrition professional is consulted for enteral feeding recommendations

26. NCP Example: LTC
On assessment, it is found that patient’s teeth no longer fit and she cannot chew regular meats and vegetables; patient is storing oral supplement in drawer as she worries about the cost

27. Write a PES statement for this patient!

28. NCP Example: LTC
Diagnosis: Inadequate energy intake (NI-1.4) related to poorly fitting dentures and hoarding of oral supplement as evidenced by observation and pt interview

29. Etiology Guides Intervention
Intervention: Nutrition professional orders dental consult (RC-1.3) to reline dentures and chopped diet (ND-1.2); puts resident on Medpass supplement (ND-3.1.1)

30. Diagnoses Apply to All Settings
Long term care
Inadequate energy intake (NI-1.4) related to patient refusal of pureed diet as evidenced by intake records, pt self-report and 8% weight loss/3 months
Inadequate fiber intake (NI-5.8.5) related to patient avoidance of fruits and vegetables as evidenced by chronic constipation and diet history
Ambulatory Care
Not ready for diet/lifestyle change (NB-1.4) related to social/environmental issues as evidenced by pt verbalization and continued weight gain

31. 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

32. Nutrition Intervention
Should be targeted at etiology
If not etiology, then signs and symptoms

33. Nutrition Interventions
Four categories of nutrition interventions:
Food and/or nutrient delivery (ND)
Nutrition education (E)
Nutrition counseling (C)
Coordination of nutrition care (RC)

34. Food and/or Nutrient Delivery
Meals and snacks (ND-1)
Enteral/parenteral nutrition (ND-2)
Medical food supplements (ND-3.1)
Vitamin and mineral supplement (ND-3.2)
Bioactive substance supplement (ND-3.3)
Feeding assistance (ND-4)
Feeding environment (ND-5)
Nutrition-related medication management (ND-6)

35. Nutrition Education (E)
Initial/brief nutrition education (E-1)
E.g. survival skills on discharge
Comprehensive nutrition education (E-2)
Purpose
Recommended modifications
Result interpretation
Other
Note: Education is appropriate for food and nutrition-related knowledge deficit. If the client knows the content, more education probably won’t help

36. Nutrition Counseling (C)
Theory or approach
Strategies
Phase

37. Nutrition Counseling: Theory or Approach
The theories or models used to design and implement an intervention; provide a research-based rationale for designing and tailoring nutrition interventions
Cognitive-behavioral therapy (C-1.2)
Health belief model (C-1.3)
Social learning theory (C-1.4)
Transtheoretical Model/Stages
of Change (C-1.5)
Other (C-1.6)

38. Nutrition Counseling: Strategies*
Motivational interviewing (C-2.1)
Goal setting (C-2.2)
Self-monitoring (C-2.3)
Problem solving (C-2.4)
Social support (C-2.5)
Stress management (C-2.6)
Stimulus control (C-2.7)
Cognitive restructuring (C-2.8)
Relapse prevention (C-2.9)
Rewards/contingency mgt (C-2.10)
Other
*Selectively applied evidence-based method or plan of action designed to achieve a particular goal

39. Coordination of Care (RC)
Coordination of other care during nutrition care (RC-1)
Team meeting
Referral to RD
Collaboration with other providers
Referral to community agencies/programs
Discharge and transfer of nutrition care to new setting/provider (RC-2)
Collaboration

40. 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

41. Nutrition Monitoring and Evaluation
Monitor progress and determine if goals are met
Identifies patient/client outcomes relevant to the nutrition diagnosis and intervention plans and goals
Measure and compare to client’s previous status, nutrition goals, or reference standards

42. Nutrition Outcomes – 4 Categories
Nutrition-Related Behavioral and Environmental Outcomes (BE)—Nutrition-related knowledge, behavior, access, and ability that impact food and nutrient intake
Food and Nutrient Intake Outcomes (FI)—Food and/or nutrient intake from all sources
Nutrition-Related Physical Signs and Symptom Outcomes (S)—Anthropomorphic, biochemical, and physical exam parameters
Nutrition-Related Patient/client centered Outcomes (PC)—perception of patient/client’s nutrition intervention and its impact

43. Nutrition-Related Behavioral and Environmental Outcomes (BE)
Knowledge/beliefs (1)
Behavior (2)
Access (3)
Physical activity and function (4)

44. Behavior-Environmental Outcomes Domain: Beliefs and Attitudes (BE-1.1)
Definition: beliefs/attitudes about and/or readiness to change food, nutrition, or nutrition-related behaviors
Potential indicators (BE-1.1)
Readiness to change
Perceived consequences of change
Perceived costs versus benefits of change
Perceived risk
Outcome expectancy
Conflict with patient/family value system
Self efficacy

45. Beliefs and Attitudes (BE-1.1)
Measurement methods or data sources
Patient self-report, client/patient assessment questionnaire or interview
Typically used to monitor and evaluate change in the following domains of nutrition intervention:
Nutrition education, nutrition counseling

46. Beliefs and Attitudes (BE-1.1)
Typically used to monitor and evaluate change in the following nutrition diagnoses
Harmful beliefs/attitudes about food- or nutrition-related topics
Not ready for diet/lifestyle change
Inability to manage self-care
Excess or inadequate oral food/beverage, energy, macronutrient, micronutrient, or bioactive substance intake
Imbalance of nutrients
Inappropriate fat foods

47. Beliefs and Attitudes (BE-1.1)
Typically used to monitor/evaluate change in the following nutrition diagnoses (cont)
Inappropriate intake of amino acids
Underweight
Overweight/obesity
Disordered eating pattern
Physical inactivity
Excess exercise

48. Behavior-Environmental Outcomes Domain: Food and Nutrition Knowledge (BE-1.2)
Definition: Level of knowledge about food, nutrition and health, or nutrition-related information and guidelines relevant to patient/client needs

49. Food and Nutrition Knowledge (BE-1.2) Potential Indicators
Level of knowledge (e.g. none, limited, minimal, substantial, and extensive
Areas of knowledge:
Food/nutrient requirements
Physiological functions
Disease/condition
Nutrition recommendations
Food products
Consequences of food behavior
Food label understanding/knowledge
Self-management parameters

50. Food and Nutrition Knowledge (BE-1.2)
Measurement methods or data sources
Pre and post-tests administered orally, on paper, or by computer
Scenario discussions
Patient/client restate key information
Review of food records
Practical demonstration/test
Typically used to monitor and evaluate change in the following domains of nutrition intervention:
Nutrition education, nutrition counseling

51. Food and Nutrition Knowledge (BE-1.2)
Typically used to monitor and evaluate change in the following nutrition diagnoses:
Food- and nutrition-related knowledge deficit
Limited adherence to nutrition-related recommendations
Intake domain

52. Ability to Plan Meals/Snacks (BE-2.1)
Definition: Patient/client ability related to planning healthy meals and snacks, which are compatible with dietary goals
Potential indicator: Meal/snack planning ability (e.g. may include ability to use planning tools, plan a menu, create/tailor a meal plan, create/use a shopping list

53. Ability to Plan Meals/Snacks (BE-2.1)
Measurement methods/data sources: food intake records, self-report or caregiver report, 24-hour recall, menu review, targeted questionnaire
Typically used to measure outcomes for these domains of nutrition interventions:
Nutrition education
Nutrition counseling

54. Ability to Plan Meals/Snacks (BE-2.1)
Typically used to monitor and evaluate change in the following nutrition diagnoses:
Excessive or inadequate oral food/beverage intake
Underweight
Overweight/obesity
Limited adherence to nutrition-related recommendations
Inability or lack of desire to manage self-care

55. Other BE Nutrition Outcomes
Behavior (2)
Ability to select healthful food/meals
Ability to prepare food/meals
Adherence
Goal setting
Portion control
Self-care management
Self-monitoring
Social support
Stimulus control
Access (3)
Access to food
Physical activity and function (4)
Breastfeeding success
Nutrition-related ADLs and IADLs
Physical activity

56. Other Outcomes Food and Nutrient Intake (FI) Energy intake (1)
Food and Beverage (2)
Enteral and parenteral (3)
Bioactive substances (4)
Macronutrients (5)
Micronutrients (6)
Physical Signs/Symptoms (S)
Anthropometric (1)
Biochemical and medical tests (2)
Physical examination (3)
Patient-Client Centered Outcomes (PC)

57. Outcomes Based Practice
Underlays Performance Improvement and Management
Meets accreditation standards (TJC, American Diabetes Association)
Supports value of nutrition providers in health delivery system
Enhances reputation/ties with medical staff and other colleagues

58. NCP Example: Acute Care
Mr. D. is a 73 y.o. white male admitted with L leg fx after fall. He lives with his son and daughter in law. Per his son, Mr. D’s appetite has been poor the past 6 months, his dentures are very loose and he refuses to wear them. He also refuses pureed foods. Ht: 6 ft.; weight 133 lb; usual weight 1 year ago 165 lb. Meds: milk of magnesia, Pepcid, Di-Gel. No significant medical hx save progressive dementia;labs after hydration serum alb 2.4 g/dL; Hgb 10.6 g/dL; HCT 35.3%; BUN, Cr, liver fxn tests WNL

59. Write a PES statement for this patient!

60. NCP Example: Acute Care
Nutrition Diagnosis
Inadequate energy intake (NI-1.4) related to dementia and poor appetite as evidenced by diet history and recent unintentional weight loss
Chewing difficulty (NC-1.2) related to ill-fitting dentures as evidenced by diet history
Increased energy expenditure (NI-1.2) related to long bone fx as evidenced by medical history

61. How would you intervene with this patient?

62. Intervention
Dental consult to have dentures relined for better fit (RC - coordination of care)
Try oral supplements to determine patient preference and evaluate acceptance (ND food-nutrient delivery)
Consider move to assisted living (RC - coordination of care)
Educate patient’s family on nutrient-dense choices for supplemental feedings (E - nutrition education)

63. Monitoring and Evaluation
Initiate calorie count while patient is hospitalized to evaluate acceptance of oral supplements
Weigh patient weekly after discharge
Evaluate patient’s ability to chew textured foods after dentures are replaced
Evaluate patient in Geriatric Clinic in one month

64. The Diet Prescription
Designates type, amount, frequency of feeding based on pt’s needs, care goals
May specify calorie goal
May limit or increase various components of the diet
Each institution usually has specific diets that have been approved by committee that are used at that institution

65. Modifications of the Normal Diet
Normal nutrition is foundation of therapeutic diet modifications
Based on DRIs
Based on Food Guide Pyramid
Purpose of diet is to supply needed nutrients

66. Modifications of the Normal Diet
Change in consistency
Increase/decrease energy value of diet
Increase/decrease type of food or nutrient consumed
Elimination of specific foods or components
Adjustment in level, ratio, balance of protein, fat, CHO
Change in number, frequency of meals
Change in route of delivery of nutrients

67. Basic Hospital Diets

68. Basic Hospital Diets —cont’d

69. “Surgical” Soft Diet

70. Clear Liquid Diet

71. Full Liquid Diet

72. Full Liquid Diet –cont’d

73. House or Standard Diet Controversies
Should the house diet be low in fat, saturated fat, sodium, and sugar to conform with the U.S. dietary guidelines?
Should the house diet be intended to maximize the nutritional intake of sick people, featuring familiar, comfort foods and fulfilling patient preferences and expectations, regardless of conformity to dietary guidelines designed for healthy people?

74. Consistency Diet Controversies
Soft Diet: what should be included or excluded? Is the diet ‘dental” soft, “surgical” soft, mechanical soft; the needs of dysphagia patients and dental patients are different
Full liquid diet: there is no evidence that it has a role as part of a surgical progression; many of the foods included are poorly tolerated by persons immediately post GI surgery (dairy products, fats, etc.) May be useful as a source of nutrition for persons with mouth pain or dental surgery

75. Consistency Diet Controversies
Thickened liquids: when speech pathologists recommend specific liquid consistencies, they may be using a different standard than is used in the food and nutrition department
There is no generally-accepted standard for nectar thick, honey thick, etc. Often these foods vary greatly among and within institutions and depending on where and by whom the thickening is done

76. Therapeutic Diet Controversies
Should patients with chronic diseases who are hospitalized with acute illnesses be placed on the restricted diet that is appropriate for them long term?

77. Therapeutic Diet Controversies
Should residents in long term care facilities have the same right as home-based clients to decide whether or not to follow a restricted diet?

78. Nutritional Care of the Terminally Ill Patient
Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients = “palliative care”
Dietary restrictions and aggressive nutrition care that negatively impacts quality of life are rarely appropriate.

79. Palliative Care
Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently

80. Continuity of Care
Due to shortened length of stay, more nutritional care is being provided in alternative settings (long term care, home care, ambulatory clinics and community programs)
Nutrition counseling and education in acute care is often limited to survival skills
Nutritional counseling should be provided in a setting conducive to long term behavior change
The acute care stay can be an opportunity to identify nutritional problems and devise a plan for follow-up care

81. Discharge Planning Discharge documentation includes
Summary of nutritional therapies and outcomes
Pertinent information such as weight, lab results, dietary intake
Potential drug-nutrient interactions
Expected progress or prognosis
Recommendations for follow-up services

82. Discharge Planning
Courtesy University of Washington Medical Centers, Seattle.