1. Exploring the Nutrition Care Process
Roxanne Davis-Cote, MPH, RD, LD
Beaufort Memorial Hospital

2. Nutrition Care Process
Today’s Objectives:
Describe the 4 Components of the Nutrition Care Process (NCP)
Devise a nutrition diagnostic statement in the PES format using standardized language
Prepare at least 1 measurable goal that would positively affect the nutrition diagnosis identified by the interventions implemented

3. Nutrition Care Process
Acronym for components: ADIME
Assessment (A)
Diagnosis (nutrition diagnosis) (D)
Intervention (I)
Monitor/Evaluate (M/E)

4. Assessment In-depth review of the medical record
Effective interviewing of patient,
caregiver, family, groups (when appropriate)
Attention to nutrition-focused physical findings
Collaboration with other health care providers for additional insight

5. Assessment Domains to Review Food/Nutrition Related History
Anthropometric Measurements (wt, ht, BMI, growth patterns, wt history)
Biochemical Data, Medical Tests, Procedures (labs, medications, procedures)
Nutrition-Focused Physical Findings (findings from evaluation of body systems to include muscle and subcutaneous fat wasting, oral health, suck/swallow/breath ability, appetite, affect)
Client History (past medical history, social history, pertinent procedures)
As you can see, these are all items that we’ve always reviewed as part of our nutrition assessment process.
The NCP puts standardized language to words we have been using in our practice.

6. Assessment Critical thinking during this step
Determine necessary data to collect
Distinguish between relevant and irrelevant information
Validate the data
Determine need for any additional information
Select appropriate assessment tools
Apply assessment tools in reliable and valid ways
Ex: Predictive equations vs. Indirect calorimetry
Nutrition Care Indicators

7. Nutrition Care Indicators
Defined markers that can be observed and measured
Incorporated in the Assessment Domains
Ex: Food/Nutrition Related History:
food/nutrient intake, medications, food/nutrition-related knowledge, food access, functional capabilities
Determines what will be measured

8. Diagnosis Nutrition Diagnosis (PES Format)
“The identification and labeling of the specific nutrition problem that food and nutrition professionals are responsible for treating independently”- IDNT Reference Manual 3rd Edition

9. Diagnosis PES Statement
Problem: Required to use EXACT WORDING as Standardized Language
Actual or Predicted
5 New Diagnoses added using the word “predicted”
Predicted Suboptimal Energy Intake (NI-1.6)
Predicted Excessive Energy Intake (NI-1.7)
Predicted Suboptimal Nutrient Intake (NI )
Predicted Excessive Nutrient Intake (NI )
Predicted Food-Medication Interaction (NC-2.4)

10. Diagnosis Etiology: Explains WHY the Problem exists
Do NOT need to use exact wording from IDNT references
Can use another diagnosis (but if done, MUST use standardized language)
Signs/Symptoms: Gives Proof as to why a nutrition problem exists
Measurable data
Potential outcome data

11. Diagnosis Determining the Nutrition Diagnosis
3 Domains: Intake, Clinical, Behavior-Environmental
When there are 2 equally acceptable choices for a problem from 2 different domains, choose from the intake domain
The Intake Domain will likely have a nutritional etiology therefore likely will have a nutrient-directed intervention

12. Diagnosis Considerations for determining Nutrition Problem:
Assessment data
Is there anything nutritionally abnormal?
What can you as a dietitian affect?
Go over the problem using your own words

13. Diagnosis
Examples:
Inadequate oral intake related to (r/t) decreased appetite and mouth sores as evidenced by (AEB) pt eating <50% meals and often skipping meals
Inadequate Enteral Nutrition (EN) infusion r/t nausea and vomiting AEB frequent feeding interruptions, 5 episodes of vomiting yesterday, and <50% infusion goal met over the past 3 days

14. Practice Time
Formulate a Diagnosis Statement in the PES format using Standardized Language
Split up into groups
Review Case Study in your area
10 minutes
Choose someone to present your diagnosis statement
Split the group up into 3 groups

15. Intervention
The nutrition-related plan designed to improve the nutrition diagnosis/etiology/signs and symptoms
1st step is Nutrition Prescription:
Individualized statement of needs the patient has at a given moment
May be adjusted as clinical picture changes
Examples:
1800kcal, 65g protein/day
Intake of 2gm K+/day
Can include preventative interventions
The main heading MUST use the standardized language

16. Intervention Examples:
Meals and Snacks: Continue current diet. Will send snacks tid.
Medical Food Supplements: recommend addition of oral supplement 2 times/day
Vitamin and Mineral Supplements: MD please consider addition of MVI daily
Nutrition-Related Medication Management: consider addition of appetite stimulant

17. Monitor/Evaluate
Helps the nutrition professional to determine whether there has been any progress made in the patient/client nutrition status and whether goals/expected outcomes are being met
Monitors progress towards goals
Compares nutrition care indicators against the patient’s baseline or evidence-based indicators

18. Monitor/Evaluate 3 Steps to M/E:
Monitor: Provide evidence showing if nutrition interventions are improving patient nutrition behavior or status
Measure: Collect data on appropriate nutrition care indicators
Evaluate: Compare current findings with previous nutrition information, goals, or reference standards and evaluate the impact of each intervention using measurable nutrition outcome indicators

19. Monitor/Evaluate Characteristics of M&E:
Measurable: Use of evidence-based standards or guidelines
Related to PES Statement
Guides nutrition intervention planning
Communicates expected outcomes
Patient-centered and individualized
At least 1 goal for each nutrition diagnosis

20. Monitor/Evaluate Examples:
Weight: patient to maintain wt of ___+/- 2kg
Liquid Meal Replacement or supplement: Patient will drink ____oral supplements/day
Food and Beverage Intake: Patient will eat % of 3 meals/day
Enteral Nutrition Intake: Patient will reach goal infusion rate within 24 hours

21. Practice
Identify at least 1 intervention be for the nutrition problem you diagnosed
Review Same Case study
Prepare at least 1 measurable goal that would positively affect the nutrition diagnosis identified by the intervention(s) implemented

22. Reassessing Nutrition Status
Ways to document progress of a Nutrition Diagnosis in Reassessment
Nutrition Diagnosis Progress Report
Monitoring and Evaluating
Data under Assessment- documented in assessment portion of note

23. Reassessing Nutrition Status
Nutrition Diagnosis Progress Report
Progress explained in the PES statement using words such as:
Improved or progress toward resolution
Continues or ongoing
Resolved
Worsened
No progress
No longer applicable

24. Reassessing Nutrition Status
Monitoring and Evaluating:
Evaluates progress towards goals
How effective have the interventions been?
M&E standards may change in reassessment
Goals change according to evolving conditions
Has initial diagnosis resolved but a new one developed?
When a nutrition diagnosis is resolved, drop it in the next reassessment
In Reassessments, designate new nutrition diagnosis under New Nutrition Diagnosis heading

25. Working NCP into Your Practice
How Can I incorporate NCP into the way I currently document?
ADIME
Assess, Diagnose, Intervene, Monitor, Evaluate
PGIE (Problem, Goal, Intervention, Evaluation):
Problem: PES Statement
Goal: Nutrition Prescription
Intervention: Nutrition Intervention/goal
Evaluate: Evaluate
SOAP
S: Food/Nutr Related history, Any other data if self-reported
O: Biochemical data, medical tests (data documented by RD or found in medical record)
A: Comparative Standards
Nutrition Diagnosis
P:Intervention
Monitor/Evaluate
PIE (Problem, Intervention, Evaluation)
P: PES Statement
I: Nutrition Intervention
E: Evaluation

26. Questions?