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

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

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

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

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.

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

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

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

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-5.11.1) Predicted Excessive Nutrient Intake (NI-5.11.2) Predicted Food-Medication Interaction (NC-2.4)

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

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

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

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

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

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

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

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

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

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

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 75-100% of 3 meals/day Enteral Nutrition Intake: Patient will reach goal infusion rate within 24 hours

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

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

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

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

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

Questions?