1. Nutrition Care Process
KNH 411

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
are carried out -
Evaluation Ø
Monitor progress Ø
Documen t Ø
Measure outcome indicators Ø
Evaluate outcomes 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. 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:

5. Nutrition Assessment Components
Gather data, considering
Dietary intake; consequences of condition; physical, psychological, behavior conditions; knowledge, readiness to change, potential for change
Compare to relevant standards
What is normal
What can you do to fix
Identify possible problem areas
ADIME (anthroplymetrics, biochemical, clinical, dietary intake)

6. Nutrition Assessment: Critical Thinking
Observe
Verbal and nonverbal
Determining appropriate data to collect
Look at key aspects
Selecting assessment tools
Distinguishing relevant from irrelevant data
Organizing data
Figure out what client needs and implement
Determining when problems require referral

7. ADA’s Nutrition Care Process Steps
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
The first step we’ll look at is the Nutrition Assessment

8. Nutrition Diagnosis Nutritional problem
Diagnose problems associated with disease
Names and describes the problem
What are you going to do to solve?
Problem may already exist, or may be at risk of occurring
Not a medical diagnosis

9. 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: Calorie energy balance (weight gain)
Class: Oral or nutrition support intake
Post operation (type of diet)
Class: Fluid intake balance
Renal patients
Class: Bioactive substances balance
Metabolic, someone missing an enzyme
Class: Nutrient balance
Deficiencies

10. Nutrition Dx Domains: Clinical
Defined as “nutritional findings/problems identified that relate to medical or physical conditions
Class: functional balance
Physical or mechanical condition
Class: Biochemical balance
Ability to metabolize nutrients
Class: weight balance
Chronic weight changes

11. 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
State of the disease
Class: physical activity, balance and function
How they get around/function
Class: food safety and access
Economic status

12. Nutrition Diagnosis Components
Problem – diagnostic label
Etiology – cause, contributing risk factor
Signs/Symptoms
Signs – observable and measureable
Symptoms – what the subject feels/expresses (objective)

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

14. 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

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

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

17. 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

18. 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

19. 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

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

21. Nutritional vs Medical Dx
Medical Diagnosis
Nutritional Diagnosis
Diabetes
Increased blood glucose, increased carbohydrate intake
Trauma and closed head injury
Total nutrition support
Hydration, increased energy needs
Liver failure
Blood glucose stability (insulin)
s/s- increased blood glucose levels

22. Nutritional vs Medical Dx
Nutritional Diagnosis
Obesity
Take in more calories than burning
Lack of access to food
Dependence mechanical ventilation
Excessive energy intake
Loading with carbohydrates
Anorexia nervosa
Decreased caloric intake
Undesirable food choices
Seen by diet history and weight history

23. 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

24. 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:
Directed at the etiology or effects of a diagnosis
Create a plan for the patient

25. Intervention Objectives
Should be patient-centered
Must be achievable
Must be measureable, quantifiable, have a goal/endpoint
Stated in behavioral terms
Pt and counselor must establish goals together
Everyone working with the patient must agree on the plan
What will the patient do or achieve if objectives met

26. Intervention Objectives
Problem 1: Involuntary weight loss
Objectives:
1. increase calorie intake
X calories divided into six small meals
2. gain 10 pounds in one month
Give plan and how to acheive

27. Intervention Objectives
Problem 2: Inadequate protein-energy intake 2° poor appetite
Objectives:
1. Eat foods high in protein
2. Eat X meals with X amount of protein

28. 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
What, when, how

29. Nutrition Intervention
Problem 1: Involuntary Weight loss
Intervention: (plan of action)
1. Instruct client on options (educate patient)
2. Gradually introduce plan
3. Introduce supplement
4. Plan for implementing and measuring

30. Nutrition Intervention
Problem 2: Inadequate protein-calorie intake 2° poor appetite
Intervention:
1. nutrient-dense foods
2. Introduce to socialization

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

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

33. Intermediate-result outcome
What gets Measured?
Nutrition
Monitoring
and Evaluation
Types of Outcomes
Direct nutrition outcomes
Clinical and health status outcomes
Patient/client-centered outcomes
Healthcare utilization
Weight, BP, nutritional status, lab values
Intermediate-result outcome
(first client visit)
End-result outcome
(follow-up visits)

34. Nutrition Goals and Objectives
Are necessary in order to evaluate
Should be achievable
Should be directly or indirectly related to nutrition care
How effective was your plan?

35. 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

36. NCP Example: Acute Care
Nutrition Diagnosis 1. Fluid intake concerns relate to dietary discretion and indicated by patient 2. Excessive sodium intake of foods eaten by diet history 3. No previous nutrition education as evidenced by patient results 4. Not self-monitoring, not weighing self

37. NCP Example: Acute Care
Nutrition Intervention
1. low sodium diet
2. go to senior center for assistance
3. attend nutrition programs
4. get scale
5. limit fluids

38. NCP Example: Acute Care
Monitoring and Evaluation 1. Get scale- weight log 2. Get vitals 3. Food log