2. Relationship Between Patient/Client/Group & Dietetics Professional - Nutrition Diagnosis   Identify and label problem   Determine cause/contributing risk factors   Cluster signs and symptoms/ defining characteristics Nutrition Assessment   Obtain/collect timely and appropriatedata   Analyze/interpret with evidence-based standards   Identify risk factors  Use appropriate tools and methods  Involve interdisciplinary collaboration Screening & Referral System Outcomes Management System  Monitor the success of the Nutrition Care Process implementation  Evaluate the impact with aggregate data  Identify and analyze causes of less than optimal performance and outcomes  Refine the use of the Nutrition Care Process ADA NUTRITION CARE PROCESS AND MODEL  Document Nutrition Monitoring and Evaluation  Monitor progress  Measure outcome indicators  Evaluate outcomes  Document Nutrition Intervention  Plan nutrition intervention  Formulate goals and determine a plan of action  Implement the nutrition intervention  Care is delivered and actions are carried out  Document Document

3.  Nutrition Assessment  Nutrition Diagnosis  Nutrition Intervention  Nutrition Monitoring and Evaluation

4.  “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;103:1061- 1072.

5.  Gather data, considering  Compare to relevant standards  Identify possible problem areas

6.  Observe › Verbal and nonverbal cues  Determining appropriate data to collect › Only key information to be recorded  Selecting assessment tools  Distinguishing relevant from irrelevant data  Organizing data to relate to the nutrition problem  Determining when problems require referral

7.  Nutrition Assessment  Nutrition Diagnosis  Nutrition Intervention  Nutrition Monitoring and Evaluation

8.  Nutritional problem  Names and describes the problem  Problem may already exist, or may be at risk of occurring  Not a medical diagnosis

9. Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support (enteral or parenteral nutrition)  Class1: Calorie energy balance  Class2: Oral or nutrition support intake  Class3: Fluid intake balance  Class4: Bioactive substances balance  Class5: Nutrient balance

10. Defined as “nutritional findings/problems identified that relate to medical or physical conditions  Class1: functional balance  Class2: biochemical balance  Class3: weight balance

11. Defined as “nutritional findings/problems identified that relate to knowledge, attitudes/beliefs, physical environment, or access to food and food safety  Class1: knowledge and beliefs  Class2: physical activity, balance and function  Class3: food safety and access

12.  Problem  Etiology  Signs/Symptoms › Signs › Symptoms

13.  Problem › Describes alterations in pt’s nutritional status › Diagnostic labels  Impaired  Altered  Inadequate/excessive  Inappropriate  Swallowing difficulty

14.  Etiology › Related factors that contribute to problem › Identifies cause of the problem › Helps determine whether nutrition intervention will improve problem › Linked to problem

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

16.  Signs/Symptoms › Evidence- that the problem exists › Linked to etiology- “as evidence by”

17.  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.  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.  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 Statement should be:  clear, concise  specific  related to one problem  Accurate- related to E  based on reliable, accurate assessment data

21. Medical DiagnosisNutritional Diagnosis DiabetesIncreased blood glucose level, excess calorie intake Trauma and closed head injury TPN, IV hydration line, increase energy needs (state of catabolism) R/T the trauma, as evidence by weight Liver failureNo insulin, blood glucose stability, R/T fact that the liver is not functioning, as evidence by increased blood glucose levels.

22. Medical DxNutritional Diagnosis ObesityIntake energy imbalance or calorie increase R/T increased calories or obesity or lack of healthy foods or SES, AEB weight, BMI Dependence mechanical ventilation Increased carbohydrates, excessive calories R/T high TPN, AEB vent settings Anorexia nervosaDecreased calorie intake, R/T history of anorexia and self limiting behavior, AEB weight and diet history

23.  Nutrition Assessment  Nutrition Diagnosis  Nutrition Intervention  Nutrition Monitoring and Evaluation

24.  “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;103:1061- 1072  Directed at the etiology or effects of a diagnosis

25. Should be patient-centered  Must be achievable  Stated in behavioral terms, quantifiable terms  Pt and counselor must establish goals together  What will the patient do or achieve if objectives met  SMART goals!

26.  Problem 1: Involuntary weight loss › Objectives:  1. Increase calorie intake, very specific  2. Gain X pounds in X month

27.  Problem 2: Inadequate protein-energy intake 2° poor appetite › Objectives: 1.Increase nutrient dense foods high in protein 2.Divide up protein rich foods throughout the day 3.Improve socialization of eating foods

28.  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

29.  Problem 1: Involuntary Weight loss › Intervention: 1. Instruct client on (high protein, high calorie feeding) 2. Gradually increase plan 3. 4.

30.  Problem 2: Inadequate protein-calorie intake 2° poor appetite › Intervention: 1. Begin with nutrient dense foods 2. 3.

31.  Nutrition Assessment  Nutrition Diagnosis  Nutrition Intervention  Nutrition Monitoring and Evaluation

32. Evaluate outcomes Compare current findings with previous status, intervention goals, and/or reference standards

33. Nutrition Monitoring and Evaluation Types of Outcomes End-result outcome Direct nutrition outcomes Clinical and health status outcomes Patient/client-centered outcomes Healthcare utilization Intermediate-result outcome

34.  Are necessary in order to evaluate  Should be achievable- and based on scientific evidence  Should be directly or indirectly related to nutrition care

35. 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. Nutrition Diagnosis- PESS 1. Fluid intake concerns, R/T dietary discretion AEB symptoms 2. Excessive Na intake R/T foods eaten AEB diet history 3. Knowledge deficit R/T no previous nutritional education AEB inability to name Na foods 4. Self monitoring deficit R/T

37. Nutrition Intervention  1. Low Na diet  2. Go to senior center to eat  3. Attend diet program  4. Find someone to help the woman to get scale

38. Monitoring and Evaluation 1. Monitor BP and tell her to keep a weight log and food log 2. Case manager will monitor readmissions 3.