Nutrition Care Process KNH 411 ADA NUTRITION CARE

Nutrition Care Process KNH 411

ADA NUTRITION CARE PROCESS AND MODEL Screening & Referral System Ø Ø Identify risk factors Use appropriate tools and methods Ø Involve interdisciplinary collaboration Nutrition Assessment Ø Obtain/collect timely and appropriate data Ø Analyze/interpret with evidence- based standards ØDocument Nutrition Diagnosis Ø Identify and label problem Ø Determine cause/contributing risk factors Ø Cluster signs and symptoms/ defining characteristics ØDocument Relationship Between Patient/Client/Group & Dietetics Professional Nutrition Monitoring and Evaluation Monitor progress Ø Measure outcome indicators Ø Evaluate outcomes Ø Ø Document Ø Ø 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 Nutrition Intervention Ø Plan nutrition intervention · Formulate goals and determine a plan of action ØImplement the nutrition intervention · Care is delivered and actions are carried out ØDocument

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

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: 1061 -1072.

Nutrition Assessment Components Gather data, considering Compare to relevant standards Identify possible problem areas

Nutrition Assessment: Critical Thinking Observe Determining appropriate data to collect Selecting assessment tools Distinguishing relevant from irrelevant data Organizing data Determining when problems require referral

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

Nutrition Diagnosis Nutritional problem Needs to be a nutrition problem not a diagnosis Names and describes the problem Problem may already exist, or may be at risk of occurring Not a medical diagnosis

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 Class: Oral or nutrition support intake Class: Fluid intake balance Class: Bioactive substances balance Class: Nutrient balance

Nutrition Dx Domains: Clinical Defined as “nutritional findings/problems identified that relate to medical or physical conditions Class: functional balance Class: Biochemical balance Class: weight balance

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 Culture and background Class: physical activity, balance and function Class: food safety and access Getting other resources involved: social worker, etc.

Nutrition Diagnosis Components Problem Etiology Signs/Symptoms Signs Symptoms

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

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

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

Nutrition Diagnosis Components Signs/Symptoms Evidence Linked to etiology

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

Nutrition Diagnosis Excessive calorie intake “related to” regular consumption of large portions of highfat meals “as evidenced by” diet history & 12 lb wt gain over last 18 mo

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

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

Nutritional vs Medical Dx Medical Diagnosis Nutritional Diagnosis Diabetes Carbohydrate intake Trauma and closed head injury Increased protein needs due to need for repair Liver failure Example: Increased intake of alcohol

Nutritional vs Medical Dx Nutritional Diagnosis Obesity Excessive calorie intake, knowledge deficit Dependence mechanical ventilation Mix of carbs, fat, and proteins Anorexia nervosa Inadequate energy intake

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

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: 1061 -1072 Directed at the etiology or effects of a diagnosis

Intervention Objectives Should be patient-centered Must be achievable Stated in behavioral terms Pt and counselor must establish goals together What will the patient do or achieve if objectives met

Intervention Objectives Problem 1: Involuntary weight loss Objectives: 1. Increase consumption (be specific with calories) (ex: instruct 500 calorie increase per day to gain one pound of weight per week) 2. Ask client about environment (financial resources, people who can help them with this process)

Intervention Objectives Problem 2: Inadequate protein-energy intake 2° poor appetite Objectives: 1. Provide protein powder (exact grams) 3 times per day 2. Incorporate higher servings of protein sources they indicated they enjoy

Nutrition 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

Nutrition Intervention Problem 1: Involuntary Weight loss Intervention: 1. Increase intake to 1, 800 calories with 3 day food record 2. Provide supplement 3. 4.

Nutrition Intervention Problem 2: Inadequate protein-calorie intake 2° poor appetite Intervention: 1. Include nutrient dense foods with meal 2. Begin meals with protein dense food rather than carbs or liquid 3. Change environment to stimulate appetitive

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

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

What gets Measured? Nutrition Monitoring and Evaluation Types of Outcomes • Direct nutrition outcomes • Clinical and health status outcomes • Patient/client-centered outcomes • Healthcare utilization Intermediate-result outcome End-result outcome

Nutrition Goals and Objectives Are necessary in order to evaluate Should be achievable Should be directly or indirectly related to nutrition care

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

NCP Example: Acute Care Nutrition Diagnosis 1. High sodium intake related to use of canned/high salt food as evidence by 24 hour recall 2. Excesive liquid intake related to dietary indiscretion as evidence by diet history 3. Knowledge deficit as related to 4. Self monitoring deficit as related to lack of access to a scale as evidence by client report

NCP Example: Acute Care Nutrition Intervention 1. Advise low sodium canned products 2. Advise them to go buy as low priced scale (may need to work with social worker to make this happen) 3. Set marker of fluid intake and monitor daily by nutrition log 4. Provide a consult/information session with the client

NCP Example: Acute Care Monitoring and Evaluation 1. Weight 2. Food log: evaluate foods 3. Assesment of heart status