Exploring the Nutrition Care Process

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)

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-5.11.1) • Predicted Excessive Nutrient Intake (NI-5.11.2) • 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

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 75-100% 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?

26. Questions?