The Nutrition Care Process

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The Nutrition Care Process

• Allie Hanson
• Concordia College
• Moorhead, MN

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Objectives

• Be able to clearly explain the Nutrition Care
  Process
• Be able to describe in your own words the 4 steps
  in the Nutrition Care Process
• Be able to write a clear and concise Nutrition
  PES Statement
• Be able to develop nutrition related chart notes

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Nutrition Care Process (NCP) Defined

• A systematic problem solving method developed by
  the ADA that dietetic professionals use to think
  critically, make decisions addressing
  nutrition-related problems, and provide safe,
  effective, highly qualified nutrition care

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Other Key Definitions

• Nutrition Care Plan
• A formal statement of the nutrition goals and
  interventions prescribed for an individual using
  the data obtained from a nutrition assessment.
  The plan, formulated by an interdisciplinary
  process, should include statements of nutrition
  goals and monitoring parameters, the most
  appropriate route of administration of
  specialized nutrition support (oral, enteral,
  and/or parenteral), method of nutrition access,
  anticipated duration of therapy, and training and
  counseling goals and methods
• Nutrition Screening
• A process to identify an individual who is
  malnourished or who is at risk for malnutrition
  to determine if a detailed nutrition assessment
  is indicated

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Providing Nutrition Care

• Nutrition Intervention
• Specific set of activities and associated
  materials used to address a (nutrition-related)
  problem
• Strategies and focus of care based on status of
  health

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Nutrition Care

• Evaluating nutritional status
• Biological
• Ex. Male, Female, age
• Lifestyle
• Ex. Smoking, Drinking, Eating Breakfast
• Environment
• Ex. Wages, Transportation
• Systems
• Ex. Health Care System, Education System

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Purpose of Providing Nutrition Care

• Influence and change the factors that contribute
  to an imbalance in nutritional status and thus
  restore an improved state of nutritional health
• Registered Dietitians are highly qualified to
  provide nutrition care

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ADAs Standardized Model of Care

• Nutrition Care Process
• American Dietetic Associations standard process
• Systematic process to make decisions
• Provides a standardized language for
  documentation and communication
• 62 terms, known as the Nutrition Diagnostic
  Terminology, are used to clearly describe
  specific types of nutrition problems that
  contribute to a persons nutritional imbalance

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ADAs Standardized Model of Care

• Four steps of the Nutrition Care Process
• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring and Evaluation

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The Nutrition Care Process Model

• Central Core
• Relationship between the client and the dietetics
  professional or team of dietetic professionals
• Important to develop trust and communicate
  effectively with others
• Essential that the client be actively involved in
  the care whenever possible
• Individualized and Client focused
• Outer Rings
• Outermost rings environmental factors that have
  an impact on the ability of the client to receive
  and benefit from the interventions of nutrition
  care
• Inner Ring strengths that dietetic
  professionals bring to the nutrition care process
• Supportive Systems
• Screening and referral system
• Identifies those individuals or groups who would
  benefit from nutrition care provided by dietetic
  professionals
• Outcomes management system
• Used to evaluated the effectiveness and
  efficiency of the entire NCP process when
  nutrition care is provided to a number of patients

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Steps in the Nutrition Care Process

• Step 1 Nutrition Assessment
• A very systematic process of obtaining,
  verifying, and interpreting data in order to make
  decisions about the nature and cause of nutrition
  related problems
• Ongoing, dynamic process involving not only
  initial data collection, but also continual
  reassessment and analysis of a clients needs and
  conditions
• Provides data to accurately describe nutrition
  problems and facilitate the formulation of a
  nutrition diagnosis at the next step of the NCP
• Provides a means to reevaluate the nutrition
  program as a part of nutrition monitoring and
  evaluation
• Focuses on the understanding the wide variety of
  factors
• Data gathered during the assessment step are also
  used to describe the severity of the problem

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Steps in the Nutrition Care Process

• Step 1 Nutrition Assessment (cont.)
• Obtain and verify appropriate data
• Varies depending on a number of factors such as
  practice setting or the individuals/groups
  health status
• Cluster and organize assessment data
• In a meaningful way that relates to specific
  types of nutrition problems
• Evaluate the data using reliable standards
• Important that data be linked to specific types
  of problems
• Important that information be compared to
  reliable standards or ideal goals
• Data includes anthropometrics, laboratory,
  clinical, history, etc.

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Steps in the Nutrition Care Process

• Step 2 Nutrition Diagnosis
• Identification and descriptive labeling of an
  actual occurrence of a nutrition problem that
  dietetics professionals are responsible for
  treating independently
• The missing link between nutrition assessment and
  nutrition intervention
• A nutrition diagnosis, in contrast to a medical
  diagnosis, is written in terms of client problem
  for which nutrition-related activities provide
  the primary intervention
• Focus on nutrition issues that may be
  consequences of or contribute to diseases
• Also address behaviors that impact food choices

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Steps in the Nutrition Care Process

• Step 2 Nutrition Diagnosis (cont.)
• Nutrition Diagnostic Terms
• Intake Domain nutrition problems that are
  related to intake, energy, nutrients, fluids, and
  bioactive substances through oral diet or
  nutrition support
• Labels such as inadequate, excessive, or
  inappropriate are used
• Clinical Domain nutrition problems that are
  related to medical or physical conditions
• Include problems in swallowing, chewing,
  digestion, absorption, and maintaining
  appropriate weight
• Behavioral-Environmental Domain problems that
  are related to knowledge, attitudes/beliefs,
  physical environment or access to food, and food
  safety

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Steps in the Nutrition Care Process

• Step 2 Nutrition Diagnosis (cont.)
• PES Statement
• Problem, etiology, signs/symptoms
• Format used in the NCP to write a nutrition
  diagnosis
• Clarifies a specific nutrition problem and
  logically links the nutrition diagnosis to
  nutrition intervention and to monitoring and
  evaluation
• (P) diagnostic label, describes in a general
  way an alteration in the nutritional status
• Words commonly used excessive, inadequate,
  inappropriate
• (E) factors that contribute to the cause or
  existence of a particular problem
• (S) defining characteristics obtained from the
  subjective and objective nutrition assessment data

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Steps in the Nutrition Care Process

• Step 2 Nutrition Diagnosis (cont.)
• PES Statement
• Generally stated in the following manner
• The problem (p) due to the etiology (e) as
  evidenced by the signs and symptoms (s).
• Example
• Patient has involuntary weight loss (p) due to
  inadequate energy intake (e) as evidenced by
  eight pounds weight loss within 4 weeks (s).

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Steps in the Nutrition Care Process

• Step 2 Nutrition Diagnosis (cont.)
• PES Statements How do I get there?
• Evaluate nutrition assessment using critical
  thinking
• Identify the problem(s)
• State them each clearly and singularly
• Focus on those that can be treated by nutritional
  intervention
• Describe the signs and symptoms
• Explore the etiology or cause
• Again focus on a nutrition-related cause Not
  medical diagnosis

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Steps in the Nutrition Care Process

• Step 2 Nutrition Diagnosis (cont.)
• PES Statement How do I evaluate?
• Ask yourself appropriate questions
• Ex. Can the dietetics professional impact,
  improve, or resolve the nutrition problem?
• Relationship to other steps
• Signs and symptoms become basis for setting ideal
  and measurable goals (step 3) and outcome
  measures (step 4)

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Steps in the Nutrition Care Process

• Step 3 Nutrition Intervention
• Involves both planning and implementing
• A specific set of activities and associated
  materials used to address the problem
• Purposefully planned actions designed with the
  intent of changing a nutrition-related behavior,
  risk factor, environmental condition, or aspect
  of health status for an individual, target group,
  or the community at large
• Dietetic professionals work not only with other
  health care professionals, but also with the
  client, family, or caregiver to create a
  realistic plan with a good probability of working
• Client-driven process is key

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Steps in the Nutrition Care Process

• Step 3 Nutrition Intervention (cont.)
• Sub Steps
• Prioritize the Nutrition Diagnosis
• Arrange problems in the order of importance and
  urgency for the client
• Identify Ideal Goals and Patient-Focused Expected
  Outcomes
• Ideal Goals science based values intended to
  control or improve specific health conditions
• Expected Outcomes the desired change(s) to be
  achieved over time as a result of nutrition
  intervention
• Implement the Nutrition Intervention

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Steps in the Nutrition Care Process

• Step 4 Nutrition Monitoring and Evaluation
• Determine the degree to which progress is being
  made and whether or not the clients goals or
  desired outcomes of nutrition care are being met
• Much more than merely watching what is
  happening
• Requires an active commitment to measuring and
  recording the appropriate outcome indicators
  relevant to the nutrition diagnosis signs and
  symptoms
• Progress should be
• 1. Monitored
• 2. Measured
• 3. Evaluated on a planned schedule

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Steps in the Nutrition Care Process

• Step 4 Nutrition Monitoring and Evaluation
  (cont.)
• Sub Steps
• Monitor Progress
• Determining that the goals and outcomes that are
  anticipated by the client and the dietetics
  professionals are indeed occurring
• Monitor, measure, evaluate on a planned schedule
• Measure Outcomes
• Data is collected over time
• Nutrition, clinical and health status,
  patient/client centered, and health care
  utilization
• Evaluate Outcomes
• To determine what changes have occurred as a
  result of the nutrition intervention
• Comparing the current findings with the previous
  signs and symptoms
• Create outcome management system
• Contribute to the body of evidence-based research

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Documentation

• Ongoing process to support the steps of the NCP
• Standardized language now part of NCP improves
  both written and oral communication among members
  of the health care team as well as communication
  with the patient
• Should be Relevant, Accurate, and Timely
• Variety of Formats are acceptable
• SOAP notes
• Focus notes
• PIE
• ADIM what is laid out by the NCP
• ADA would like to be using this
• Electronic Medical Records

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SOAP Note Format

• Subjective (S)
• Patient information or data collected from the
  patient or caregiver
• Have no proof of
• Objective (O)
• Empirical information, information drawn from
  physical tests and medical staff observations
  that are of consequence to the patients
  nutritional status
• Have proof of
• Assessment (A)
• Nutrition diagnosis or interpretation of the
  patients nutrition problems
• PES Statement
• Plan (P)
• An outline of interventions necessary to treat
  each nutrition problem
• What you plan to do

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ADIM Note Format

• Organized to reflect the Nutrition Care Process
• Assessment (A)
• Relevant data about the patients condition
• Diagnosis (D)
• PES Statements listed and prioritized
• Intervention (I)
• Documentation of the specific treatment goals and
  expected outcomes, interventions, and response of
  the client
• Monitoring and Evaluation (M)
• Documentation of progress toward goals
• Factors that are facilitating or hampering
  progress
• Changes in the clients level of understanding or
  behavior
• Future plans for care

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Trivia Game!
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• What does the medical abbreviation a.c. mean?
• Before meals

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• What is the nutrition care process?
• A systematic problem solving method developed by
  the ADA that dietetic professionals use to think
  critically, make decisions addressing
  nutrition-related problems, and provide safe,
  effective, highly qualified nutrition care

30

• What are the steps of the nutrition care process?
  Briefly describe each step.
• Nutrition Assessment (A)
• Relevant data about the patients condition
• Nutrition Diagnosis (D)
• PES Statements listed and prioritized
• Nutrition Intervention (I)
• Documentation of the specific treatment goals and
  expected outcomes, interventions, and response of
  the client
• Nutrition Monitoring and Evaluation (M)
• Documentation of progress toward goals
• Factors that are facilitating or hampering
  progress
• Changes in the clients level of understanding or
  behavior
• Future plans for care

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• What does the medial abbreviation FH mean?
• Family History

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• What does the medical abbreviation b.i.d. mean?
• Twice a day (bis in die)

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• What is the nutrition care plan?
• A formal statement of the nutrition goals and
  interventions prescribed for an individual using
  the data obtained from a nutrition assessment.
  The plan, formulated by an interdisciplinary
  process, should include statements of nutrition
  goals and monitoring parameters, the most
  appropriate route of administration of
  specialized nutrition support (oral, enteral,
  and/or parenteral), method of nutrition access,
  anticipated duration of therapy, and training and
  counseling goals and methods

34

• What does the medical abbreviation NPO mean?
• Nothing by Mouth

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• How should an error be corrected in the medical
  record?
• Should not be erased. Draw a line through it and
  write error over it, put correct info, date of
  correction, and signature.

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• Where would the following statement fall in a
  SOAP note (subjective, objective, assessment, or
  plan)? Results of a laboratory test performed at
  the hospital.
• Objective

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• What does the medical abbreviation SOB mean?
• Shortness of breath

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• Where would the following statement fall in a
  SOAP note (subjective, objective, assessment, or
  plan)? Patient-centered and measurable overall
  treatment goal.
• Plan

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• What are measurable goals?
• Clear and concise measurable goals that specify
  an outcome that can be assessed. It is a target
  measure.

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• What is a screening process?
• A process to identify an individual who is
  malnourished or who is at risk for malnutrition
  to determine if a detailed nutrition assessment
  is indicated

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• What does the medical abbreviation cc mean?
• This medical abbreviation is prohibited by JCAHO
  (Joint Commission on Accreditation of Healthcare
  Organizations)
• Means cubic centimeters, use ml instead

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• What does the medical abbreviation c mean?
• With (cum)

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• Where would the following statement fall in a
  SOAP note (subjective, objective, assessment, or
  plan)? Calculated energy intake from observed
  food intake by the client at the hospital.
• Objective

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• What does the medical abbreviation Hx mean?
• History

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• What is a nutrition assessment?
• An analysis of an individuals nutrition status
  incorporating both subjective and objective data,
  including information on diet, psychosocial
  parameters, education, and motivation

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• What does the medical abbreviation R/O mean?
• Rule out

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• Where would the following statement fall in a
  SOAP note (subjective, objective, assessment, or
  plan)? Usual body weight and dietary intake
  information given by the client.
• Subjective

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• Where would the following statement fall in a
  SOAP note (subjective, objective, assessment, or
  plan)? Dietitians evaluation of the nutritional
  status.
• Assessment

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• Where would the following statement fall in a
  SOAP note (subjective, objective, assessment, or
  plan)? Recommendations by the dietitian for the
  physicians approval.
• Plan

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• What is her usual BMI?
• 27.3

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• What is your interpretation of her usual BMI?
• Overweight

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• What is her percent weight change?
• 13

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• What is your interpretation of here percent
  weight change?
• Significant (10-20 significant)

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• Calculate her current percent UBW.
• 88

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• What is your interpretation of her current
  percent UBW?
• Mild Malnutrition

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• Miss J.S. is a 43-year-old woman coming to the
  St. Marks Regional Diabetes Center to meet with
  you for an initial nutrition interview. Miss
  J.S.s height is 54. She tells you that her
  weight has always been stable (around 160 lb),
  but that a year ago she started to become ill. At
  the interview, you measure her weight to be 140
  lb. You find in her medical record that she was
  diagnosed with breast cancer 12 months ago.
  (Number 12, pg 228)
• Write a PES statement for Miss J.S.
• Patient is mildly malnourished due to recent
  significant weight loss as evidenced by percent
  weight change of 13 and percent UBW of 88.