Exploring the Nutrition Care Process

Report
EXPLORING THE
NUTRITION CARE PROCESS
Roxanne Davis-Cote, MPH, RD, LD
Beaufort Memorial Hospital
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

NUTRITION CARE PROCESS

Acronym for components: ADIME
Assessment (A)
 Diagnosis (nutrition diagnosis) (D)
 Intervention (I)
 Monitor/Evaluate (M/E)

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

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)
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
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
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

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)

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

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

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

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
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

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

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

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
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

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
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

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
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

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

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

WORKING NCP INTO YOUR PRACTICE

How Can I incorporate NCP into the way I currently
document?
ADIME
Assess, Diagnose,
Intervene, Monitor,
Evaluate
PGIE (Problem, Goal,
Intervention, Evaluation):
Problem: PES Statement
Goal: Nutrition
Prescription
Intervention: Nutrition
Intervention/goal
Evaluate: Evaluate
SOAP
S: Food/Nutr Related history,
Any other data if self-reported
O: Biochemical data, medical
tests (data documented by RD
or found in medical record)
A: Comparative Standards
Nutrition Diagnosis
P:Intervention
Monitor/Evaluate
PIE (Problem, Intervention,
Evaluation)
P: PES Statement
I: Nutrition Intervention
E: Evaluation
QUESTIONS?

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