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Diagnosis, Intervention, Evaluation, and Documentation ADA NUTRITION CARE PROCESS AND MODEL Screening & Referral System   Identify risk factors   Use appropriate tools and methods  Involve interdisciplinary collaboration Nutrition Assessment  Obtain/collect timely and appropriate data  Analyze/interpret with evidence- based standards Document Nutrition Diagnosis  Identify and label problem   Determine cause/contributing risk factors  Cluster signs and symptoms/ defining characteristics  Document Relationship Between Patient/Client/Group & Dietetics Professional Nutrition Monitoring and Evaluation   Monitor progress   Measure outcome indicators   Evaluate outcomes   Document 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  Plan nutrition intervention • Formulate goals and determine a plan of action the nutrition intervention Implement  • Care is delivered and actions are carried out  Document  Nutrition Assessment Leads to Nutrition Diagnosis • • • • Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation Nutrition vs Medical Dx Medical Dx Nutrition Diagnosis Diabetes Excessive CHO intake related to evening visits to Coldstone Creamery as evidenced by diet hx and high hs blood glucose Trauma and Increased energy expenditure related to closed head multiple trauma as evidenced by results injury of indirect calorimetry Liver failure Altered gastrointestinal function related to cirrhosis of the liver as evidenced by steatorrhea and growth failure Nutritional vs Medical Dx Medical Dx Nutrition Diagnosis Obesity Excessive energy intake related to lack of access to healthy food choices (restaurant eating) as evidenced by diet history and BMI of 35 Dependence mechanical ventilation Excessive energy intake related to high volume PN as evidenced by RQ >1 Anorexia nervosa Inappropriate food choices related to history of anorexia nervosa and selflimiting behavior as evidenced by diet history and weight loss of lb PES Statement • • • Problem: nutrition diagnosis label Etiology: the focus of the intervention Signs and symptoms: change when nutrition problems are successfully treated; the focus of monitoring and evaluation Problem (Diagnostic Label) Falls into three general domains: • Intake (NI) • Excessive or Inadequate intake compared to requirements • Clinical (NC) • Medical or physical conditions that are outside normal • Behavioral/environmental (NB) • Knowledge, attitudes, beliefs, physical environment, access to food, food safety Etiology • Etiology (Cause/Contributing Factors) • Related factors that contribute to problem • Identifies cause of the problem • Helps determine whether nutrition intervention will improve problem • Linked to problem by words “related to” (RT) • Note: etiology may not always be clear Etiology • Etiology (Cause/Contributing Factors) • Excessive energy intake (problem) “related to” regular consumption of large portions of highfat meals (etiology)… • Swallowing difficulty (problem) RT recent stroke (etiology)… • Involuntary wt gain RT decrease in exercise… Diagnostic Labels Can Be Problems or Etiologies • Inadequate energy intake (NI-1.4) related to foodnutrition knowledge deficit (NB-1.1) • Food-nutrition knowledge deficit (NB-1.1) related to lack of previous nutrition education • Involuntary weight loss (NC-3.2) related to inadequate energy intake (NI-1.4) • Inadequate oral food-beverage intake (NI-2.1) related to swallowing difficulty (NC-1.1) Basic Hospital Diets —cont’d “Surgical” Soft Diet Clear Liquid Diet Full Liquid Diet Full Liquid Diet –cont’d House or Standard Diet Controversies • Should the house diet be low in fat, saturated fat, sodium, and sugar to conform with the U.S dietary guidelines? • Should the house diet be intended to maximize the nutritional intake of sick people, featuring familiar, comfort foods and fulfilling patient preferences and expectations, regardless of conformity to dietary guidelines designed for healthy people? Consistency Diet Controversies • Soft Diet: what should be included or excluded? Is the diet ‘dental” soft, “surgical” soft, mechanical soft; the needs of dysphagia patients and dental patients are different • Full liquid diet: there is no evidence that it has a role as part of a surgical progression; many of the foods included are poorly tolerated by persons immediately post GI surgery (dairy products, fats, etc.) May be useful as a source of nutrition for persons with mouth pain or dental surgery Consistency Diet Controversies • Thickened liquids: when speech pathologists recommend specific liquid consistencies, they may be using a different standard than is used in the food and nutrition department • There is no generally-accepted standard for nectar thick, honey thick, etc Often these foods vary greatly among and within institutions and depending on where and by whom the thickening is done Therapeutic Diet Controversies • Should patients with chronic diseases who are hospitalized with acute illnesses be placed on the restricted diet that is appropriate for them long term? Therapeutic Diet Controversies • Should residents in long term care facilities have the same right as homebased clients to decide whether or not to follow a restricted diet? Nutritional Care of the Terminally Ill Patient • Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients = “palliative care” • Dietary restrictions and aggressive nutrition care that negatively impacts quality of life are rarely appropriate Palliative Care • Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently Continuity of Care • Due to shortened length of stay, more nutritional care is being provided in alternative settings (long term care, home care, ambulatory clinics and community programs) • Nutrition counseling and education in acute care is often limited to survival skills • Nutritional counseling should be provided in a setting conducive to long term behavior change • The acute care stay can be an opportunity to identify nutritional problems and devise a plan for follow-up care Discharge Planning Discharge documentation includes • Summary of nutritional therapies and outcomes • Pertinent information such as weight, lab results, dietary intake • Potential drug-nutrient interactions • Expected progress or prognosis • Recommendations for follow-up services Discharge Planning Courtesy University of Washington Medical Centers, Seattle ... readiness to change food, nutrition, or nutrition-related behaviors Potential indicators (BE-1.1) • Readiness to change • Perceived consequences of change • Perceived costs versus benefits of change... by diet history, medical dx and weight loss of 10 lb during cancer tx • Cannot treat the etiology (decreased taste perception) but can treat S&S by recommending foods with stronger flavors Evaluating... improved? • Ex: If nutrition dx is excessive energy intake, can another diet history at next visit and see if intake has changed; can also check weight NCP Example: Long Term Care • 85 y.o resident