Bài giảng cung cấp cho người học các kiến thức: Chẩn đoán đánh giá can thiệp dinh dưỡng, chăm sóc sức khỏe, thể trạng cơ thể, mức độ dinh dưỡng,... Hi vọng đây sẽ là một tài liệu hữu ích dành cho các bạn sinh viên đang theo học môn dùng làm tài liệu học tập và nghiên cứu. Mời các bạn cùng tham khảo chi tiết nội dung tài liệu.
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 Sys tem 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 Implement the nutrition intervention 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 (NI1.4) related to food nutrition knowledge deficit (NB1.1) • Foodnutrition knowledge deficit (NB1.1) related to lack of previous nutrition education • Involuntary weight loss (NC3.2) related to inadequate energy intake (NI1.4) • Inadequate oral foodbeverage intake (NI2.1) related to swallowing difficulty (NC1.1) ... Evaluating Your PES Statement • Can the RD resolve or improve the nutrition diagnosis? • Can your intervention address the etiology and thus resolve it or improve the problem? • Or can your intervention address the signs ... 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 Your PES Statement... 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