Download The Nutrition Care Process

No 7
The Nutrition Care Process
Nutritional care
Is an organized group of activates allowing identification of nutritional needs
and provision of care to meet these needs.
Nutrition Care Process Steps
 Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation
The care provided as a result of following this process is called medical nutrition
therapy (MNT)
Nutrition Care process and Medical Nutrition Therapy
The type of nutritional care provided for an individual depends on
1-The presence of disease or potential disease
2-The environment
3-The stage of growth and development
4-Socioeconomic issues
5- An assessment of the adequacy of nutritional intake
6-Manipulation of the diet
7-Provision of enteral or parenteral support
8-Intervention in the form of counseling or education
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Comprehensive nutritional care involves many disciplines
 The physician, dietetics professional, nurse, pharmacist, physical or
occupational therapist, social worker, speech therapist, case manager, and
other care providers may all be integral in achieving desired outcomes,
depending on the care setting. The patient is also an integral part of the
nutrition care process.
 Team conferences, formal or informal are useful in all settings whether the
patient or client is receiving care in the home, in the community, in a
nursing home ,in a long term care facility ,in a clinic or in a hospital.
 Nutritional screening, using simple assessment techniques, helps to identify
patients who would benefit from more intensive nutritional assessment.
 In the hospital setting, nutritional screening must be designed efficiently so
that it can be accomplished within 24 hours of each patient’s admission
 Different personal administer the screen, depending on the setting, and the
information will vary according to the type of patient being screened.
 Patients identified as being “at risk “ during the initial screening process
should have their nutritional status reviewed by a dietetics professional.
Nutritional Assessment
Involves evaluation of medical, social, nutritional, and medication histories
,physical examination and biochemical data.
The identification of nutritional problems (both present and potential) evolves
from a thorough assessment of these factors .
 In a hospital setting, screening should be repeated during the course of the
patient’s stay because nutritional risk increases in patients who are
hospitalized for 10 days or longer.
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 Reassessment is important in all care settings to determine whether
changes in diagnosis or condition have occurred that alter the patient’s
nutritional risk.
 A screening program can be a valuable tool in providing appropriate and
cost effective care to patients regardless of the setting.
 Nutrition Assessment: Critical Thinking
• Organizing data to re-Observing verbal and non-verbal cues to guide
interviewing methods
• Determining appropriate data to collect
• Selecting assessment tools and procedures and applying in valid and
reliable ways
• Distinguishing relevant from irrelevant data
• Organizing data to relate to nutrition problems
• Determining when problems require referral
• late to nutrition problems
• Determining when problems require referral
 Nutrition Diagnosis
 Nutritional problem that the dietitian is responsible for treating
 Names and describes the problem
 Problem may already exist, or may be at risk of occurring
 Not a medical diagnosis
 Type 2 diabetes = medical diagnosis
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 Excessive carbohydrate intake resulting in elevated blood
glucose levels = nutrition diagnosis.
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
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 Linked to problem by words “related to” (RT)
 Note: etiology may not always be clear
 Etiology (Cause/Contributing Factors)
 Excessive energy intake (problem) “related to” regular consumption
of large portions of high-fat meals (etiology)…
 Swallowing difficulty (problem) RT recent stroke (etiology)…
 Involuntary wt gain RT decrease in exercise…
Signs and Symptoms
 Signs/Symptoms (Defining characteristics)
 Evidence that problem exists
 Linked to etiology by words “as evidenced by”
 Evaluation and monitoring of effectiveness of intervention is done by
reviewing signs and symptoms
Etiology Guides Intervention!
 The clinician determines what the intervention is by looking at the root
cause of the nutrition problem.
 If the cause of excessive energy intake is eating frequently in fast food
restaurants, how would you intervene?
Nutrition Diagnosis Statement Should Be
 Clear, concise
 Specific
 Related to one problem
 Accurate – related to one etiology
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 Based on reliable, accurate assessment data
 Evaluating Your PES Statement
 There are no right or wrong PES statements
 But some are better than others
Nutrition Intervention
Purposely-planned actions designed with the intent of changing a nutritionrelated behavior, risk factor, environmental condition, or aspect of health status
for an individual, a target group, or population at large.”
 Should be targeted at etiology
 If not etiology, then signs and symptoms
Nutrition Interventions
Four categories of nutrition interventions:
 Food and/or nutrient delivery (ND)
 Nutrition education (E)
 Nutrition counseling (C)
 Coordination of nutrition care (RC)
Food and/or Nutrient Delivery
 Meals and snacks (ND-1)
 Enteral/parenteral nutrition (ND-2)
 Medical food supplements (ND-3.1)
 Vitamin and mineral supplement (ND-3.2)
 Bioactive substance supplement (ND-3.3)
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 Feeding assistance (ND-4)
 Feeding environment (ND-5)
 Nutrition-related medication management (ND-6)
Nutrition Education (E)
 Initial/brief nutrition education (E-1)
 E.g. survival skills on discharge
 Comprehensive nutrition education (E-2)
 Purpose
 Recommended modifications
 Result interpretation
 Other
Nutrition Counseling (C)
 Theory or approach
 Strategies
 Phase
Coordination of Care (RC)
 Coordination of other care during nutrition care (RC-1)
 Team meeting
 Referral to RD
 Collaboration with other providers
 Referral to community agencies/programs
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 Discharge and transfer of nutrition care to new setting/provider (RC-2)
 Collaboration
 Referral to community agencies/programs
Nutrition Monitoring and Evaluation
 Monitor progress and determine if goals are met
 Identifies patient/client outcomes relevant to the nutrition diagnosis and
intervention plans and goals
 Measure and compare to client’s previous status, nutrition goals, or
reference standards
Nutrition Outcomes – 4 Categories
 Nutrition-Related Behavioral and Environmental Outcomes (BE)—Nutritionrelated knowledge, behavior, access, and ability that impact food and
nutrient intake
 Food and Nutrient Intake Outcomes (FI)—Food and/or nutrient intake from
all sources
 Nutrition-Related Physical Signs and Symptom Outcomes (S)—
Anthropomorphic, biochemical, and physical exam parameters
 Nutrition-Related Patient/client centered Outcomes (PC)—perception of
patient/client’s nutrition intervention and its impact
Expected Outcomes of Nutritional CARE
 Improved nutrition status.
 Improved food and nutrient intake.
 Improved Knowledge.
 Positive behavior change.
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 Improved laboratory values ,weight, blood pressure.
 Risk factor reduction.
 Prevention or delay of complications.
 Ability to identify and access available community resources.
 Reduced hospital admissions.
 Improved self- management .
 Improved quality of life.
To achieve the expected outcomes we should
 Involve the client, family members in all management discussions.
 Individualize the approach to nutritional care.
 Provide culturally appropriate information and educational materials.
 Involve the client in the development of realistic plans, which include a
variety of foods which are liked, available.
 Facilitate follow up visits and modification of goals when necessary.
 Schedule on going education, reviews, support and dialogue to improve
acceptance and compliance.
 Give general information about the targeted chronic disease risk factors,
prognosis, treatment and its side effect.
 Suggest workable strategies for positive behavior change and the adoption
of healthy lifestyles.
Documentation of care
 There are specific factors that should be included in the documentation and
captures information from the assessment process .Documentation is an
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essential component of the nutritional care process .All interventions of
nutritional care including initial nutritional assessment must be
documented in the client’s medical records. The medical record is a
permanent legal document that record the client’s history .
Documentation of care should be continuous and serve to
 Establish a record of the nutritional care process .
 Maintain a strong professional communication network to inform all
members of the health care team of the client’s status ,plans and action
taken.
 Provide a framework /indication for intervention ,re-assessment or followup care by other member of the care team.
 Facilitate continuity of care ,thus contributing to accuracy and better
quality management.
 Provide a reference point for evaluating the impact of medical nutrition
therapy on medical and clinical outcomes and client’s quality of life by
linking assessment with goals ,intervention and strategies.
 Provide data for establishing cost- benefit and cost effectiveness of medical
nutrition therapy.
 Provide information on referral for other services.
Nutrition information which should documented includes:
 Evaluation of current diet.
 Nutrition assessment data.
 Planned medical nutrition therapy.
 Counseling and education.
 Acceptance and tolerance level.
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 Appetite.
 Planned follow-up.
 Referrals.
 Response to therapy.
 Any data relevant to client’s health /nutritional status.
Continuing Care
 Continuing Care is an essential component of management and allows for
evaluations and reassessment .Follow up facilitates achieving behavior
change. Effective nutritional care requires more than one visit .The visits
provide opportunities to sustain progress and control of the conditions, to
review problems, observe the effect of treatment and re –design the
management plan and intervention strategies if necessary .Follow-up visits
can help to provide the motivation to succeed as well as to establish good
relations with the client and reinforce education messages.
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