nutrition care process in template for emailing...
TRANSCRIPT
12/3/2012
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Nutrition Care Process
Jane McClinchy
2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 1
Learning outcomesAt the end of the session, you should be able to:
• Describe the main steps of the NCP
• Be able to write a nutrition diagnosis
• (note I will not be covering groups)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 2
Content
• Explore why a process is needed in
dietetics
• Look at the stages of the Process
• Workshop with case studies
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 3
Time Activity 13.00 Introduction to the process13.45 Workshop 14 30 Feedback14.30 Feedback 15.00 Finish
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 4
Need for a process
• Uncertainties in health care funding• Electronic health records• SNOMED:SNOMED:• Systematized Nomenclature of Medicine
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 5
EFAD competencies Dietetics process and professional reasoning• 3.1 Meet the needs of clients in complex situations related to health, social
situations and the environment. Clients may be individuals, groups, organisations or populations
• 3.2 Implement the Dietetic process, including screening, assessment, identifying needs, formulating goals, planning, implementing interventions and evaluating outcomes, in order to enable client choice.
• 3 3 Implement theories and models nutritional and activity analysis in order3.3 Implement theories and models, nutritional and activity analysis in order to integrate reasoning related to the dietetic process with client need. (This guides the selection and provides best possible practice for individuals and groups).
• For the Clinical Dietitian• 3.4 Make a dietetic/nutrition related diagnosis.• 3.5 Treat and counsel a client/patient using special dietetic/nutritionally
modified products.
• European Federation of the Associations of Dietitians (EFAD) and Thematic Network DietitiansImproving Education and Training Standards in Europe (DIETS) (2009) European Dietetic Competences and their Performance Indicators attained at the point of qualification and entry to the profession of Dietetics retrieved from http://efad.topshare.com/iextranet/1468/5/0/70
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 6
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Different processes in useSOAP BDAP ABCDE
SPPNDP NCP
Subjective Background A, B, C, D, E
A, B, C, D, E
Objective Data
Assessment Assessment Summary Nutritional diagnosis
Nutritional diagnosisdiagnosis diagnosis
Plan Plan Plan Plan intervention
Plan and deliver intervention Deliver
intervention Monitor Monitoring
and Evaluation
Evaluation
Others?2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 7
Process- pros and cons
Pros• Problem solving-scientific
• Provides security
Cons• Less flexible
• May mask creativityy
• Sequential/cyclical
• Patient centred
y y
• ? The unexpected
• Not patient centred
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 8
Barriers
• Lack of knowledge• Time• Need for training and support• Difficulty in determining nutritional
diagnosis statements
• Ferguson et al. (2012) Personal communication
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 9
Benefits of using a process?Using a process leads to:
• Consistent quality of practice• Evidence of professional clinical decision
making• Autonomy of practice• Autonomy of practice• Consistent record keeping and therefore
improved care • Key step in determining and measuring
outcomes of dietetic care • Can be used to promote the profession
• (Source BDA 2012)2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 10
Structural framework
• ‘…which helps us to inform what the [nutritional] diagnosis is, which helps to inform what intervention we’re going to plan which helps us inform whatplan, which helps us inform what outcomes we’re going to consider’ (FG2-P1)
• (Aylesbury and McClinchy, 2012 in press)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 11
MDT Communications
• ‘…that we’re efficient, precise and concise and methodical in what we write…I think it is an important part of MDT communications’ (FG3-P1)( )
• ‘what’s important in terms of the profile of the profession is that what’s written is concise and neat and to the point…doctors want the nitty gritty’ (FG1-P1)
•
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 12
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Transfer of patients between..
‘when patients are transferred…you get the notes with the patient sometimes it can take a while trying to figure out what thea while trying to figure out…what the intervention has been whereas if it was all standardised…it would be more focussed’ (FG2-P4)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 13
Monitor/
Assessment
Nutritional
The NCP follows the
steps…
evaluate Diagnosis
Plan Implement intervention
2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 14
The spiral
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 15 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 16
Nutrition assessment in the NCP …Food/Nutrition-related history
Food and nutrient intake, usual diet, medications, food availability, knowledge/beliefs about food, physical activity level
Anthropometric measurements
Height, weight, body mass index, growth velocity, circumferences etcg y,
Biochemical data, medical tests and procedures
Lab data such as electrolytes, glucose, lipids, tests such as resting metabolic rate, abdominal x-rays etc
Nutrition-focused physical findings
Skin turgor and integrity, dentition, appearance of subcutaneous fat/muscle mass etc
Client history Medical/surgical/family history/social2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 17
Nutrition assessment –another way …
• Anthropometry • Biochemistry• Clinical functional psychological• Clinical, functional, psychological • Dietary• Environmental, behavioural, social
• Critical thinking 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 18
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• The RD determines the relevant data• Compare these to an individualised goal
or standard • Eg nutritional intake is…• Estimated nutritional requirements q
• And therefore defines the nutritional related problem in the form of a nutrition
diagnosis
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 19
Nutrition diagnosis
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 20
Nutrition diagnosis
• Identification of an actual occurrence, risk of, or
potential for developing a nutritional problem
that a dietitian is responsible for treating p g
independently or of leading the strategy to
manage.
• PAS statement (PES in USA)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 21
Nutrition diagnosis
P-A-S format (P-E-S USA)
• Problem - (diagnostic label) describes alterations in a
patient / client/group/communities’ nutritional status
• (A)etiology - cause or contribution risk factors
• Signs or symptoms - defining characteristics
Problem related to (A)etiology as evidenced by
Signs/symptoms
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 22
Nutrition diagnosis
P-A-S format
• Problem - (diagnostic label) describes alterations in a
patient / client/group/communities’ nutritional status
Note UK spelling AetiologyAmerican spelling Etiology
• (A)etiology - cause or contribution risk factors
• Signs or symptoms - defining characteristics
Problem related to (A)etiology as evidenced by
Signs/symptoms
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p g gyIn USA PES statement
Nutrition diagnosisPAS statement
Problem
Diagnostic termIn USA
Related to
(A)etiology
Factors identified in
As evidenced by
Signs and Symptoms
Measureable
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In USA standardized terminology Must be nutritional ie not medical diagnosis& resp for treating independently
identified in assessment: potential intervention should be linked to this.Should be able to resolve the problem by addressing the aetiology
Measureable parameters that are monitored and evaluated for improvement
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Nutrition diagnosis example
Overview:
Obesity caused by consumption of high energy snack
foods as evidenced by weight gain, BMI, diet history
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Overview:
Nutrition diagnosis example
Obesity caused by consumption of high energy snack
foods as evidenced by weight gain, BMI, diet history
Problem?
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Problem:
Nutrition diagnosis example
Obesity caused by consumption of high energy snack
foods as evidenced by weight gain, BMI, diet history
Aetiology?
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 27
Aetiology:
Nutrition diagnosis example
Obesity caused by consumption of high energy snack
foods as evidenced by weight gain, BMI, diet history
Sign or symptom?
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 28
Signs or symptoms:
Nutrition diagnosis example
Obesity caused by consumption of high energy snack
foods as evidenced by weight gain, BMI, diet history
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 29
P for nutritional Problem
Intake• Too much or too little of a food or nutrient compared to
actual or estimated needs High energy intake
Nutrition diagnosis
Clinical• Nutrition problems that relate to medical or physical
conditions
Behavioural-environmental• Knowledge, attitudes, beliefs, physical environment,
access to food or food safety
High energy intake
Obesity
Limited exercise 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 30
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P for nutritional ProblemIntake• Too much or too little of a food or nutrient compared to
actual or estimated needs• E.g.
Nutrition diagnosis
g
• Energy balance
• Macro nutrients
• Micronutrients-vitamins/minerals
• Types of foods e.g. fruit and veg/ energy dense foods
• Fibre/alcohol
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 31
P for nutritional Problem
Clinical• Nutrition problems that relate to medical or physical
conditions
Nutrition diagnosis
• E.g.
• Functional (of the GI tract) swallowing/appetite/diarrhoea
• Biochemical e.g. lab values (LDL/HbA1c),
• Weight gain/loss, over or under
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 32
P for nutritional Problem
Behavioural-environmental• Knowledge, attitudes, beliefs, physical environment,
access to food or food safety
Nutrition diagnosis
access to food or food safety
• E.g.• Need for knowledge/Not ready to make changes• Physical activity-inactivity/self-feeding difficulty• Limited access to food
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 33
A for Aetiology,
• Links to intake, clinical, behavioural issues
Nutrition diagnosis
• Consider if there is a potential intervention that
would address and therefore resolve or improve
the problem and/or cause?
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 34
A for Aetiology must link to a potential intervention
Intake• Too much or too little of a food or nutrient
Advice about appropriate foods
Nutrition diagnosis
Clinical• Changes in nutritional requirements because of a clinical
condition
Behavioural-environmental• Uncertainty Limited knowledge, attitudes, beliefs, physical
environment/activity, access to food or food safety
Advice about appropriate foods
Advice to change behaviour 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 35
Change in nutrition prescription
A for aetiology or cause-some more examplesIssue Cause InterventionIntake Choosing too
much/not enough/ Education/setting goals/making
Nutrition diagnosis
ginappropriate foods/fluids
g gappropriate foods/fluids available
Clinical Increased nutritional requirements
Increase in nutritional prescription
Behavioural Uncertainty about what foods to eat
Advice/information/goal setting
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 36
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• Clinical problems and aetiologies must be nutritional
Issue Cause Intervention
Clinical Increased nutritional Increased energy
Nutrition diagnosis
requirements (patient with infection)
prescription
Stroke e.g. ?
Diabetes e.g. ?
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• Clinical problems and aetiologies must be nutritional
Issue Cause InterventionClinical Increased nutritional
requirements (patient with Increased energy prescription
Nutrition diagnosis
infection) Stroke e.g. Impaired movement of food /fluid from mouth to stomach
Texture modified diet
Diabetes e.g. change in ability to metabolise refined carbohydrate
Low GI diet
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 38
Signs or symptoms:
• How do you know
• Must link to the information you collected on your assessment
Nutrition diagnosis
• Must link to the information you collected on your assessment
• Then consider whether the signs and symptoms are specific
enough that you can measure
• A, B, C, D, E
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Now complete the following for a patient whose
problem was an excessive oral intake:
• P What’s the problem ?
Nutrition diagnosis
• A Why is this happening ?
• S How do we know a problem exists ?
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 40
Excessive oral intake
• P What’s the problem ?
could be excessive intake of energy dense foods such
Nutrition diagnosis
as…
• A Why is this happening ?
• S How do we know a problem exists ?
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 41
Excessive oral intake
• P What’s the problem ?
could be excessive intake of energy dense foods such
Nutrition diagnosis
as…
• A Why is this happening ?
could be lack of knowledge
• S How do we know a problem exists ?
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Excessive oral intake
• P What’s the problem ?
could be excessive intake of energy dense foods such
Nutrition diagnosis
as…
• A Why is this happening ?
could be lack of knowledge
• S How do we know a problem exists ?
could be high BMI, diet history
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 43
Nutrition diagnosisExcessive oral intake
• P What’s the problem ?
could be excessive intake of energy dense foods such
as…
• A Why is this happening ?
could be lack of knowledge
• S How do we know a problem exists ?
could be high BMI, diet history
ND=Excessive intake of energy dense foods caused by a lack of knowledge as evidenced by high BMI, diet history
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• More than one?
• Focus on the most pressing problem
• Prioritise towards the one relating to intake as this is
Nutrition diagnosis
likely to be more specific to your role
• Agree with patient and health care team
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 45
Nutrition Care Process
Quiz
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 46
Nutrition Care Process Quiz
• Which are not part of the Nutrition Diagnosis
• Assessment
• Signs and symptoms
• Medical diagnosis
• Problem
• Aetiology
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 47
Nutrition Care Process Quiz
• Which are not part of the Nutrition Diagnosis
• Assessment x
• Signs and symptoms
• Medical diagnosis x
• Problem
• Aetiology
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 48
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Nutrition Care Process Quiz
Which is a nutrition assessment?
• 8kg weight loss over the past 4 months• 8kg weight loss over the past 4 months
• Oral nutrition supplement prescribed because
intake <75% of estimated needs
• Excessive fat intake
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 49
Nutrition Care Process Quiz
Which is a nutrition assessment?
• 8kg weight loss over the past 4 months• 8kg weight loss over the past 4 months
• Oral nutrition supplement prescribed because
intake <75% of estimated needs
• Excessive fat intake
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 50
Nutrition Care Process Quiz
Which is the right order for the nutritional diagnosis
SAPSAP
APS
PAS
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 51
Nutrition Care Process Quiz
Which is the right order for the nutritional diagnosis
SAPSAP
APS
PAS
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 52
Getting to intervention…
… from assessment
ViaVia
nutrition diagnosis
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 53
Definition of intervention
• A nutrition and dietetic intervention is a set of activities and
associated resources which are used to address the
identified nutrition and dietetic diagnosis.
• Note: all interventions are planned with the communities, service
users and carers who are the recipients of the intervention. This
client centred approach is a key element in developing a realistic
plan that has a high probability of positively influencing the outcome.
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 54
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What is an intervention?
•
Food and/or nutrient delivery Oral diets, enteral and parenteral nutrition, supplements, feeding assistance, feeding environment, nutrition-related medication management
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 55
medication management Nutrition education Basic education on content and
survival skillsNutrition counselling Theoretical, cognitive,
behaviour based counselling for self-efficacy and self management
Coordination of nutrition care Team meetings, referral to experts or outside agencies
Intervention
• Planning• Implementation
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 56
Components of the PlanComponent Definition Links with
NDOutcomes measurable and specific Signs and
symptomsIntermediate goals
which will achieve the outcomes
Problem
Plan provision of food Aetiology
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 57
Plan provision of food, provision of nutrition support, education package, counselling, coordination of care, social marketing campaigns, food availability, food shopping and cooking skills
Aetiology
Planning nutrition intervention Outcomes Examples (use info from S&S)
Anthropometric change
Weight, MUAC, waist:hip ratio
Biochemical indicators Lab values, indicators of nutritional status
Clinical/symptoms Clinical status, complications, symptom scales
Environmental/behavioural/ Social
Client-focussed outcomes: quality of life, client identified outcomes, satisfaction, self-efficacy, self-ural/ Social identified outcomes, satisfaction, self efficacy, selfmanagement, functional ability
Behavioural Food related behaviour, physical activity
Psychological Self-efficacy, self management, mental health state
Healthcare utilisation and cost outcomes
Medication changes, special procedures, planned/unplanned clinical visits, preventable hospitalisations, length of hospitalisation, prevent or delay nursing home admission 2nd Dec 2012 58Jane McClinchy University of Hertfordshire
NCP
Planning nutrition intervention Goals
Area Examples:
Diet and nutrition goals (changes)
Reduced energy intake by 600 kcalsReduce fat intake
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 59
(changes) Reduce fat intake
Environment/behavioural/social Increase physical activity by 30 minutes 5 times per week
Plan -designed to meet the outcomesand goals
Plan Examples
Dietetic prescription for an individual
Xx kcals reducing dietXxmls of xx feed at xx mls per hourHigh protein and high energy diet
Education plan for an individual Specifics of education e.g. which foods are
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 60
or group high or low in fat
Community programme or health community strategy
Exercise prescription scheme Fruit in schools
Behavioural strategies and counselling
Use of SMART goal setting Food diary
Motivational intervention Motivational interviewing
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Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: weight maintained at xxGoal? Plan?
Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Patient will choose lower energy foodsGoal?Plan?
Outcome: weight loss 05.-1 kg per weekGoal?Plan?2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 61
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 62
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 min 5 x per week Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 63
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 64
Nutrition intervention -implementation
Activities
• Communication and negotiation
• Education
• Collaboration with other health care professionals
• Use of behavioural change strategy or approach e.g. use
of SMART goals
• Use of educational tool e.g. diet sheet/food models
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 65
Diagnosis:Patient is obese caused by excessive energy intake of 25% above estimated requirements as evidenced by raised BMI and diet history
Interventions• Diet information • Sample meal plan with
600 kcal energy deficit • Smart goals enabling
Nutrition intervention – implementation
Intervention planning:Outcome : 0.5-1 kg loss of weight per week Goal: Consume 600 Kcal less Plan: 600 kcal energy deficit diet prescription
achievement of 600 kcal energy deficit
• Agree ‘episode of care’ and review timescale
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 66
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Nutrition intervention -implementation
Collaboration with other health care professionals
• Information for carers
• Asking Nurse to weigh
• Ward staff implement food record chart
• MDT home visit team implement
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 67
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week
SMART goal on the length/frequency of a specific exercise
Outcome:
Link with intervention
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods
SMART goals on selection of lower energy foods
Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
SMART goals enabling 600 kcal energy deficit
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 68
Nutrition monitoring and review
Definition:• The review and measurement of the client, group or
population’s nutritional status at planned intervals with regard to the nutrition diagnosis, intervention plan, goals and outcomes
Components:• Check understanding or compliance• Determine if the intervention is being implemented as
prescribed• Obtain evidence that the plan is/is not changing
behaviour, nutrition or health status• Identify other positive or negative outcomes
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 69
Nutrition monitoring & review
Review and measurement of status at scheduled times
Nutritional diagnosis Plan ImplClinical: ObesityOverweight
Excessive energy intake
High BMI
a pG: weight loss 05.‐1 kg per weekP: 600 kcal energy deficit
SMART goals enabling 600 kcal energy deficit
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 70
Nutrition monitoring & review
• For the patient what will you measure or monitor?
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Nutrition monitoring & review
• Or ABCDE
Parameter What will you measure?AnthropometryAnthropometry
Biochemistry
Clinical
Dietary
Environmental
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Evaluation
DefinitionSystematic comparison of current findings against previous
status, intervention goals and outcomes
To enable for example decisions about p• Discharge• Continuation of intervention• Reassessment
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Monitor/
Assessment
Nutritional
The NCP follows the
steps…
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 74
evaluate Diagnosis
Plan Implement intervention
Sample NCP statementAssessment Diet weight, phys activity
Nutritional diagnosisPatient is obese caused by excessive energy intake of 25% above estimated requirements as evidenced by raised BMI and diet history
Planning intervention Outcome: weight loss 05.-1 kg per week Outco e e g t oss 05 g pe eeGoal: 600 kcal energy deficit Plan: Dietetic prescription and education
Implementation of intervention SMART goals enabling 600 kcal energy deficit
Monitoring Review weight, diet, understanding , patient acceptability
Evaluation against original outcome measure and decision about the future
Jane McClinchy University of Hertfordshire NCP 752nd Dec 2012
Workshop
Spend 15 mins on each activity• ND ‘fill in the blanks’ sheet• Writing a NCP statement case 1a or 1b• Your own action plan for implementing the
NCP in your work
• 14.30-15.00 Feedback • 15.00 Finish 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 76
Feedback
2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 77
Weight loss • Problem• Inadequate energy Intake (or could have food
intake) • Aetiology (Cause)Aetiology (Cause)• Energy intake not meeting needs to prevent
weight loss(food refusal-could be a meal/specific food items/snacks)
• Signs (Objective)/Symptoms (Subjective)• Xkg lost in y days, low BMI
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 78
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• Problem• Self –feeding difficulty (behavioural)• Aetiology (Cause)• Impaired ability to place food in mouth (spillage• Impaired ability to place food in mouth (spillage
of ____ % during meals)• Signs (Objective)/Symptoms (Subjective)• • X kg weight loss in Y days/ Rapid weight loss• • Advanced stages of Parkinson’s/MS/
Excessive shaking of hands2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 79
• Low Iron, HgB/HCT• Signs and symptoms-low haemoglobin• Abnormal Lab Values• Aetiology-change in ability to eliminate by products of
metabolism/metabolise/absorb• Diabetes• Problem-Inconsistent carbohydrate intake• Tube Feeding• Signs Symptoms -X kg lost in y days• Dysphagia• Aetiology- Impaired movement of food/fluid from mouth
to stomach• Problem-Inadequate food/beverage intake
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 80
Nutritional diagnosis P-Energy and protein intake below estimated requirements A-Increased requirements and reduced appetiteS-Medical notes report sepsis, weight loss 4% and food record chart shows intake of 600 kcals and 20g protein
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 81
Intervention Planning Outcome: Maintain current weight of 72 kgPatient reports improved appetiteGoal: Increase nutritional intake initially by 600 kcals and 24g proteinPlan:Plan: High protein, high energy diet including prescription of oral nutritional supplements which provide 600kcals and 24g proteinImplementation SMART goal with patient on consumption of ONSWork with nursing staff on help with menu selections (favourite foods to help with appetite) 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 82
Monitoring Monitor appetite and weightEvaluationIntake will be lower than requirements initially, so increase energy prescription once appetite has improved
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 83
Learning outcomesAt the end of the session, you should be able to:
• Describe the main steps of the NCP
• Be able to write a nutrition diagnosis
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 84
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Feedback
• Implementation of NCP• Try to use PAS• SMART goals• Step wise approach• Try to see the problem first• Identify the most important problem•
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 85
Further reading
Resources on the Academy of Nutrition and Dietetics http://www.eatright.org/
Search Nutrition Care Process and a number of accessible pdfs are available
Resources on the BDA website are available to members only:
BDA (2012) Model and Process for Nutrition and Dietetic Practice
http://members.bda.uk.com/profdev/profpractice/modeldieteticpractice/index.ht
ml
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 86