nutrition care process practical applications andrea maher rd, ld alicia aguiar ms, rd, ld

Nutrition Care ProcessPractical Applications

Andrea Maher RD, LD

Alicia Aguiar MS, RD, LD

International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the

Nutrition Care Process, Second Edition

• Functional changes (swallowing, GI)

• Altered lab data

• Altered body weightBehavioral/Environmental

Why should I learn NCP Process? Promotes critical thinking to treat current and

pertinent nutrition problems Determines a nutrition diagnosis that drives the

care plan Utilizes a vocabulary to describe the dietitian’s

process within and outside the profession Affirms via documentation that the nutrition

diagnosis has been resolved

Why should I learn NCP Process? If we can name it

We can do it We can teach it We can measure it We can improve it We can get paid for it

Annalynn Skipper, PhD, RD, FADA, author and consultant

Step 1: Nutrition Assessment

Method in which we obtain, verify and interpret data needed to identify nutrition related problems.

Determines whether a nutrition diagnosis exists

The PES statement is then derived from the synthesis of information from the nutrition assessment data

Step 1: Nutrition Assessment

Mark page 11 of your pocket guide:

“Assessment”

Step 2: Nutrition Diagnosis


“Diagnosis”


Nutrition diagnosis are categorized under

3 domains Intake (page 139) Clinical (page 140) Behavioral-Environmental (page 140)

Currently, 60 nutrition diagnosis identified In the LTC setting, the Intake domain will be

used most frequently

Step 2: Nutrition Diagnosis, cont. The dietitian is responsible for treating

independently No right or wrong nutrition diagnosis—some

are more appropriate than others When faced with equally good choices from

different domains (Intake, Clinical or Behavioral-Environmental) choose Intake

Intake domain more likely to be caused by a nutritional etiology and have a nutrition directed intervention


Medical Diagnosis Disease/pathology of

specific organs or body systems

Does not change as long as the condition exists

Ex: Diabetes

Nutrition Diagnosis Problem related to

nutrition that RD can influence

Changes as the resident’s response changes

Ideally, with nutrition intervention, diagnosis is resolved

Ex: Excessive CHO intake



are more appropriate than others When faced with equally good choices from


Intake Domain more likely to be caused by a nutritional etiology and have a nutrition directed intervention



are better than others When faced with equally good choices from


Intake Domain more likely to caused by a nutritional etiology and have a nutrition directed intervention

Step 2: Nutrition Diagnosis, cont.

Components: Problem – (Nutrition Diagnosis) Etiology – cause or contributing risk factors Signs or symptoms –objective and/or subjective

data used to determine whether the resident has the nutrition diagnosis specified.


Problem – related to – Etiology – as evidenced by – Signs or symptoms

Always remember: The etiology explains why (ask Why 5 times) the problem exists. The signs and symptoms are proof of the problem.



E.g. page 194Inconsistent carbohydrate intake (NI-5.8.3)

related to nutrition-related knowledge deficit concerning appropriate timing of carbohydrate intake as evidenced by wide variations in blood glucose levels, dx IDDM, frequently skips breakfast meal.

Step 2: Nutrition Diagnosis – PES Statements


E.g. page 217Altered nutrition-related laboratory values (NC-2.2) related to kidney dysfunction as

evidenced by abnormal BUN, Cr and K+ levels, hemodialysis, preference for fresh fruits, poor patient knowledge of modified diet.

Step 3: Nutrition Intervention


“Intervention”

Step 3: Nutrition Intervention Used to remedy a nutrition diagnosis Intended to change a nutrition-related behavior,

environmental condition or aspect of nutritional health

Always collaborate interventions with the resident and other health care providers Resident response may lead us to revise our intervention Carry out and communicate plan of care Document if resident chooses to not follow an intervention

Step 3: Nutrition Intervention Organized into four domains

Food and/or Nutrient Delivery page 261 Nutrition Education page 262 Nutrition Counseling page 262 Coordination of Care page 262

In the LTC setting, the Food and/or Nutrient Delivery domain will most frequently be used

Step 4: Nutrition Monitoring and Evaluation

See page 11 of your pocket guide:

“Monitoring and Evaluation”uses the same terms as the “Assessment” except for those

indicators that are shaded.

Step 4: Nutrition Monitoring and Evaluation Determines the amount of progress made to

reach the specified goal(s) Specific outcomes that can be measured and

compared to previous data or reference standards, e.g. Weight or BMI Laboratory values

Step 4: Nutrition Monitoring and Evaluation Organized in five domains

Food/Nutrition-Related History Outcomes page 11 Anthropometric Measurement Outcomes page 13 Biochemical Data, Medical Tests, and Procedure

Outcomes page 13 Nutrition-Focused Physical Finding Outcomes page 14 Comparative Standards page 15

In the LTC setting, the Food/Nutrition-Related History Outcomes and Anthropometric Measurement Outcomes is likely to be used more frequently

Case Study #1

Background Information1/22/09: Resident A is a 99 yo female with depression,

lactose intolerance and recently dx gastroenteritis. She reports her appetite isn’t good lately. Meal intake records also show a decline. She feeds herself, A&O x 3.

Ht- 61”, Wt 1/20= 120.8#, ↓10% (14#) x 30 days and ↓16% x 180 days.

Diet: General, ground meat. Nursing has just moved her to the ADR for cuing and

supervision.

Case Study #1

Step #1- Prioritize Assessment Problems- What is the most immediate problem?

Step #2- Nutrition Diagnosis

Verify the problem→ confirm the appropriate one

Case Study #1- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below

Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)

Problem:Etiology: Signs/ Symptoms:

Case Study #1□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below



Case Study #1


Step #2- Nutrition Diagnosis

Verify the problem→ confirm the appropriate one

Inadequate food and beverage intake (pg 146)

(definition)- Oral food/beverage intake that is less than established reference standards or recommendations based on physiological needs



Problem: Inadequate oral food and beverage intakeEtiology: related to p.o. intake less than calorie expenditureSigns/ Symptoms: as evidenced by depressed meal intake, significant wt loss of 10% in 30

days and 16% in 180 days, resident verbalizes decreased appetite

Case Study #1


Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance

Step #3- Nutrition Intervention- aimed at “fixing” the etiology

Case Study #1

Nutrition InterventionNutrition Prescription: Recommend ~1500 kcal and 48 grams protein from

meal and planned snacks to meet nutrient needs

Interventions: See Care Plan □ Yes. □ No. [X] Meals/Snacks: Add Super Cereal, provide whole milk each meal, add pm ice cream, HS pudding

[ ] Food Supplements: [X] Vit/Min: Rec MVI/mineral

[ ] Feeding Assistance: [ ] Nutrition Education:

[ ] Coordination of Care (Refer to): [ ] Enteral Nutrition:

Case Study #1




Step #4- Monitoring and Evaluation

Case Study #1

Monitoring/Evaluation

[X] Food intake: Monitor meal/snack pattern [X] Acceptance of cuing from nursing

[ ] Nutrition quality of life responses [ ] Behavior

[X] Lab Data: □ Hgb A1C □ Glucose, casual X Albumin □ Other:

[X] Weight- screen weekly for changes [ ] Med use: [ ] Other:

Follow up: □ 7 days □ 1 week X 1 month □ Quarterly X Monitor with MDS

Inform physician/family of significant wt change.

Case Study #2

Background InformationYou are informed when you arrive at the facility a week

later (1/29/09) that this same resident from case study #1 has developed a stage II pressure area on her L/buttock (3 cm diameter). Wt 1/27=116#, down 4# from last week.

Case Study #2

Bring your PES statement(s) forward to begin your note

Collect supporting data Document the status of your problem, e.g.

Resolved Improved Need to adjust intervention or nutrition Rx if

problem is not improving NCP continues until problem is resolved

Case Study #21/29/09 Nutrition Dx: Inadequate oral food and beverage intake related to p.o.

intake less than calorie expenditure/energy needs for healing as evidenced by depressed meal intake, significant wt loss, new stage II pressure area on L/buttock.

Interventions- Nutrition Rx: Recommend ~1600 kcal and 57 grams protein from meal, planned snacks and supplement to meet nutrient needs. Continue current interventions, see care plan. Add: Med Pass supplement BID (ND-3.1.1) for additional 240 kcal, 10 gm protein. Recommend Vit C 500 mg (ND-3.2.3) to promote wound healing.

Monitor/Evaluation: Monitor skin status monthly/prn (PD 1.1.8), Monitor weight weekly (AD-1.1.2), Monitor meal/snack patterns (FH-1.3.2.3), Monitor albumin level as ordered (BD-1.11).

Notify family/physician of significant weight changes.RD signature

Transitioning charting to NCP format You do not need to change the style of your

charting format Narrative

Just include standard language terms in your sentences SOAP

S= Assessment terminology O= Data documented elsewhere in chart or data

documented by the dietitian A= Nutrition Diagnosis, written as a PES statement P= Nutrition Prescription and Intervention. Monitoring

indicators and evaluation criteria also go here.

Case Study #3- Annual assessment Background Information4/06/09: Resident B is a 95 yo female with dx HTN,

constipation, severe low back pain, GERD, advanced cancer. He is on hospice care. Feeds himself then staff finish. Ongoing poor appetite.

Ht- 60”, Wt 4/09= 92#, ↓8% (9#) x 30 days and ↓21% x 180 days.

Diet: Pureed. House supplement 60 mL TID

Case Study #3







Problem: Etiology:Signs/ Symptoms:



Problem: Increased nutrient needs Etiology: related to increased demand for energySigns/ Symptoms: as evidenced by significant wt loss trend of 8% (9#) x 30 days and 21% x

180 days, cancer, hospice care

Case Study #3





Case Study #3

Nutrition InterventionNutrition Prescription: Recommend continue current pureed diet and

supplement as tolerated by resident for comfort measures

Interventions: See Care Plan □ Yes. □ No. [X] Meals/Snacks: Cont current pureed diet, provide snacks as tolerated

[X] Food Supplements: Cont supplement [ ] Vit/Min:

[X] Feeding Assistance: Mouth care after meals/prn [ ] Nutrition Education:

[X] Coordination of Care (Refer to): Hospice [ ] Enteral Nutrition:

Case Study #3





Case Study #3


[X] Food intake: Monitor meal/snack pattern [ ] Acceptance of

[X] Nutrition quality of life responses [ ] Behavior

[ ] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other:

[X] Weight- screen monthly/prn for changes [ ] Med use: [ ] Other:

Follow up: □ 7 days □ 1 week X 1 month □ Quarterly X Monitor with MDS

Case Study #4- Initial assessment Background Information4/06/09: Resident C is an 86 yo male with dementia.

He has a good appetite per meal intake records. He feeds himself with set up assist. A&O x 2 with confusion.

Ht- 68”, Admit wt 4/09= 162#, no significant wt changes found, UBW= 170# per spouse

Diet: Mechanical SoftDuring mealtime observation you notice that he has

difficulties keeping the food on his plate- spilling food on himself.

Case Study #4







Problem: Etiology: Signs/ Symptoms:



Problem: Self-feeding difficultyEtiology: related to impaired cognitive abilitySigns/ Symptoms: being provided foods that may not be conducive to self-feeding, dropping of

food from untensil, dx dementia

Case Study #4





Case Study #4

Nutrition InterventionNutrition Prescription: Provide adaptive equipment to facilitate independent

eating

Interventions: See Care Plan □ Yes. □ No. [ ] Meals/Snacks:

[ ] Food Supplements: [ ] Vit/Min:

[X] Feeding Assistance: Provide Adaptive Equipment, Encourage finger foods

[X] Coordination of Care (Refer to): OT [ ] Enteral Nutrition:

Case Study #4





Case Study #4


[X] Food intake: Monitor meal intake [ ] Acceptance of

[ ] Nutrition quality of life responses [X] Behavior: Fatigue/ability to feed self

[ ] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other:

[X] Weight- screen monthly/prn for changes [ ] Med use: [ ] Other:

Follow up: □ 7 days □ 1 week □ 1 month X Quarterly X Monitor with MDS

No nutrition diagnoses □ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below



No nutrition diagnoses, cont.

What do you do if there is not a nutrition diagnosis? The nutrition diagnoses describe actual problems,

not “potential for” or “at risk for” concerns Potential/at risk concerns would be recorded in

the resident’s care plan (per NCP Long Term Care Toolkit)- if you decide if you still want to care plan without a nutrition diagnoses

You still need to set up Monitoring and Evaluation for follow up reassessment

No nutrition diagnoses, cont.

Skip to Step #4- Monitoring and Evaluation

[X] Food intake: Monitor meal/snack pattern [ ] Acceptance of

[ ] Nutrition quality of life responses [ ] Behavior

[X] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other: as available

[X] Weight- screen weekly x 4 wks [ ] Med use: [ ] Other:

Follow up: □ 7 days □ 1 week □ 1 month X Quarterly X Monitor with MDS

Nutrition Reassessment, e.g. Qtr Review

When completing a reassessment, we determine progress of the goal Positive Outcome Obtained

Continue Plan of Care Resolve Problem

Status quo Continue Plan of care Change Intervention

Decline Change Intervention

Nutrition Care Process-Where do we go from here?

Get the resources you need to get started Practice writing PES statements and using the

assessment terminology Review current systems of documentation in your

facilities Develop changes in systems, if needed Communicate to key stakeholders in your facility Implement the Nutrition Care Process Evaluate progress and get feedback

Andrea Maher RD, LD

[email protected]

nutrition care process practical applications andrea maher rd, ld alicia aguiar ms, rd, ld

Documents

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pertinent nutrition

nutrition assessment

intake intake domain