the nutrition care process chapter 21. © 2004, 2002 elsevier inc. all rights reserved. nutrition...
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The Nutrition Care ProcessThe Nutrition Care Process
Chapter 21Chapter 21
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutrition Care ProcessNutrition Care Process
Assess nutritional status.
Analyze data to identify nutritional needs.
Plan and prioritize nutritional care objectives to meet these needs.
Implement strategies necessary to meet the objectives.
Evaluate the nutritional care outcomes.
Assess nutritional status.
Analyze data to identify nutritional needs.
Plan and prioritize nutritional care objectives to meet these needs.
Implement strategies necessary to meet the objectives.
Evaluate the nutritional care outcomes.
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutrition Care ProcessNutrition Care Process
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutrition Care Process –cont’dNutrition Care Process –cont’d
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutrition Care Process –cont’dNutrition Care Process –cont’d
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutrition Care ProcessNutrition Care Process
See Appendix 56 See Appendix 56
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutritional AssessmentNutritional Assessment
The process by which the nutritional status of an individual is determined
Usually includes dietary history and intake data, laboratory data, clinical examination and health history, anthropometric data, and psychosocial data
The process by which the nutritional status of an individual is determined
Usually includes dietary history and intake data, laboratory data, clinical examination and health history, anthropometric data, and psychosocial data
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutritional Screening InformationNutritional Screening Information
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Nutrition Screening and Assessment ToolNutrition Screening and Assessment Tool
Courtesy Carolinas Medical Center, Charlotte, N.C.
© 2004, 2002 Elsevier Inc. All rights reserved.
Development of a Plan for Nutritional CareDevelopment of a Plan for Nutritional Care
Prioritize problems
Client and counselor must jointly establish achievable goals
Express objectives in behavioral terms
State objectives in quantifiable terms
Prioritize problems
Client and counselor must jointly establish achievable goals
Express objectives in behavioral terms
State objectives in quantifiable terms
© 2004, 2002 Elsevier Inc. All rights reserved.
Implementation of Nutritional CareImplementation of Nutritional Care
Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives.
Interventions should be specific:
—What? —When?
—Where? —How?
Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives.
Interventions should be specific:
—What? —When?
—Where? —How?
© 2004, 2002 Elsevier Inc. All rights reserved.
Evaluation of Nutritional CareEvaluation of Nutritional Care
Evaluate care provided
Review plan frequently
Reassess plan—may be new needs
Identify any new needs
Formulate a new nutritional care plan
Evaluate care provided
Review plan frequently
Reassess plan—may be new needs
Identify any new needs
Formulate a new nutritional care plan
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutritional Care RecordNutritional Care Record
Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives
Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives
© 2004, 2002 Elsevier Inc. All rights reserved.
Care RecordCare Record
Courtesy St. John’s Hospital, Springfield, Ill.
© 2004, 2002 Elsevier Inc. All rights reserved.
Documentation StyleDocumentation Style
DAP (diagnosis, assessment, plan)
PIE (problem, intervention, evaluation)
PES (problem, etiology, symptoms)
IER (intervention, evaluation, revision)
HOAP (history, observation, assessment, plan)
SAP (screen, assess, plan)
SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions)
SOAP (subjective, objective, assessment, plan)
DAP (diagnosis, assessment, plan)
PIE (problem, intervention, evaluation)
PES (problem, etiology, symptoms)
IER (intervention, evaluation, revision)
HOAP (history, observation, assessment, plan)
SAP (screen, assess, plan)
SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions)
SOAP (subjective, objective, assessment, plan)
© 2004, 2002 Elsevier Inc. All rights reserved.
SOAP NotesSOAP Notes
S: Subjective
Info provided by patient, family, or other
Pertinent socioeconomic, cultural info
Level of physical activity
Significant nutritional history
S: Subjective
Info provided by patient, family, or other
Pertinent socioeconomic, cultural info
Level of physical activity
Significant nutritional history
© 2004, 2002 Elsevier Inc. All rights reserved.
SOAP Notes—cont’dSOAP Notes—cont’d
O: Objective
Factual, reproducible observations
Diagnosis
Height, age, weight—and weight gain patterns
Lab data
Clinical data (nausea, diarrhea)
Diet order
Medications
O: Objective
Factual, reproducible observations
Diagnosis
Height, age, weight—and weight gain patterns
Lab data
Clinical data (nausea, diarrhea)
Diet order
Medications
© 2004, 2002 Elsevier Inc. All rights reserved.
SOAP Notes—cont’dSOAP Notes—cont’d
A: Assessment
Interpretation of patient’s status based on subjective and objective info
Evaluation of nutritional history
Assessment of laboratory data and medications
Assessment of diet order
Assessment of patient’s comprehension and motivation
A: Assessment
Interpretation of patient’s status based on subjective and objective info
Evaluation of nutritional history
Assessment of laboratory data and medications
Assessment of diet order
Assessment of patient’s comprehension and motivation
© 2004, 2002 Elsevier Inc. All rights reserved.
SOAP Notes—cont’dSOAP Notes—cont’d
P: Plan
Diagnostic studies needed
Further workup, data needed
Medical nutrition therapy goals
Recommendations for nutritional care
P: Plan
Diagnostic studies needed
Further workup, data needed
Medical nutrition therapy goals
Recommendations for nutritional care
© 2004, 2002 Elsevier Inc. All rights reserved.
Basic Hospital DietsBasic Hospital Diets
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Basic Hospital Diets —cont’dBasic Hospital Diets —cont’d
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Soft DietSoft Diet
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Clear Liquid DietClear Liquid Diet
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Full Liquid DietFull Liquid Diet
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Full Liquid Diet –cont’dFull Liquid Diet –cont’d
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutritional Care of the Terminally Ill PatientNutritional Care of the Terminally Ill Patient
Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients.
Dietary restrictions are rarely appropriate.
Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients.
Dietary restrictions are rarely appropriate.
© 2004, 2002 Elsevier Inc. All rights reserved.
Palliative CarePalliative Care
Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently
Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently
© 2004, 2002 Elsevier Inc. All rights reserved.
Discharge PlanningDischarge 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 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
© 2004, 2002 Elsevier Inc. All rights reserved.
Discharge PlanningDischarge Planning
Courtesy University of Washington Medical Centers, Seattle.