Nutrition Care Process Terminology

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Nutrition Care Process TerminologyOverview&Resources6/20/2014

Nutrition Care Process Model2

Nutrition Care Process: StepsStep 1 Nutrition AssessmentStep 2 Nutrition DiagnosisStep 3 Nutrition InterventionStep 4 Nutrition Monitoring &Evaluation3

Step 1: Nutrition Assessment4

Step 1: Nutrition AssessmentNutrition Assessment (NA) Obtain adequate information in order toidentify nutrition-related problems Systematic process of– Obtaining– Verifying and– Interpreting the data Make decisions about the nature and causeof nutrition related problems Re-assessment at subsequent encountersaddresses Monitoring and Evaluationparameters5

Step 1: Nutrition AssessmentCritical Thinking Skills Determining appropriate data to collect Determining the need for additional information Selecting appropriate assessment tools and procedures Applying the assessment tools in valid and reliable ways Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating the data6

Nutrition AssessmentResults of Nutrition Assessment Leads to appropriate initial determination that anutrition diagnosis/problem exists If a nutrition diagnosis can be made, the RDNlabels the problem and creates a PES* statementin Step 2 of the Nutrition Care Process*PES: Problem, Etiology, Signs/Symptoms7

Nutrition AssessmentResults of Nutrition Assessment If a nutrition problem is not identified, furtherinformation or testing may be necessary to makea determination If the assessment indicates that no nutritionproblem currently exists that warrants a nutritionintervention, the term “No nutrition diagnosis atthis time (NO-1.1)” may be documented8

Nutrition AssessmentResults of Nutrition Assessment/ReassessmentThe RDN will determine If a nutrition diagnosis/problem exists The plan for continuation of care, specifically:o Progression through the NCPo Need for additional information/testingo Discharge from nutrition care9

Nutrition AssessmentDomains (Categories)1. Food/Nutrition Related History2. Anthropometric Measurements3. Biochemical Data, Medical Tests, Procedures4. Nutrition-Focused Physical Findings5. Client History10

Nutrition AssessmentComponents of Nutrition Assessment Process Review data collected for factors that affectnutritional and health status Cluster individual data elements to identify anutrition diagnosis as described in the nutritiondiagnosis reference sheets Identify standards for data comparison11

Nutrition AssessmentNutrition Care IndicatorsClearly defined markers – measureable Food and nutrient intakeMedication useGrowth and body compositionFood and nutrition related knowledgeAttitudes and behaviorsFood accessPhysical activityAnthropometric dataLaboratory valuesPhysical findings (observed or reported)Personal and family medical history, social factors12

Nutrition AssessmentAssessment of Nutrition Care IndicatorsNutrition Care Criteria – what it is compared against Nutrition Prescription or Goalo Dietary Interventiono Behavior change Reference Standard: select what is appropriate forintervention or goaloooNationalInstitutionalRegulatory standards13

Nutrition AssessmentReference Sheet Content for each Termincludes:1. Definition2. Indicators for3.4.5.6.7.8. Assessment Monitoring and EvaluationMeasurement methods or data sourcesNutrition interventions that are associatedNutrition diagnoses with which data are usedCriteria for evaluationExample for assessment and M&ELiterature references14

Nutrition AssessmentData Sources and Tools Screening or referral form Patient interview Medical or health records Consultation with caregivers and family Community based surveys Statistical reports, administrative data,epidemiological studies15

Nutrition AssessmentSummary Nutrition Assessment is the first step of the NCP Dynamic process that develops throughout the NCP Data is used for all other steps of the NCP New information may provide reason forreassessment or change in approach and intervention16

Step 2: Nutrition Diagnosis17

Step 2: Nutrition Diagnosis New concept for dietetics profession Definition of Diagnose The act of identifying a disease or conditionfrom it’s signs and symptoms Investigation or analysis of the cause or natureof a condition, situation, or problem. This implies Pre-defined list of potential conditions Pre-defined criteria (signs and symptoms) towhich the current situation can be compared18

PES StatementThe nutrition diagnosis or nutrition problem issummarized into a structured sentence called Nutrition diagnosis statementOR PES Statement19

PES StatementThis statement has 3 distinct components: P (Problem) E (Etiology) S (Signs and Symptoms)–This information is obtained during the nutritionassessment phase of the Nutrition Care Process20

PES StatementThis statement has a distinct format:Problem related to Etiology as evidenced bySigns and Symptoms21

Evaluating Your PES StatementP(Problem): Can the RDN resolve or improve the nutritiondiagnosis? Consider the “intake” nutrition diagnosis as theone more specific to the role of the RDN.E(Etiology): Determine if this is the “root cause” for theproblem. If addressing the etiology will not resolve theproblem, can the RDN intervention lessen the signs andsymptoms?S(Signs and Symptoms): Will measuring the signs andsymptoms indicate if the problem is resolved or improved?Are the signs and symptoms specific enough that the RDNcan monitor and document resolution or improvement of thenutrition diagnosis?22

Evaluating Your PES StatementPES Overall:Does the nutrition assessment data supportthe specific nutrition diagnosis, etiology, andsigns and symptoms?23

Example PES Statements Excessive Fat Intake related to limited access to healthfuloptions – frequent consumption of high-fat, fast-food mealsas evidenced by serum cholesterol level of 230 mg/dL andpatient report of 10 meals per week of hamburgers and fries Excessive Energy Intake related to unchanged dietary intakeand restricted mobility while fracture heals as evidenced by5 lb weight gain during last 3 weeks due to patient report ofconsumption of 500 kcal/day more than estimated needs Swallowing Difficulty related to post stroke complications asevidenced by results of swallowing tests and reports ofchoking during mealtimes24

Nutrition Diagnosis EtiologyIdentifying the etiology leads to selection ofthe nutrition intervention aimed at resolvingthe underlying cause of the nutrition problemIf the intervention cannot be aimed atresolving the underlying cause, as is the casein Physiologic-Metabolic etiologies, then thenutrition intervention is targeted atminimizing the signs/symptoms of thenutrition problem25

Nutrition Diagnosis EtiologyEtiologies are grouped by the type of cause orcontributing risk factor. See Nutrition Diagnosis EtiologyMatrix for definitions. Beliefs-AttitudesCulturalKnowledgePhysical FunctionPhysiologicSocial-PersonalTreatmentFor the following, the category alone may be the cause or contributingrisk factor of the Nutrition Dx AccessBehavior26

Nutrition Dx Reference SheetsA reference sheet is available for each nutritiondiagnosis. Each reference sheet contains4 components. See sample reference sheets. Problem or Nutrition Diagnosis LabelDefinition of the Nutrition Diagnosis LabelEtiology (cause/contributing risk factors)Signs/Symptoms (defining characteristics)Grouped by– nutrition assessment category, andpotential indicators of the specific nutrition diagnosis27

Nutrition Diagnostic TerminologyThree general domains Intake– Excessive or Inadequate intake compared torequirements (actual or estimated) Clinical– Medical or physical conditions that are outside normal Behavioral-Environmental– Relate to knowledge, attitudes, beliefs, physicalenvironment, access to food, or food safety28

Step 3: Nutrition Intervention29

Nutrition InterventionNutrition intervention is purposeful plannedactions intended to positively change a nutritionrelated behavior, environmental condition, oraspect of health status Directed to the etiology or cause of the problemidentified in the PES statement Sometimes the intervention must be directed towardthe signs and symptoms if the RDN cannot impactthe etiology30

Nutrition InterventionTwo interrelated components Planning Implementation31

Nutrition Intervention Planning:o Prioritize the nutrition diagnoseso Review practice guidelines (EAL) and policieso Confer with the patient ( others)o Set goals and determine expected outcomeso Defining the specific nutrition intervention strategyo Define time and frequency of care32

Nutrition InternventionImplementationo Communicate the plan of careo Carry out the plan of careo Continue data collectionMonitor and Evaluateo Follow‐up and verify the implementationo Revise nutrition intervention strategy if needed33

Nutrition InterventionFour Domains Food and/or Nutrient Delivery Nutrition Education Nutrition Counseling Coordination of Nutrition Care34

Nutrition InterventionUse of Nutrition Interventions Based on Practice Setting Food and/or Nutrient Delivery: institutional settings (hospitals, long‐term care) home care Nutrition Education‐Content: institutionalized settings Nutrition Education‐Application: outpatient/non institutionalized settingsprivate practicecommunity Nutrition Counseling: outpatient/non institutionalized settingsprivate practicecommunity Coordination of Nutrition Care: all practice settings35

Nutrition InterventionReference Sheets include: Definition Details of Intervention Examples of typical use Other considerations References36

Nutrition InterventionSummary:Defined nutrition intervention terminology‐ Assists in communication within the dieteticsprofession and among other health careproviders. Allows documentation of the impact of theprofession on specific diagnoses and etiologies inall patient/client populations.37

Step 4: Nutrition Monitoring & Evaluation38

Nutrition Monitoring & EvaluationCritical thinking skills for Nutrition Monitoring &Evaluation: Selecting appropriate indicators/measures Using appropriate criteria (previous status, nutritionintervention goals, or reference standards) for comparison Defining where patient/client is now in terms of expectedoutcome Explaining variance from expected outcomes Identifying factors that help/hinder progress Deciding between discharge or continuation of nutritioncare39

Nutrition Monitoring & EvaluationDetermines whether the patient is meeting thenutrition intervention goals or desiredoutcomesA nutrition reassessment is needed to identifywhether the nutrition-related problem stillexists and evaluate the progress madetoward resolving the problem.40

Nutrition Monitoring & EvaluationIs the nutrition intervention strategy workingto resolve the nutrition diagnosis, itsetiology, and/or signs and symptoms?Assesses the patient’s progress by comparingspecific markers or nutrition care indicatorsagainst recognized, science-based standardsor baselines.41

Nutrition Monitoring & EvaluationDefinitionsNutrition Monitoring: preplanned review and measurement ofselected nutrition care indicators of patient/client’s statusrelevant to the defined needs, nutrition diagnosis, nutritionintervention, and outcomes.Nutrition Evaluation: the systematic comparison of currentfindings with the previous status, nutrition interventiongoals, effectiveness of overall nutrition care, or a referencestandardNutrition Care Outcomes: the results of nutrition care that aredirectly related to the nutrition diagnosis and the goals ofthe intervention planNutrition Care Indicators: markers that can be measured andevaluated to determine effectiveness of nutrition care42

Nutrition Monitoring & EvaluationNutrition Care Outcomes: intermediate outcomes toother broader health care outcomes Acute or chronic disease: occurrence, duration, severity Infections Wound healing Health care cost Patient functional ability43

Nutrition Monitoring & EvaluationNutrition Care Outcome Characteristics: Represent results the RDN can impact Can be linked to nutrition intervention goals Are measureable with tools and resourcesavailable to the RDN Occur in a reasonable time period44

Nutrition Monitoring & EvaluationNutrition Monitoring & Evaluation Components Monitor progress toward the nutritionintervention or goal Measure the appropriate nutrition careindicators Evaluate the nutrition care indicators againstappropriate standards selected during thenutrition care planning45

Nutrition Monitoring & EvaluationNutrition Care Indicators: Factors that food and nutrition professionals can impactdirectly, such as food and nutrient intake; growth andbody composition; food and nutrition-related knowledge,attitudes, and behaviors; and food access Laboratory values, such as HgbA1c, hematocrit, orserum cholesterol Functional capabilities, such as physical activity Patient perception of nutrition care and results ofnutrition care, such as nutrition quality of life46

Nutrition Monitoring & EvaluationMeasurement and Evaluation of Nutrition Indicators:Nutrition Care Criteria – what it is comparedagainst Nutrition Prescription or Goalo Dietary Interventiono Behavior change Reference Standard: select what is appropriate forintervention or goaloooNationalInstitutionalRegulatory standards47

Nutrition Monitoring & EvaluationSelection and Interpretation ofNutrition Care Indicators:Primary factors that influence the selection,measurement, and interpretation of individualnutrition care outcomes: Practice setting Age of patient Disease state and severity48

Nutrition Monitoring & EvaluationReference SheetsThese reference sheets are combined with the nutrition assessmentreference sheets and contain these eight components: Definition of the nutrition assessment and nutrition monitoring andevaluation termThe nutrition assessment and nutrition monitoring and evaluationindicatorsMeasurement method or data sources recommendedThe nutrition interventions with which the nutrition assessmentand nutrition monitoring and evaluation data are usedThe nutrition diagnoses with which the nutrition assessment andnutrition monitoring and evaluation data are usedThe criteria for evaluationThe patient/client nutrition assessment and nutrition monitoring andevaluation documentation exampleReferences49

Nutrition Monitoring & EvaluationDocumentationQuality documentation for nutrition monitoring and evaluationincludes the following: Date and time Indicators measured, results, and the method for obtaining themeasurement Criteria to which the indicator is compared (nutritionprescription/goal or a reference standard) Factors facilitating or hampering progress Other positive or negative outcomes Future plans for nutrition care, nutrition monitoring, and follow-upor discharge50

Nutrition Monitoring & EvaluationData Sources and ToolsTo monitor and evaluate a patient/client’s progress, thefollowing tools may be used: Patient/client questionnairesSurveysPretests and posttestsPatient/client/family member interviewsAnthropometric measurementsBiochemical and medical test resultsFood and nutrition intake tools51

Nutrition Monitoring & EvaluationNutrition Care Outcome Management SystemPotential benefits of aggregate nutrition care indicator datainclude the following: Provide for process improvement and fosterunderstanding of what works and what does not Can be used for outcomes measurement studies andquality improvement initiatives Link care processes and resource utilization Give an opportunity to identify and analyze causes ofless than optimal performance and outcomes Define information for inclusion in centralized datasystems relevant to nutrition care Can be used to quantify the food and nutritionprofessional’s contribution to health care52

Nutrition Monitoring & EvaluationNutrition Care Outcome Management SystemFactors that can impact aggregate nutrition care indicator datainterpretation include: Method for collecting the outcome (diet record, recall) Data source (patient, family/caregiver, chart) Intervention components (type, duration, and intensity) Education and skill level of RDN Nutrition program attributes53

Nutrition Monitoring & EvaluationSummaryNutrition Monitoring and Evaluation describes thepatient’s progress through consistent terms that areevaluated based on carefully selected indicatorsand criteria.Documentation of patient progress and outcomeswith consistent terminology that can be collectedusing research methodology will result indocumenting the value of the work of the RDN54

NCP Resources55

Books IDNT ReferenceManual, ed. 4 IDNT PocketGuide, ed. 456

eNCPT57

eNCPT Language translations Translations will be the collaborative work between the Academy andinterested national dietetic associations Unique URL Organizations can purchase a unique link for a specified number ofsimultaneous users and to provide access to their members No Terminology License Organizations will be granted permission to use the NCPT in theirElectronic Health Record by purchasing a multi-seat subscription toeNCPT58

NCPT Toolkits59

International Website60

NCP – Important LinksNCP Websitewww.eatright.org/ncpAcademy International Nutrition Care Processwww.aincp.webauthor.comNCP ls/content.aspx?id 5902NCP Publications and Toolkitswww.eatright.org/shopNCP Tutorial Moduleshttp://adaeal.com/ncp/61

Nutrition Evaluation: the systematic comparison of current findings with the previous status, nutrition intervention goals, effectiveness of overall nutrition care, or a reference standard Nutrition Care Outcomes: the results of nutrition care that are directly related to the nutrition diagnosis and the goals of the intervention plan

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