Diagnosis, Intervention, Evaluation NCP

Diagnosis, Intervention, Evaluation NCP - Diagnosis...

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Unformatted text preview: Diagnosis, Intervention, Evaluation, and Documentation ADA NUTRITION CARE PROCESS AND MODEL Screening & Referral System Identify risk factors Use appropriate tools and methods Involve interdisciplinary collaboration Nutrition Assessment btain/collect timely and O appropriate data nalyze/interpret with A evidence - based standards Document Nutrition Diagnosis dentify and label problem I Determine cause/contributing risk factors luster signs and symptoms/ C defining characteristics Document Relationship Between Patient/Client/Group & Dietetics Professional Nutrition Monitoring and Evaluation Monitor progress Measure outcome indicators Evaluate outcomes Document Outcomes Management Sys tem Monitor the success of the Nutrition Care Process implementation Evaluate the impact with aggregate data Identify and analyze causes of less than optimal performance and outcomes Refine the use of the Nutrition Care Process Nutrition Intervention Plan nutrition intervention • Formulate goals and determine a plan of action Implement the nutrition intervention • Care is delivered and actions are carried out Documen t Nutrition Assessment Leads to Nutrition Diagnosis • • • • Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Nutrition Monitoring and Evaluation Nutrition vs Medical Dx Medical Dx Nutrition Diagnosis Diabetes Excessive CHO intake related to evening visits to Coldstone Creamery as evidenced by diet hx and high hs blood glucose Trauma and Increased energy expenditure related to closed head multiple trauma as evidenced by results injury of indirect calorimetry Liver failure Altered gastrointestinal function related to cirrhosis of the liver as evidenced by steatorrhea and growth failure Nutritional vs Medical Dx Medical Dx Nutrition Diagnosis Obesity Excessive energy intake related to lack of access to healthy food choices (restaurant eating) as evidenced by diet history and BMI of 35. Dependence mechanical ventilation Excessive energy intake related to high volume PN as evidenced by RQ >1 Anorexia nervosa Inappropriate food choices related to history of anorexia nervosa and selflimiting behavior as evidenced by diet history and weight loss of 5 lb PES Statement • • • Problem: nutrition diagnosis label Etiology: the focus of the intervention Signs and symptoms: change when nutrition Signs problems are successfully treated; the focus of monitoring and evaluation of Problem (Diagnostic Label) Falls into three general domains: • Intake (NI) • Excessive or Inadequate intake compared to Excessive requirements • Clinical (NC) • Medical or physical conditions that are Medical outside normal outside • Behavioral/environmental (NB) • Knowledge, attitudes, beliefs, physical Knowledge, environment, access to food, food safety environment, Etiology • Etiology (Cause/Contributing Factors) • Related factors that contribute to problem • Identifies cause of the problem • Helps determine whether nutrition Helps intervention will improve problem intervention • Linked to problem by words “related to” Linked (RT) (RT) • Note: etiology may not always be clear Etiology • Etiology (Cause/Contributing Factors) • Excessive energy intake (problem) Excessive “related to” regular consumption of large portions of high-fat meals (etiology)… portions • Swallowing difficulty (problem) RT Swallowing recent stroke (etiology)… recent • Involuntary wt gain RT decrease in Involuntary exercise… exercise… Diagnostic Labels Can Be Problems or Etiologies • • • • Inadequate energy intake (NI-1.4) related to foodnutrition knowledge deficit (NB-1.1) Food-nutrition knowledge deficit (NB-1.1) related Food-nutrition to lack of previous nutrition education to Involuntary weight loss (NC-3.2) related to Involuntary inadequate energy intake (NI-1.4) inadequate Inadequate oral food-beverage intake (NI-2.1) Inadequate related to swallowing difficulty (NC-1.1) related Signs and Symptoms • • Signs/Symptoms (Defining characteristics) • Evidence that problem exists • Linked to etiology by words “as Linked evidenced by” evidenced Evaluation and monitoring of effectiveness Evaluation of intervention is done by reviewing signs and symptoms and Nutrition Dx with S/S • • • Excessive energy intake (NI-1.5) (P) Excessive “related to” regular consumption of large related portions of high-fat meals (E) “as evidenced by” diet history & 12 lb wt as gain over last 18 mo (Signs) gain Nutrition Assessment Identifies Etiology and S/S • • Problem: excessive energy intake Etiology: reviewing the diet history, we Etiology: learn that learn • Patient eats in fast food restaurants 2x Patient day day • Patient supersizes portions because it’s a Patient bargain bargain • Patient has only 15 minutes for lunch PES Statement Excessive energy intake P Related to eating frequently in fast food restaurants E As evidenced by BMI of 30 and diet history S Etiology Guides Intervention! • • The clinician determines what the The intervention is by looking at the root cause of the nutrition problem. If the cause of excessive energy intake is If eating frequently in fast food restaurants, how would you intervene? how Signs and Symptoms Direct Intervention and Evaluation Intervention/ Eval P Excessive energy intake E RT eating frequently in fast food restaurants Intervention: Counsel patient about best choices in fast food restaurants (C2.4) S As evidenced by BMI and diet history Eval: Recheck weight (S1.1.4) and diet history (BE2.1.1.) at next visit PES Statements • • • Excessive fat intake (NI-5.6.2) related to high Excessive intake of fried foods and bakery goods as evidenced by diet history and hyperlipidemia evidenced Excessive energy intake (NI-1.5) related to high Excessive intake of fried foods and snack items as evidenced by diet history and BMI by Food/nutrition related knowledge deficit (NB-1.1) related to lack of education on cholesterol lowering diet as evidenced by history and patient self-report self-report Nutrition Diagnosis Statement Should Be • • • • • Clear, concise Specific Related to one problem Accurate – related to one etiology Based on reliable, accurate assessment Based data data Evaluating Your PES Statement • • There are no right or wrong PES statements But some are better than others Evaluating Your PES Statement • • • Can the RD resolve or improve the nutrition Can diagnosis? Can your intervention address the etiology Can and thus resolve it or improve the problem? and Or can your intervention address the signs Or and symptoms? and Evaluating Your PES Statement • • Ex: Inadequate energy intake related to Ex: decreased taste perception as evidenced by diet history, medical dx and weight loss of 10 lb. during cancer tx 10 Cannot treat the etiology (decreased taste Cannot perception) but can treat S&S by recommending foods with stronger flavors recommending Evaluating Your PES Statement • • • Altered nutrition-related labs related to GI Altered bleed as evidenced by medical hx and decreased hgb/hct in medical record decreased Labs likely won’t improve until GI bleed Labs is addressed; the etiology is not a nutritional deficit nutritional CAN address inadequate intake of iron, CAN copper, B12, protein, etc. Evaluating Your PES Statement • • • When all things are equal and there is a choice When between two nutrition diagnoses from different domains, consider the Intake domain diagnosis as the one more specific to the role of the RD the Instead of Altered nutrition-related labs related to Instead GI bleed as evidenced by medical hx and decreased hgb/hct in medical record Consider Inadequate intake of iron (NI-5.10.1) Consider related to increased needs due to GI bleed as evidenced by medical history, blood count, diet history, and serum ferritin history, Evaluating Your PES Statement • • Will measuring the signs and symptoms tell Will you if the problem is resolved or improved? Ex: If nutrition dx is excessive energy Ex: intake, can do another diet history at next visit and see if intake has changed; can also check weight check NCP Example: Long Term Care • • • • 85 y.o. resident of LTC facility has lost 85 >10% weight in the last 6 months >10% Medical workup negative Oral supplement is ordered but patient Oral continues to lose weight continues Nutrition professional is consulted for Nutrition enteral feeding recommendations enteral NCP Example: LTC • On assessment, it is found that patient’s On teeth no longer fit and she cannot chew regular meats and vegetables; patient is storing oral supplement in drawer as she worries about the cost worries Write a PES statement for this patient! NCP Example: LTC • Diagnosis: Inadequate energy intake (NI1.4) related to poorly fitting dentures and 1.4) hoarding of oral supplement as evidenced by observation and pt interview by Etiology Guides Intervention • Intervention: Nutrition professional orders Intervention: dental consult (RC-1.3) to reline dentures and chopped diet (ND-1.2); puts resident on Medpass supplement (ND-3.1.1) Medpass Diagnoses Apply to All Settings Long term care Inadequate energy intake (NI-1.4) related to patient refusal of pureed diet as evidenced by intake records, pt self-report and 8% weight loss/3 months Long term care Inadequate fiber intake (NI-5.8.5) related to patient avoidance of fruits and vegetables as evidenced by chronic constipation and diet history Ambulatory Care Not ready for diet/lifestyle change (NB-1.4) related to social/environmental issues as evidenced by pt verbalization and continued weight gain ADA’s Nutrition Care Process Steps • • • • Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Nutrition Monitoring and Evaluation Nutrition Intervention • • 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) 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 Note: Education is appropriate for food and nutrition-related knowledge deficit. If the client knows the content, more education probably won’t help Nutrition Counseling (C) • • • Theory or approach Strategies Phase Nutrition Counseling: Theory or Approach The theories or models used to design and The implement an intervention; provide a researchimplement based rationale for designing and tailoring based nutrition interventions nutrition • Cognitive-behavioral therapy (C-1.2) • Health belief model (C-1.3) • Social learning theory (C-1.4) • Transtheoretical Model/Stages Transtheoretical of Change (C-1.5) of • Other (C-1.6) Other Nutrition Counseling: Strategies* • • • • • • • Motivational Motivational interviewing (C-2.1) interviewing Goal setting (C-2.2) Self-monitoring (C-2.3) Self-monitoring Problem solving (C-2.4) Social support (C-2.5) Stress management (C2.6) Stimulus control (C-2.7) • • • • Cognitive Cognitive restructuring (C-2.8) restructuring Relapse prevention Relapse (C-2.9) (C-2.9) Rewards/contingency Rewards/contingency mgt (C-2.10) mgt Other *Selectively applied evidence-based method or plan of action designed to achieve a particular goal Coordination of Care (RC) • • Coordination of other care during nutrition care Coordination (RC-1) (RC-1) • Team meeting • Referral to RD • Collaboration with other providers • Referral to community agencies/programs Discharge and transfer of nutrition care to new Discharge setting/provider (RC-2) setting/provider • Collaboration • Referral to community agencies/programs ADA’s Nutrition Care Process Steps • • • • Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation Nutrition Monitoring and Evaluation • • • Monitor progress and determine if goals are Monitor met met Identifies patient/client outcomes relevant Identifies to the nutrition diagnosis and intervention plans and goals plans Measure and compare to client’s previous Measure status, nutrition goals, or reference standards standards Nutrition Outcomes – 4 Categories • • • • Nutrition-Related Behavioral and Environmental Nutrition-Related Outcomes (BE)—Nutrition-related knowledge, behavior, access, and ability that impact food and nutrient intake nutrient Food and Nutrient Intake Outcomes (FI)—Food Food and/or nutrient intake from all sources and/or Nutrition-Related Physical Signs and Symptom Nutrition-Related Outcomes (S)—Anthropomorphic, biochemical, and physical exam parameters and Nutrition-Related Patient/client centered Nutrition-Related Outcomes (PC)—perception of patient/client’s nutrition intervention and its impact nutrition Nutrition-Related Behavioral and Environmental Outcomes (BE) • • • • Knowledge/beliefs (1) Behavior (2) Access (3) Physical activity and function (4) Behavior-Environmental Outcomes Domain: Beliefs and Attitudes (BE-1.1) Definition: beliefs/attitudes about and/or readiness to Definition: change food, nutrition, or nutrition-related behaviors behaviors Potential indicators (BE-1.1) • Readiness to change • Perceived consequences of change • Perceived costs versus benefits of change • Perceived risk • Outcome expectancy • Conflict with patient/family value system • Self efficacy Beliefs and Attitudes (BE-1.1) Measurement methods or data sources • Patient self-report, client/patient Patient assessment questionnaire or interview assessment Typically used to monitor and evaluate Typically change in the following domains of nutrition intervention: nutrition • Nutrition education, nutrition counseling Beliefs and Attitudes (BE-1.1) Typically used to monitor and evaluate change in the Typically following nutrition diagnoses following • Harmful beliefs/attitudes about food- or Harmful nutrition-related topics nutrition-related • Not ready for diet/lifestyle change • Inability to manage self-care • Excess or inadequate oral food/beverage, Excess energy, macronutrient, micronutrient, or bioactive substance intake bioactive • Imbalance of nutrients • Inappropriate fat foods Beliefs and Attitudes (BE-1.1) Typically used to monitor/evaluate change in the Typically following nutrition diagnoses (cont) following • Inappropriate intake of amino acids • Underweight • Overweight/obesity • Disordered eating pattern • Physical inactivity • Excess exercise Behavior-Environmental Outcomes Domain: Food and Nutrition Knowledge (BE-1.2) Definition: Level of knowledge about food, Definition: nutrition and health, or nutrition-related information and guidelines relevant to patient/client needs patient/client Food and Nutrition Knowledge (BE-1.2) Potential Indicators • • Level of knowledge (e.g. none, limited, minimal, Level substantial, and extensive substantial, Areas of knowledge: • Food/nutrient requirements • Physiological functions • Disease/condition • Nutrition recommendations • Food products • Consequences of food behavior • Food label understanding/knowledge • Self-management parameters Food and Nutrition Knowledge (BE-1.2) Measurement methods or data sources • Pre and post-tests administered orally, on paper, or Pre by computer by • Scenario discussions • Patient/client restate key information • Review of food records • Practical demonstration/test Typically used to monitor and evaluate change in the Typically following domains of nutrition intervention: following • Nutrition education, nutrition counseling Food and Nutrition Knowledge (BE-1.2) Typically used to monitor and evaluate Typically change in the following nutrition diagnoses: change • Food- and nutrition-related knowledge Fooddeficit deficit • Limited adherence to nutrition-related Limited recommendations recommendations • Intake domain Ability to Plan Meals/Snacks (BE-2.1) • • Definition: Patient/client ability related to Definition: planning healthy meals and snacks, which are compatible with dietary goals are Potential indicator: Meal/snack planning Potential ability (e.g. may include ability to use planning tools, plan a menu, create/tailor a meal plan, create/use a shopping list meal Ability to Plan Meals/Snacks (BE-2.1) • • Measurement methods/data sources: food Measurement intake records, self-report or caregiver report, 24-hour recall, menu review, targeted questionnaire targeted Typically used to measure outcomes for Typically these domains of nutrition interventions: these • Nutrition education • Nutrition counseling Ability to Plan Meals/Snacks (BE-2.1) Typically used to monitor and evaluate change in the Typically following nutrition diagnoses: following • Excessive or inadequate oral food/beverage intake • Underweight • Overweight/obesity • Limited adherence to nutrition-related Limited recommendations recommendations • Inability or lack of desire to manage self-care Other BE Nutrition Outcomes Behavior (2) • Ability to select healthful Ability food/meals food/meals • Ability to prepare Ability food/meals food/meals • Adherence • Goal setting • Portion control • Self-care management • Self-monitoring • Social support • Stimulus control Access (3) • Access to food Physical activity and Physical function (4) • Breastfeeding success • Nutrition-related ADLs Nutrition-related and IADLs and • Physical activity Other Outcomes Food and Nutrient Intake Food (FI) (FI) • Energy intake (1) • Food and Beverage (2) • Enteral and parenteral (3) • Bioactive substances (4) • Macronutrients (5) • Micronutrients (6) Physical Signs/Symptoms (S) • Anthropometric (1) • Biochemical and medical Biochemical tests (2) tests • Physical examination (3) Patient-Client Centered Patient-Client Outcomes (PC) Outcomes Outcomes Based Practice • • • • Underlays Performance Improvement Underlays and Management and Meets accreditation standards (TJC, Meets American Diabetes Association) American Supports value of nutrition providers Supports in health delivery system in Enhances reputation/ties with medical Enhances staff and other colleagues staff NCP Example: Acute Care • Mr. D. is a 73 y.o. white male admitted with L leg Mr. fx after fall. He lives with his son and daughter in law. Per his son, Mr. D’s appetite has been poor the past 6 months, his dentures are very loose and he refuses to wear them. He also refuses pureed foods. Ht: 6 ft.; weight 133 lb; usual weight 1 year ago 165 lb. Meds: milk of magnesia, Pepcid, Diago Gel. No significant medical hx save progressive Gel. dementia;labs after hydration serum alb 2.4 g/dL; Hgb 10.6 g/dL; HCT 35.3%; BUN, Cr, liver fxn tests WNL tests Write a PES statement for this patient! NCP Example: Acute Care Nutrition Diagnosis • Inadequate energy intake (NI-1.4) related to Inadequate dementia and poor appetite as evidenced by diet history and recent unintentional weight loss loss • Chewing difficulty (NC-1.2) related to illfitting dentures as evidenced by diet history fitting • Increased energy expenditure (NI-1.2) Increased related to long bone fx as evidenced by medical history medical How would you intervene with this patient? Intervention • • • • Dental consult to have dentures relined for better Dental fit (RC - coordination of care) fit Try oral supplements to determine patient Try preference and evaluate acceptance (ND-3.1.1 food-nutrient delivery) food-nutrient Consider move to assisted living (RC Consider coordination of care) coordination Educate patient’s family on nutrient-dense choices Educate for supplemental feedings (E - nutrition education) for Monitoring and Evaluation • • • • Initiate calorie count while patient is Initiate hospitalized to evaluate acceptance of oral supplements supplements Weigh patient weekly after discharge Weigh Evaluate patient’s ability to chew textured Evaluate foods after dentures are replaced foods Evaluate patient in Geriatric Clinic in one Evaluate month month The Diet Prescription • • • • Designates type, amount, frequency of Designates feeding based on pt’s needs, care goals feeding May specify calorie goal May limit or increase various May components of the diet components Each institution usually has specific Each diets that have been approved by committee that are used at that institution institution Modifications of the Normal Diet • • Normal nutrition is foundation of Normal therapeutic diet modifications therapeutic • Based on DRIs • Based on Food Guide Pyramid Purpose of diet is to supply needed Purpose nutrients nutrients Modifications of the Normal Diet • • • • • • • Change in consistency Increase/decrease energy value of diet Increase/decrease type of food or nutrient Increase/decrease consumed consumed Elimination of specific foods or components Adjustment in level, ratio, balance of protein, Adjustment fat, CHO fat, Change in number, frequency of meals Change in route of delivery of nutrients Basic Hospital Diets Basic Hospital Diets —cont’d “Surgical” Soft Diet Clear Liquid Diet Full Liquid Diet Full Liquid Diet –cont’d House or Standard Diet Controversies • • Should the house diet be low in fat, Should saturated fat, sodium, and sugar to conform with the U.S. dietary guidelines? with Should the house diet be intended to Should maximize the nutritional intake of sick people, featuring familiar, comfort foods and fulfilling patient preferences and expectations, regardless of conformity to dietary guidelines designed for healthy people? people? Consistency Diet Controversies • • Soft Diet: what should be included or excluded? Is Soft the diet ‘dental” soft, “surgical” soft, mechanical soft; the needs of dysphagia patients and dental patients are different patients Full liquid diet: there is no evidence that it has a Full role as part of a surgical progression; many of the foods included are poorly tolerated by persons immediately post GI surgery (dairy products, fats, etc.) May be useful as a source of nutrition for persons with mouth pain or dental surgery persons Consistency Diet Controversies • • Thickened liquids: when speech Thickened pathologists recommend specific liquid consistencies, they may be using a different standard than is used in the food and nutrition department and There is no generally-accepted standard for There nectar thick, honey thick, etc. Often these foods vary greatly among and within institutions and depending on where and by whom the thickening is done by Therapeutic Diet Controversies • Should patients with Should chronic diseases who are hospitalized with acute illnesses be placed on the restricted diet that is appropriate for them long term? Therapeutic Diet Controversies • Should residents in Should long term care facilities have the same right as homesame based clients to decide based whether or not to follow a restricted diet? diet? Nutritional Care of the Terminally Ill Patient • • Maintenance of comfort and quality of life Maintenance are the main goals of nutritional care for terminally ill patients = “palliative care” terminally Dietary restrictions and aggressive nutrition Dietary care that negatively impacts quality of life are rarely appropriate. are Palliative Care • Encourages the alleviation of physical Encourages symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently to Continuity of Care • • • • Due to shortened length of stay, more nutritional Due care is being provided in alternative settings (long term care, home care, ambulatory clinics and community programs) community Nutrition counseling and education in acute care is Nutrition often limited to survival skills often Nutritional counseling should be provided in a Nutritional setting conducive to long term behavior change setting The acute care stay can be an opportunity to The identify nutritional problems and devise a plan for follow-up care follow-up Discharge Planning Discharge documentation includes • Summary of nutritional therapies and Summary outcomes outcomes • Pertinent information such as weight, lab Pertinent results, dietary intake results, • Potential drug-nutrient interactions • Expected progress or prognosis • Recommendations for follow-up services Discharge Planning Courtesy University of Washington Medical Centers, Seattle. ...
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