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Presented by:
Sarah Lippman Sharon Pokorny Cindy Salazar Lucy Ta Peer Nutri<on Counseling Spring 2013
NUTRITION CARE PROCESS (NCP)
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What Is The Nutri.on Care Process And Model?
• A systema.c method that allows nutri.on professionals to provide pa.ents with quality care.
• Intended to be used as framework to guide Registered Die..ans in providing consistency in care and predictability of outcomes.
• Provides structure for research and data collec.on and a standardized language.
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Nutri.on Care Process Steps
1. Assessment: nutri.onal health status
2. Diagnosis: interpret data
3. Interven.on: develop a plan of ac.on
4. Monitor/Evaluate: monitor the effec.veness of the plan
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ADA NUTRITION CARE PROCESS AND MODEL
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Step 1: Nutri.on Assessment
• The founda.on of the Nutri.on Care Process
• Necessary to iden.fy the cause and significance of nutri.on related problem
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How Nutri.on Professionals Collect Data
�From individuals: • Directly from pa.ents through interview • Through observa.ons and measurements • Medical records • Referring health care provider �From popula.on groups: • Data from surveys • Administra.ve data sets • Epidemiological or research studies
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Categories of Nutri.on Assessment Data
Food and nutrition-related history • Food intake, nutrition and health awareness and
management, physical activity and exercise, and food availability.
Biochemical data, medical tests and procedures • Include laboratory data (e.g., electrolytes, glucose,
lipid panel, and gastric emptying time).
Anthropometric measurements • Include height, weight, body mass index (BMI),
growth rate, and rate of weight change.
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Categories of Nutri.on Assessment
Data Nutri.on-‐focused physical findings
• Include oral health, general physical appearance, muscle and subcutaneous fat was.ng
Client history • Include medica.on and supplement history, social history, medical/health history, and personal history.
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Cri.cal Thinking in Nutri.on Assessment
• Helps o Determine appropriate data to collect and the need for addi.onal informa.on
o Select assessment tools and procedures o Apply assessment tools in valid and reliable ways o Dis.nguish relevant and important data o Validate the data
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Step 2: Nutri.on Diagnosis/Problem
• Cri.cal step between nutri.on assessment and nutri.on interven.on
• Involves using standardized terminology for iden.fying and labeling the specific nutri.on-‐related problem that nutri.on professionals are responsible for trea.ng independently
• Different than a medical diagnosis which describes a disease or pathology of organs or body systems (e.g., diabetes)
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Nutri.on Diagnosis/Problem
• Three domains: 1. Intake – related to intake of energy, nutrients, fluids, or
bioac.ve substances through oral diet or NS (EN or PN) 2. Clinical – includes nutri.onal findings/problems iden.fied
as related to medical or physical condi.ons
3. Behavioral-‐Environmental – includes iden.fied nutri.onal findings/problems that relate to knowledge; a^tudes/beliefs; physical environment; access to food, water, or nutri.on-‐related supplies; and food safety
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Nutri.on Diagnosis/Problem
Medical or Nutri.onal Diagnosis? • High cholesterol • Swallowing difficulty • Diabetes • Elevated fas.ng glucose • Altered GI func.on • Excessive fat intake • Disordered ea.ng pabern
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Nutrition Diagnosis/Problem • It is summarized into a structured sentence named the nutri.on diagnosis statement or the PES statement because it is comprised of a problem (P), e.ology (E), and signs and symptoms (S).
• The generic format is:
Nutri.on related problem (P) related to… e.ology (E) as evidenced by… signs and symptoms (S)
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Nutri.on Diagnosis/Problem (P) Problem (nutri.on diagnosis label) – describes altera.ons in the pa.ent/client’s nutri.onal status (E) E<ology (cause/contribu.ng risk factors) – are those
factors contribu.ng to the existence or maintenance of the nutri.on related problem (S) Signs/Symptoms (defining characteris.cs) – consist of objec.ve (signs) and/or subjec.ve (symptoms) data used to determine if the pa.ent/client has the nutri.on diagnosis specified
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Nutri.on Diagnosis/Problem
A well-‐wriben PES statement should be:
• Simple, clear, and concise
• Specific to the pa.ent/client • Related to only one nutri.on-‐related problem
• Related accurately to the e.ology • Based on reliable and accurate nutri.on assessment data
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Nutri.on Diagnosis/Problem Examples of PES statements:
1. Excessive fat intake related to limited access to healthful op.ons and poor nutri.on knowledge as evidenced by serum cholesterol level of 230 mg/dL and patent’s self reported food intake .
2. Involuntary weight loss related to poor oral food and
beverage intake as evidenced by 15-‐lb loss in 3 months. 3. Excessive energy intake related to poor food choices as
evidenced by a BMI of 31.
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Nutri.on Diagnosis/Problem Evalua<ng the PES statement (P) – Can the problem be resolved by the nutri.on professional? Use the nutri.on diagnosis from the intake domain as that one is the most specific to the role of the R.D. (E) – Is the e.ology chosen the “root cause” of the problem which can be addressed with a nutri.on interven.on? If not, can the interven.on lessen the signs and symptoms? (S) – Can the signs and symptoms be monitored (measured/evaluated) to indicate if there is improvement with the nutri.on diagnosis? Overall Does the nutri.on assessment data support the nutri.on diagnosis with the e.ology and signs and symptoms?
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Step 3: Nutri.on Interven.on Purposefully planned ac.ons intended to posi.vely change a nutri.on related behavior, environmental condi.on, or aspect of health status for an individual, target group, or community. Purpose: resolve or improve the iden.fied nutri.on problem
• How are Nutri.on Interven.ons determined? o Interven.on strategies are selected based on nutri.on diagnosis and e.ology o Eg. Change nutri.onal intake, nutri.on-‐elated knowledge or behavior, access to services etc.
o Interven.on goals provide a framework for monitoring progress and measuring outcomes
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Nutri.on Interven.on Domains • Each domain defines classes of nutri.on interven.on strategies based on specific terms necessary for medical record documenta.on, billings, communica.on, and research
• More than one nutri.on interven.on may be simultaneously implemented as part of the pa.ent plan
1. Food and/or Nutrient Delivery • Individualized approach for food/nutrient provision,
including meals/snacks, EN/TPN, supplements 2. Nutri<on Educa<on • Formal instruc.on/training on management/modifica.on of
food choices and ea.ng behavior in order to impart knowledge to pa.ents on maintaining or improving health
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Nutri.on Interven.on Domains 3. Nutri<on Counseling • A suppor.ve process, characterized by a collabora.ve counselor-‐pa.ent rela.onship, to set priori.es, establish goals, and create individualized ac.on plans that foster responsibility for self-‐care to treat exis.ng condi.ons and promote health
4. Coordina<on of Nutri<on Care • Consulta.on with, referral to, or coordina.on of nutri.on care with other health care providers that can assist in trea.ng or managing nutri.on-‐related problems
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Nutri.on Interven.on Reference Sheets • Developed for each nutri.on interven.on
• Includes nutri.on interven.on label, defini.on, descrip.ve details, and nutri.on diagnosis for which it’s commonly associated
• Designed to assist food and nutri.on professionals with consistent and correct u.liza.on of the nutri.on interven.ons
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Components Nutri.on Interven.on 1. Planning • Priori.ze nutri.on diagnoses
• Nutri.on interven.on è e.ology (PES) • Consult AND’s EBNPG & other prac.ce guides • Determine pt-‐focused expected outcomes for each nutr dx • Confer with pa.ent/family members/caregivers • Define nutri.on interven.on plan, strategies • Define .me, frequency of care • ID resources needed 2. Implementa<on: Ac<on Phase • Communica.on: nutri.on care plan • Carrying out plan
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Nutri.on Prescrip.on • Essen.al component of the interven.on: concisely state individualized recommenda.ons (based on reference standards, dietary guidelines, pa.ent’s ND.
o Use assessment data: PES; evidence, policies, and procedures; pa.ent preferences.
• Nutri.on Rx è interven.on selec2on, or implementa.on o IDs specific interven.on strategies o è pa.ent-‐focused goals -‐ Clear, measureable, achievable, <me-‐defined -‐ Essen.al in order to measure the quan.fiable and qualifiable impact of interven.on
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Step 4: Nutri.on Monitoring and Evalua.on
• IDs important measures of change/pt. outcomes relevant to the ND & interven.on: how to measure and evaluate outcomes.
• Purpose: evaluate efficacy of nutri.on (pa.ent mee.ng goals?) § Reassessment to ID if the nutri.on-‐related problem s.ll exists; evaluate the progress
§ Progress assessed by: comparing specific markers, nutri.on care indicators to, science-‐based standards, baselines
o Contributes to body of literature quan.fying effec.veness of nutri.on interven.ons
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Nutri.on Monitoring and Evalua.on: Defini.ons
• Monitoring: o Preplanned review, measurement of selected nutri.on care
indicators relevant to defined needs, nutri.on diagnosis, nutri.on interven.on, outcomes
• Evalua<on: o The systema.c comparison of findings with previous status,
nutri.on interven.on goals, effec.veness of nutri.on care, reference standard
• Nutri<on Care Outcomes: o Results of nutri.on care directly related to nutri.on
diagnosis goals of interven.on plan • Nutri<on Care Indicators (NCI):
o Markers – measured, evaluated to determine effec.veness of nutri.on care
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Nutri.on Care Outcomes • Food/Nutri.on-‐Related History o Food and Nutrient Intake; Food, Nutrient Administra.on, Medica.on/Supplement Use; Knowledge/Beliefs/A^tudes; Behavior; Factors Affec.ng Access to Food and Food/Nutri.on Related Supplies; Physical Ac.vity and Func.on; and Nutri.on Related Pa.ent-‐Centered Measures
• Biochemical Data, Medical Tests, and Procedures o Lab data and tests • Anthropometric Measurements o Height; Weight/History; BMI; Growth Pabern Indices/% Ranks • Nutri.on-‐Focused Physical Findings o Findings from an evalua.on of body systems, muscle and subcutaneous fat was.ng, oral health, suck/swallow/breath ability, and affect
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Nutrition Monitoring and Evaluation: Components
• Monitor Progress: § Check pa.ents understanding/compliance § Determine if interven.on is being implemented § Provide evidence: interven.on is/is not working § ID other +/-‐ outcomes § Gather informa.on (lack of progress?) § Support conclusions with evidence
• Measure Outcomes: § Select the NCI(s) to measure outcomes(s) § Use standardized NCIs to ñ validity & reliability
• Evaluate Outcomes: § Compare data with Rx/goals, reference standards § Evaluate impact of all interven.ons on overall pa.ent health
outcomes
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Nutri.on Monitoring & Evalua.on: Documenta.on
Quality documenta<on for nutri<on monitoring and evalua<on include: • Date and .me • Indicators measured, results, and method for obtaining • Criteria to which the indicator is compared • Factors facilita.ng or hindering success • Other posi.ve or nega.ve outcomes • Future plans for nutri.on care, nutri.on monitoring, and follow-‐up or discharge
Data Sources and Tools: • Pa.ent ques.onnaires • Surveys • Pretests/Posbests • Pa.ent interviews
• Anthropometric measurements • Biochemical/medical test results • Food and nutri.on intake tools
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NCP Example #1 Nutri<on Assessment • Medical hx: -‐ 72 year old female admibed with decompensated CHF -‐ Admibed two .mes in the past month with the same dx -‐ Meds: Lasix and Toprol -‐ No.ced swollen face and extremi.es on day prior to admission
-‐ Has lost 5 lbs. in 24 hrs since admission -‐ Output > input by 2 L
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NCP Example #1 Nutri<on Assessment • Diet hx: -‐ Was told to weigh herself daily but has no scale at home -‐ Does not add salt to foods at the table -‐ Ate canned soup for lunch and 3 slices of pizza for dinner the day before admission
-‐ Usually goes out to eat at restaurants -‐ Does not restrict fluids -‐ Has never received nutri.on counseling -‐ Current Diet Order: 2 g Na
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NCP Example #1
Nutri<on Diagnosis • Excessive sodium intake as related to consump.on of canned soup, pizza, and restaurant foods as evidenced by diet history.
• Lack of nutri.on knowledge as related to never seeing a nutri.on counselor as evidenced by excess consump.on of high sodium foods.
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NCP Example #1 Nutri<on Interven<on • Excess sodium intake: -‐ Teach pa.ent how to read nutri.on label to avoid high Na foods
-‐ Abend Senior Feeding Sites where they serve low Na foods -‐ Abend heart failure diet program • Lack of nutri.on knowledge: -‐ See an RD weekly or bi-‐weekly at the heart failure clinic -‐ Compliance with diet
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NCP Example #1 Monitoring and Evalua<on • Pa.ent should weigh herself daily and keep track in a log; report to heart failure case manager if pa.ent weigh 2 pounds or more in 24 hours
• Pa.ent should keep track of diet by wri.ng 3 day diet logs to show to the RD for review
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NCP Example #2 Nutri<on Assessment • Medical hx: -‐ 70 year old male admibed for cardiac bypass surgery -‐ History of hypertension, thyroid dysfunc.on, asthma, prostate surgery
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NCP Example #2 Nutri<on assessment • Diet hx: -‐ Has lost weight without trying and has been ea.ng poorly for several weeks before admission, leading to referral to the RD for nutri.on assessment.
-‐ Caloric intake: 1,200kcal/day -‐ Meals: irregular throughout the day; drinks coffee frequently • Personal hx: -‐ Lives alone at home -‐ Lost his wife 3 months ago -‐ Rarely sits down to a cooked meal in the past 6 months
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NCP Example #2 Nutri<on Diagnosis • Involuntary weight loss as related to irregular meals throughout the day as evidenced by a consump.on of 1,200 calories a day.
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NCP Example #2 Nutri<on Interven<on • Involuntary weight loss: -‐ Modify diet to include adequate calories and protein -‐ Nutrient and caloric dense foods to prevent weight loss and promote weight gain
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NCP Example #2 Monitoring and Evalua<on • Monitoring will include weekly weight measurements and nutrient intake analyses
• If nutri.on status is not improving, such as weight records and goals not being met, he needs to be reassessed and develop new goals and create plans for new interven.ons
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References Academy of Nutri.on and Diete.cs. (2013). Interna.onal Diete.cs & Nutri.on
Terminology (IDNT) Reference Manual: Standardized Language for the Nutri.on Care Process (4th ed.). Chicago, IL.
American Diete.c Associa.on. Frequently Asked Ques2ons Regarding the Nutri2on
Care Process and Model (2008). Retrieved November 2, 2009 from www.eatright.org
Bueche, J., Charney, P., Pavlinac, J., Skipper, A., Thompson, E., Myers, E. (2008). Nutri.on
care process and model part I: The 2008 update. Journal of the American Diete2cs Associa2on, 113-‐117. Retrieved November 13, 2010 from
hbp://www.eatright.org/HealthProfessionals/content.aspx.?id=7077&terms=NCP Mahan, L.K., & Escob-‐Stump, S. (2012). Krause’s Food and the Nutri.on Care Process (13th
ed.). St. Louis, MO. Nutri.on Care Process: Diagnosis, Interven.on, Evalua.on, and Monitoring. Retrieved
from www3.uakron.edu.