An Overview of the Nutrition Care Process

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Objectives

  • Define and explain the Nutrition Care Process (NCP)
  • Identify how the steps and criteria of the NCP promote quality care
  • Implement the NCP to guide and document nutrition care and outcomes

 

Standardized Language and Toolkits

A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes. Hakel-Smith N, Lewis NM. J Am Diet Assoc. 2004 Dec; 104(12):1878-84.

Nutrition care process and model part I: the 2008 update. Writing Group of the Nutrition Care Process/Standardized Language Committee. J Am Diet Assoc. 2008 Jul; 108(7):1113-7.

Nutrition care process part II: using the International Dietetics and Nutrition Terminology to document the nutrition care process. Writing Group of the Nutrition Care Process/Standardized Language Committee. J Am Diet Assoc. 2008 Aug; 108(8):1287-93.

Why Standardized Nutrition Documentation?

  • To ensure quality of care
  • To improve outcomes
  • To describe the services and enhance visibility of the registered dietitian/dietetic technician, registered (RD/DTR)
  • To facilitate electronic medical record documentation
  • To facilitate reimbursement for nutritional services

What is the Nutrition Care Process?

The Nutrition Care Process (NCP) model is a systematic problem solving method that registered dietitians and diet technicians use to think critically and make decisions to address nutrition related problems, and provide safe, effective, and high quality nutrition care. There are four steps to the NCP:

  1. Nutrition Assessment and Reassessment
  2. Nutrition Diagnosis
  3. Nutrition Intervention
  4. Nutrition Monitoring and Evaluation

You will see this referred to as ADIME.

What is IDNT?

  • International Dietetics Nutrition Terminology
  • Standardized language for Registered Dietitians & Dietetic Technicians, Registered
  • Developed to identify unique contribution of RD/DTR within the universal health care record
  • Facilitates clear consistent documentation of care and communication between health care professionals

Hierarchy of the IDNT

Step 1: Assessment

  • Food/Nutrition Related History
  • Anthropometric Measurements
  • Biological Data, Medical Tests and Procedures
  • Nutrition-Focused Physical Findings
  • Client History

Step 2: Diagnosis

  • Food and or Nutrient Intake
  • Clinical
  • Behavioral/Environmental
  • Hierarchy of the IDNT

Step 3: Intervention

  • Food and/or Nutrient Delivery
  • Nutrition Education
  • Nutrition Counseling
  • Coordination of Nutrition Care

Step 4: Monitoring and Evaluation

  • Food/Nutrition-Related History
  • Anthropometric Measurements
  • Biochemical Data, Medical Tests and procedures
  • Nutrition Focused Physical Findings

Step 1- Nutrition Assessment

  • Systematic process of Obtaining, Verifying, and Interpreting data
  • Critical thinking during this step:
    • Determining appropriate data to collect
    • Determining the need for additional information
    • Selecting assessment tools and procedures that match the situation
    • Applying assessment tools in valid and reliable ways
    • Distinguishing relevant from irrelevant data
    • Distinguishing important from unimportant data
    • Validating the Data

Step 2: Nutrition Diagnosis

  • Identify and describe a specific nutrition problem that can be resolved or improved through treatment/nutrition intervention
  • Use IDNT standardized Nutrition Diagnoses
  • Record the nutrition diagnosis as a Problem, Etiology, Signs/Symptoms§ (PES) statement
  • Document the link between nutrition assessment and nutrition intervention

Medical vs Nutrition Diagnosis

Medical

  • Disease of specific organs or systems
  • Does not change as long as condition exists
  • Example:§ Diabetes

Nutrition

  • Problem related to nutrition that RD can influence
  • Temporary - can be altered as resident's response changes
  • Example: Excessive carbohydrate intake

PES Statement

  • Problem (Nutrition Diagnostic Label)
  • Etiology "As Related to"
  • Signs and symptoms "As Evidenced by"

Nutrition Diagnosis

Critical thinking during this step:

  • Problem — Can the RD/DTR resolve or improve the nutrition diagnosis for this individual/group or population?
  • Etiology — Evaluate what you have used as your etiology to determine if it is the "root cause" or the most specific root cause that the RD/DTR can address with a nutrition intervention.
  • Signs & Symptoms — Will measuring the signs and symptoms indicate if the problem is resolved or improved?

Step 3: Nutrition Intervention

  • Plan and implement appropriate nutrition interventions that are tailored to the person's needs.
  • Select intervention to change nutritional intake, nutrition-related knowledge or behavior, environmental conditions, or access to supportive care and services.
  • Nutrition intervention goals provide the basis for monitoring progress and measuring outcomes.

Critical thinking during this step:

  • Setting goals and prioritizing
  • Defining the nutrition prescription or basic plan
  • Making interdisciplinary connections
  • Initiating behavioral and other nutrition interventions
  • Matching nutrition intervention strategies with individual needs, nutrition diagnosis and values
  • Choosing from among alternatives to determine a course of action
  • Specifying the time and frequency of care

Step 4: Monitoring and Evaluation

Monitor:

  • Assess the effectiveness of nutrition intervention

Measure:

  • Measure outcomes by collecting data on nutrition indicators

Evaluate:

  • Compare current findings with previous findings and evaluate impact of the intervention
  • Identify outcomes relevant to the nutrition diagnosis and intervention goals
  • Determine the amount of progress made and whether goals/expected outcomes are met

Critical thinking during this step:

  • Selecting appropriate indicators/measures
  • Using appropriate reference standards for comparison
  • Defining what is the progress toward expected outcomes
  • Explaining a variance from expected outcomes
  • Determining factors that help or hinder progress
  • Deciding between discharge and continuation of nutrition care

Case Study 1

Mr. Bolton is 86 years old with dementia, severe hypertension and wandering behavior who resides in a secured unit. His is able to feed himself with set-up and verbal cueing. He has had frequent falls and has recently been re-admitted to the hospital for UTI, which is his third this year. Mr. Bolton is 5'10" and currently weighs 166#. Mr. Bolton's fluid intake averages 24 ounces a day. The Registered Dietitian has calculated his daily fluid needs as 2200 ml (approximately 9 § cups / 73.3 ounces).

Assessment: 86 yo male with severe HTN, Alzheimer's Dementia with wandering. PMHX: Chronic UTI, falls.

Ht: 5'10" Wt: 166lbs
IBW: 166lbs +/- 10%
UBW: 165# BMI: 24
Wt change: None/Intentional /Unintentional
Details: Will not remove his sweater and perspires heavily
Current Medical Nutrition Therapy: Mechanical chopped diet with thin liquid
Food allergies/intolerances: None
Labs: BUN 50, Na 152 Medications: Lasix
Est. Nutr. Needs: 1886 kcals ( 25kcal/kg)
75 gms protein (1.0 gms/kg) Fluid needs: 2200 ml
Present intake meeting needs: Unable to determine Yes NO

Nutrition Diagnosis:

Problem: Inadequate fluid intake§(NI-3.1)
"related to"
Etiology: Increased physical activity/wandering, Impaired cognitive ability/dementia, Decreased thirst sensation
"as evidenced by"
Signs/Symptoms: Current fluid intake not meeting needs, frequent UTI, laboratory values/elevated BUN/Na.

Nutrition Intervention(s):
Meals and Snacks (ND-1)
Modify distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2)

Goal: Will drink between 9 and 10 cups of fluid each day through target date.

Monitoring / Evaluation:

  • Fluid/Beverage Intake (FH — 1.2.1)
  • Total Fluid estimated needs (CS-3.1.1)

Recommendations:

  1. Provide at least two eight-ounce beverage preferences with meals, such as: iced tea, fruit punch or coffee with skim milk.
  2. Offer eight ounces of fluid with medication pass every shift.
  3. Offer eight ounces of fluid with each snack service. Mr. Bolton prefers fruit punch.
  4. Offer sips of fluid each time Mr. Bolton passes the nurses station.
  5. Use verbal prompts to cue Mr. Bolton to drink fluids and praise him each time he consumes a beverage.

Case Study 2

Mr. Smithers is 83 years old with dementia, and has difficulty swallowing. He is a very slow eater and is fed in his room by staff. Recently his meal intake has decreased. Mr. Smithers is 6'5" tall and currently weighs 146#. He has experienced a 30-pound weight loss since admission three years ago, and his Body Mass Index has decreased to 17kg/m2. The Registered Dietitian calculated his daily energy needs as 1986 calories and 95 grams of protein. His serum albumin level has declined from 3.3 g/dL last quarter to 3.0 g/dL.

Assessment: 83 yo male with Alzheimer's dementia and swallowing difficulty. Slow eater and is fed by staff in room.
Ht: 6'5" Wt: 146lbs
IBW: 208lbs UBW: 176# BMI: 17
Wt change:§ None/Intentional /Unintentional
Details:§ Slow wt loss of 30lbs over past 3 years.
Current Medical Nutrition Therapy: Pureed diet with thin liquid
Food allergies/intolerances: None
Labs: Alb 3.0§Medications:§ Megace
Est. Nutr. Needs: 2159 kcals ( 25kcal/kg + 500kcal for wt gain)
79 gms protein (1.2 gms/kg)Fluid needs:2200 ml
Present intake meeting needs:Unable to determine Yes NO

Nutrition Diagnosis:

Problem: Unintentional Weight Loss (NC-3.2)
"related to"
Etiology: Lack of self-feeding ability / Impaired cognitive ability/dementia
"evidenced by"
Signs/Symptoms: Poor po intake. Unintentional 30 lb. wt. loss since admission and decline of serum albumin since last quarter.

Nutrition Intervention(s):

  1. Modify distribution, type or amount of food and nutrients within meals or at specified time (ND-1.2)
  2. Commercial beverage (ND — 3.1.1)
  3. Feeding environment (ND — 5)

Goal: 1) Maintain weight between 138 and 154 pounds
2) Maintain BMI >17
3) Eat 10 meals a week in the Dining Room

Monitoring / Evaluation:

  • Energy Intake (FH — 1.1.1)
  • Mealtime behavior (FH — 5.4) and/or Caregiver fatigue during feeding process resulting in inadequate intake (FH — 5.4.7)
  • Weight (AD-1.1.2) and/or Weight change (AD-1.1.4) and/or BMI (AD — 1.1.7)
  • Albumin (BD-1.11.1)and/or Prealbumin (BD-1.11.2)
  • Estimated Energy Needs (CS — 1.1)

Recommendations:

  1. Continue to provide Pureed consistency diet.
  2. If/when less than 50% meal intake occurs, offer substitute first and then a high calorie liquid nutritional supplement.
  3. Offer high calorie snacks between meals and before bedtime including pureed preferences of : banana pudding, vanilla ice cream, peanut butter with syrup.
  4. Escort Mr. Smithers to the dining room for lunch and dinner no more than 15 min prior to meal service.
  5. Staff to sit and assist Mr. Smithers.
  6. Weigh Mr. Smithers weekly for one month and reassess.
  7. Notify the MD, RD and family if Mr. Smithers loses an additional 4 lbs despite interventions.

References

  • Nutrition care process and model part I: the 2008 update. Writing Group of the Nutrition Care Process/Standardized Language Committee. J Am Diet Assoc. 2008 Jul; 108(7):1113-7.
  • Nutrition care process part II: using the International Dietetics and Nutrition Terminology to document the nutrition care process. Writing Group of the Nutrition Care Process/Standardized Language Committee. J Am Diet Assoc. 2008 Aug; 108(8):1287-93.
  • International Dietetics & Nutrition Terminology Reference Manual - Third Edition