NF 381

Diet Therapy 1

Dr Hadil Subih
 www.mc.vanderbilt.edu

NUTRITION CARE PROCESS

and MODEL
 Nutrition Care Process (NCP) &
Model

“A systematic problem solving method that

dietetics professionals use to critically think
and make decisions to address nutrition related
problems and provide safe, effective, high
quality nutrition care.”
 Nutrition Care Process Steps
1 Nutrition Screening and
Assessment
2 Nutrition Diagnosis
Nutrition Planning and
3 Intervention
Nutrition Monitoring and
Evaluation noME

Document each step in the medical

 Nutrition Screening
• Conducted within 24 hours
of admission to health care
facility

• Identify nutritional risk, yet

simple enough to be
completed in 5 – 15
minutes
 Nutrition Assessment
• Obtain, verify and interpret data

• Compare to standards and identify

possible problem areas

• Review all the ABCD’s of

nutritional assessment including
psycho-social, functional &
behavioral factors

• Is a dynamic process and includes

re-assessment
 Nutrition Diagnosis
• Identify the
nutrition related
problem
• What is it about the
client that is the
dietitian’s concern?
• NOT a medical
diagnosis.
 PES
The Format
• Problem– label of diagnosis
• Etiology--cause and/or risk factors
contributing to diagnosis
• Signs or symptoms
Problem -- related to
Etiology-- as evidenced by
Signs or symptoms
 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 Excessive energy intake related to high
mechanical volume PN as evidenced by RQ >1
ventilation
Anorexia Inappropriate food choices related to
nervosa history of anorexia nervosa and self-
limiting behavior as evidenced by diet
history and weight loss of 5 lb
VitaminBo
Cracked mouth inadequate up tale in v1 m o
proteins
related to lack ofchicken fishes or
eredidencedbythe interviewand
the
as mouth
Cracked
External symptoms whichis
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 of
injury indirect calorimetry
Liver failure Altered gastrointestinal function related to
cirrhosis of the liver as evidenced by
steatorrhea and growth failure

highblood Cholesterol
saturated
 excessive uptake d stat re
and resultsofthe
baddiet bad lifestyle as evidenced
by
test
Falls into three general domains
• Intake (NI) gÉ IÉdgw
– Excessive or Inadequate intake compared to
requirements
• Clinical (NC)
– Medical or physical conditions that are outside
normal
• Behavioral/environmental (NB)
– Knowledge, attitudes, beliefs, physical
environment, access to food, food safety
 diagnosis

Nutrition Dx with S/S

Tosymptoms
• Excessive energy intake (P) signs
• “related to” regular consumption of large
portions of high-fat meals (E)
• “as evidenced by” diet history & 12 lb wt gain
over last 18 mo (Signs)
 PES
Excessive energy intake P

Related to eating frequently in fast food E

restaurants

As evidenced by BMI of 30 and diet S

history
Signs and Symptoms Direct Intervention and
Evaluation

Intervention/ Eval
P Excessive energy
intake
E RT eating Intervention: Counsel
frequently in fastpatient about best choices
food restaurantsin fast food restaurants (C-
2.4)
S As evidenced by Eval: Recheck weight (S-
BMI and diet 1.1.4) and diet history (BE-
history 2.1.1.) at next visit
 Nutrition Diagnosis Statement
Should Be
• Clear, concise to as
• Specific I a
• K
Related to one problem
•
ab
Accurate – related to one etiology is
• Based on reliable, accurate assessment data
Eta
 Evaluating your PES Statement

• Ex: Inadequate energy intake related to

decreased taste perception as evidenced by
diet history, medical dx and weight loss of 10
lb. during cancer tx
• Cannot treat the etiology (decreased taste
perception) but can treat S&S by
recommending foods with stronger flavors

o o
 g t.pk
intervention

0Bgii Nutrition Intervention

yiW w.b
Plan and implement actions to
address the identified nutrition
problem:
•
wind
Food and/or nutrient delivery (ND)
• Nutrition education (E)
• Nutrition counseling (C) M's
• Coordination of nutrition care (RC)
mtasurment et e
t.by
Mreassesmentnkh
www.t
Nutrition monitoring and evaluation
• Evaluation of outcomes
is
sina.j.biz
• Compare current results
a yÉ
YE
with previous results and
je compare to goals of
É
ja intervention and/or
reference standards
 NCP example
six
• MJ is 85 y.o. has lost >10% weight in the last 6
so
months
• Medical workup negative
• Oral supplement is ordered but patient
continues to lose weight
• Nutrition professional is consulted for enteral
feeding recommendations
• On assessment, it is found that patient’s 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
unintended weight loss related

to chewing difficulty as evidenced by

loss lessthan 10 of herweight
• Write a PES statement
for this patient! of loss
related to chewingdifficultyand
unenteded wheightloss
evidencedby
teeth as
of
losslessthan70

herweight
• Diagnosis: Inadequate energy intake related to
poorly fitting dentures and hoarding of oral
supplement as evidenced by observation and pt
interview
• Intervention: Nutrition professional orders
dental consult to reline dentures and chopped
diet; puts resident on supplement
NUTRITIONA
L
ASSESSMENT
ABCD’s
of nutritional
assessment:
•Anthropometric
•Biochemical
•Clinical
•Dietary
 ANTHROPOMETR
IC
Physical measurements
including:
● Height and weight
● Body mass index
● Triceps and other skin folds
● Midarm circumference
and midarm muscle
circumference
 0851015 on rim
• Anthropometric measurementsa can be used
to assess SOMATIC protein and energy
stores.
• Protein status is assessed by evaluating
both somatic and visceral protein status.
Somatic protein status is a measure of the
protein in skeletal muscle and adipose
E
tissues, while visceral protein status is a
measure of all otherco all
proteins (organs,
viscera, serum, blood cells, white blood
cells).
 Anthropometric gnaw
Marasmus D

They are often used to assess for

Marasmus=very low wt
Marasmus is a form of severe malnutrition
characterized by energy deficiency. BMI IG
Obesity= high wt and % body fat BMI
35
o
MARASM OBESI
US TY
BMI<16 BMI>35
 BODY MASS INDEX (BMI)
Range Meaning
Under 16 Anorexic 216
Between 16 and 20 Thin 16 20
Between 21 and 25 Ideal 21 25
Between 26 and 30 Overweight26 30
Between 31 and 35 Very Overweight3135
Over 35 Morbidly Obese as
 6 ft 1
in

803 245 lbs

BODY
lbs
MASS BMI=33
INDEX
BMI=109
 •Daniel Lambert, once the
heaviest man in England.
•He lived from 1770 - 1809.

•He weighed 336kg

•He was 5 ft 11 ins tall (180cm)

•What was his BMI?

http://www.middlecroft.com/malnutri.htm
 Biochemical Assessment
• Laboratory tests in blood,
plasma, serum, urine or Sec
tissues that help determine FI
status for a nutrient. TA im
It
– Blood is mainly composed of plasma,
serum, white blood cells and red blood
cells.
– The components of plasma and serum
are similar as both contain hormones,
glucose, electrolytes, antibodies,

L
antigens, nutrients and certain other
particles except clotting factors which
are present only in plasma.

I
Plasma – clotting factors = Serum
 9
9
serum Biochemical assessment
• Can help detect status of
many nutrients including
-Serum proteins
-blood forming nutrients
-vitamins (fat and water soluble)
-minerals
-disease related values
-enzymes: reported in ranges
(normal/healthy people)
 Examples: Albumin
5863 d
• Increased levels: dehydration, a high protein
diet.
• Decreased levels: malnutrition, pregnancy, A
acute or chronic inflammation, infection,
cirrhosis, liver disease, alcoholism, renal EE
disease, overhydration.
dilution of in
saltand meniral
in thebody
 Blood Urea Nitrogen (BUN)
congestive heart fail
ro
• Increased levels: GI bleeding, CHF, MI,
Myocardial
excessive protein intake, renal disease,
infraction
dehydration.
• Decreased level: Liver failure, malnutrition,
overhydration.
 CLINICAL ASSESSMENT
• Physical examination for signs and symptoms
of nutrition related disorders
• For example, signs and symptoms of protein
malnutrition include: edema, flaky paint
dermatitis, hair easily plucked, poor wound
healing, infections

Edemas tt
AsCiles
sH4Z61
 Dietary Assessment
• Dietary information is
collected through a tool
like a 24 hour recall, Food
frequency questionnaire
(FFQ), Food record.
• Strength and limitation
– What was eaten?
– How much was eaten?
– How often is this eaten?
• Dietary assessment data is then analyzed for
nutrient content and/or compared to standards:
• My plate guide
• Dietary Reference Intakes (DRI)
http://www.nal.usda.gov/fnic/etext/000105.htm
l
• Food analysis-
http://www.nat.uiuc.edu/mainnat.html on the
WEB or other sites or software

www.looklocally.com
 NCP example 1
Medical hx: 72 y.o. female admitted with decompensated
CHF; heart failure team consulted; has been admitted with
same dx 2x in past month; meds: Lasix and Toprol; current
diet order: 2 grams sodium; has lost 5 pounds in 24 hours
since admission; Output > input by 2 liters

• Nutrition history: has been told to weigh herself daily but has
no scale at home. Does not add salt to foods at the table.
Noticed swollen face and extremities on day prior to
admission. Day before admission ate canned soup for lunch
and 3 slices of pizza for dinner; does not restrict fluids; has
never received nutrition counseling
 Nutrition Diagnosis
• Excessive sodium intake r/t frequent use of canned
soups and restaurant foods as evidenced by diet history.
• Knowledge deficit r/t no previous nutrition education as
evidenced by frequent use of high sodium convenience
foods and inability to name high sodium foods.
• Excess fluid intake r/t dietary indiscretions as evidenced
by diet hx and current fluid status.
• Self-monitoring deficit r/t lack of access to scale as evidenced
by patient self report.
 Nutrition intervention
Excessive sodium intake: Patient will attend Senior
Feeding site that provides low sodium meals; Patient will
implement survival skills low sodium diet principles and
attend heart failure diet program in heart failure clinic.
• Self-monitoring deficit: Patient will obtain free home
scale from CHF case manager; will limit fluids to 2 liters/
day per instructions in Heart Failure Clinic if adherence
to low sodium diet does not achieve appropriate fluid
balance.
 Monitoring and Evaluation
• Patient will weigh himself daily and keep log; report
to heart failure case manager if weight ↑ 2 lb in 24
hours
• Patient will bring 3 day diet record to heart failure
clinic for review by dietitian
• Heart failure case manager will track hospital
readmissions over 12 months
 NCP: Example 2
JW is a 70 yr. old white man admitted for cardiac bypass
surgery. The nutrition risk reveals that he has lost weight
without trying and has been eating poorly for several weeks
before admission, leading to referral to the RD for nutrition
assessment.
• Caloric intake: 1,200kcal/day (less than energy requirements
as stated in the recommended dietary allowances).
Meals: irregular throughout the day; drinks coffee frequently.
History: of hypertension, thyroid dysfunction, asthma, prostate surgery.
JW lives alone in his own home. He lost his wife 3 months ago,
and for the past 6 months he rarely sits down to a cooked
meal.
 Nutrition diagnosis
• Involuntary weight loss related to missing meals as
evidenced by loss of 15 lbs over 3 months.
• Inadequate oral food and beverage intake
…………
 Nutrition Intervention
Diagnosis 1: Involuntary weight loss
• During the hospitalization JW will maintain his
current weight, following discharge he will begin to
slowly gain weight up to a target weight of 145lb
• JW will modify his diet to include adequate calories
and protein through the use of nutrient-dense foods to
prevent further weight loss and eventually promote
weight gain.
• Diagnosis 2: Inadequate oral food and beverage
intake
• While in the hospital JW will include nutrient-
dense foods in his diet, especially when his
appetite is limited.
• Following discharge JW will attend a local
senior center for lunch on a daily basis to help
improve his socialization and caloric intake.