ADA NUTRITION CARE PROCESS AND MODEL

Screening & Referral

System
 Identify risk factors
 Use appropriate tools
and methods
 Involve
interdisciplinary
collaboration Nutrition Diagnosis
 Identify and label problem
Nutrition Assessment  Determine cause/contributing risk
 Obtain/collect timely and
factors
appropriate data  Cluster signs and symptoms/
 Analyze/interpret with defining characteristics
evidence- based standards
Document
 Document

Relationship
Between
Patient/Client/Group Nutrition Intervention
& Dietetics  Plan nutrition intervention
Professional  Formulate goals and
determine a plan of action
Implement the nutrition intervention
Nutrition Monitoring and  Care is delivered and actions
-
Evaluation are carried out
 Monitor progress  Document
 Measure outcome indicators
 Evaluate outcomes
 Document

Outcomes
Management System
 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
ADA’s Nutrition Care
Process Steps

 Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation
Nutrition Assessment
(Definition)
 “Asystematic process of obtaining,
verifying, and interpreting data in order to
make decisions about the nature and
cause of nutrition-related problems.”
 Lacey and Pritchett, JADA 2003;103:1061-
1072.
Nutrition Assessment
Components
 Gather data, considering
 Dietary intake
 Nutrition related consequences of
health and disease condition
 Psycho-social, functional, and
behavioral factors
 Knowledge, readiness, and potential for
change
 Compare to relevant standards
 Identify possible problem areas
Nutrition Assessment:
Critical Thinking
 Observing verbal and non-verbal
cues to guide interviewing methods
 Determining appropriate data to
collect
 Selecting assessment tools and
procedures and applying in valid
and reliable ways
 Distinguishing relevant from
irrelevant data
 Organizing data to relate to
nutrition problems
ADA’s Nutrition Care
Process Steps

 Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation
 Nutrition Diagnosis
 Nutritional problem that the dietitian is responsible for
treating
 Names and describes the problem
 Problem may already exist, or may be at risk of
occurring
 Not a medical diagnosis
 Type 2 diabetes = medical diagnosis
 Excessive carbohydrate intake resulting in elevated blood
glucose levels = nutrition diagnosis.
Nutrition Dx Domains:
Intake
Defined as “actual problems related to
intake of energy, nutrients, fluids,
bioactive substances through oral diet or
nutrition support (enteral or parenteral
nutrition)
 Class: Calorie energy balance
 Class: Oral or nutrition support intake
 Class: Fluid intake balance
 Class: Bioactive substances balance
 Class: Nutrient balance
 Nutrition Dx Domains:
Clinical
Defined as “nutritional findings/problems
identified that relate to medical or physical
conditions
 Class: functional balance (change in
physical or mechanical functioning with
nutritional consequences)
 Class: Biochemical balance: change in
capacity to metabolize nutrients as a result
of medications, surgery, or as indicated by
altered lab values
 Class: weight balance: chronic weight or
changed weight status when compared
with usual or desired body weight
Nutrition Dx Domains:
Behavioral-Environmental
Defined as “nutritional findings/problems
identified that relate to knowledge,
attitudes/beliefs, physical encironment, or
access to food and food safety
 Class: knowledge and beliefs
 Class: physical activity, balance and
function
 Class: food safety and access
Nutrition Diagnosis Components
 Problem (Diagnostic Label)
 Etiology (Cause/contributing risk factors)
 Signs/Symptoms (Defining characteristics)
 Signs = objective data = observable, measurable
changes
 Symptoms = subjective data = changes pt feels
and expresses
 Nutrition Diagnosis
Components
 Problem (Diagnostic Label)
 Describes alterations in pt’s nutritional status
 Diagnostic labels
 Impaired (nutrient utilization…)
 Altered (GI function…)
 Inadequate/excessive (calorie intake…)
 Inappropriate (intake of types of carbohydrate)
 Swallowing difficulty
Nutrition Diagnosis Components

 Etiology (Cause/Contributing Factors)

 Related factors that contribute to problem
 Identifies cause of the problem
 Helps determine whether nutrition intervention will
improve problem
 Linked to problem by words “related to” (RT)
 Note: etiology may not always be clear
Nutrition Diagnosis Components

 Etiology (Cause/Contributing Factors)

 Excessive calorie intake (problem) related to
regular consumption of large portions of high-fat
meals (etiology)
 Swallowing difficulty (problem) related to stroke
(etiology)
 Nutrition Diagnosis Components

 Signs/Symptoms (Defining characteristics)

 Evidence that problem exists
 Linked to etiology by words “as evidenced by”
Nutrition Diagnosis Components
 Etiology (Cause/Contributing Factors)
 Excessive calorie intake (problem) “related to”
regular consumption of large portions of high-fat
meals (etiology) as evidenced by diet history and
weight status
 Swallowing difficulty (problem) related to stroke
(etiology) as evidenced by coughing following
drinking of thin liquids (signs and symptoms)
Nutrition Diagnosis
 Excessive calorie intake (P)
 “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 (S & S)
 Nutrition Diagnosis Components
 Food, nutrition and nutrition-related
knowledge deficit (P) R/T lack of education
on infant feeding practices (E) as
evidenced by infant receiving bedtime
juice in a bottle (S)
 Altered GI function (P) R/T ileal resection (E)
as evidenced by medical history and
dumping syndrome symptoms after meals
(S)
Nutrition Diagnosis Components

Nutrition Diagnosis Statement should be:

 clear, concise
 specific
 related to one problem
 accurate – related to one etiology
 based on reliable, accurate
assessment data
 Nutritional vs Medical Dx
Medical Diagnosis Nutritional Diagnosis

Diabetes Excessive CHO intake r/t visits to Coldstone Creamery

as evidenced by diet hx and high hs blood glucose

Trauma and closed Increased energy needs r/t multiple trauma as

head injury evidenced by results of indirect calorimetry

Liver failure Altered gastrointestinal function r/t cirrhosis of the liver

as evidenced by steatorrhea and growth failure
 Nutritional vs Medical Dx

Medical Dx Nutritional Diagnosis

Obesity Excessive energy intake r/t lack of access to healthy food

choices (restaurant eating) as evidenced by diet history
and BMI of 35.

Dependence mechanical Excessive energy intake r/t high volume PN as evidenced

ventilation by RQ >1

Anorexia nervosa Undesirable food choices r/t history of anorexia nervosa

and self-limiting behavior as evidenced by diet history
and weight loss of 5 lb
ADA’s Nutrition Care
Process Steps

 Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation
 Nutrition Intervention
Definition
 “Purposely-planned actions designed with the
intent of changing a nutrition-related behavior, risk
factor, environmental condition, or aspect of health
status for an individual, a target group, or
population at large.” –
 Lacey and Pritchett, JADA 2003;103:1061-1072
 Directed at the etiology or effects of a diagnosis
Intervention Objectives
Should be patient-centered
 Must be achievable
 Stated in behavioral terms, quantifiable terms
 Pt and counselor must establish goals together
 may involve other members of health care team
 What will the patient do or achieve if objectives met
Intervention Objectives
 Problem 1: Involuntary weight loss
 Objectives:
 1. Pt will stop losing wt and begin to gain wt slowly,
to a target wt of 145#
 2. Pt will modify his diet to increase intake to meet
calorie and protein needs
Intervention Objectives
 Problem 2: Inadequate protein-energy intake 2° poor
appetite
 Objectives:
1. Pt will attend senior center for lunch
daily to improve socialization and calorie
intake
2. Pt will include nutrient-dense foods in
his diet
 Nutrition Intervention

 Intervention translates assessment

data into strategies, activities, or
interventions that will enable the
patient or client to meet the
established objectives.
 Interventions should be specific:
—What? —When?
—Where? —How?
 Nutrition Intervention
 Problem 1: Involuntary Weight loss
 Intervention:
 Pt will try to eat three meals a day plus bedtime snack
 Pt will include at least one nutrient-dense supplement per
day in his diet
 Pt will increase energy intake to 1800 kcal per day,
complete 3-day food record for analysis of adequacy
 Nutrition Intervention

 Problem 2: Inadequate protein-calorie intake 2°

poor appetite
 Intervention:
 Pt will include nutrient-dense foods with meals,
especially when appetite is minimal
 Patient will begin meal with nutrient-dense foods, follow
with others
 Pt will attend senior center for lunch daily to improve
socialization/appetite
ADA’s Nutrition Care
Process Steps

 Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation
Nutrition Monitoring & Evaluation
Components

Evaluate outcomes
Compare current findings
with previous status,
intervention goals, and/or
reference standards
 What gets Measured?
Nutrition
Monitoring
and Evaluation

Types of Outcomes

•Direct nutrition outcomes

•Clinical and health status outcomes
•Patient/client-centered outcomes
•Healthcare utilization

Intermediate-result outcome End-result outcome

Nutrition Goals and
Objectives
 Are necessary in order to evaluate the
effectiveness of nutrition care
 Should be achievable and based on
scientific evidence
 Should be directly or indirectly related to
nutrition care
 NCP Example: Acute Care
Nutrition Assessment
 Medical hx: 72 y.o. female admitted with
decompensated CHF; heart failure team consulted;
has been admitted with same dx x 2 in past month;
meds: Lasix and Toprol; current diet order: 2 gram
sodium; has lost 5 pounds in 24 hours since admission;
Output > input by 2 liters
 Nutrition history: has been told to weigh self 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
 NCP Example: Acute Care
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
 NCP
Nutrition Example: Acute Care
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
NCP Example: Acute Care
Monitoring and Evaluation
 Patient will weigh self 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