ND140 NUTRITION CARE PROCESS YEAR: 2

TERM: 2

Chapter 4.3 texture of foods (or thickness • feeding assistance

Nutrition Intervention of beverages), providing
enteral or parenteral
• managing feeding
environment
nutrition, assisting with
meals, having mealtime
Definition and Purpose environments that optimize
nutritional intakes, and
• 3rd step of the Nutrition Care Process managing nutrition-related
medication appropriately
• Specific set of activities and associated materials used to
address the problem • formal process to instruct or • Content (Purpose of
• Purposely planned action(s) designed with the intent of Nutrition
train a client in a skill; impart NE)
changing a nutrition-related behavior, risk factor, knowledge • Nutrition Education-
Education
• tends to be fact-based and Application (Result
environmental condition, or aspect of health status to (NE)
includes ways of improving Interpretation)
resolve or improve the identified nutrition diagnosis/es or patient knowledge and skills
nutrition problem(s)
• Involves • supportive process by a • Theoretical
o Selecting collaborative counsellor- Basis/Approach
client relationship o Cognitive
o Planning • establishes food, nutrition, Behavior Theory
o Implementing appropriate actions to meet the and physical activity o Health Belief
client or groups’ nutrition needs priorities, goals, and action Model
• Selected and tailored to the needs by planning and plans o Social Learning
• involves helping patients Theory
implementing appropriate interventions identify and solve their own o Transtheoretical
• driven by nutrition diagnosis issues in nutrition Model/Stages of
• provides basis upon which outcomes are measured and Nutrition o behavior change change
evaluated Counseling • counseling models • Strategies
• helps to establish priorities o Motivational
• must be based on scientific principles and rationale, and, and goals Interviewing
when available, grounded in a high level of quality research • strategies o Goal Setting
(evidence-based) o motivational o Self-monitoring
• dietetic professionals interviewing
o self-monitoring
o may actually do the interventions, or may o problem solving
delegate or coordinate nutrition care that others o social support
provide o stimulus control
o may work collaboratively with the client or group, o stress management
and the family or caregiver
• consultation with, referral to, • Collaboration and
• client-driven or coordination of nutrition Referral of Nutrition
o key element in the success of intervention care with other healthcare Care
providers, institutions, or o Team meeting
agencies that can assist in o Referral to RND
Determining Nutrition Interventions treating or managing with different
nutrition-related problems expertise
• nutrition diagnosis and its etiology drive the selection of • underlines the importance of • Discharge and Transfer
Coordination dietitians working within of Nutrition Care to
nutrition interventions of Nutrition interdisciplinary or New Setting or Provider
• typically directed toward resolving the nutrition diagnosis by Care multidisciplinary teams to
altering or eliminating the nutrition etiology achieve the best possible
nutrition outcomes
• less often directed at relieving the signs and symptoms of a • may include consulting with,
nutrition problem referring to, or coordination
• provides basis upon which outcomes are measured and nutrition care with other
evaluated health professionals,
institutions, or dietitians with
specialist skills
Data Sources / Tools for Interventions
Population- • interventions designed to
based improve the nutritional well-
• Evidence-based nutrition guides for practice and protocols Nutrition being of a population
(e.g. PPAN programs) Action
• Current research literature
• Current consensus guidelines and recommendations from
other professional organizations
Steps
• Results of outcomes management studies or Continuous
Quality Index projects 1. Planning the nutrition intervention (formulate and determine
• Current patient education materials at appropriate reading a plan of action)
level and language • Prioritize nutrition interventions based on
• Behavior change theories (self-management training, urgency, impact, and available resources
motivational interviewing, behavior modification, modelling) • Collaborating with the client to identify goals
(desired changes) of the intervention for each
Domains of Nutrition Intervention diagnosis
§ expected outcomes should be written in
observable and measurable terms that
Domains Description Examples of Codes are clear and concise; tailored to what
is reasonable to the patient’s
• customized approach for • meals and snacks
Food and/or food/nutrient provision
circumstances and appropriate
• enteral and parenteral
Nutrient • includes prescribing nutrition expectations for treatments and
Delivery nutritionally fortified meals, • nutrition supplement outcomes
adding high-protein or high- therapy • nutrition prescription
energy snacks, changing
ND140 NUTRITION CARE PROCESS
§ based on a client’s customized
recommended dietary intake of energy
and/or selected food or nutrients based
on current reference standards and
dietary guidelines and a client’s health
condition and nutrition diagnosis
• Select specific nutrition intervention strategies
that are focused on the etiology of the problem
and that are known to be effective based on best
current knowledge and evidence
• Define the time and frequency of care, including
intensity, duration, and follow-up
2. Implementation is the action phase and calls for the
dietetics professionals to:
• communicate the plan of nutrition care;
• carry out the plan of nutrition care; and
• continue data collection and modify the plan of
care as needed.
• other characteristics that define quality
implementation include:
• individualize the interventions to the setting and
client;
• collaborate with other colleagues and health care
professionals;
• follow up and verify that implementation is
occurring and needs are being met; and
• revise strategies as changes in
condition/response occurs.
Critical Thinking Skills
Critical thinking
• required to determine which intervention strategies are
implemented based on analysis of the assessment data
and nutrition diagnosis
Types Needed in the Intervention Step
• Setting goals and prioritizing;
• transferring knowledge from one situation to another;
• defining the nutrition prescription or basic plan;
• making interdisciplinary connections;
• initiating behavioral and other interventions;
• matching intervention strategies with client needs,
diagnoses, and values;
• choosing from among alternatives to determine a course of
action; and
• specifying the time and frequency of care.
Documentation of Nutrition Interventions
• on-going process that supports all of the steps in the
Nutrition Care Process
• should be relevant, accurate, and timely; supports further
intervention or discharge from care
• should include changes in the client’s level of
understanding and food-related behaviors, changes in
clinical or functional outcomes
• includes
• date and time
• specific treatment goals and expected outcomes
• recommended interventions, individualized for
patient
• any adjustments of plan and justifications
• patient receptivity
• referrals made and resources used
• any other information relevant to providing care
and monitoring progress over time
• plans for follow-up and frequency of care
• rationale for discharge (if appropriate)
YEAR: 2
TERM: 2
Chapter 4.4
Nutrition Monitoring and Evaluation
Definition and Purpose
• 4th step of the Nutrition Care Process
• Monitoring
o Refers to the review and measurement of a
client’s status at a scheduled (pre-planned)
follow-up point with regard to the nutrition
diagnosis, intervention plans/goals, and
outcomes
• Evaluation
o Systematic comparison of current findings with
previous status, intervention goals, or a reference
standard
• Use selected outcome indicators (markers) that are
relevant to the client’s defined needs, diagnosis, goals, and
disease state
• Determines the degree to which progress is being made
• Requires active commitment to measuring and recording
the appropriate outcome indicators
• Promotes more uniformity within the dietetics profession in
assessing the effectiveness of intervention
• Data is used to create an outcomes management system
• First interaction = appropriate outcomes are selected to be
monitored and evaluated at the next interaction
• Subsequent interactions = outcomes are used to
demonstrate amount of progress
• Factors to consider when selecting indicators
o Medical diagnosis
o Healthcare outcomes
o Client goals
o Nutrition quality management goals
o Practice setting
o Client population
o Disease state or severity
• Progress should be monitored, measured, and evaluated
on a planned schedule until discharge
o short inpatient stays and lack of return for
ambulatory visits do not preclude monitoring,
measuring, and evaluation
o innovative methods
§ confidential self-report via mailings
§ telephone follow-up
o changes in nutritional status
o alterations in outcome indicators (e.g. hemoglobin
A1C, weight)
Data Sources / Tools for Monitoring and Evaluation
• Patient/client/group records
• Anthropometric measurements, laboratory tests,
questionnaires, surveys
• Patient/client/group (or guardian) interviews/surveys, pre-
tests, and post-tests
• Mail or telephone follow-up
• ADA’s Evidence Based Guides for Practice and other
evidence-based sources
• Data collection forms, spread sheets, and computer
programs
Types of Outcomes Collected
• outcome(s) to be measured should be directly related to
the nutrition diagnosis and the goals established in the
intervention plan; examples include:
o Direct nutrition outcomes
§ knowledge gained
§ behavior change
§ food or nutrient intake changes
ND140 NUTRITION CARE PROCESS YEAR: 2
TERM: 2

§ improved nutritional status 3. Evaluate outcomes

o clinical and health status outcomes • compare current findings with previous status,
§ laboratory values intervention goals, and/or reference standards
§ weight
§ blood pressure Critical Thinking
§ risk factor profile changes
§ signs and symptoms • selecting appropriate indicators/measures
§ clinical status • using appropriate reference standard for comparison
§ infections
• defining where client is now in terms of expected outcomes
§ complications
• explaining variance from expected outcomes
o patient/client-centered outcomes
• determining factors that help or hinder progress
§ quality of life
§ satisfaction • deciding between discharge or continuation of nutrition
§ self-efficacy care
§ self-management
§ functional ability Documentation of Monitoring and Evaluation
o health care utilization and cost outcomes
§ medication changes • ongoing process
§ special procedures • supports all of the steps in the NCP
§ planned/unplanned clinic visits • integral in monitoring and evaluation activities
§ preventable hospitalizations • should be relevant, accurate, and timely
§ length of hospitalization • includes statement of where client is now in terms of
§ prevent or delay nursing home expected outcomes
admission • enables pooling of data for outcomes measurement and
quality improvement purposes
Domains of Nutrition Monitoring and Evaluation • includes
o date and time
• food and nutrient intake o specific indicators measured and results
• food and nutrient administration o progress toward goals (incremental small change
• medication
can be significant therefore use of a Likert type
Food/Nutrition-related • complementary/alternative medicine use
History Outcomes • knowledge/beliefs scale may be more descriptive than a “met” or
• food and supplies availability “not met” goal evaluation tool)
• physical activity o factors facilitating or hampering progress
• nutrition quality of life o other positive or negative outcomes
• height o future plans for nutrition care, monitoring, and
Anthropometric • weight
Measurement • body mass index (bmi) growth pattern
follow up or discharge
Outcomes indices/percentile ranks
• weight history Determination of Continuation of Care
Biochemical data, • lab data (e.g. electrolytes glucose) and tests
Medical Tests, and (e.g. gastric emptying time, resting metabolic
Procedure Outcomes rate) • decision to actively continue care or discharge the client
• physical appearance from nutrition care
Nutrition-Focused
Physical Finding
• muscle and fat wasting o when necessary and appropriate nutrition care is
Outcomes
• swallow function completed or no further change is expected at
• appetite this time
• if nutrition care is continued
Collection and Use if Nutrition Monitoring and Evaluation o process cycles back as necessary to
Outcome Data assessment, diagnosis, and/or intervention
o refinement of the diagnosis, and adjustment
• three components and/or reinforcement of the plan
• if nutrition care does not continue
1. Monitor progress o patient may still be monitored for a change in
• check patient/client/group understanding and status and reentry to nutrition care at a later date
compliance with plan
• determine if the intervention is being Choosing an Appropriate Nutrition Intervention
implemented as prescribed
• provide evidence that the plan/intervention • ensure practice is up to date by consulting evidence-based
strategy is or is not changing patient/client/group guidelines and policies
behavior or status • discuss possible interventions with the client and their
• identify other positive or negative outcomes family in relation to nutrition care
• gather information indicating reasons for lack of • identify the expectation of client and family in relation to
progress nutrition care
• support conclusions with evidence • create a specific Nutrition Prescription that meets the
patient's nutritional requirements
2. Measure outcomes o address any additional needs they express
• select outcome indicators that are relevant to the • Develop a plan follow-up appointments
nutrition diagnosis or signs or symptoms, nutrition
goals, medical diagnosis, and outcomes and Note: not all conditions can be resolved through dietetic intervention
quality management goals
• use standardized indicators to
o Increase the validity and reliability of
measurements of change
o Facilitate electronic charting, coding,
and outcomes measurement
ND140 NUTRITION CARE PROCESS YEAR: 2
TERM: 2

Chapter 5 • Medical directives

o Do not resuscitate orders
Documentation of Nutritional Care Process o Living will
o Other documents that outline what is
Medical Record and what isn’t wanted by a patient if
unable to communicate
• Objective source of data
• Contains valuable patient information Standard Language and Medical Abbreviations
• Should be kept confidential
• Explains all detail about the patient’s history, clinical *Refer to glossary of medical abbreviations
findings, diagnostic test results, pre- and post-operative
care, progress, and medication Problem-Oriented Medical Record (POMR)
• Characteristics
o Legible • gives emphasis to client’s perceptions of their problems
o Accurate
• requires continuous evaluation and revision of the care
o Documentation is presented in an orderly manner
plan
• provides greater continuity of care among health- care
Purposes team members
• enhances effective communication among health-care
1. Record information from the patient team members
2. Record caregivers findings and (planned) treatments
• increases efficiency in gathering data
3. Communicate information to other caregivers
• all data base is collected before beginning of identifying the
4. Coordinate the activities of caregivers
patient problem
5. Serve as a formal (legal/financial) record
6. Provide data for studies and research
Organization and Nutrition Documentation
Access
Documentation
1. Property of the hospital or patient’s medical practitioner • not separate from care; not optional
o Cannot be released without patient’s permission • any written or electronically generated information about a
2. All patients have right to access and obtain copies of their client that describes client status or the care or services
records provided to that client
3. Patient’s legal representative has the right as long as
patient has signed a release of records to accompany any Narrative Documentation
request from the legal representative • traditional method for recording health care provided
4. Other healthcare providers (if directly involved in the care • story-like format to document information specific to client
and treatment of the patient) conditions and health care
5. Parents of a minor • data are recorded in the progress notes without an
6. When summoned in a court of law (e.g. traffic accidents, organizing framework
medical negligence, insurance claim) • often requires the reader to sort through information to
7. Researchers (if patient’s identity is not revealed) locate the data required

Components Subjective Data, Objective Data, Assessment, Plan (SOAP)

1. Identification information • problem-oriented technique whereby the care provider

o 1st part of medical record identifies and lists the patient’s health concerns
o name • commonly used in primary health care settings such as in
o date of birth the community health centers, rural health units, and
o PhilHealth number or government-issued private clinics
identification number • used still in secondary health facilities
o date of admission
o other personal information (socioeconomic Problem, Etiology, Signs & Symptoms (PES)
background)
• structured sentence that describes the specific nutrition
2. Patient’s Medical History problem
o past and present diagnosis • needed for all nutrition assessments except those with “no
o medical care nutrition diagnosis”
o treatments
• format of documentation
o allergies
• may be used with the other documentation format in one
o current food intake (if monitoring is needed)
chart
3. Medication History
• all that is taken by the patient (drug alternatives,
over the counter medications, prescription
medications)

4. Family Medical History

5. Treatment History and Medical Directives

Assessment, Diagnosis, Intervention, Monitoring and
• All treatment given and their efficacy
• Collaborative care provided by each group of Evaluation (ADIME)
healthcare professional
• Therapy (physical, nutrition, psychological, etc.) Assessment
ND140 NUTRITION CARE PROCESS
Food/Nutrition-related History Intake,
administration
(oral/enteral nutrition/parenteral
nutrition), intravenous fluid, medication
and herbal
supplements, knowledge/beliefs/attitude
s, seen by dietitian previously, behavior,
meal-time behaviors, feeding difficulties,
nutrition-related activities of daily living,
nutrition-related quality of life, readiness
to change, access to food, physical
activity and function
Anthropometric Measurements Height,
weight, weight history, BMI,
growth pattern indices/percentile, hand-
grip strength, mid-upper arm
circumference, Subjective Global
Assessment
Biochemical Data, Medical Tests
and Procedures
Examples include laboratory data,
fluid balance tests, gastric residual
volume, resting metabolic rate
Diagnosis
Problem—Use nutrition diagnoses terminology
Etiology—“Root cause,” can use free text
Signs and Symptoms—Quantifiable data, basis for monitoring and evaluation
outcomes, free text. If no Nutrition Diagnosis: “No nutrition diagnosis exists”
Synthesize all assessment data
1. Inadequate oral intake as related to cancer treatment and associated
nausea, vomiting and inability to prepare meals as evidenced by BMI: 15
kg/m2 and 20% loss of body weight in 3/12 and consuming only 2 small
meals/day
2. Inadequate protein–energy intake as related to poor appetite and elevated
requirements as evidenced by patient consuming ~50% of requirements 1 000
kcal (4 000 kJ) and 40 g protein/day
Intervention
Nutrition Prescription/Goal
Nutrition Intervention
Food and/or Nutrient Delivery
Meal and snacks
Enteral and parenteral nutrition
Oral or vitamin/mineral supplement
(type frequency)
Feeding assistance (opening packages)
and environment
Nutrition-related medication
management, such as. anti-emetic
Nutrition Education
What was provided? What resources
given?
Nutrition Counseling
Theoretical basis, such as
cognitive behavioral
therapy
Strategies, such as counseling, goal
setting, rewards
Coordination of Nutrition Care
Coordination of care with others,
such as food charts, weight
Nutrition-Focused Physical
Findings Muscle and
subcutaneous fat wasting,
oral health, cognition, bowels,
pressure injury, vital signs,
nutrition impact symptoms
Client History Personal (age,
language, literacy),
medical, family and social
history (housing,
economic considerations),
recent crisis, supports
Comparative Standards
Estimated needs and method for
estimating (Schofield),
weight/growth recommendation
s. Must contain all evidence for
etiology and signs and
symptoms
Nutrition Assessment,
Monitoring and Evaluation
Tools
Tools used for health or disease
status or risk assessment,
reassessment, and
monitoring and evaluation such
as subjective global assessment
tool ratings,
nutrition assessment tool
ratings, household food security
tool ratings, food variety tool
ratings
Prescription—Patient’s
individualized recommended
dietary intake
of energy/selected food or
nutrients based on
reference standards or dietary
guidelines
Example—Increase intake by 1
000 kcal (4 000 kJ) and
40 g protein/day to provide 2
000 kcal (8 000 kJ)
90 g protein (1.5 g/kg)
Goal—High-energy, high-
protein diet for weight
maintenance during admission
Plan
Commence oral nutrition
supplements providing 1000
kcal
(4000 kJ) and 45 g protein
Educate patient and
family on importance
of nutrition weight
maintenance and
optimal treatment
outcomes. Education
resources provided
YEAR: 2
TERM: 2
Discharge and transfer of
nutrition care
Monitoring and Evaluation
Follow-up Time Includes
Information to be assessed at
What will you assess at review? next review to determine if
goal/prescription
and interventions have been
Food/Nutrition-related History
implemented and are effective
Anthropometric measurements
Signs and symptoms from PES
Biochemical data, medical tests,
Statements Data for monitoring
procedures Nutrition-focused physical
progress (patient understanding
findings
or compliance with intervention),
Nutrition assessment, monitoring,
measurement and evaluation of
and evaluation tools
outcomes (data to compare to
nutrition goals). Prescription to
determine further action
Intervention, Evaluation, Revision of Care (IER) Notes
• simplified SOAP
• Problem, Etiology, Signs & Symptoms (PES)
• structured sentence that describes the specific nutrition
problem
• intervention
§ intervention was identified and changed to meet
client’s needs
• evaluation
o how outcomes are evaluated
• revision of care
o changes to the original problem come from
revised interventions, outcomes of care, or
timelines used to denote changes
Problems, Intervention, Evaluation (PIE) Notes
• numbered or labeled according to the client’s problems
• resolved problems are dropped from daily documentation
after the RND’s review
• continuing problems are documented daily
Charting by Exception
• recording only unusual or out-of-the ordinary events or the
problem
Guidelines in Charting
• standardized
• should be followed no matter what organizational style is
used
• lifted from nursing profession
• most important law to observe = Data Privacy Act
• initial entry and assessment
o narrative notes include all patient care activities
(e.g. diet, hygiene, ambulation, etc.) or family,
tests, specific problems
• all entry are signed and dated
o every timed entry must have a legal signature
§ 1st initial, last name and legal status
o last entry on a page must have a legal signature
§ plan the last entry on a page so it has
a logical statement and signature
o each page of notes is a legal document must be
dated and signed
§ A note made by students should be
countersigned by an Instructor or
practicum supervisor fro validity.
ND140 NUTRITION CARE PROCESS YEAR: 2
TERM: 2

DOs DONTs Sample Medical Nutrition Therapy Case Study Format

Check that you have

the correct
chart before you write
Chart a patient's refusal to allow
treatment. Be sure to report this to
the patient's physician.
Write "late entry" and the
date and time if you forgot to
document something. Sign
the late entry notes.
Write often enough to tell the whole
story
Chart preventive measures.
Chart contemporaneously
(contemporaneous notes are
credible).
Chart a verbal order unless you 1. Overview of the Patient
a. socio-demographic characteristics
have received one
b. Past Medical History
Chart a symptom (for instance: c. Current Medical History
d. Diagnosis
complaint of excessive thirst),
without also charting what you e. Description of the disease (pathophysiology, risk
did about it factors)
Wait until the end of the day 2. Medical Nutrition Therapy
and rely on memory. a. Prescribed diet
b. Description of the diet
c. Meal plans
Ever alter a record. If you make an
error, do mark through it with one
d. Diet guides
line, indicate you are making a
correction, and initial (or sign) and 3. Nutrition Care Process of the Patient- document the 4
date steps:
a. Assessment
Document what someone else
said they heard, saw, or felt
b. Diagnosis
(unless the information is critical c. Intervention
-- then quote and attribute d. Monitoring & Evaluation
sources).
4. Follow-up Assessment
Write trivia: "a good day." (What
does that mean?)

Be imprecise. Avoid
Write legibly, offering concise,
terms like "large
clear notes reflecting facts
amounts" and "appears."

Chart what you report to other Write your opinions.

healthcare providers.

Chart solutions as well as Blanket chart or pre-

problems. chart. It is considered
fraud to chart that you've
done something you
didn't do

Document your observations.

Write only what you see,
hear, feel, or smell.

Encourage others to
document relevant
information that they share
with you

Document circumstances and

handling of Errors

Chart your efforts to answer your

patients' questions.

Chart patient/family teaching and

Response

Chart all referrals/support efforts.

Gather Information from a Patient History

using a Case Study

• some information needed to come up with appropriate

intervention need to be gathered first hand from the patient
• generally aims to generate information to be used to
identify prevailing nutrition problem and formulation of
possible solutions/interventions
• may include secondary data gathering like literature
reviews (e.g. nature of the disease, intervention that are
found effective for a particular condition)
• actual interview with the patient is recommended