LESSON 6: NUTRITION INTERVENTION ND 206

Nutrition Care Process

NUTRITION INTERVENTION
▪ Purposefully planned action/designed with the
intent of changing a nutrition-related behavior,
risk factor, environmental condition or aspect of
nutritional health status.
▪ Must include identification of the goals and
objectives of nutrition care.
▪ Aimed at resolving the etiology or underlying
1. PLANNING (FORMULATER AND DETERMINE
cause of the nutrition problem.
▪ Minimize the signs/symptoms of the nutrition
problem
NUTRITION INTERVENTION OBJECTIVES
▪ Patient-centered, achievable, stated in behavioral
terms and quantifiable terms
▪ May involve other members of health care team
▪ Indicate what patient will do or achieve if
objectives are met
▪ Translates assessment data into strategies,
activities, or interventions that will enable to the
patient to meet the established objectives
FOUR DOMAINS OF NUTRITION INTERVENTION
▪ Food and Nutrient Delivery (ND)
▪ Nutrition Education (E)
▪ Nutrition Counseling (C)
▪ Coordination of Nutrition Care by a Nutrition
Professional (RC)
FOOD AND/ OR NUTRIENT DELIVERY (ND)
Individualized approach for food/nutrient provision.
COORDINATION OF NUTRIENT CARE (RC)
▪ Consulting with and referring to other health
professionals
▪ Coordination of nutrition care with other
healthcare providers/institutions/diet itians with
special skills
STEPS IN NUTRITION INTERVENTION
PLAN OF ACTION)
▪ Prioritize nutrition diagnosis based on severity of
problems; safety; patient’s needs; likelihood that
intervention will impact problem.
▪ Consult evidence-based guidelines and policies
▪ Determine patient-focused outcomes for each
diagnosis.
▪ Define nutrition care plan (nutrition
prescription, time and frequency of care, etc)
▪ Confer with patients/relatives
2. IMPLEMENTATION
▪ Communicate the plan of nutrition care
▪ Carry out the plan of nutrition care
▪ Continue data collection and modify plan of care
as needed.
NUTRITION PRESCRIPTION
▪ The opening action in the Nutrition Intervention
▪ Should state the individual’s recommended
energy and nutrient intake based on current
reference standards and dietary guidelines

▪ Prescribing nutritionally fortified meals EXAMPLE:

▪ Adding high-protein or high energy snacks
Diet Rx: 1800 kcal, 225g CHO, 90g Protein, 60 grams Fats
▪ Changing textures of food or beverages
divided into 3 meals and 2 snacks, 2g Sodium, < 200 mg
▪ Providing enteral or parenteral nutrition
Cholesterol
▪ Having mealtime that optimize nutritional
intakes HOW TO CHOOSE AN APPROPRIATE NUTRITION
▪ Managing nutrition-related medications INTERVENTION
appropriately 1. Decide which of the Nutrition Diagnosis
takes priority.
NUTRITION EDUCATION (E) 2. Use/ Consult appropriate evidence-based
▪ Instruct or train a patient in a skill guidelines and policies.
▪ Impart knowledge 3. Discuss possible interventions with the
▪ Examples: individual and his/her family.
o reading food labels, 4. Identify the expectations of the individual
o making recipe modifications and his/her family in relation to nutrition
care.
NUTRITION COUNSELING (C)
▪ Collaborative counselor patient relationship 5. Create a specific Nutrition prescription that

▪ helps patients identify and solve their nutrition- meets patient’s nutritional needs

related problems. 6. Develop a plan for follow-up/review

▪ Assists individuals with establishing priorities consultations.

and goals.

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 EXAMPLE: NUTRITION INTERVENTION
EXAMPLE #1:

Disordered eating pattern related to unsupported

beliefs/attitudes about food or nutrition-related
topics as evidenced by reported use of laxative
after meals and statements that calories are not
absorbed when laxatives are used.

Nutrition Intervention:

NUTRITION COUNSELLING

EXAMPLE #2:

Swallowing difficulty related to post stroke

complications as evidenced by results of
swallowing tests and reports of choking during
mealtimes

Nutrition Intervention:

Food and Nutrient Delivery: TEXTURE-

MODIFIED DIET

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LESSON 7: NUTRITION MONITORING AND EVALUATION ND 206
Nutrition Care Process

NUTRITION MONITORING AND EVALUATION 4 TYPES OF OUTCOMES

▪ Monitoring – refers to the review and 1. DIRECT NUTRITION OUTCOMES
measurement of the patient’s status at a ▪ Behavior change, food or nutrient intake
scheduled follow-up point with regard to the nut changes, improved NS, knowledge gained
dx, intervention plans, and outcomes 2. CLINICAL AND HEALTH STATUS OUTCOMES
▪ Evaluation – systematic comparison of current ▪ Lab values, weight, BP, risk factor profile
findings with previous status, intervention goals, changes, signs and symptoms, clinical status,
or a reference standard infections
▪ Use selected outcome indicators (markers) that 3. CLIENT-CENTERED OUTCOMES
are relevant to the patient’s defined needs, nut ▪ Quality of life measures, satisfaction, self-
dx, nut goals, and disease state efficacy, self-management, and client’s
▪ To determine the degree to which progress is functional ability
being made and goals/desired outcomes of 4. HEALTHCARE UTILIZATION AND COST
nutrition care are being met OUTCOMES

▪ Requires an active commitment to measuring ▪ Medication changes, special procedures,

and recording the appropriate outcome planned/unplanned clinic visits, preventable

indicators relevant to the nut dx and intervention hospitalizations, length of hospitalization, or

strategies prevention/delay of nursing home admission

▪ Used to create an OUTCOMES CATEGORIES IN NUTRITION MONITORING AND

EVALUATION
MANAGEMENT SYSTEMS
1. Food and Nutrition Related History (FH) Outcomes
OUTCOMES MANAGEMENT SYSTEMS
2. Anthropometric Measurements (AD) Outcomes
1. Monitor progress
3. Biochemical Data, Medical Tests and Procedures (BD)
2. Measure outcomes
Outcomes
3. Evaluate outcomes
4. Nutrition-Focused Physical Findings (PD) Outcomes
MONITOR PROGRESS
EXAMPLES
▪ Check patient/client/group understanding and
compliance with plan
▪ Determine if the intervention is being
implemented as prescribed
▪ Provide evidence that the plan/intervention
strategy is or is not changing patient/client/group
behavior or status
▪ Identify other positive or negative outcomes
▪ Gather information indicating reasons for lack of
progress
▪ Support conclusions with evidence
MEASURE OUTCOMES
▪ Select outcome indicators that are relevant to the
nutrition diagnosis or signs or symptoms,
nutrition goals, medical diagnosis, and outcomes
and quality management goals
▪ Use standardized indicators to increase the
SAMPLE CASE – DIALYSIS PATIENT
validity and reliability of measurements of
▪ Assessment Data:(sources of info): diet recall,
change; and facilitate electronic charting, coding
monthly serum phosphorus level.
and outcomes management
▪ PES: Excessive mineral intake of Phosphorus
EVALUATE MEASURES (NI5.10.6) related to overconsumption of high
▪ Compare current findings with previous status,
Phosphorus foods and not taking Phosphate
intervention goals, and/or reference standards
Binders as evidenced by hyperphosphatemia
▪ Intervention: Teaching patient about use of
taking phosphate binders with meals and

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 instruction on high phosphorus foods to limit to
<1200mg/day
▪ Monitoring and Evaluation: Phosphorus levels
(goal ≤ 5.5mg/dL); keeping records of P intake
from food and binders
SAMPLE CASE – GASTROESOPHAGEL REFLUX
DISEASE (GERD)
▪ Assessment: Diet recall
▪ PES: Undesirable food choices (NB-1.7) related to
lack of prior exposure to accurate nutrition-
related information evidenced by alcohol intake
of ~10 drinks/week and high fat diet and
complaints of heart burn.
▪ Intervention: Educate and counsel patient on
dietary management of GERD and the role of
alcohol and fat in promoting heart burn.
▪ Monitoring and Evaluation: Report of decreased
alcohol and fat consumption and less heart burn
and discomfort.

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LESSON 8: DOCUMENTATION OF NUTRITIONAL CARE PROCESSES ND 206
Nutrition Care Process

MEDICAL RECORD Basic Components:

▪ a permanent legal document that records the
1. Data Base - History, Physical Exam and
client’s history, assessment and diagnosis.
Laboratory Data
▪ Serves to:
2. Complete Problem List
o Maintain a strong professional network
3. Initial Plans
-> inform all members
4. Daily Progress Note
o Provide a framework for intervention,
5. Final Progress Note or Discharge Summary
re-assessment or follow-ups
o Facilitate continuity of care Documentation
o Evaluate impact of MNT and cost-
▪ Who, where, why, how
benefit and cost-effectiveness
▪ “if it is not written, consider it undone”
o Provide info on referral for other
▪ General guidelines:
services
o Legal documents, ink
COMPONENTS OF MEDICAL RECORDS o Accurate, complete, clear, concise info
1. Identification information o Enter info immediately
2. Medical History o Each page is identified by client’s name
3. Medication Information and record number, date, time
4. Family History o Only standard abbreviations
5. Treatment History o Sign all entries, complete
6. Medical Derivatives o Co-signed by C.I. if interns
7. Laboratory Results o Should not be used for argument
8. Consent Forms
9. Financial Information FORMAT OF DOCUMENTATION
▪ SOAP – Subjective, Objective, Assessment,
STANDARD LANGUAGE AND MEDICAL Planning
ABBREVIATIONS ▪ DAR – Diagnosis, Assessment,
An abbreviation is a shortened form of a written word or
Recommendations
phrase. Abbreviations may be used to save space and time,
▪ DAR – Data, Action, Response
to avoid repetition of long words and phrases, or simply to
▪ PIE – Problem, Intervention, Evaluation
conform to conventional usage.
▪ PGIE – Problem, Goal, Intervention, Evaluation

Improve efficiency: Using standardized terminology – ▪ ADIME – Assessment, Diagnosis, Intervention,

especially abbreviations or acronyms – can help patients Monitoring, Evaluation

receive the care and medications they need faster. This

SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN
allows facilities to see a greater number of patients and (SOAP) DOCUMENTATION
improve their overall efficiency. ▪ SUBJECTIVE
o Data from patient/caregiver, e.g.
Example of Abbreviations Used in Nutrition
Food/NutritionRelated History. Include
diet recall/food allergies.
▪ OBJECTIVE
o Physical evidence, e.g. Anthropometric
Measures, Biochemical Data, Medical
Tests and Procedures.
▪ ASSESSMENT
o PES Statement: Problem, Etiology,
PROBLEM-ORIENTED MEDICAL RECORDS
Signs and Symptoms (overall nutrition
Problem Oriented Medical Record (POMR) is a medical
status.
record approach that provides a quick and structured
acquisition of the patient's history. POMR, unlike classical
health records, focuses on patient's problems, their
evolution, and the relations between the clinical events

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▪ PLAN
o Nutrition Prescription and Nutrition
Intervention Details. Monitoring and
Evaluation Plan

ADIME
▪ A: Assessment
▪ D: Nutrition Diagnosis
o → Problem-high risk code assigned →
Etiology-the cause of the problem or
risk code → Signs/Symptoms-the
evidence collected that trigger the high
risk code to be assigned
▪ I: Intervention
o Specific behavior change identified to
address the Nutrition Diagnosis
▪ M/E: Monitoring/Evaluation
o next steps, follow-up information and
referrals

EXAMPLE - ADIME
▪ A: Per mother, continues to offer formula in the
bottle which she feels keeps infant fuller longer
& sleeps better. Mother states infant eats well,
likes mashed potatoes. Mother is surprised infant
likes to self-feed. Offered 3 (oz) bottles of
formula/day and 6oz apple juice/day.
▪ D: Limited adherence to nutrition related
recommendations r/t infant feeding practices
AEB mother offering cereal in the bottle with
belief infant is fuller longer & sleeps better.
▪ I: Begin protein foods such as plain meat &
beans. Recommended/encouraged to spoon feed
cereal and avoid offering cereal in bottle.
▪ ME: No RD F/U unless requested by client. F/U
on how introduction to protein foods went.

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