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)
• “A systematic 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
• Determining when problems require referral
 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 Example: Acute Care
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
 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