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Nutrition Care ProcessPractical Applications
Andrea Maher RD, LD
Alicia Aguiar MS, RD, LD
International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the
Nutrition Care Process, Second Edition
• Functional changes (swallowing, GI)
• Altered lab data
• Altered body weightBehavioral/Environmental
Why should I learn NCP Process? Promotes critical thinking to treat current and
pertinent nutrition problems Determines a nutrition diagnosis that drives the
care plan Utilizes a vocabulary to describe the dietitian’s
process within and outside the profession Affirms via documentation that the nutrition
diagnosis has been resolved
Why should I learn NCP Process? If we can name it
We can do it We can teach it We can measure it We can improve it We can get paid for it
Annalynn Skipper, PhD, RD, FADA, author and consultant
Step 1: Nutrition Assessment
Method in which we obtain, verify and interpret data needed to identify nutrition related problems.
Determines whether a nutrition diagnosis exists
The PES statement is then derived from the synthesis of information from the nutrition assessment data
Step 1: Nutrition Assessment
Mark page 11 of your pocket guide:
“Assessment”
Step 2: Nutrition Diagnosis
Mark page 139 of your pocket guide:
“Diagnosis”
Step 2: Nutrition Diagnosis
Nutrition diagnosis are categorized under
3 domains Intake (page 139) Clinical (page 140) Behavioral-Environmental (page 140)
Currently, 60 nutrition diagnosis identified In the LTC setting, the Intake domain will be
used most frequently
Step 2: Nutrition Diagnosis, cont. The dietitian is responsible for treating
independently No right or wrong nutrition diagnosis—some
are more appropriate than others When faced with equally good choices from
different domains (Intake, Clinical or Behavioral-Environmental) choose Intake
Intake domain more likely to be caused by a nutritional etiology and have a nutrition directed intervention
Step 2: Nutrition Diagnosis
Medical Diagnosis Disease/pathology of
specific organs or body systems
Does not change as long as the condition exists
Ex: Diabetes
Nutrition Diagnosis Problem related to
nutrition that RD can influence
Changes as the resident’s response changes
Ideally, with nutrition intervention, diagnosis is resolved
Ex: Excessive CHO intake
Step 2: Nutrition Diagnosis, cont. The dietitian is responsible for treating
independently No right or wrong nutrition diagnosis—some
are more appropriate than others When faced with equally good choices from
different domains (Intake, Clinical or Behavioral-Environmental) choose Intake
Intake Domain more likely to be caused by a nutritional etiology and have a nutrition directed intervention
Step 2: Nutrition Diagnosis, cont. The dietitian is responsible for treating
independently No right or wrong nutrition diagnosis—some
are better than others When faced with equally good choices from
different domains (Intake, Clinical or Behavioral-Environmental) choose Intake
Intake Domain more likely to caused by a nutritional etiology and have a nutrition directed intervention
Step 2: Nutrition Diagnosis, cont.
Components: Problem – (Nutrition Diagnosis) Etiology – cause or contributing risk factors Signs or symptoms –objective and/or subjective
data used to determine whether the resident has the nutrition diagnosis specified.
Step 2: Nutrition Diagnosis, cont.
Problem – related to – Etiology – as evidenced by – Signs or symptoms
Always remember: The etiology explains why (ask Why 5 times) the problem exists. The signs and symptoms are proof of the problem.
Step 2: Nutrition Diagnosis, cont.
Problem – related to – Etiology – as evidenced by – Signs or symptoms
E.g. page 194Inconsistent carbohydrate intake (NI-5.8.3)
related to nutrition-related knowledge deficit concerning appropriate timing of carbohydrate intake as evidenced by wide variations in blood glucose levels, dx IDDM, frequently skips breakfast meal.
Step 2: Nutrition Diagnosis – PES Statements
Problem – related to – Etiology – as evidenced by – Signs or symptoms
E.g. page 217Altered nutrition-related laboratory values (NC-2.2) related to kidney dysfunction as
evidenced by abnormal BUN, Cr and K+ levels, hemodialysis, preference for fresh fruits, poor patient knowledge of modified diet.
Step 3: Nutrition Intervention
Mark page 261 of your pocket guide:
“Intervention”
Step 3: Nutrition Intervention Used to remedy a nutrition diagnosis Intended to change a nutrition-related behavior,
environmental condition or aspect of nutritional health
Always collaborate interventions with the resident and other health care providers Resident response may lead us to revise our intervention Carry out and communicate plan of care Document if resident chooses to not follow an intervention
Step 3: Nutrition Intervention Organized into four domains
Food and/or Nutrient Delivery page 261 Nutrition Education page 262 Nutrition Counseling page 262 Coordination of Care page 262
In the LTC setting, the Food and/or Nutrient Delivery domain will most frequently be used
Step 4: Nutrition Monitoring and Evaluation
See page 11 of your pocket guide:
“Monitoring and Evaluation”uses the same terms as the “Assessment” except for those
indicators that are shaded.
Step 4: Nutrition Monitoring and Evaluation Determines the amount of progress made to
reach the specified goal(s) Specific outcomes that can be measured and
compared to previous data or reference standards, e.g. Weight or BMI Laboratory values
Step 4: Nutrition Monitoring and Evaluation Organized in five domains
Food/Nutrition-Related History Outcomes page 11 Anthropometric Measurement Outcomes page 13 Biochemical Data, Medical Tests, and Procedure
Outcomes page 13 Nutrition-Focused Physical Finding Outcomes page 14 Comparative Standards page 15
In the LTC setting, the Food/Nutrition-Related History Outcomes and Anthropometric Measurement Outcomes is likely to be used more frequently
Case Study #1
Background Information1/22/09: Resident A is a 99 yo female with depression,
lactose intolerance and recently dx gastroenteritis. She reports her appetite isn’t good lately. Meal intake records also show a decline. She feeds herself, A&O x 3.
Ht- 61”, Wt 1/20= 120.8#, ↓10% (14#) x 30 days and ↓16% x 180 days.
Diet: General, ground meat. Nursing has just moved her to the ADR for cuing and
supervision.
Case Study #1
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis
Verify the problem→ confirm the appropriate one
Case Study #1- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
Case Study #1□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
Case Study #1□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
Case Study #1
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis
Verify the problem→ confirm the appropriate one
Inadequate food and beverage intake (pg 146)
(definition)- Oral food/beverage intake that is less than established reference standards or recommendations based on physiological needs
Case Study #1□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Inadequate oral food and beverage intakeEtiology: related to p.o. intake less than calorie expenditureSigns/ Symptoms: as evidenced by depressed meal intake, significant wt loss of 10% in 30
days and 16% in 180 days, resident verbalizes decreased appetite
Case Study #1
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Case Study #1
Nutrition InterventionNutrition Prescription: Recommend ~1500 kcal and 48 grams protein from
meal and planned snacks to meet nutrient needs
Interventions: See Care Plan □ Yes. □ No. [X] Meals/Snacks: Add Super Cereal, provide whole milk each meal, add pm ice cream, HS pudding
[ ] Food Supplements: [X] Vit/Min: Rec MVI/mineral
[ ] Feeding Assistance: [ ] Nutrition Education:
[ ] Coordination of Care (Refer to): [ ] Enteral Nutrition:
Case Study #1
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #1
Monitoring/Evaluation
[X] Food intake: Monitor meal/snack pattern [X] Acceptance of cuing from nursing
[ ] Nutrition quality of life responses [ ] Behavior
[X] Lab Data: □ Hgb A1C □ Glucose, casual X Albumin □ Other:
[X] Weight- screen weekly for changes [ ] Med use: [ ] Other:
Follow up: □ 7 days □ 1 week X 1 month □ Quarterly X Monitor with MDS
Inform physician/family of significant wt change.
Case Study #2
Background InformationYou are informed when you arrive at the facility a week
later (1/29/09) that this same resident from case study #1 has developed a stage II pressure area on her L/buttock (3 cm diameter). Wt 1/27=116#, down 4# from last week.
Case Study #2
Bring your PES statement(s) forward to begin your note
Collect supporting data Document the status of your problem, e.g.
Resolved Improved Need to adjust intervention or nutrition Rx if
problem is not improving NCP continues until problem is resolved
Case Study #21/29/09 Nutrition Dx: Inadequate oral food and beverage intake related to p.o.
intake less than calorie expenditure/energy needs for healing as evidenced by depressed meal intake, significant wt loss, new stage II pressure area on L/buttock.
Interventions- Nutrition Rx: Recommend ~1600 kcal and 57 grams protein from meal, planned snacks and supplement to meet nutrient needs. Continue current interventions, see care plan. Add: Med Pass supplement BID (ND-3.1.1) for additional 240 kcal, 10 gm protein. Recommend Vit C 500 mg (ND-3.2.3) to promote wound healing.
Monitor/Evaluation: Monitor skin status monthly/prn (PD 1.1.8), Monitor weight weekly (AD-1.1.2), Monitor meal/snack patterns (FH-1.3.2.3), Monitor albumin level as ordered (BD-1.11).
Notify family/physician of significant weight changes.RD signature
Transitioning charting to NCP format You do not need to change the style of your
charting format Narrative
Just include standard language terms in your sentences SOAP
S= Assessment terminology O= Data documented elsewhere in chart or data
documented by the dietitian A= Nutrition Diagnosis, written as a PES statement P= Nutrition Prescription and Intervention. Monitoring
indicators and evaluation criteria also go here.
Case Study #3- Annual assessment Background Information4/06/09: Resident B is a 95 yo female with dx HTN,
constipation, severe low back pain, GERD, advanced cancer. He is on hospice care. Feeds himself then staff finish. Ongoing poor appetite.
Ht- 60”, Wt 4/09= 92#, ↓8% (9#) x 30 days and ↓21% x 180 days.
Diet: Pureed. House supplement 60 mL TID
Case Study #3
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #3- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
Case Study #3- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
Case Study #3□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Etiology:Signs/ Symptoms:
Case Study #3□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Increased nutrient needs Etiology: related to increased demand for energySigns/ Symptoms: as evidenced by significant wt loss trend of 8% (9#) x 30 days and 21% x
180 days, cancer, hospice care
Case Study #3
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #3
Nutrition InterventionNutrition Prescription: Recommend continue current pureed diet and
supplement as tolerated by resident for comfort measures
Interventions: See Care Plan □ Yes. □ No. [X] Meals/Snacks: Cont current pureed diet, provide snacks as tolerated
[X] Food Supplements: Cont supplement [ ] Vit/Min:
[X] Feeding Assistance: Mouth care after meals/prn [ ] Nutrition Education:
[X] Coordination of Care (Refer to): Hospice [ ] Enteral Nutrition:
Case Study #3
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #3
Monitoring/Evaluation
[X] Food intake: Monitor meal/snack pattern [ ] Acceptance of
[X] Nutrition quality of life responses [ ] Behavior
[ ] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other:
[X] Weight- screen monthly/prn for changes [ ] Med use: [ ] Other:
Follow up: □ 7 days □ 1 week X 1 month □ Quarterly X Monitor with MDS
Case Study #4- Initial assessment Background Information4/06/09: Resident C is an 86 yo male with dementia.
He has a good appetite per meal intake records. He feeds himself with set up assist. A&O x 2 with confusion.
Ht- 68”, Admit wt 4/09= 162#, no significant wt changes found, UBW= 170# per spouse
Diet: Mechanical SoftDuring mealtime observation you notice that he has
difficulties keeping the food on his plate- spilling food on himself.
Case Study #4
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #4- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
Case Study #4- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Etiology: Signs/ Symptoms:
Case Study #4- Is there a nutrition dx?□ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Self-feeding difficultyEtiology: related to impaired cognitive abilitySigns/ Symptoms: being provided foods that may not be conducive to self-feeding, dropping of
food from untensil, dx dementia
Case Study #4
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #4
Nutrition InterventionNutrition Prescription: Provide adaptive equipment to facilitate independent
eating
Interventions: See Care Plan □ Yes. □ No. [ ] Meals/Snacks:
[ ] Food Supplements: [ ] Vit/Min:
[X] Feeding Assistance: Provide Adaptive Equipment, Encourage finger foods
[X] Coordination of Care (Refer to): OT [ ] Enteral Nutrition:
Case Study #4
Step #1- Prioritize Assessment Problems- What is the most immediate problem?
Step #2- Nutrition Diagnosis- verify the problem→ confirm the appropriate one using the pocket guide for guidance
Step #3- Nutrition Intervention- aimed at “fixing” the etiology
Step #4- Monitoring and Evaluation
Case Study #4
Monitoring/Evaluation
[X] Food intake: Monitor meal intake [ ] Acceptance of
[ ] Nutrition quality of life responses [X] Behavior: Fatigue/ability to feed self
[ ] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other:
[X] Weight- screen monthly/prn for changes [ ] Med use: [ ] Other:
Follow up: □ 7 days □ 1 week □ 1 month X Quarterly X Monitor with MDS
No nutrition diagnoses □ No nutrition diagnosis at this time. □ Proceed to nutrition diagnosis below
Nutrition Diagnostic CodesNI-1.4 Inadequate energy intake NC-1.1 Swallowing difficultyNI-1.5 Excessive energy intake NC-1.2 Chewing difficultyNI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs NI-3.1 Inadequate fluid intake NC-3.1 UnderweightNI-3.2 Excessive fluid intake NC-3.2 Involuntary weight lossNI-5.1 Increased nutrient needs NC-3.3 Overweight/obesityNI-5.3 Inadequate protein-energy intake NC-3.4 Involuntary weight gainNI-5.7.1 Inadequate protein intake NB-1.7 Undesirable food choicesNI-5.8.4 Inconsistent carbohydrate intake NB-3.2 Inability to manage self-careNI-5.8.5 Inadequate fiber intake NB-2.6 Self-feeding difficultyNI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem:Etiology: Signs/ Symptoms:
No nutrition diagnoses, cont.
What do you do if there is not a nutrition diagnosis? The nutrition diagnoses describe actual problems,
not “potential for” or “at risk for” concerns Potential/at risk concerns would be recorded in
the resident’s care plan (per NCP Long Term Care Toolkit)- if you decide if you still want to care plan without a nutrition diagnoses
You still need to set up Monitoring and Evaluation for follow up reassessment
No nutrition diagnoses, cont.
Skip to Step #4- Monitoring and Evaluation
[X] Food intake: Monitor meal/snack pattern [ ] Acceptance of
[ ] Nutrition quality of life responses [ ] Behavior
[X] Lab Data: □ Hgb A1C □ Glucose, casual □ Albumin □ Other: as available
[X] Weight- screen weekly x 4 wks [ ] Med use: [ ] Other:
Follow up: □ 7 days □ 1 week □ 1 month X Quarterly X Monitor with MDS
Nutrition Reassessment, e.g. Qtr Review
When completing a reassessment, we determine progress of the goal Positive Outcome Obtained
Continue Plan of Care Resolve Problem
Status quo Continue Plan of care Change Intervention
Decline Change Intervention
Nutrition Care Process-Where do we go from here?
Get the resources you need to get started Practice writing PES statements and using the
assessment terminology Review current systems of documentation in your
facilities Develop changes in systems, if needed Communicate to key stakeholders in your facility Implement the Nutrition Care Process Evaluate progress and get feedback
Andrea Maher RD, LD
maher@huxcomm.net
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