1. The nutrition care process components:
    • Assessment
    • Diagnosis
    • Intervention
    • Monitoring and evaluation
  2. PES statement
    • Problem (diagnosis)
    • Etiology (cause)
    • Signs/Symptoms
  3. PES Statement w/ example 1
    1. Problem (Nutrition Diagnosis) “Excessive calorie intake”

    2. Etiology (Cause / Contributing Factor) “related to frequent consumption of large portions of high fat meals”

    3. Signs/Symptoms (defining characteristics) “as evidenced by average daily intake of calories exceeding recommended needs by 500 kcals/day and weight gain exceeding goal by 10# in second trimester”
  4. PES Statement w/ example 2
    • 1. Problem (Nutrition Diagnosis)
    • “Undesirable food choices”

    • 2. Etiology (Cause / Contributing Factor)
    • “related to mother introducing cow’s milk too early”

    • 3. Signs/Symptoms (defining characteristics)
    • “as evidenced by mother stating that she has used cow’s milk since
    • 4th month instead of formula.”
  5. Sample PES statements
    • Inadequate protein intake (NI 52.1) related to poor appetite as evidenced by dietary intake of <67% of calculated needs and low pre-albumin.

    • Altered nutrition-related lab values (NC-2.2) related to excessive intake of saturated fat and cholesterol and genetic factors as evidenced by diet history and client history.

    • Inappropriate intake of food fats (saturated fat and cholesterol) (NI-5.6.3) related to frequent use of baked goods and fried foods as evidenced by diet history and elevated LDL and TC
  6. Implementation of Nutritional Care
    • Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives.
  7. Interventions should be specific:
    —What? —When?

    —Where? —How?

    • Some interventions Include:
    • • Tube feeding
    • • IV feeding (Parenteral)
    • • Supplements
    • • Therapeutic Diet
    • • Nutrition education
  8. Nutritional Care Record
    • Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives

    • Most facilities now have computerized medical records!
  9. Charting and Documentation
    • • Purpose of medical record
    • – Communication among health care team
    • – Legal documentation of care
    • – Contains
    • • Physician orders
    • • H&P
    • • Lab test results
    • • Consults
    • • Progress notes
    • • prognosis
  10. Documentation Style
    • • DAP (diagnosis, assessment, plan)
    • • SOAP (subjective, objective, assessment, plan)
    • • The Academy promotes the ADIME
    • – Assessment
    • – Diagnosis
    • – Intervention
    • – Monitoring
    • – Evaluation
  11. SOAP - Explain
    (Subjective, Objective, Assessment, Plan)

    S: Subjective

    • • Info provided by patient, family, or other
    • • Pertinent socioeconomic, cultural info
    • • Level of physical activity
    • • Significant nutritional history

    O: Objective

    • • Factual, reproducible observations
    • • Diagnosis
    • • Height, age, weight—and weight gain patterns
    • • Lab data
    • • Clinical data (nausea, diarrhea)
    • • Diet order
    • • Medications

    A: Assessment

    • • PES statements can go here
    • • Interpretation of patient’s status based on subjective and objective info
    • • Evaluation of nutritional history
    • • Assessment of laboratory data and medications
    • • Assessment of diet order
    • • Assessment of patient’s comprehension and motivation

    P: Plan

    • • Diagnostic studies needed
    • • Further workup, data needed
    • • Medical nutrition therapy goals
    • • Recommendations for nutritional care
  12. Good medical notes:
    • Vary in detail by facility

    • Are concise, complete, accurate

    • Are easy to read

    • Don’t have “weasel-words” (may)

    • Use appropriate abbreviations and terminology

    • Do not follow normal rules of writing!

    • Time, date, signature always included

    • Should be done immediately

    • Corrections do not cover original entries
  13. ADIME
    • • A = Assessment (S and O)
    • • D = Diagnosis (PES statement)
    • • I = Intervention (plan)
    • • ME – if follow up, document progress
  14. Pureed Diet
    • provides foods that require little or no chewing and can be easily swallowed

    • for those without teeth, inflamed gums, inability to chew

    • • allowed foods - foods that are creamy in texture and foods that are strained or pureed (baby food is sometimes used)
    • • increase caloric density, small frequent feedings

    • component pureeing (eg lasagna - puree each ingredient individually then layer)

    • can be adequate in all nutrients
  15. Mechanical Soft Diet
    • designed to minimize the amount of chewing necessary to ingest food

    • for people with limited ability to chew/swallow, but can tolerate more than pureed

    • naturally smooth foods, chopped, ground or pureed foods,no raw fruits or vegetables, seeds, nuts, or dried fruits

    • Nutritionally adequate
  16. Soft Diet
    • for patients who are unable to tolerate a regular diet

    • – patients with poor dentition
    • – progression from liquid to regular diet
    • – mild GI disturbances
    • – too weak to eat regular diet foods

    • fiber, texture, and seasoning is modified (see chart)

    • – low to moderate fiber
    • – avoid raw fruits and veggies
    • – avoid grainy breads and cereals
    • – avoid gas-forming foods (cabbage family)
    • – avoid highly seasoned, strong smelling, fried foods
  17. Cold, semi-liquid (T & A)
    • a diet that is thermally, mechanically, and chemically non-irritating to throat

    • soft, smooth, cold or lukewarm foods

    • avoid chocolate, orange or red coloring (may mask bleeding)

    • if used more than 3-5 days, use a liquid food supplement
  18. Nutritional Care of the Terminally Ill Patient
    • Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients.

    • Dietary restrictions are rarely appropriate.
  19. Palliative Care
    • Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently
  20. Discharge documentation includes
    • Summary of nutritional therapies and outcomes

    • Pertinent information such as weight, lab results, dietary intake

    • Potential drug-nutrient interactions

    • Expected progress or prognosis

    • Recommendations for follow-up services
  21. JCAHO
    • Joint Commission on Accrediation of Healthcare Organizations

    – Predominant accrediting body for healthcare

    – Had standards that are assessed in organizations by documentation and site visits q 3 yrs

    – Voluntary, but impacts reputation and insurance reimbursement
  22. JCAHO Nutrition care standards
    • Provision of appropriate nutritional care in a timely and effective manner using an interdisciplinary approach

    – Screening

    – Assessment and reassessment

    – Development of nutrition care plan

    – Ordering and communication of diet order

    – Preparation/distribution of diet order

    – Monitoring of the process

    – Continuous quality improvement

    – Qualified RD must be involved in planning the above processes
  23. Managed Care Systems
    • Finance and deliver care through a contracted network of providers for a monthly premium

    – MCO (Managed care Organizations)

    – PPO (preferred provider organizations

    – HMO (health mantenance organizations
  24. Strategies of Managed Care Systems
    • Purpose – contain healthcare costs while providing efficient/effective care

    – Practice guidelines are often used

    – Define care for specific diagnoses
  25. Payment Systems
    • Several reimbursement systems exist

    – Cost=based reimbursement

    – Negotiated bids

    – Diagnostic related groups (DRGs)

    • Payment is based on principal, secondary diagnoses, surgical procedure and age/gender of pt

    • There are over 500 DRGs
  26. Patient Focused Care (PFC)
    • Focuses on pt needs and perspective rather than caregiver’s assumptions

    • Reduces number of people pts see due to cross training of professionals and decentralization of services

    • Dietitian can be centralized (part of core nutrition dept) or decentralized (part of a special unit)
Card Set
The Nutrition Care Process