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The nutrition care process components:
- Assessment
- Diagnosis
- Intervention
- Monitoring and evaluation
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PES statement
- Problem (diagnosis)
- Etiology (cause)
- Signs/Symptoms
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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”
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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.”
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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
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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.
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Interventions should be specific:
—What? —When?
—Where? —How?
- Some interventions Include:
- • Tube feeding
- • IV feeding (Parenteral)
- • Supplements
- • Therapeutic Diet
- • Nutrition education
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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!
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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
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Documentation Style
- • DAP (diagnosis, assessment, plan)
- • SOAP (subjective, objective, assessment, plan)
- • The Academy promotes the ADIME
- – Assessment
- – Diagnosis
- – Intervention
- – Monitoring
- – Evaluation
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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
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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
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ADIME
- • A = Assessment (S and O)
- • D = Diagnosis (PES statement)
- • I = Intervention (plan)
- • ME – if follow up, document progress
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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
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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
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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
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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
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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.
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Palliative Care
• Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently
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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
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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
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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
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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
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Strategies of Managed Care Systems
• Purpose – contain healthcare costs while providing efficient/effective care
– Practice guidelines are often used
– Define care for specific diagnoses
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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
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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)
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