Transcript Slide 1

Nutrition Care Process
Practical 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 weight
Behavioral/Environmental
Why should I learn NCP Process?
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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?
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If we can name it
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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
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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
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Nutrition diagnosis are categorized under
3 domains
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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.
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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
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Medical Diagnosis
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Disease/pathology of
specific organs or body
systems
Does not change as long as
the condition exists
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Nutrition Diagnosis
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Ex: Diabetes
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.
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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.
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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.
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Components:
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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.
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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.
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Problem – related to – Etiology – as
evidenced by – Signs or symptoms
E.g. page 194
Inconsistent 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
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Problem – related to – Etiology – as
evidenced by – Signs or symptoms
E.g. page 217
Altered 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
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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
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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
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Organized into four domains
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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
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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.
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Weight or BMI
Laboratory values
Step 4: Nutrition Monitoring and
Evaluation
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Organized in five domains
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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
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Background Information
1/22/09: 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
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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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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
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Case Study #1
□ No nutrition diagnosis at this time.
□ Proceed to nutrition diagnosis below
Nutrition Diagnostic Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Inadequate oral food and beverage intake
Etiology: related to p.o. intake less than calorie expenditure
Signs/ 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
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Step #1- Prioritize Assessment ProblemsWhat 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 Intervention
Nutrition 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
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Step #1- Prioritize Assessment ProblemsWhat 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
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Background Information
You 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
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Bring your PES statement(s) forward to begin
your note
Collect supporting data
Document the status of your problem, e.g.
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Resolved
Improved
Need to adjust intervention or nutrition Rx if
problem is not improving
NCP continues until problem is resolved
Case Study #2
1/29/09
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
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You do not need to change the style of your
charting format
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Narrative
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Just include standard language terms in your sentences
SOAP
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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
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Background Information
4/06/09: 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
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Step #1- Prioritize Assessment ProblemsWhat 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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Increased nutrient needs
Etiology: related to increased demand for energy
Signs/ 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
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Step #1- Prioritize Assessment ProblemsWhat 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 Intervention
Nutrition 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
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Step #1- Prioritize Assessment ProblemsWhat 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
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Background Information
4/06/09: 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 Soft
During mealtime observation you notice that he has
difficulties keeping the food on his plate- spilling
food on himself.
Case Study #4
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Step #1- Prioritize Assessment ProblemsWhat 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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-5.9/5.10 Inadequate vitamin/mineral intake (specify)
Problem: Self-feeding difficulty
Etiology: related to impaired cognitive ability
Signs/ Symptoms: being provided foods that may not be conducive to self-feeding,
dropping of food from untensil, dx dementia
Case Study #4
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Step #1- Prioritize Assessment ProblemsWhat 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 Intervention
Nutrition 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
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Step #1- Prioritize Assessment ProblemsWhat 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 Codes
NI-1.4 Inadequate energy intake
NC-1.1 Swallowing difficulty
NI-1.5 Excessive energy intake
NC-1.2 Chewing difficulty
NI-2.1 Inadequate oral food/beverage intake NC-2.2 Altered nutrition-related labs
NI-3.1 Inadequate fluid intake
NC-3.1 Underweight
NI-3.2 Excessive fluid intake
NC-3.2 Involuntary weight loss
NI-5.1 Increased nutrient needs
NC-3.3 Overweight/obesity
NI-5.3 Inadequate protein-energy intake
NC-3.4 Involuntary weight gain
NI-5.7.1 Inadequate protein intake
NB-1.7 Undesirable food choices
NI-5.8.4 Inconsistent carbohydrate intake
NB-3.2 Inability to manage self-care
NI-5.8.5 Inadequate fiber intake
NB-2.6 Self-feeding difficulty
NI-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



Status quo



Continue Plan of Care
Resolve Problem
Continue Plan of care
Change Intervention
Decline

Change Intervention
Nutrition Care ProcessWhere 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
[email protected]