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
 ADAs 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
 ADAs 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 pts 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
 ADAs 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
 ADAs 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