By: Sylvia Escott-Stump, MA, RD, LDN
Past President, Academy of Nutrition and Dietetics
East Carolina University Greenville, North Carolina, USA
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Today’s Objectives
Participants will be able to discuss the importance of using standardized language and the nutrition care process in any environment.
Participants will identify at least one behavioral change they will make after the seminar.
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Funding Agencies
Accrediting Organizations
Quality Nutrition Care and
Professional Performance
…Who Demands it?
Consumers © S. Escott-Stump 3
What About Others?
Other Disciplines Have Diagnoses
Medicine
Nursing
Physical Therapy
Occupational Therapy
Other Countries The Dutch have a 5-
step process including Intake, Assessment, Nutrition Diagnosis, Intervention, Monitoring-Evaluation.
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International Nutrition Diagnostic and Terminology (INDT)
–updated annually
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Progress in Other Countries
Several countries are validating or adopting international standardized nutrition terminology.
Canada, Great Britain, Australia, Netherlands
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This Study Purpose
To describe the current status of Nutrition Care Process and standardized terminology internationally.
To share sample
training and template ideas.
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The Nutrition Care Process and Model (NCP)
provides a consistent structure in the delivery of care given by dietitians.
Consistency in the steps of nutrition assessment and nutrition diagnosis will lead to more effective interventions and outcomes.
Use of standardized language validates nutrition care, will increase the demand for services, and predict patient outcomes more reliably.
Survey Assumptions
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A twenty-question survey was emailed to 25 dietitians in 8
countries: 19 surveys were completed.
The survey contained questions using a hedonic scale and
open ended questions about: use of a standardized nutrition language in medical record
documentation use of nutrition diagnosis and PES statements opinions on the helpfulness of the documentation in their specific
facilities. The questions also addressed the current format of
charting at the facilities, demographic information, and interest in a training seminar on the use and implementation of the NCP.
Methods
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Results
The following graphs summarize:
demographics of the surveyed population
the current use of the NCP in various settings
perceptions of this process.
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Demographics
60% Hospitals
30% Nursing homes
10% Community settings
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Years experience in Dietetic Practice
years of experience
# o
f die
titians
2
6
7
3
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0
2
4
6
8
10
12
Positive
Negative
Neutral
Unsure
Use of Nutrition Diagnosis/ PES Statements in Charting
# o
f p
art
icip
an
ts
Key: Positive indicates an answer of always or sometimes.
Negative indicates an answer of rarely or never
3
11
4
1
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0
2
4
6
8
10
12
14
Positive
Negative
Neutral
Unsure
Usefulness of Standardized Language and Process in Your Work Setting
# o
f p
art
icip
an
ts
Key: Positive indicates a response of definitely yes. Negative indicates a response of
definitely no; neutral indicates a response of maybe.
3
2
13
1
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0
2
4
6
8
10
12
Positive
Negative
Neutral
Unsure
Open to Use of International Standardized Nutrition Terminology
# o
f p
art
icip
an
ts
Key: Positive reflects a response of definitely yes, negative reflects a response of
definitely no, and neutral reflects a response of maybe.
12
0
5
2
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Other Comments: Why Use the NCP?
It streamlines my work.
It is more efficient.
It clarifies communication between dietitians and with other healthcare professionals.
It supports consistency between different settings (community, hospital, nursing home.)
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Survey Conclusion
Few dietitians are
consistently using the process and language in their documentation.
The majority are open to being trained.
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Solutions??
Training
Practice
Sample templates
Increased Adoption
Practice
Templates
Training
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Training
Emphasize the Importance
Offer 2 Training Sessions
Different days
Different times
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Training Implementation
Assess competency
Complete the training
exercises
Finish checklist
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Nutrition Care Process: 4-Steps
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Recommended Training Sequence
Week 1: Assessment &
Nutrition Diagnosis
Week 2: Goals/Interventions/
Nutrition Prescriptions
Week 3: Monitoring/Evaluation
Week 4: Full documentation
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Nutrition Care Process and Model Lacey & Pritchett , JADA August 2003; updated 2008
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The Nutrition Care Process
NCP is a systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care.
Use of the NCP results in a higher probability of producing desired outcomes.
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Charting Acronym: A-D-I-ME
Assessment Diagnosis Intervention Monitoring
and Evaluation
ADIME
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Malnutrition Yields Undesirable Outcomes!!
Malnutrition leads to depression of the immune
system
impaired wound healing
muscle wasting
longer lengths of hospital stay
higher treatment costs
increased mortality
“Screening and implementation of published best-practice guidelines may effectively reduce hospital malnutrition and save costs”
-Barker et al, 2011
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Begin with Assessment
Changes in nutritional intake, appetite or weight are essential components of nutrition assessment.
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ABCDs
Anthropometrics
Biochemical Assessment
Clinical (Physical) Assessment
Dietary Assessment
Assessment Factors
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Sample Color-coded Assessment Forms
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Nutrition Nutrition Nutrition Nutrition
Assessment Diagnosis Intervention Mon-Eval
Problem Etiology Signs & Symptoms
STEP 2: Nutrition Diagnosis…
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Problem-Etiology-Signs/Symptoms (P-E-S)
Write an accurate P-E-S statement:
Problem (nutrition diagnosis)
its Etiology (cause)
Signs and symptoms (measurable indicators)
This requires deep critical thinking by the qualified dietitian.
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Common Nutrition Diagnoses
CARDIOVASCULAR DISEASES
Excessive energy intake (NI 1.5)
Excessive fat intake (NI 51.2) Inadequate vitamin intake (NI
54.1) Inadequate mineral intake (NI
55.1) Food medication interaction
(NC 2.3) Food-nutrition-related
knowledge deficit (NB 1.1) Limited adherence to
nutrition-related recommendations (NB 1.6)
DIABETES Inappropriate intake of food
fats (NI 51.3) Inadequate carbohydrate
intake (NI 53.1) Excessive carbohydrate intake
(NI 53.2) Inappropriate intake of types
of carbohydrate (NI 53.3) Inconsistent carbohydrate
intake (NI 53.4) Altered nutrition-related
laboratory values (NC 2.3) Overweight/obesity (NC 3.3) Food and nutrition-related
knowledge deficit (NB 1.1)
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There are 4 domains of Intervention: Food/Nutrient Delivery, Nutrition Education, Nutrition Counseling, and Coordination of Care. The assessment/consult condenses each domain’s labels to relevant factors. Planning: reviewing the diagnosis, policies and guides, and conferring with patient and medical team members. Implementing: carrying out and communicating, continuing, and/or revising the plan of care. Nutrition Intervention is directed toward the etiology of the problem. In some cases the etiology can not be changed. The intervention should reduce the impact of the signs and symptoms.
Week 2: Intervention/Goals
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First Three Steps of the NCP Nutrition Assessment:
Gather signs/symptoms
Understand etiology
Determine Nutrition Diagnosis:
write as PES
Nutrition Intervention:
Based on etiology of Dx
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Step 3 Intervention
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Enteral and Parenteral □ Initiate
□ Modify rate/conc/comp/schd
□ Insert EN feeding tube
□ Site Care
□ Discontinue
Meals and Snacks □ General healthy diet
□ Modify type beverage or food
group
□ Specific beverage or food group
Medical Food Supplements □ Commercial beverage
□ Commercial food
□ Modified beverage
□ Modified food
□ Purpose
Vitamin and Mineral
Supplements
□ Multivitamin/mineral
□ Multi-trace element
□ Vit A
□ Vit C
□ Vit D
□ Vit K
□ Vit E
□ Riboflavin
□ Niacin
□ Folate
□ Vit B6
□ Vit B12
□ Thiamin
□ Calcium
□ Chloride
□ Iron
□ Magnesium
□ Potassium
□ Phosphorus
□ Sodium
□ Zinc
Bioactive Substance
Supplement
□ Initiate
□ Dose change
□ Form change
□ Route Change
□ Administration schedule
□ Discontinue
Feeding Assistance □ Adaptive equipment
□ Feeding Position
□ Meal set-up
□ Mouth care
Feeding Environment □ Lighting
□ Odors
□ Distractions
□ Table height
□ Room Temperature
Nutrition Related Medication
Management
□ Initiate Dose
change
□ Form change
□ Route change
□ Administration schedule
□ Discontinue
Nutrition Education, Initial/Brief □ Purpose of education
□ Recommended modifications
□ Adv. or related topics
□ Result interpretation
□ Skill development
Comprehensive Education,
Instruction In-depth Skills
□ Purpose of the nutrition
□ Recommended modifications
□ Adv. or related topic
□ Result interpretation
□ Skill development
Counseling, Theoretical
basis/Approach
□ Cognitive-behavior theory
□ Health belief model
□ Social learning theory
□ Transtherortical/Stages
Counseling Strategies □ Motivational interviewing
□ Goal Setting
□ Self monitoring
□ Problem solving
□ Social support
□ Stress management
□ Stimulus control
□ Cognitive restricting
□ Relapse prevention
□ Rewards/contingency management
Coordination of Other Care
during Nutrition Care
□ Team meeting
□ Referral to RD
□ Collaboration/referral
□ Referral to community
Coordination of DC/Transition □ Collaboration/referral □ Referral to community
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Nutrition Prescription The nutrition prescription
drives the intervention selection.
Consider Recommended Dietary intake, nutrient intake, evidence guides, and health condition of the patient.
Dietitian then makes recommendations to the medical team to resolve the patient’s nutrition diagnosis.
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Step 4 Monitoring & Evaluation
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Nutrition Nutrition Nutrition Nutrition
(re)Assessment Diagnosis Intervention Mon-Eval
Problem Etiology Signs & Symptoms
Review and Evaluate for Success
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Full Documentation Old Assessment Note New Assessment Note
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Sample Template
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ASSESSMENT: Summary of subjective and objective data from chart review and
patient/caregiver. Ht___Current Wt___ Usual Weight_____ IBW range_______ Current IBW %____ Estimated needs for Energy_____kcals Protein___ gms/ Kg Fluid______cc Other Nutrients_________________________(specify) Summary of Diet History:_________________________ Intake approximately ________% at meals and/or ______% from TF and/or _______% from
PN Abnormal lab values_____________________________ Liquids, Nausea, Vomiting, Diarrhea >5 days yes/no Usual Meds______________________________________________________________ Side effects? Yes/no Current Meds____________________________________________________________ Side effects? Yes/no Food allergies____________________________________ Food intolerances:_________________________________
Sample A-D-I-ME Paper Form
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NUTRITION DIAGNOSIS(ES):
______________related to___________________as evidenced by________________________________.
______________related to___________________as evidenced by________________________________.
______________related to___________________as evidenced by________________________________.
INTERVENTIONS:
Food and Nutrient Delivery:
Education (imparting of information only):
Counseling (1:1 in-depth):
Coordinatiion of Care:
MONITORING:
Previous Wt______Current Wt______ %Change______Comment on Progress______________________
Previous labs compared with current labs:
Food-drug interaction potential and status:
Other potential problems or risks: Refeeding syndrome___Unintentional weight loss___
EVALUATION:
Previous Clinical Concerns: Comment on Progress____________________
Previous Behavioral-Environmental Concerns: Comment on Progress___________________
Previous Intake compared with Current Intake:__________ Comment on Progress___________________
Previous Educational Needs and Sessions Provided:_______Comment on Progress____________________
Date:___________Dietitian (RD) ___________________Nutrition Provider #___________________
Sample A-D-I-ME Paper Form
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Study Implications
Further surveys should be conducted to determine how the NCP can be used: In other acute care
units
In long-term care
In community settings, including home care.
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Top Priority for RD: Nutrition Diagnoses, including but
not limited to: Inadequate Energy Intake NI-1.4
Inadequate oral food/beverage intake NI - 2.1
Inadequate intake from enteral/parenteral nutrition NI – 2.4
Inappropriate infusion of enteral/parenteral nutrition NI-2.5
Inadequate fluid intake NI-3.1
Malnutrition NI 5.2
Inadequate protein-energy intake NI 5.3
Inadequate protein intake NI 52.1
Inadequate vitamin intake NI-54.1
Food-medication interaction NC – 2.3
Involuntary weight loss NC - 3.2
Food and Nutrition related knowledge deficit NB1.1
Care Levels - Example
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Conclusion
Health care payers, medical team members, and administrators will be able to identify the true cost-benefit of dietitian services when similar terminology crosses international borders of care.
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ADA. Nutrition Care Process and Model Part 1: The 2008 Update. J. Am Diet Assoc. 2008; 108:
1113-1117.
ADA. Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process. J. Am Diet Assoc. 2008; 108: 1287-1293.
Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health 2011; 8:514-27.
Hakel-Smith N, Lewis N, Eskridge K. Orientation to Nutrition Care Process Standards Improves Nutrition Care Documentation by Nutrition Practitioners. J. Am Diet Assoc. 2005; 105: 1582-1589.
Lacey K, Pritchett E. Nutrition Care Process and Model: ADA Adopts Road Map to Quality Care and Outcomes Management. J. Am Diet Assoc. 2003; 103: 1061-1072.
Mathieu J, Foust M, Ouellette P. Implementing Nutrition Diagnosis, Step Two in the Nutrition Care Process and Model: Challenges and Lessons Learned in Two Health Care Facilities. J Am Diet. Assoc. 2005; 105: 1636-1640.
McCarthy, M. A Renal Nutrition Forum Series with Practice-Based Examples of the Nutrition Care Process (NCP): What’s Happening Among Dialysis Providers? Renal Nutrition Forum 2010; 29.1: 12-13.
References
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Thank you, MDA!
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