Embracing the international agenda The Nutrition Care Process

Transcription

1 Embracing the international agenda The Nutrition Care Process Vera Todorovic Consultant Dietitian Doncaster and Bassetlaw Hospitals NHS Foundation Trust 11/12

2 Linking the processes Nutrition care process Nutrition diagnosis (Problem Etiology Signs and symptoms (PES) statements ) IDNT terminology To standardise the processes that are used for describing the nutritional activities relating to patient /client care so that information and data gathered during these processes are clear,consistent and meaningful. To ensure that referring agents have a robust summary of the nutritional activities and course of action taken with patients /clients they have referred

3 But this isn t anything new is it? No but. We haven't always used the same words to describe things (standardised language- IDNT ) We haven't always named the nutrition problem that we are trying to treat (nutrition diagnosis) We haven't always structured our documentation to clearly link the assessment data to a problem (Nutrition Assessment Terms, PES (Problem,Etiology,Signs and Symptoms ) Statement and Intervention Terms) We haven't always identified what signs and symptoms we expected to change based on our intervention Our notes don t always articulate whether the problem has improved or been resolved according to our plan. (Intended outcomes, Monitoring and Evaluation Terminology )

4 ADA Nutrition Care Process and model Nutrition Assessment Obtain/collect timely and appropriate data Analyze/interpret with evidence - based standards Document Nutrition Diagnosis Identify and label problem Determine cause/contributing risk factors Cluster signs and symptoms/ defining characteristics Document Nutrition Monitoring and Evaluation Monitor progress Measure outcome indicators Evaluate outcomes Document Relationship Between Patient/Client/Group & Dietetics Professional Nutrition Intervention Plan nutrition intervention Formulate goals and determine a plan of action Implement the nutrition intervention Care is delivered and actions - are carried out Documen t

5 International Dietetic and Nutrition Terminology (IDNT) Nutrition Assessment and Monitoring and Evaluation - 6 domains Nutrition diagnosis -3 domains Nutrition Intervention -4 domains Standardised and agreed terms reflecting the steps in the Nutrition Care Process Nutrition Diagnosis Problem Etiology Signs and symptoms The critical link between the assessment and intervention. A nutrition diagnosis is a problem that requires a nutrition intervention and a treatment plan

6 Nutrition Assessment - domains, indicators and terms Food and nutrition related history Food and nutrient intake (eg oral fluids,energy intake ), food and nutrient administration, medication/herbal supplement use,knowledge, beliefs and attitudes,behaviour, food and supply availability, physical activity and function, Anthropometric measurements Height, weight, BMI, growth pattern indices/percentiles, weight history Biochemical data, medical tests, procedures Lab data and tests (eg gastric emptying time) Nutrition focused physical findings Findings from an evaluation of body systems, muscle and subcutaneous fat wasting, oral health, suck/swallow/breathe ability, appetite Client history Current and past information related to personal, medical, family and social history Comparative standards Measurement against recommended standards/requirements

7 Nutrition Diagnosis Nutritional problem that the dietitian is responsible for treating Names and describes the problem Not a medical diagnosis Type 2 diabetes = medical diagnosis Excessive carbohydrate intake resulting in elevated blood glucose levels = nutrition diagnosis.

8 PES statement Definition example Problem (what?) the nutrition diagnosis Inadequate energy intake (P) Etiology (why?) cause of the problem Related to (R/T) Changes in taste and appetite (E) Signs or symptoms (How do I know? ) evidence of the problem As evidenced by (E/B ) Average daily kcal intake 50% less than estimated recommendations (S)

9 Nutritional vs Medical Dx Medical diagnosis 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 35kg/m2. Anorexia nervosa Undesirable food choices r/t history of anorexia nervosa and self-limiting behavior as evidenced by diet history and weight loss of 3kg

10 NCP Example: Patient at home Medical Diagnosis: CVA 2 years ago in hospital, bedbound but stable. Cared for at home No oral intake. PEG in situ.carers report weight gain Nutrition History : PEG feed protocol in place from hospital. Has not been adjusted since then but carers give extra sugary fluids and yoghurts via PEG. No scales at home. Nutrition Diagnosis Weight gain r/t PEG feed in excess of nutritional requirements as e/b by feed protocol currently in place and additional food and fluids given by carers via PEG. Knowledge deficit of carers r/t no up to date nutrition education as to the general principles of feeding via the PEG e/b frequent use of high sugar fluids and yoghurts via PEG Self-monitoring deficit (proxy ) r/t lack of access to scale/measuring tools as e/b carers report

11 NCP Example (cont): Patient at home Nutrition Intervention Excessive nutritional intake: Dietitian will review the feed in line with current nutritional requirements (eg 1700kcal, 60g pr, 2000ml ) and discuss with the carers limiting the additional nutritional products that are currently to go via the PEG (specify ). Excessive weight gain: a modest reduction in MUAC measurements over next 3 months (eg 5%) Education: The carers will be visited by the Homecare nurse to revisit PEG care (eg and will be taught.). They will also be offered some basic nutrition training by the dietitian (eg who will instruct them on..) Self-monitoring deficit: The carers will be shown how to carry out MUAC measurements to help determine if weight is changing appropriately Monitoring and Evaluation Carers to carry out MUAC in 3 months and report to dietitian Dietitian will review feed intake in one month Dietitian will check what nutritional updates the carers have engaged with

12 Linking to outcomes Domain Measures (that are measurable) Biochemical Behaviour change Food and nutrient intake Physical/anthropometric Eg MUAC correctly measured Eg meets nutritional requirements compared to standards Eg weight loss to target Psychological Patient focused Symptom change Outcome domains based on BDA Outcomes framework and ADA Care Processes. Outcomes reflect the nutritional diagnosis and interventions which are monitored and evaluated

13 Moving forward Develop templates and toolkits for various clinical conditions Add to the IDNT terminology where UK specific synonyms are required Integration with IT systems