SAMPLE. The Nutrition Care Process. Chapter 1

Transcription

1 Chapter 1 The Nutrition Care Process The Nutrition Care Process (NCP) was developed by a workgroup of the Academy of Nutrition and Dietetics Quality Management Committee to serve as a framework to describe the process of how registered dietitians (RDs) provide care to patients/clients (1). The goal of the NCP is to improve the quality and consistency of patient/client care and the resulting patient/client outcomes. The emphasis is on standardizing the care process, rather than standardizing individual patient/client care (1,2). This chapter provides an overview of the four steps of the Nutrition Care Process (see Box 1.1) and sets the context for the rest of the pocket guide, which focuses on the first step of the NCP, nutrition assessment. Box 1.1 Steps in the Nutrition Care Process Step 1: Nutrition Assessment A method for obtaining, verifying, interpreting, and documenting data needed to identify a nutrition-related problem. Step 2: Nutrition Diagnosis The identification and labeling of a specific nutrition problem that a dietetics professional is responsible for treating independently. Nutrition diagnoses may be temporary and resolved with nutrition interventions, (continued) 1

2 2 Box 1.1 Chapter 1 Steps in the Nutrition Care Process (continued) as opposed to medical diagnoses, which pertain to diseases or pathologies of organs or body systems. This step results in the documentation of the nutrition diagnosis (PES) statement, which is composed of the following components: the problem (P), the etiology (E), and the signs and symptoms (S). Step 3: Nutrition Intervention Specific actions taken to change nutrition-related behaviors, risk factors, environmental conditions, or aspects of nutritional health. Step 4: Nutrition Monitoring and Evaluation The review of the patient/client s status at a preplanned follow-up and the systematic comparison of current findings with previous status, intervention goals, or a reference standard. Source: Data are from references 1 and 2. Nutrition Assessment The first step of the Nutrition Care Process, nutrition assessment, is the foundational step where the RD identifies and evaluates data needed to make a nutrition diagnosis, plan and implement a nutrition intervention, and monitor and evaluate outcomes (1,2). Nutrition assessment follows identification of the patient/client by appropriate screening or referral (see Chapter 2 for more on nutrition screening). The sources and types of data evaluated in the nutrition assessment depend on the setting. Some possible sources of data for the nutrition assessment include the referring health care provider/agency, patient/client interview, medical record, patient/client rounds, community-based surveys, administrative data, and epidemiological studies. Critical thinking is needed to separate out irrelevant data and to identify the appropriate norms or standards for

3 The Nutrition Care Process 3 evaluation of relevant data. See Box 1.2 for categories of nutrition assessment and selected examples of data collected (2). Box 1.2 Categories of Nutrition Assessment Data Food/Nutrition-Related History Food and nutrient intake; food and nutrient administration; medication and complementary/alternative medicine use; knowledge/beliefs/attitudes; behavior; food and supply availability; physical activity and function; nutrition-related patient/client-centered measures Anthropometric Measurements Height, weight, body mass index (BMI), growth pattern indices/percentile ranks, and weight history Biochemical Data, Medical Tests, and Procedures Laboratory data (eg, electrolytes, glucose, and lipid panel), and tests (eg, gastric emptying time and resting metabolic rate) Nutrition-Focused Physical Findings Findings from an evaluation of body systems, muscle and subcutaneous fat wasting, oral health, suck/swallow/breathe ability, appetite, and affect Client History Current and past information related to personal, medical, family, and social history Source: Data are from reference 2. Nutrition DiAGNosis After the assessment process, data are synthesized to form one or more nutrition diagnoses for the patient. The 4th edition of the International Dietetics & Nutrition Terminology (IDNT) Reference Manual defines more than 140 nutrition diagnoses for use in the profession of dietetics. These diagnoses are divided into three domains:

4 4 Chapter 1 Intake, Clinical, and Behavioral-Environmental (2). Each domain is further divided into classes and, in some cases, subclasses. The Academy of Nutrition and Dietetics uses the domains, classes, and subclasses to create alpha-numeric codes for each nutrition diagnosis or problem. For example, food-medication interaction is coded NC 2.3, where the domain (NC) is Clinical, the class (2) is biochemical, and the third diagnosis (3) in this class is food-medication interaction. These codes should not be visible in the patient s nutrition documentation. The Academy has also developed a nutrition assessment matrix to identify pertinent assessment parameters and a selection of possible nutrition diagnoses associated with those parameters (2,3). For example, for the parameter of increased body mass index, the matrix provides 10 nutrition diagnoses: NI 1.3 (Excessive energy intake) NI 1.5 (Predicted excessive energy intake) NC (Overweight, adult or pediatric) NC (Obese, pediatric) NC (Obese, Class I) NC (Obese, Class II) NC (Obese, Class III) NB 1.5 (Disordered eating pattern) NB 2.1 (Physical inactivity) NB 3.2 (Limited access to food or water) In the patient s nutrition documentation, each nutrition diagnosis is summarized as a problem, etiology, and signs and symptoms (PES) statement. For more guidance on determining nutrition diagnoses, as well as on developing nutrition PES statements, refer to the International Dietetics & Nutrition Terminology (IDNT) Reference Manual (2).

5 The Nutrition Care Process 5 Nutrition Intervention Following the identification and documentation of a nutrition diagnosis, at least one nutrition intervention is selected, with the goal of improving or resolving the problem identified (2). Nutrition intervention strategies are categorized under the following headings: Food and/or Nutrient Delivery Nutrition Education Nutrition Counseling Coordination of Nutrition Care When planning and implementing an intervention, RDs must use critical thinking to prioritize and set goals; outline a nutrition prescription; make connections with other members of the health care team; initiate interventions using strategies that meet the patient/client s needs, nutrition diagnosis, and values; select the best course of action; and specify the time and frequency of care. Monitoring and EvALuation Following the implementation of a nutrition intervention, the RD must select appropriate indicators to determine whether progress has been made in addressing the identified nutrition diagnoses (2). These expected outcomes are monitored to see whether the desired change is being achieved. Monitoring and evaluation outcomes are categorized as: Food/Nutrition-Related History Outcomes Anthropometric Measurement Outcomes Biochemical Data, Medical Tests, and Procedures Outcomes Nutrition-Focused Physical Finding Outcomes

6 6 Chapter 1 References 1. 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: Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; Academy of Nutrition and Dietetics. Nutrition Assessment Matrix Food/Nutrition-Related Nutrition Diagnostic Terminology. =5903. Accessed March 8, 2013.