chan doan.danh gia can thiep dinh duong

Nutrition vs Medical DxMedical Dx Nutrition Diagnosis visits to Coldstone Creamery as evidenced by diet hx and high hs blood glucose Liver failure Altered gastrointestinal function relat

Diagnosis, Intervention, Evaluation, and Documentation

Relationship Between Patient/Client/Group

& Dietetics Professional

-Nutrition Diagnosis

  Identify and label problem

  Determine cause/contributing risk factors

  Cluster signs and symptoms/

defining characteristics

Nutrition Assessment

  Obtain/collect timely and appropriate data

  Analyze/interpret with evidence- based standards



  Identify risk factors

  Use appropriate tools

  Evaluate the impact with aggregate data

  Identify and analyze causes of less than

optimal performance and outcomes

  Refine the use of the Nutrition Care

 Plan nutrition intervention

• Formulate goals and

determine a plan of action

  Implement the nutrition intervention

• Care is delivered and actions are carried out

  Document Document

Nutrition Assessment Leads to Nutrition Diagnosis

Nutrition vs Medical Dx

Medical Dx Nutrition Diagnosis

visits to Coldstone Creamery as evidenced by diet hx and high hs blood glucose

Liver failure Altered gastrointestinal function related to

cirrhosis of the liver as evidenced by steatorrhea and growth failure

Nutritional vs Medical Dx

Medical Dx Nutrition Diagnosis

of access to healthy food choices (restaurant eating) as evidenced by diet history and BMI of 35.

self-limiting behavior as evidenced by diet history and weight loss of 5 lb

PES Statement

problems are successfully treated; the focus of monitoring and evaluation

Problem (Diagnostic Label)

Falls into three general domains:

environment, access to food, food safety

will improve problem

regular consumption of large portions of fat meals (etiology)…

stroke (etiology)…

Diagnostic Labels Can Be Problems

or Etiologies

food-nutrition knowledge deficit (NB-1.1)

to lack of previous nutrition education

inadequate energy intake (NI-1.4)

related to swallowing difficulty (NC-1.1)

Signs and Symptoms

intervention is done by reviewing signs and

symptoms

Nutrition Dx with S/S

of high-fat meals (E)

over last 18 mo (Signs)

Nutrition Assessment Identifies

Etiology and S/S

bargain

PES Statement

Related to eating frequently in fast food

As evidenced by BMI of 30 and diet

Etiology Guides Intervention!

by looking at the root cause of the nutrition

problem

frequently in fast food restaurants, how would you intervene?

Signs and Symptoms Direct

Intervention and Evaluation

Intervention: Counsel patient about best choices

in fast food restaurants 2.4)

(S-PES Statements

• Excessive fat intake (NI-5.6.2) related to high

intake of fried foods and bakery goods as

evidenced by diet history and hyperlipidemia

• Excessive energy intake (NI-1.5) related to high

intake of fried foods and snack items as evidenced

by diet history and BMI

• Food/nutrition related knowledge deficit (NB-1.1)

related to lack of education on cholesterol

lowering diet as evidenced by history and patient self-report

Nutrition Diagnosis Statement Should Be

Evaluating Your PES Statement

Evaluating Your PES Statement

diagnosis?

thus resolve it or improve the problem?

symptoms?

Evaluating Your PES Statement

taste perception as evidenced by diet history,

medical dx and weight loss of 10 lb during cancer tx

perception) but can treat S&S by recommending foods with stronger flavors

Evaluating Your PES Statement

as evidenced by medical hx and decreased

hgb/hct in medical record

addressed; the etiology is not a nutritional deficit

B12, protein, etc

Evaluating Your PES Statement

• When all things are equal and there is a choice

between two nutrition diagnoses from different domains, consider the Intake domain diagnosis as the one more specific to the role of the RD

• Instead of Altered nutrition-related labs related to

GI bleed as evidenced by medical hx and

decreased hgb/hct in medical record

• Consider Inadequate intake of iron (NI-5.10.1)

related to increased needs due to GI bleed as

evidenced by medical history, blood count, diet history, and serum ferritin

Evaluating Your PES Statement

the problem is resolved or improved?

do another diet history at next visit and see if

intake has changed; can also check weight

NCP Example: Long Term Care

weight in the last 6 months

to lose weight

feeding recommendations

NCP Example: LTC

longer fit and she cannot chew regular meats and vegetables; patient is storing oral supplement in drawer as she worries about the cost

Write a PES statement for this

patient!

NCP Example: LTC

related to poorly fitting dentures and hoarding of oral supplement as evidenced by observation and

pt interview

Etiology Guides Intervention

consult (RC-1.3) to reline dentures and chopped diet (ND-1.2); puts resident on Medpass

supplement (ND-3.1.1)

Diagnoses Apply to All Settings

Long term

intake records, pt self-report and 8% weight loss/3 months

Long term

evidenced by chronic constipation and diet history

Ambulatory

evidenced by pt verbalization and continued weight gain

ADA’s Nutrition Care

Nutrition Intervention

Nutrition Interventions

Four categories of nutrition interventions:

Food and/or Nutrient Delivery

Nutrition Education (E)

Nutrition Counseling (C)

Nutrition Counseling:

Theory or Approach

The theories or models used to design and

implement an intervention; provide a based rationale for designing and tailoring

research-nutrition interventions

of Change (C-1.5)

Nutrition Counseling: Strategies*

setting/provider (RC-2)

ADA’s Nutrition Care

Nutrition Monitoring and Evaluation

nutrition diagnosis and intervention plans and

goals

nutrition goals, or reference standards

Nutrition Outcomes – 4 Categories

Outcomes (BE)—Nutrition-related knowledge, behavior, access, and ability that impact food and nutrient intake

and/or nutrient intake from all sources

Outcomes (S)—Anthropomorphic, biochemical, and physical exam parameters

Outcomes (PC)—perception of patient/client’s nutrition intervention and its impact

Nutrition-Related Behavioral and Environmental Outcomes (BE)

Behavior-Environmental Outcomes

Domain: Beliefs and Attitudes (BE-1.1)

Definition: beliefs/attitudes about and/or readiness to change food, nutrition, or nutrition-related

behaviors

Potential indicators (BE-1.1)

Beliefs and Attitudes (BE-1.1)

Measurement methods or data sources

Beliefs and Attitudes (BE-1.1)

Typically used to monitor and evaluate change in the following nutrition diagnoses

nutrition-related topics

energy, macronutrient, micronutrient, or

bioactive substance intake

Beliefs and Attitudes (BE-1.1)

Typically used to monitor/evaluate change in the following nutrition diagnoses (cont)

Behavior-Environmental Outcomes Domain: Food and Nutrition Knowledge (BE-1.2)

Definition: Level of knowledge about food, nutrition and health, or nutrition-related information and

guidelines relevant to patient/client needs

Food and Nutrition Knowledge (BE-1.2) Potential Indicators

substantial, and extensive

Food and Nutrition Knowledge (BE-1.2)

Measurement methods or data sources

by computer

Food and Nutrition Knowledge (BE-1.2)

Typically used to monitor and evaluate change in the following nutrition diagnoses:

recommendations

Ability to Plan Meals/Snacks (BE-2.1)

planning healthy meals and snacks, which are

compatible with dietary goals

(e.g may include ability to use planning tools,

plan a menu, create/tailor a meal plan, create/use a shopping list

Ability to Plan Meals/Snacks (BE-2.1)

records, self-report or caregiver report, 24-hour recall, menu review, targeted questionnaire

domains of nutrition interventions:

Ability to Plan Meals/Snacks (BE-2.1)

Typically used to monitor and evaluate change in the following nutrition diagnoses:

Other BE Nutrition Outcomes

Other Outcomes

Food and Nutrient Intake

(FI)

Outcomes Based Practice

Management

American Diabetes Association)

health delivery system

and other colleagues

NCP Example: Acute Care

fx after fall He lives with his son and daughter in law Per his son, Mr D’s appetite has been poor the past 6 months, his dentures are very loose and

he refuses to wear them He also refuses pureed foods Ht: 6 ft.; weight 133 lb; usual weight 1 year ago 165 lb Meds: milk of magnesia, Pepcid, Di-Gel No significant medical hx save progressive dementia;labs after hydration serum alb 2.4 g/dL; Hgb 10.6 g/dL; HCT 35.3%; BUN, Cr, liver fxn tests WNL

Write a PES statement for this

patient!

NCP Example: Acute Care

Nutrition Diagnosis

dementia and poor appetite as evidenced by diet history and recent unintentional weight loss

dentures as evidenced by diet history

long bone fx as evidenced by medical history

How would you intervene with this

patient?

fit (RC - coordination of care)

preference and evaluate acceptance (ND-3.1.1

food-nutrient delivery)

coordination of care)

for supplemental feedings (E - nutrition education)

Monitoring and Evaluation

to evaluate acceptance of oral supplements

after dentures are replaced

The Diet Prescription

based on pt’s needs, care goals

the diet

have been approved by committee that are

used at that institution

Modifications of the Normal Diet

diet modifications

Modifications of the Normal Diet

consumed

fat, CHO

Basic Hospital Diets

Basic Hospital Diets —cont’d

“Surgical” Soft Diet

Clear Liquid Diet

Full Liquid Diet

Full Liquid Diet –cont’d

House or Standard Diet

Controversies

sodium, and sugar to conform with the U.S

dietary guidelines?

nutritional intake of sick people, featuring

familiar, comfort foods and fulfilling patient

preferences and expectations, regardless of

conformity to dietary guidelines designed for

healthy people?

Consistency Diet Controversies

diet ‘dental” soft, “surgical” soft, mechanical soft; the needs of dysphagia patients and dental patients are

different

part of a surgical progression; many of the foods

included are poorly tolerated by persons immediately post GI surgery (dairy products, fats, etc.) May be

useful as a source of nutrition for persons with mouth pain or dental surgery

Consistency Diet Controversies

recommend specific liquid consistencies, they

may be using a different standard than is used in the food and nutrition department

nectar thick, honey thick, etc Often these foods vary greatly among and within institutions and depending on where and by whom the thickening

is done

Therapeutic Diet Controversies

chronic diseases who

are hospitalized with

acute illnesses be

placed on the

restricted diet that is

appropriate for them

long term?

Therapeutic Diet Controversies

long term care

facilities have the

same right as

home-based clients to decide

whether or not to

follow a restricted

diet?

Nutritional Care of the

Terminally Ill Patient

main goals of nutritional care for terminally ill

patients = “palliative care”

that negatively impacts quality of life are rarely appropriate

Palliative Care

anxiety, and fear while attempting to maintain the patient’s ability to function independently

Continuity of Care

care is being provided in alternative settings (long term care, home care, ambulatory clinics and

community programs)

often limited to survival skills

setting conducive to long term behavior change

identify nutritional problems and devise a plan for follow-up care

Discharge Planning

Discharge documentation includes

outcomes

results, dietary intake

Discharge Planning

Courtesy University of Washington Medical Centers, Seattle.