Unit 4

Nutritional Assessment And Therapy

In
Patient Care (Nutrition care process)

Mrs. Mehrunnisha

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 Diagnosis, Intervention, Evaluation,
and Documentation

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 Nutrition Care Process: Steps

Step 1 • Nutrition Assessment

Step 2 • Nutrition Diagnosis

Step 3 • Nutrition Intervention

• Nutrition Monitoring &

Step 4 Evaluation

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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.”

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 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

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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

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 Nutrition Assessment
•Results of Nutrition Assessment:

• Leads to appropriate initial determination that a nutrition

diagnosis/problem exists

•*PES: Problem, Etiology, Signs/Symptoms

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Nutrition Assessment
• If a nutrition problem is not identified, further
information or testing may be necessary to
make a determination.
• If the assessment indicates that no nutrition
problem currently exists that warrants a
nutrition intervention, the term “No nutrition
diagnosis at this time” may be documented

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 Nutrition Assessment
•Domains (Categories):

1. Food/Nutrition Related History

2. Anthropometric Measurements

3. Biochemical Data, Medical Tests, Procedures

4. Nutrition-Focused Physical Findings

5. Client History
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 Nutrition Assessment
•Components of Nutrition Assessment Process:
• Review data collected for factors that affect nutritional and
health status

• Cluster individual data elements to identify a nutrition diagnosis

as described in the nutrition diagnosis reference sheets

• Identify standards for data comparison

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 Nutrition Assessment:
•Nutrition Care Indicators:
Clearly defined markers – measureable
1. Food and nutrient intake
2. Medication use
3. Growth and body composition
4. Food and nutrition related knowledge
5. Attitudes and behaviors
6. Food access
7. Physical activity
8. Anthropometric data
9. Laboratory values
10. Physical findings (observed or reported)
11. Personal and family medical history, social factors
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 Step 2: Nutrition Diagnosis
•New concept for dietetics profession
•Definition of Diagnose
• The act of identifying a disease or condition from it’s signs and symptoms
• Investigation or analysis of the cause or nature of a condition, situation, or problem.
•This implies
• Pre-defined list of potential conditions
• Pre-defined criteria (signs and symptoms) to which the current situation can be
compared

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 PES Statement

•The nutrition diagnosis or nutrition problem is

summarized into a structured sentence called

• Nutrition diagnosis statement

OR

• PES Statement

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PES Statement
• Problem: nutrition diagnosis label
• Etiology: the focus of the intervention
• Signs and symptoms: change when nutrition problems are
successfully treated; the focus of monitoring and evaluation

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PES Statement

•This statement has 3 distinct components:

• P (Problem)
• E (Etiology)
• S (Signs and Symptoms)
• This information is obtained during the nutrition assessment
phase of the Nutrition Care Process
•This statement has a distinct format:

Problem related to Etiology as evidenced by

Signs and Symptoms
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 PES Statement
Excessive energy intake P

Related to eating frequently in fast food E

restaurants

As evidenced by BMI of 30 and diet history S

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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

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 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

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Nutrition Dx Domains:
Behavioral-Environmental
Defined as “nutritional findings/problems identified that relate
to knowledge, attitudes/beliefs, physical environment, or
access to food and food safety
• Class: knowledge and beliefs
• Class: physical activity, balance and function
• Class: food safety and access

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 Nutrition Diagnosis Components
• Problem (Diagnostic Label)
• Describes alterations in pt’s nutritional status
• Diagnostic labels
• Impaired (nutrient utilization…)
• Altered (GI function…)
• Inadequate/excessive (calorie intake…)
• Inappropriate (intake of types of carbohydrate)
• Swallowing difficulty

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 Diagnostic Labels Can Be Problems or Etiologies

• Inadequate energy intake related to food-nutrition

knowledge deficit .
• Food-nutrition knowledge deficit related to lack of
previous nutrition education.
• Involuntary weight loss related to inadequate energy
intake.
• Inadequate oral food-beverage intake related to
swallowing difficulty.
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 Nutrition Dx with S/S
• Excessive energy 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 (Signs)

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 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

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 Nutrition Intervention
•Nutrition intervention is purposeful planned actions
intended to positively change a nutrition related behavior,
environmental condition, or aspect of health status.
• Directed to the etiology or cause of the problem identified in the
PES statement.
• Sometimes the intervention must be directed toward the signs
and symptoms if the RDN cannot impact the etiology.

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 Nutrition Intervention

•Two interrelated components:

• Planning

• Implementation

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Nutrition Intervention
• Planning:
o Prioritize the nutrition diagnoses

o Review practice guidelines and policies

o Confer with the patient (+ others)

o Set goals and determine expected outcomes

o Defining the specific nutrition intervention strategy

o Define time and frequency of care

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 Nutrition Intervention
•Four Domains:
1. Food and/or Nutrient Delivery

2. Nutrition Education

3. Nutrition Counseling

4. Coordination of Nutrition Care

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 Nutrition Intervention
• Use of Nutrition Interventions Based on Practice Setting
• Food and/or Nutrient Delivery:
• institutional settings (hospitals, long-term care)
• home care
• Nutrition Education-Content:
• institutionalized settings
• Nutrition Education-Application:
• outpatient/non institutionalized settings
• private practice
• community
• Nutrition Counseling:
• outpatient/non institutionalized settings
• private practice
• community
• Coordination of Nutrition Care:
•
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 Food and/or Nutrient Delivery
• Meals and snacks (ND-1)
• Enteral/parenteral nutrition (ND-2)
• Medical food supplements (ND-3.1)
• Vitamin and mineral supplement (ND-3.2)
• Bioactive substance supplement (ND-3.3)
• Feeding assistance (ND-4)
• Feeding environment (ND-5)
• Nutrition-related medication management (ND-6)
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 Nutrition Education (E)

• Initial/brief nutrition education (E-1)

• E.g. survival skills on discharge
• Comprehensive nutrition education (E-2)
• Purpose
• Recommended modifications
• Result interpretation
• Other
Note: Education is appropriate for food and nutrition-related
knowledge deficit. If the client knows the content, more education
probably won’t help

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Nutrition Counseling (C)
• Theory or approach
• Strategies
• Phase

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 Coordination of Care
Coordination of other care during nutrition care
• Team meeting
• Referral to RD
• Collaboration with other providers
• Referral to community agencies/programs

Discharge and transfer of nutrition care to new setting/provider

• Collaboration
• Referral to community agencies/programs

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 Nutrition Monitoring & Evaluation
•Critical thinking skills for Nutrition Monitoring & Evaluation:

• Selecting appropriate indicators/measures

• Using appropriate criteria (previous status, nutrition intervention

goals, or reference standards) for comparison

• Defining where patient/client is now in terms of expected outcome

• Explaining variance from expected outcomes

• Identifying factors that help/hinder progress

• Deciding between discharge or continuation of nutrition care

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 Nutrition Monitoring & Evaluation
•Determines whether the patient is meeting the
nutrition intervention goals or desired outcomes

•A nutrition reassessment is needed to identify whether

the nutrition-related problem still exists and evaluate
the progress made toward resolving the problem.

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Nutrition Monitoring & Evaluation
•Is the nutrition intervention strategy working to
resolve the nutrition diagnosis, its etiology, and/or
signs and symptoms?
•Assesses the patient’s progress by comparing
specific markers or nutrition care indicators against
recognized, science-based standards or baselines.

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 Nutrition Monitoring & Evaluation

Definitions:
•Nutrition Monitoring: preplanned review and measurement of selected
nutrition care indicators of patient/client’s status relevant to the defined
needs, nutrition diagnosis, nutrition intervention, and outcomes.

•Nutrition Evaluation: the systematic comparison of current findings with

the previous status, nutrition intervention goals, effectiveness of overall
nutrition care, or a reference standard

•Nutrition Care Outcomes: the results of nutrition care that are directly
related to the nutrition diagnosis and the goals of the intervention plan

•Nutrition Care Indicators: markers that can be measured and evaluated to

determine
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 Nutrition Monitoring & Evaluation

•Nutrition Monitoring & Evaluation Components:

•Monitor: Progress toward the nutrition intervention or
goal
•Measure :The appropriate nutrition care indicators
•Evaluate: The nutrition care indicators against
appropriate standards selected during the nutrition care
planning

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 Nutrition Monitoring & Evaluation

•Nutrition Care Outcomes: intermediate outcomes to

other broader health care outcomes:
• Acute or chronic disease: occurrence, duration, severity
•Infections
• Wound healing
• Health care cost
• Patient functional ability

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 Nutrition Monitoring & Evaluation

•Nutrition Care Indicators:

• Factors that food and nutrition professionals can impact directly, such
as food and nutrient intake; growth and body composition; food and
nutrition-related knowledge, attitudes, and behaviors; and food access

• Laboratory values, such as HgbA1c, hematocrit, or serum cholesterol

• Functional capabilities, such as physical activity

• Patient perception of nutrition care and results of nutrition care, such

as nutrition quality of life
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Monitoring and Evaluation
• Initiate calorie count while patient is hospitalized to evaluate
acceptance of oral supplements
• Weigh patient weekly after discharge
• Evaluate patient’s ability to chew textured foods after
dentures are replaced
• Evaluate patient in Geriatric Clinic in one month

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 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
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 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 history and current fluid status
• Self-monitoring deficit r/t lack of access to scale as
evidenced by patient self report
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 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
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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

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