Nutrition Care Process Practical Applications

1
Nutrition Care ProcessPractical Applications

• Andrea Maher RD, LD
• Alicia Aguiar MS, RD, LD

2
International Dietetics Nutrition Terminology
(IDNT) Reference Manual Standardized Language
for the Nutrition Care Process, Second Edition

• Functional changes (swallowing, GI)
• Altered lab data
• Altered body weight

Behavioral/Environmental
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Why should I learn NCP Process?

• Promotes critical thinking to treat current and
  pertinent nutrition problems
• Determines a nutrition diagnosis that drives the
  care plan
• Utilizes a vocabulary to describe the dietitians
  process within and outside the profession
• Affirms via documentation that the nutrition
  diagnosis has been resolved

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Why should I learn NCP Process?

• If we can name it
• We can do it
• We can teach it
• We can measure it
• We can improve it
• We can get paid for it
• Annalynn Skipper, PhD, RD, FADA, author and
  consultant

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Step 1 Nutrition Assessment

• Method in which we obtain, verify and interpret
  data needed to identify nutrition related
  problems.
• Determines whether a nutrition diagnosis exists
• The PES statement is then derived from the
  synthesis of information from the nutrition
  assessment data

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Step 1 Nutrition Assessment

• Mark page 11 of your pocket guide
• Assessment

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Step 2 Nutrition Diagnosis

• Mark page 139 of your pocket guide
• Diagnosis

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Step 2 Nutrition Diagnosis

• Nutrition diagnosis are categorized under
• 3 domains
• Intake (page 139)
• Clinical (page 140)
• Behavioral-Environmental (page 140)
• Currently, 60 nutrition diagnosis identified
• In the LTC setting, the Intake domain will be
  used most frequently

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Step 2 Nutrition Diagnosis, cont.

• The dietitian is responsible for treating
  independently
• No right or wrong nutrition diagnosissome are
  more appropriate than others
• When faced with equally good choices from
  different domains (Intake, Clinical or
  Behavioral-Environmental) choose Intake
• Intake domain more likely to be caused by a
  nutritional etiology and have a nutrition
  directed intervention

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Step 2 Nutrition Diagnosis

• Medical Diagnosis
• Disease/pathology of specific organs or body
  systems
• Does not change as long as the condition exists
• Ex Diabetes

• Nutrition Diagnosis
• Problem related to nutrition that RD can
  influence
• Changes as the residents response changes
• Ideally, with nutrition intervention, diagnosis
  is resolved
• Ex Excessive CHO intake

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Step 2 Nutrition Diagnosis, cont.

• The dietitian is responsible for treating
  independently
• No right or wrong nutrition diagnosissome are
  more appropriate than others
• When faced with equally good choices from
  different domains (Intake, Clinical or
  Behavioral-Environmental) choose Intake
• Intake Domain more likely to be caused by a
  nutritional etiology and have a nutrition
  directed intervention

12
Step 2 Nutrition Diagnosis, cont.

• The dietitian is responsible for treating
  independently
• No right or wrong nutrition diagnosissome are
  better than others
• When faced with equally good choices from
  different domains (Intake, Clinical or
  Behavioral-Environmental) choose Intake
• Intake Domain more likely to caused by a
  nutritional etiology and have a nutrition
  directed intervention

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Step 2 Nutrition Diagnosis, cont.

• Components
• Problem (Nutrition Diagnosis)
• Etiology cause or contributing risk factors
• Signs or symptoms objective and/or subjective
  data used to determine whether the resident has
  the nutrition diagnosis specified.

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Step 2 Nutrition Diagnosis, cont.

• Problem related to Etiology as evidenced by
  Signs or symptoms
• Always remember The etiology explains why (ask
  Why 5 times) the problem exists. The signs and
  symptoms are proof of the problem.

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Step 2 Nutrition Diagnosis, cont.

• Problem related to Etiology as evidenced
  by Signs or symptoms
• E.g. page 194
• Inconsistent carbohydrate intake (NI-5.8.3)
  related to nutrition-related knowledge deficit
  concerning appropriate timing of carbohydrate
  intake as evidenced by wide variations in blood
  glucose levels, dx IDDM, frequently skips
  breakfast meal.

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Step 2 Nutrition Diagnosis PES Statements

• Problem related to Etiology as evidenced
  by Signs or symptoms
• E.g. page 217
• Altered nutrition-related laboratory values
• (NC-2.2) related to kidney dysfunction as
  evidenced by abnormal BUN, Cr and K levels,
  hemodialysis, preference for fresh fruits, poor
  patient knowledge of modified diet.

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Step 3 Nutrition Intervention

• Mark page 261 of your pocket guide
• Intervention

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Step 3 Nutrition Intervention

• Used to remedy a nutrition diagnosis
• Intended to change a nutrition-related behavior,
  environmental condition or aspect of nutritional
  health
• Always collaborate interventions with the
  resident and other health care providers
• Resident response may lead us to revise our
  intervention
• Carry out and communicate plan of care
• Document if resident chooses to not follow an
  intervention

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Step 3 Nutrition Intervention

• Organized into four domains
• Food and/or Nutrient Delivery page 261
• Nutrition Education page 262
• Nutrition Counseling page 262
• Coordination of Care page 262
• In the LTC setting, the Food and/or Nutrient
  Delivery domain will most frequently be used

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Step 4 Nutrition Monitoring and Evaluation

• See page 11 of your pocket guide
• Monitoring and Evaluation
• uses the same terms as the Assessment except
  for those indicators that are shaded.

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Step 4 Nutrition Monitoring and Evaluation

• Determines the amount of progress made to reach
  the specified goal(s)
• Specific outcomes that can be measured and
  compared to previous data or reference standards,
  e.g.
• Weight or BMI
• Laboratory values

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Step 4 Nutrition Monitoring and Evaluation

• Organized in five domains
• Food/Nutrition-Related History Outcomes page 11
• Anthropometric Measurement Outcomes page 13
• Biochemical Data, Medical Tests, and Procedure
  Outcomes page 13
• Nutrition-Focused Physical Finding Outcomes page
  14
• Comparative Standards page 15
• In the LTC setting, the Food/Nutrition-Related
  History Outcomes and Anthropometric Measurement
  Outcomes is likely to be used more frequently

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Case Study 1

• Background Information
• 1/22/09 Resident A is a 99 yo female with
  depression, lactose intolerance and recently dx
  gastroenteritis. She reports her appetite isnt
  good lately. Meal intake records also show a
  decline. She feeds herself, AO x 3.
• Ht- 61, Wt 1/20 120.8, ?10 (14) x 30 days
  and ?16 x 180 days.
• Diet General, ground meat.
• Nursing has just moved her to the ADR for cuing
  and supervision.

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Case Study 1

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis
• Verify the problem? confirm the appropriate
  one

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Case Study 1- Is there a nutrition dx?

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms
  
  
  

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Case Study 1

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms
  
  
  

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Case Study 1

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms

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Case Study 1

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis
• Verify the problem? confirm the appropriate
  one
• Inadequate food and beverage intake (pg 146)
• (definition)- Oral food/beverage intake that is
  less than established reference standards or
  recommendations based on physiological needs

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Case Study 1

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem Inadequate oral food and beverage intake
• Etiology related to p.o. intake less than
  calorie expenditure
• Signs/ Symptoms as evidenced by depressed meal
  intake, significant wt loss of 10 in 30 days and
  16 in 180 days, resident verbalizes decreased
  appetite

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Case Study 1

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology

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Case Study 1

• Nutrition Intervention
• Nutrition Prescription Recommend 1500 kcal and
  48 grams protein from meal and planned snacks to
  meet nutrient needs
• Interventions See Care Plan ? Yes. ? No. X
  Meals/Snacks Add Super Cereal, provide whole
  milk each meal, add pm ice cream, HS pudding
• Food Supplements
  X Vit/Min Rec MVI/mineral
• Feeding Assistance
  Nutrition Education
• Coordination of Care (Refer to)
  Enteral Nutrition

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Case Study 1

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

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Case Study 1

• Monitoring/Evaluation
• X Food intake Monitor meal/snack pattern X
  Acceptance of cuing from nursing
• Nutrition quality of life responses
  Behavior
• X Lab Data ? Hgb A1C ? Glucose, casual X
  Albumin ? Other
• X Weight- screen weekly for changes
  Med use Other
• Follow up ? 7 days ? 1 week X 1 month
  ? Quarterly X Monitor with MDS
• Inform physician/family of significant wt change.

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Case Study 2

• Background Information
• You are informed when you arrive at the facility
  a week later (1/29/09) that this same resident
  from case study 1 has developed a stage II
  pressure area on her L/buttock (3 cm diameter).
  Wt 1/27116, down 4 from last week.

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Case Study 2

• Bring your PES statement(s) forward to begin your
  note
• Collect supporting data
• Document the status of your problem, e.g.
• Resolved
• Improved
• Need to adjust intervention or nutrition Rx if
  problem is not improving
• NCP continues until problem is resolved

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Case Study 2

• 1/29/09
• Nutrition Dx Inadequate oral food and beverage
  intake related to p.o. intake less than calorie
  expenditure/energy needs for healing as evidenced
  by depressed meal intake, significant wt loss,
  new stage II pressure area on L/buttock.
• Interventions- Nutrition Rx Recommend 1600 kcal
  and 57 grams protein from meal, planned snacks
  and supplement to meet nutrient needs. Continue
  current interventions, see care plan. Add Med
  Pass supplement BID (ND-3.1.1) for additional 240
  kcal, 10 gm protein. Recommend Vit C 500 mg
  (ND-3.2.3) to promote wound healing.
• Monitor/Evaluation Monitor skin status
  monthly/prn (PD 1.1.8), Monitor weight weekly
  (AD-1.1.2), Monitor meal/snack patterns
  (FH-1.3.2.3), Monitor albumin level as ordered
  (BD-1.11).
• Notify family/physician of significant
  weight changes.
• RD signature

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Transitioning charting to NCP format

• You do not need to change the style of your
  charting format
• Narrative
• Just include standard language terms in your
  sentences
• SOAP
• S Assessment terminology
• O Data documented elsewhere in chart or data
  documented by the dietitian
• A Nutrition Diagnosis, written as a PES
  statement
• P Nutrition Prescription and Intervention.
  Monitoring indicators and evaluation criteria
  also go here.

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Case Study 3- Annual assessment

• Background Information
• 4/06/09 Resident B is a 95 yo female with dx
  HTN, constipation, severe low back pain, GERD,
  advanced cancer. He is on hospice care. Feeds
  himself then staff finish. Ongoing poor
  appetite.
• Ht- 60, Wt 4/09 92, ?8 (9) x 30 days and
  ?21 x 180 days.
• Diet Pureed. House supplement 60 mL TID

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Case Study 3

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

40
Case Study 3- Is there a nutrition dx?

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms
  
  
  

41
Case Study 3- Is there a nutrition dx?

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms
  
  
  

42
Case Study 3

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms

43
Case Study 3

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem Increased nutrient needs
• Etiology related to increased demand for energy
• Signs/ Symptoms as evidenced by significant wt
  loss trend of 8 (9) x 30 days and 21 x 180
  days, cancer, hospice care

44
Case Study 3

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

45
Case Study 3

• Nutrition Intervention
• Nutrition Prescription Recommend continue
  current pureed diet and supplement as tolerated
  by resident for comfort measures
• Interventions See Care Plan ? Yes. ? No.
  X Meals/Snacks Cont current pureed diet,
  provide snacks as tolerated
• X Food Supplements Cont supplement
  Vit/Min
• X Feeding Assistance Mouth care after
  meals/prn Nutrition Education
• X Coordination of Care (Refer to) Hospice
  Enteral Nutrition

46
Case Study 3

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

47
Case Study 3

• Monitoring/Evaluation
• X Food intake Monitor meal/snack pattern
  Acceptance of
• X Nutrition quality of life responses
  Behavior
• Lab Data ? Hgb A1C ? Glucose, casual ?
  Albumin ? Other
• X Weight- screen monthly/prn for changes
  Med use Other
• Follow up ? 7 days ? 1 week X 1 month
  ? Quarterly X Monitor with MDS

48
Case Study 4- Initial assessment

• Background Information
• 4/06/09 Resident C is an 86 yo male with
  dementia. He has a good appetite per meal
  intake records. He feeds himself with set up
  assist. AO x 2 with confusion.
• Ht- 68, Admit wt 4/09 162, no significant wt
  changes found, UBW 170 per spouse
• Diet Mechanical Soft
• During mealtime observation you notice that he
  has difficulties keeping the food on his plate-
  spilling food on himself.

49
Case Study 4

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

50
Case Study 4- Is there a nutrition dx?

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms
  
  
  

51
Case Study 4- Is there a nutrition dx?

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms

52
Case Study 4- Is there a nutrition dx?

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem Self-feeding difficulty
• Etiology related to impaired cognitive ability
• Signs/ Symptoms being provided foods that may
  not be conducive to self-feeding, dropping of
  food from untensil, dx dementia
  
  
  

53
Case Study 4

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

54
Case Study 4

• Nutrition Intervention
• Nutrition Prescription Provide adaptive
  equipment to facilitate independent eating
• Interventions See Care Plan ? Yes. ? No.
  Meals/Snacks
• Food Supplements
  Vit/Min
• X Feeding Assistance Provide Adaptive
  Equipment, Encourage finger foods
• X Coordination of Care (Refer to) OT
  Enteral Nutrition

55
Case Study 4

• Step 1- Prioritize Assessment Problems- What is
  the most immediate problem?
• Step 2- Nutrition Diagnosis- verify the problem?
  confirm the appropriate one using the pocket
  guide for guidance
• Step 3- Nutrition Intervention- aimed at
  fixing the etiology
• Step 4- Monitoring and Evaluation

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Case Study 4

• Monitoring/Evaluation
• X Food intake Monitor meal intake
  Acceptance of
• Nutrition quality of life responses
  X Behavior Fatigue/ability to feed self
• Lab Data ? Hgb A1C ? Glucose, casual ?
  Albumin ? Other
• X Weight- screen monthly/prn for changes
  Med use Other
• Follow up ? 7 days ? 1 week ? 1 month
  X Quarterly X Monitor with MDS

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No nutrition diagnoses

• ? No nutrition diagnosis at this time.
  ? Proceed to nutrition diagnosis below
  
  
• Nutrition Diagnostic Codes
• NI-1.4 Inadequate energy intake
  NC-1.1 Swallowing difficulty
• NI-1.5 Excessive energy intake
  NC-1.2 Chewing difficulty
• NI-2.1 Inadequate oral food/beverage intake
  NC-2.2 Altered nutrition-related labs
• NI-3.1 Inadequate fluid intake
  NC-3.1 Underweight
• NI-3.2 Excessive fluid intake
  NC-3.2 Involuntary weight loss
• NI-5.1 Increased nutrient needs
  NC-3.3 Overweight/obesity
• NI-5.3 Inadequate protein-energy intake
  NC-3.4 Involuntary weight gain
• NI-5.7.1 Inadequate protein intake
  NB-1.7 Undesirable food choices
• NI-5.8.4 Inconsistent carbohydrate intake
  NB-3.2 Inability to manage self-care
• NI-5.8.5 Inadequate fiber intake
  NB-2.6 Self-feeding difficulty
• NI-5.9/5.10 Inadequate vitamin/mineral intake
  (specify)
• Problem
• Etiology
• Signs/ Symptoms
  
  
  

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No nutrition diagnoses, cont.

• What do you do if there is not a nutrition
  diagnosis?
• The nutrition diagnoses describe actual problems,
  not potential for or at risk for concerns
• Potential/at risk concerns would be recorded in
  the residents care plan (per NCP Long Term Care
  Toolkit)- if you decide if you still want to
  care plan without a nutrition diagnoses
• You still need to set up Monitoring and
  Evaluation for follow up reassessment

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No nutrition diagnoses, cont.

• Skip to Step 4- Monitoring and Evaluation
• X Food intake Monitor meal/snack pattern
  Acceptance of
• Nutrition quality of life responses
  Behavior
• X Lab Data ? Hgb A1C ? Glucose, casual ?
  Albumin ? Other as available
• X Weight- screen weekly x 4 wks Med use
  Other
• Follow up ? 7 days ? 1 week ? 1 month X
  Quarterly X Monitor with MDS

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Nutrition Reassessment, e.g. Qtr Review

• When completing a reassessment, we determine
  progress of the goal
• Positive Outcome Obtained
• Continue Plan of Care
• Resolve Problem
• Status quo
• Continue Plan of care
• Change Intervention
• Decline
• Change Intervention

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Nutrition Care Process-Where do we go from here?

• Get the resources you need to get started
• Practice writing PES statements and using the
  assessment terminology
• Review current systems of documentation in your
  facilities
• Develop changes in systems, if needed
• Communicate to key stakeholders in your facility
• Implement the Nutrition Care Process
• Evaluate progress and get feedback

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• Andrea Maher RD, LD
• maher_at_huxcomm.net