The Nutrition Care Process

The Nutrition Care ProcessThe Nutrition Care Process

Chapter 21Chapter 21

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutrition Care ProcessNutrition Care Process

Assess nutritional status.

Analyze data to identify nutritional needs.

Plan and prioritize nutritional care objectives to meet these needs.

Implement strategies necessary to meet the objectives.

Evaluate the nutritional care outcomes.

Assess nutritional status.

Analyze data to identify nutritional needs.

Plan and prioritize nutritional care objectives to meet these needs.

Implement strategies necessary to meet the objectives.

Evaluate the nutritional care outcomes.


Nutrition Care ProcessNutrition Care Process


Nutrition Care Process –cont’dNutrition Care Process –cont’d


Patient/Nutrition Care ProcessPatient/Nutrition Care Process

Admission

MD orders: PE, Dx, PMHx, Diet order, Labs, Tests/Procedures, Consults, Meds RN Assessment: Ht, Wt, I/Os, Vitals, PO, FPG, Allergies, GI Status, Feeding ability/Dentition, Wounds

Nutrition Screen: Age, Dx, Diet Rx, Anthros, Labs, Oral intake, GI, Meds

Admission

MD orders: PE, Dx, PMHx, Diet order, Labs, Tests/Procedures, Consults, Meds RN Assessment: Ht, Wt, I/Os, Vitals, PO, FPG, Allergies, GI Status, Feeding ability/Dentition, Wounds

Nutrition Screen: Age, Dx, Diet Rx, Anthros, Labs, Oral intake, GI, Meds


Nutriton AssessmentGather & evaluate/analyze data

Update screen info from MRInterview pt/familyD/w staff

Document assessment & planSOAP, PIE, DAR, NarrativePaper vs. computer chart

Nutriton AssessmentGather & evaluate/analyze data

Update screen info from MRInterview pt/familyD/w staff

Document assessment & planSOAP, PIE, DAR, NarrativePaper vs. computer chart


Implement Strategies (Interventions)

– Education, Referrals, Food Preferences, snacks/supplements

Nutrition F/U Assessments

– Evaluate outcomes, Document assessment,

– Implement further strategies PRN

Implement Strategies (Interventions)

– Education, Referrals, Food Preferences, snacks/supplements

Nutrition F/U Assessments

– Evaluate outcomes, Document assessment,

– Implement further strategies PRN


Nutritional AssessmentNutritional Assessment

The process by which the nutritional status of an individual is determined

Usually includes dietary history and intake data, laboratory data, clinical examination and health history, anthropometric data, and psychosocial data

The process by which the nutritional status of an individual is determined

Usually includes dietary history and intake data, laboratory data, clinical examination and health history, anthropometric data, and psychosocial data


Nutritional Screening InformationNutritional Screening Information


Nutrition Screening and Assessment ToolNutrition Screening and Assessment Tool

Courtesy Carolinas Medical Center, Charlotte, N.C.


Development of a Plan for Nutritional CareDevelopment of a Plan for Nutritional Care

Prioritize problems

Client and counselor must jointly establish achievable goals

Express objectives in behavioral terms

State objectives in quantifiable terms

Prioritize problems

Client and counselor must jointly establish achievable goals

Express objectives in behavioral terms

State objectives in quantifiable terms


Implementation of Nutritional CareImplementation of Nutritional Care

Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives.

Interventions should be specific:

—What? —When?

—Where? —How?

Implementation is the component of the nutritional care process that translates assessment data into strategies, activities, or interventions that will enable the patient or client to meet the established objectives.

Interventions should be specific:

—What? —When?

—Where? —How?


Evaluation of Nutritional CareEvaluation of Nutritional Care

Evaluate care provided

Review plan frequently

Reassess plan—may be new needs

Identify any new needs

Formulate a new nutritional care plan

Evaluate care provided

Review plan frequently

Reassess plan—may be new needs

Identify any new needs

Formulate a new nutritional care plan


Nutritional Care RecordNutritional Care Record

Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives

Written documentation of the nutritional care process, including the interventions and activities used to meet the nutritional objectives


Care RecordCare Record

Courtesy St. John’s Hospital, Springfield, Ill.


Documentation StyleDocumentation Style

DAP (diagnosis, assessment, plan)

PIE (problem, intervention, evaluation)

PES (problem, etiology, symptoms)

IER (intervention, evaluation, revision)

HOAP (history, observation, assessment, plan)

SAP (screen, assess, plan)

SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions)

SOAP (subjective, objective, assessment, plan)

DAP (diagnosis, assessment, plan)

PIE (problem, intervention, evaluation)

PES (problem, etiology, symptoms)

IER (intervention, evaluation, revision)

HOAP (history, observation, assessment, plan)

SAP (screen, assess, plan)

SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions)

SOAP (subjective, objective, assessment, plan)


SOAP NotesSOAP Notes

S: Subjective

Info provided by patient, family, or other

Pertinent socioeconomic, cultural info

Level of physical activity

Significant nutritional history

S: Subjective

Info provided by patient, family, or other

Pertinent socioeconomic, cultural info

Level of physical activity

Significant nutritional history


SOAP Notes—cont’dSOAP Notes—cont’d

O: Objective

Factual, reproducible observations

Diagnosis

Height, age, weight—and weight gain patterns

Lab data

Clinical data (nausea, diarrhea)

Diet order

Medications

O: Objective

Factual, reproducible observations

Diagnosis

Height, age, weight—and weight gain patterns

Lab data

Clinical data (nausea, diarrhea)

Diet order

Medications



A: Assessment

Interpretation of patient’s status based on subjective and objective info

Evaluation of nutritional history

Assessment of laboratory data and medications

Assessment of diet order

Assessment of patient’s comprehension and motivation

A: Assessment

Interpretation of patient’s status based on subjective and objective info

Evaluation of nutritional history

Assessment of laboratory data and medications

Assessment of diet order

Assessment of patient’s comprehension and motivation



P: Plan

Diagnostic studies needed

Further workup, data needed

Medical nutrition therapy goals

Recommendations for nutritional care

P: Plan

Diagnostic studies needed

Further workup, data needed

Medical nutrition therapy goals

Recommendations for nutritional care


Basic Hospital DietsBasic Hospital Diets


Basic Hospital Diets —cont’dBasic Hospital Diets —cont’d


Soft DietSoft Diet


Clear Liquid DietClear Liquid Diet


Full Liquid DietFull Liquid Diet


Full Liquid Diet –cont’dFull Liquid Diet –cont’d


Nutritional Care of the Terminally Ill PatientNutritional Care of the Terminally Ill Patient

Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients.

Dietary restrictions are rarely appropriate.

Maintenance of comfort and quality of life are the main goals of nutritional care for terminally ill patients.

Dietary restrictions are rarely appropriate.


Palliative CarePalliative Care

Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently

Encourages the alleviation of physical symptoms, anxiety, and fear while attempting to maintain the patient’s ability to function independently


Discharge PlanningDischarge Planning

Discharge documentation includes

Summary of nutritional therapies and outcomes

Pertinent information such as weight, lab results, dietary intake

Potential drug-nutrient interactions

Expected progress or prognosis

Recommendations for follow-up services

Discharge documentation includes

Summary of nutritional therapies and outcomes

Pertinent information such as weight, lab results, dietary intake

Potential drug-nutrient interactions

Expected progress or prognosis

Recommendations for follow-up services


Discharge PlanningDischarge Planning

Courtesy University of Washington Medical Centers, Seattle.

The Nutrition Care Process

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