Nutrition Care Process Documentation PDF

9/3/24 Nutrition Care Process Documentation Estimating Nutrient Needs LECTURE 1 – FALL 2024 1 1 Nutritional Status...

9/3/24 Nutrition Care Process Documentation Estimating Nutrient Needs LECTURE 1 – FALL 2024 1 1 Nutritional Status v Assessment of nutritional status: reflection of how well a person’s physiologic nutritional needs are being met v Adequate nutritional status is a result of a balance between nutrient intake and nutrient requirements v The basis of nutrition assessment: o what is the current nutritional status? o what is the nutritional risk? 2 2 1  9/3/24 Nutritional Status v Nutrition Imbalance: deficiency or excess v Nutrient deficiency can result from any of the following (or a combination of any of the following): o Inadequate nutrient intake o Inadequate absorption o Inadequate utilization o Increased nutrient requirement o Increased excretion 3 3 Nutritional Status v Nutrient Intake o Includes all intake: diet, supplements, formula o Many influential factors, such as: § appetite § ability to chew and swallow § purchasing power § culture § eating behaviors § emotional climate § social support § others… 4 4 2  9/3/24 Nutritional Status v Nutrient Requirements o Maintenance o Physiologic stressors § acute or chronic diseases, disorders or syndromes § fever § trauma o Normal anabolic states § pregnancy § childhood growth § rehabilitation 5 5 Estimating Nutrient Needs 6 6 3  9/3/24 Basal Metabolic Rate (BMR) v Minimum amount of energy expended that is compatible with life v Synonymous with Basal Energy Expenditure (BEE) v Measured in morning, in fasting state (no food or drink 12-14 hours prior), resting (physically/mentally), before person engages in any physical activity, lying in supine position, in thermally neutral environment (not hot, not cold, room temperature; prevents activation of heat generating processes, such as shivering) o these strict conditions make obtaining BEE impractical in clinical setting o usually the goal measurement in research setting 7 Resting Metabolic Rate (RMR) v Energy expended in activities necessary to sustain normal body functions and homeostasis; to sustain life and keep vital organs functioning (heart, lungs, brain, liver kidney) o includes energy required for maintenance of body temperature o higher than BEE by 10-20% v Synonymous with Resting Energy Expenditure (REE) v Resting Energy Expenditure can be obtained any time of day, after resting for 30 minutes, fasted for at least 5 hours o more frequently measured, though rarely fasted in clinical setting 8 4  9/3/24 Resting Metabolic Rate (RMR) v Factors affecting Resting Energy Expenditure o Body Composition / Size § Lean Body Mass: LBM (also known as fat free mass) more metabolically active than adipose tissue § Athletes have higher REE than non-athletes § Taller = large body surface area and higher metabolic rate o Gender § Males tend to have greater REE; attributed to body composition/size § Males: more muscle mass Females: more fat mass o Age § REE decreases ~2% for every decade after 30 years § In large part affected by proportion of LBM: decreases with increasing age, highest during periods of growth 9 Resting Metabolic Rate (RMR) v Factors affecting Resting Energy Expenditure o Climate § People living in tropical climates have higher REE o Body Temperature § Fever → ↑ REE § 7% for each degree above 98°F; 13% for each degree above 37°C o Energy Restriction § After several weeks of energy restriction, REE declines o Hormone Status § Genetic influence, predisposition to higher/lower REE § Hypothyroidism (decrease) and hyperthyroidism (increase) o Other Factors § Caffeine, nicotine; metabolic stress, disease 10 5  9/3/24 Additional Energy Components v Thermic Effect of Food (TEF) o Energy required to digest, absorb, metabolize, store nutrients contained in foods consumed and to eliminate byproducts and waste o Measurable increase in EE from REE o Accounts for 10% of Energy Expenditure for typical mixed meal o Influenced by amount and macronutrient composition of food consumed § fat lowest TEF, protein highest o Can be measured x several hours after meal; peaks ~60-120 mins after meal, can last 4-6 hours depending on size and composition of meal o Typically not calculated into BEE due to high variability 11 Additional Energy Components v Physical Activity (Activity Thermogenesis) o energy expended in physical activity o includes exercise-related and/or non-exercise activity (part of daily work and movement, includes shopping, fidgeting, even chewing gum) o in very active individuals can exceed REE by twofold or more o could be as low as 100kcals/d (sedentary) or as high as 3000kcals/d (athletes) v Total Energy Expenditure (TEE) o TEE = BMR + TEF + Activity Factor o Activity factors vary depending on activity level (textbook chapter 2) o Sedentary; Light Active; Active; Very Active 12 6  9/3/24 Additional Energy Components v Illness/Trauma o trauma, surgery (elective trauma), and illness increase metabolic rate o highly variable depending on disease or condition o injury or illness factor is really part of BMR although in older texts it is often accounted for when prediction equations are used because many of the equations do not account for the incremental increase in metabolic rate o in practice, injury factors are rarely used (they were used in the past) and they are not part of current research on energy expenditure o incorporated into measured Energy Expenditure (EE) in clinical setting 13 Methods for Predicting or Measuring EE o Direct calorimetry o Indirect calorimetry o Predictive equations o Rule of thumb 14 7  9/3/24 Direct Calorimetry Individual is placed in room/chamber that permits moderate activity Provides measure of energy expended in the form of heat Limited by confined testing conditions; not representative of normal daily activities Used in research settings only; too expensive, complex engineering, time consuming, impractical for use in clinical setting 15 Indirect Calorimetry v Estimates EE (energy expenditure) by determining oxygen consumption and carbon dioxide production over period of time v Gold Standard in acute care settings o Metabolic Carts used bedside in hospitals o Mainly used in ICU setting o Expensive; not every facility has a metabolic cart v Handheld indirect calorimeter o Designed to measure oxygen consumption, uses static value for carbon dioxide production o MedGem (handheld device) o Benefit: easy mobility and relatively low cost o These devices are often used in gyms 16 8  9/3/24 Indirect Calorimetry v Requirements for Indirect Calorimetry ◦ Hemodynamically stable patient ◦ Cooperative patient ◦ Rest period before measurement ◦ Fi02 < 60% (fractional inspired oxygen concentration; percent of oxygen you are breathing; normal=21%) ◦ Absence of chest tubes or other sources of air leak ◦ Absence of hyperventialtion v Using the results, Resting Energy Expenditure (REE) can be calculated o To calculate the 24-hour energy expenditure: REE = [3.9 (VO2) + 1.1 (VCO2)] 1.44 VO2 = O2 consumption (mL/min) VCO2 = CO2 production (mL/min) 17 17 Predictive Equations v Over the years several equations have been developed to estimate REE o Examples § Mifflin-St Jeor § Harris Benedict § Penn State v Many were developed for use with healthy individuals (i.e Harris Benedict); application to other populations is questionable 18 9  9/3/24 Mifflin-St Jeor v Men: o RMR = 5 + 10(wt in kg) + 6.25(ht in cm) – 5(age in yrs) v Women: o RMR = -161 + 10(wt in kg) + 6.25(ht in cm) – 5(age in yrs) v Most valid of the equations in healthy adults; less so for obese v Used to estimate energy expenditure of healthy individuals 19 Harris Benedict v Men: o BMR = 66.5 + (13.75 x wt(kg)) + (5.003 x ht(cm) – (6.755 age(yrs)) v Women: o BMR = 655.1 + ( 9.563 x wt(kg)) + (1.850 x ht(cm)) – (4.676 x age(yrs)) v Until recently was most widely used equation v Found to overestimate REE in both normal & obese individuals by 7-27% v Databases that were used to develop Harris Benedict no longer reflect the population; use of this equation is not recommended 20 10  9/3/24 Penn State University Equation v PSU (2003b): RMR = Mifflin (0.096) + VE(31) + Tmax (167) – 6212 ◦ Use in non obese critically ill ventilated ◦ Use in the obese critically ill ventilated less that 60 years old v PSU (2010): RMR = Mifflin (0.71) + VE(64) + Tmax (85) – 3085 ◦ Use in obese critically ill ventilated 60 years or older v Equation used for critically ill patients v Can be used when indirect calorimetry is not available or feasible 21 Special Considerations: Obesity v ASPEN Guidelines o 2a. In the critically ill obese patient, if indirect calorimetry is unavailable, energy requirements should be based on the Penn State University 2010 predictive equation or the modified Penn State University equation if the patient is over age of 60 years (strong) o 2b. In the hospitalized obese patient, if indirect calorimetry is unavailable and the Penn State University equations cannot be used (VE and Tmax unavailable), energy requirements may be based on the Mifflin-St Jeor equation using actual body weight (weak) 22 11  9/3/24 Weight Based Calculations Patient Type Estimated Energy Needs Healthy Adult, Ambulatory 25-30kcal/kg Healthy Adult, Active 30-35kcal/kg Overweight 21-25kcal/kg Obese 18-21kcal/kg Critically Ill, intubated 25-30kcal/kg Critically ill (BMI >30) 11-14kcal/kg actual body weight Pressure Injury 30-35kcal/kg 23 23 Weight Based Calculations Patient Type Estimated Energy Needs Cancer 25-35kcal/kg Cancer, head & neck 28-32kcal/kg, 30-40kcal/kg if wt loss CKD Stages 1-4 25-30kcal/kg CKD Stage 5 on dialysis 30-35kcal/kg Cirrhosis 25-35kcal/kg Transplant, 6 months post-op 25-30kcal/kg 24 24 12  9/3/24 Estimated Protein Requirements v Based on o Nutritional status; degree of malnutrition o Degree of stress of disease or injury o Physiologic ability to metabolize protein o Physiologic ability to utilize protein o Nitrogen balance (less valid) input vs output v Metabolically Stressed o Provide enough to meet metabolic demand o Allow approximately 1.5 g protein/kg/day § Assuming adequate organ function § < 1.5 grams may be necessary, depending on liver/renal function 25 25 Estimated Protein Requirements Condition Protein Requirement DRI Reference 0.8g/kg body weight Adult maintenance 0.8-1 g/kg Older Adults >1 g/kg Renal disease: pre-dialysis (stage IV) 0.6-0.8 g/kg Renal disease: hemodialysis >1.2-1.3 g/kg up to 1.5-1.8 g/kg Hepatitis (acute or chronic) 1-1.5 g/kg Hepatic encephalopathy 0.6-0.8 g/kg (BCAA) *if refractory 26 26 13  9/3/24 Estimated Protein Requirements Condition Protein Requirement Cancer 1-1.5g/kg, 1.5-2.5 if cachectic Bone Marrow Transplant 1.5 g/kg Inflammatory bowel disease 1-1.5 g/kg Short bowel syndrome 1.5-2 g/kg BMI >27, normal renal/liver 1.5-2 g/kg IBW Obesity Class I or II, trauma (ICU) 1.9 g/kg IBW Obesity Class III, trauma (ICU) 2.5 g/kg/IBW 27 27 Estimated Protein Requirements Condition Protein Requirement Organ transplant: short term 1.5-2 g/kg Organ transplant: long term 1 g/kg Pregnancy +25 g/d in 2nd & 3rd trimester Pulmonary disease 1.2-1.5 g/kg Critical illness 1.5-2 g/kg *burns, sepsis, traumatic brain injury Stroke 1-1.2 g/kg Pressure Injury 1.25-1.5 g/kg 28 28 14  9/3/24 Estimated Fluid Requirements v Goals o Maintenance of adequate hydration o Tissue perfusion o Electrolyte balance v Needs based on o Body weight o Body surface o RDA v Consider o Insensible losses: 75% skin, 25% lung (500-900 ml) o Measured losses: stool (250 ml), urine (800-1500ml), other drainage o Fluid balance alterations due to: § Metabolic changes (fever) § Medical therapy (diuretic treatment) 29 29 Estimated Fluid Requirements v Factors affecting fluid requirements Factor Increase in Fluid Needs Fever 13% for each 1 degree Co above normal (37oC is normal); 7% for each degree Fo Sweating 10-25% Hyperventilation 10-60% Extraordinary wound/fistula, gastric Varies (based on average 24 hour output) and/or renal fluid losses v Fluid requirements may increase or decrease for certain disease states o i.e. may decrease with CHF, CKD/dialysis, cirrhosis, … 30 30 15  9/3/24 Estimated Fluid Requirements v Based on Age o Young Adult: 35-40ml per kg (actual body weight) o 20-55 years old: 30-35ml per kg (actual body weight) –may be higher if active o 55-75 years old: 25-30ml per kg (actual body weight) o >75 years old: 25ml per kg (actual body weight); >100 years old: 20ml per kg v RDA Method o 1 ml fluid per 1 kcal of estimated needs v Fluid Balance Method o Daily urine output +500ml per day v Holliday Segar Method o 10kg o >20 kg : 1500ml +20ml/kg for each kg >20 kg o pediatrics 31 31 Nutrition Care Process 32 32 16  9/3/24 Nutrition Care Process o A systematic approach to providing high quality nutrition care. Standardizes the process of providing nutrition care. Nutrition What do you do at each Assessment step in the nutrition care process? Step 1 Nutrition Diagnosis Step 2 Nutrition Intervention Nutrition Step 3 Monitoring & Evaluation Step 4 33 33 Nutrition Care Process Ø Step 1: Nutrition Assessment: Collecting and documenting pertinent information such as food or nutrition-related history, biochemical data, medical tests and procedures, anthropometric measurements, nutrition-focused physical findings and client history Ø Step 2: Nutrition Diagnosis: Data collected during the nutrition assessment guides in selection of the appropriate nutrition diagnosis (naming the specific problem) o uses standardized language Ø Step 3: Nutrition Intervention: Intervention (MNT) directed to root cause (or etiology) of the nutrition problem and aimed at alleviating the signs and symptoms of the diagnosis Ø Step 4: Monitoring/Evaluation: To determine if the patient/client has achieved, or is making progress toward, planned goals –re-assess interventions if progress isn’t made 34 34 17  9/3/24 Nutrition Care Process 35 35 Nutrition Screening o Nutrition screening is typically completed within § 24 hours of admission to an acute care facility § 1st visit at an ambulatory clinic or office practice o Purpose of nutrition screening is to identify individuals who are malnourished or at nutritional risk; determine if a more detailed assessment is warranted o Who completes the nutritional screen § RN, DTR, RD § another health care professional § patient generated o Patients found to be at nutritional risk are referred to RD for full assessment 36 36 18  9/3/24 Effective Screening & Assessment Tools o Simple o Efficient o Quick o Inexpensive o Low risk to individual being screened o Valid and Reliable 37 37 Quality of Screening & Assessment Tools o Validity § How well the tool measures what it’s designed to measure (accuracy) o Reliability § The degree to which repeated, independent measurements of the same variable give the same value (precise); consistent results o Sensitivity & Specificity § Used to assess validity § Sensitivity is the percentage of undernourished individuals correctly identified by the screening tool as being at nutritional risk § Specificity is the percentage of well-nourished individuals correctly identified by the screening tool as being not at nutritional risk 38 38 19  9/3/24 Screening & Assessment Tools o Nutrition Screening Tools § Malnutrition Screening Tool (MST) § Malnutrition Universal Screening Tool (MUST) § Nutrition Risk Screening (NRS 2002) § Mini Nutrition Assessment (MNA) Short Form o Assessment Tools § Subjective Global Assessment (SGA) (1987) § Patient Generated Subjective Global Assessment (PG-SGA) (1990) § Mini Nutrition Assessment (MNA) Long Form 39 39 Malnutrition Screening Tool (MST) 40 40 20  9/3/24 Malnutrition Universal Screening Tool (MUST) 41 41 Nutrition Risk Screening (NRS 2002) 42 42 21  9/3/24 Mini Nutrition Assessment (MNA) Short Form 43 43 Skipper A, et al. Nutrition screening tools: An analysis of the evidence. JPEN 2012;36(3):292-298. o Eleven tools were evaluated for validity and reliability in an acute care setting and hospital based ambulatory clinic setting § NRS-2002 received a grade I § MNA-SF, MST, and MUST received a grade II o Other Considerations for Screening § Do non-validated screens contribute to evidence based practice? § What about pediatrics? (focus of tools for >18 years old) § Intervention strategy for what is identified § Evaluation of outcomes of screening process § Re-screening 44 44 22  9/3/24 SGA Revision (1990) PG-SGA o PG-SGA: Patient Generated Subjective Global Assessment § history section of the assessment became patient generated § scoring and triage component was added (healthcare professional) § tool was validated in oncology patients o Quick, valid and reliable § Inpatient/Outpatient § 98% sensitivity and 82% specificity at predicting SGA classification SGA Classification: Well Nourished, Moderately (or suspected of being) Malnourished, Severely Malnourished o Identifies a more extensive range of nutrition impact symptoms 45 45 PG-SGA (1990) first part of form is filled out by the patient 46 23  9/3/24 PG-SGA (1990) second part filled out by healthcare professional 47 Clinical Nutrition Assessment 1. Gather information from chart, staff, patient interview, family 2. Analyze data to identify nutritional problems (nutrition diagnoses) 3. Goal to identify and implement appropriate MNT strategies o Systematic method; ongoing, nonlinear, dynamic process o Type of Data Collected § Biochemical Data, Medical History § Food/Nutrition Related History § Anthropometric Data § Nutrition Focused Physical Examination Findings § Client History, Functional/Socioeconomic Status 48 48 24  9/3/24 Medical & Surgical History o Past medical and surgical history o Current (or previous) medication & supplement usage o Current chief complaints, symptoms o Current medical diagnoses o Overall clinical status o Recent or planned medical or surgical procedures o Recent or planned diagnostic tests o Biochemical data, laboratory values o Family history § Acute and chronic disease § Surgical history 49 49 Anthropometric data o Height o Weight o BMI (kg/m2) o Ideal body weight (IBW) o Percent ideal body weight § %IBW = Actual weight/IBW x 100 o Usual body weight (UBW) o Percent usual body weight § %UBW = Actual weight/UBW x 100 o Weight change o Timeframe for weight change(s) o Percent weight change § %wt change = (UBW - Actual Wt)/UBW x 100% o Also important to consider weight trend 50 50 25  9/3/24 Anthropometric data o Estimating Ideal Body Weight (IBW) § Females: 100# for first 5ft + 5# for each additional inch § Males: 106# for first 5ft +6# for each additional inch § Assumes medium frame size; adjust +/-10% for frame size to estimate an appropriate desirable body weight range § For height less than 5ft, subtract 2# for each inch below 5ft § Another method: calculate weight for BMI of 22 o Adjusting for amputations: Foot 1.5% Entire Leg 16% BKA 5.9% Hand 0.7% (hand +lower arm 2.3%) AKA 11.6% Entire Arm 5% o Body composition data § MAMC –mid arm muscle circumference § Skinfold –estimating body fat § Bioelectrical impedance (BIA) –body fat in relation to lean body mass § Dual energy x-ray absorptiometry (DXA) –bone mineral density 51 51 Nutrition Focused Physical Exam 52 52 26  9/3/24 Food and Nutrition History v Current diet and dietary habits (In Detail) § Usual eating patterns, dietary habits - Meals, snacks, beverages, dining out, weekday vs weekend, et al § Recent changes to eating pattern, previous intake § Dietary restrictions - Therapeutic, textural, religious, ethical beliefs, preferences, et al o Methods available for analysis of nutrition intake § 24-hour recall § 3-day food intake § Food frequency questionnaire § Food diary/record § Calorie count (in acute/sub-acute care) v Supplements (vitamin, mineral, herbal, protein, fiber, et al) v Likes and dislikes, aversions, allergies, intolerances 53 53 Food and Nutrition History v Additional considerations o Appetite o Recent changes in appetite o Alterations in taste o Satiety o Dentition o Chewing and swallowing ability o Food Allergies and Intolerances o GI complaints § Nausea, vomiting, diarrhea, constipation, bloating, gas § Abdominal pain interfering with intake § Change from baseline bowel patterns § Potential impact on absorption 54 54 27  9/3/24 Client History o Occupation (desk job vs active) o Activity patterns § sedentary time (TV, phone, computer) § exercise intensity, frequency, and duration § planned (gym) vs throughout the day o Functional status; ability to participate in activities of daily living o Readiness to learn, behavior change o Knowledge and beliefs about nutrition § self-monitoring/management practices § past nutrition counseling and education § past diets/diet behaviors o Cultural and religious beliefs o Socioeconomic information 55 55 Client History v Additional considerations o Food planning o Food purchasing o Food preparation abilities and limitations o Food safety practices o Food/nutrition program utilization o Food insecurity 56 56 28  9/3/24 Documentation v Medical Record: Systematic documentation of a patient’s medical history, current medical issues and medical care received or planned o Communication and record keeping tool v Evaluated by regulatory agencies o The JC (formerly JCAHO), State Department of Health, CMS o Compliance with professional practice standards o “if it is not documented, it did not happen” v Legal document o Subject to HIPAA Guidelines 57 57 HIPPA The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191) [HIPAA] was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. ◦ Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. ◦ Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. ◦ The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the U.S. health care system. 58 58 29  9/3/24 Components of the Medical Record v Admission record v Clinical record v Clinical record cont’d ◦ Name/address/family contact ◦ History and Physical ◦ Orders -require signature ◦ Medical, surgical history ◦ Consultation reports ◦ Age ◦ Family history ◦ Nursing notes ◦ Reason for admission ◦ Social history ◦ Vital signs ◦ Religion ◦ Current PE ◦ Height/weight ◦ Occupation/education ◦ Current complaints ◦ Intakes/outputs ◦ HCP ◦ Current medical issues ◦ Surgical reports ◦ HIPAA signature ◦ Admitting diagnosis ◦ Progress notes ◦ Screening forms ◦ Medications ◦ Nutrition notes ◦ Health insurance ◦ Medical test results: ◦ Discharge note/record ◦ Other pertinent information ◦ labs ◦ Discharge diagnoses ◦ imaging 59 59 Progress Notes v Daily updates entered into the medical record v Documents: o clinical changes o new information o results of tests v Generally entered by all members of the health care team (doctors, nurses, physical therapists, dietitians, pharmacists…) 60 60 30  9/3/24 Charting Do and Do Not v Sign all entries and include credentials v No personal opinions v Use professional language v Avoid abbreviations that are unclear or have multiple meanings o Most institutions have an approved list of abbreviations o The Joint Commission has a list of forbidden abbreviations which have been associated with medical errors in the past 61 61 Order Writing Privileges v Non-physician licensed professionals write orders within scope of practice v Nutrition related examples o Diet orders o Enteral/parenteral regimens o Nutritionally relevant labs o Anthropometric requests o Consultation requests (such as SLP) *speech language pathaologist v Usually dictated by state law and/or institutional policy and procedure as approved by governing medical body 62 62 31  9/3/24 Electronic Medical Record (EMR) Documentation Styles v ADIME (assessment, diagnosis, intervention, monitoring, evaluation) v SOAP (subjective, objective, assessment, plan) v DAP (diagnosis, assessment, plan) v DAR (data, action, response) v PIE (problem, intervention, evaluation) v IER (intervention, evaluation, revision) v HOAP (history, observation, assessment, plan) v SAP (screen, assess, plan) v SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions) 63 63 ADIME vs. SOAP ADIME SOAP Facilitates NCP Essentially the same! o A – assessment o Subjective (A) o D – diagnosis o Objective (A) o I – intervention o Assessment (D) o M – monitoring o Plan (I, M, E) o E - evaluation o Statement like PES is a natural component 64 64 32  9/3/24 SOAP Notes S: Subjective o Information obtained during verbal interview with the patient, significant other, family members, nurse, aide, staff members, et al O: Objective o Factual, reproducible observations: such as medical diagnoses, anthropometrics, labs, medications, diet orders, etc. A: Assessment o Interpretation of patient’s nutritional status & risk level based on subjective and objective information P: Plan o Recommended ACTIONS for nutritional care 65 65 Assessment (A) v All data pertinent to clinical nutrition decision making o Current medical issues, signs/symptoms, complaints o Nutrition history, current diet order, intake, tolerance o Medical and surgical history o Medications, supplements The “S” and “O” in SOAP note. It includes subjective and o Anthropometrics objective information o Nutrition focused physical assessment o Laboratory values o Psycho-social, functional, behavioral o Nutritional status, estimated nutritional needs o Nutrition knowledge, readiness for change 66 66 33  9/3/24 Diagnosis (D) v Identifies the current nutrition problem(s) v Uses standardized nutrition diagnostic language as per the Academy of Nutrition and Dietetics (AND) v Patients may have more than one diagnosis ◦ Prioritize the most pertinent problem(s) ◦ Focus on diagnoses you can address v Note: nutrition diagnosis is NOT a medical diagnosis ◦ Should identify and label current NUTRITION problems ◦ Expressed as PES statement(s) Diagnosis is found in the “A” part of a SOAP 67 67 PES Statement v (P) Problem The problem is the “What?” o Standardized term used to label the nutritional problem (eNCPT) o Describes alterations in the patient/client’s nutritional status v (E) Etiology The etiology is the “Why?” o Factors that may be causing or contributing to the problem o Linked to the nutrition diagnosis term by the words “related to” v (S) Signs/Symptoms Answers the question “How do I know?” o Data or indicators used to determine the patient’s nutrition diagnosis o Linked to the etiology by the words “as evidenced by” XXXX (problem)… related to (etiology)… as evidenced by (signs/symptoms) 68 34  9/3/24 Diagnostic Terminology v The eNCPT is a comprehensive guide for implementing the Nutrition Care Process using a standardized language o Describes a specific nutrition related problem that can be resolved or improved with nutrition intervention § 79 nutrition diagnoses/problems identified § Nutrition diagnosis ≠ Medical diagnosis (most of the time) 69 69 AND/eNCP Terminology; diagnostic terminology (see PDF) v Intake (NI): Problems related to (inadequate or excessive) intake of energy, nutrients, fluids through oral diet or nutrition support o Energy balance o Oral or nutrition support o Fluid o Bioactive substances o Nutrient o Fat and cholesterol o Protein o Carbohydrate and fiber o Vitamin o Mineral o Multi-nutrient 70 35  9/3/24 AND/eNCP Terminology; diagnostic terminology (see PDF) v Clinical (NC): Nutritional findings or problems identified that relate to medical or physical conditions o Functional (swallowing, chewing, altered GI, etc) o Biochemical (altered nutrition-related lab values, etc) o Weight (underweight, overweight/obesity, unintended weight gain/loss, etc) v Behavioral-Environmental (NB): Relate to knowledge, attitudes/beliefs, physical environment, access to food, or food safety o Knowledge and beliefs o Physical activity and function o Food safety and access v Other (NO): No nutrition diagnosis at this time 71 PES Statement v (P) Problem o Standardized term used to label the nutritional problem (eNCPT) o Describes alterations in the patient/client’s nutritional status v (E) Etiology o Factors that may be causing or contributing to the problem o Linked to the nutrition diagnosis term by the words “related to” v (S) Signs/Symptoms o Data or indicators used to determine the patient’s nutrition diagnosis o Linked to the etiology by the words “as evidenced by” XXXX (problem)… related to (etiology)… as evidenced by (signs/symptoms) 72 36  9/3/24 PES: Signs and Symptoms v (S) Signs/Symptoms o Evidence that this problem exists o Examples: weight loss, high or low lab values, nausea & vomiting, diarrhea, low fiber intake on diet recall, excess alcohol intake, high fat intake o Linked to to the etiology of your PES using the phrase “as evidenced by” v No diagnosis? If the assessment indicates that no nutrition problem currently exists that warrants a nutrition intervention, the term “No nutrition diagnosis at this time (NO-1.1)” may be documented Think of this section as “How do you know that…..” 73 73 PES Statement (Examples) v Inadequate energy intake (problem) related to decreased appetite and altered taste perception in setting of cancer treatment (etiology) as evidenced by diet history and loss of 10# in the past month (sign) v Excessive caloric intake (problem) related to frequent consumption from fast food restaurants (etiology) as evidenced by 30lb weight gain in the past year (sign) v Chewing difficulty (problem) related to mouth sores (etiology) as evidenced by report of pain while eating resulting in intake of