Module 4 Nutrition Care Process PDF

MODULE 4 NUTRITION CARE PROCESS (ADIME PROCESS)  OBJECTIVES: Upon completion of this module, the student should be able to do the following: 1. List the basic steps of the nutrition care process. 2. Describe tools used in the assessment of nutritional status, such as: a....

MODULE 4 NUTRITION CARE PROCESS (ADIME PROCESS)  OBJECTIVES: Upon completion of this module, the student should be able to do the following: 1. List the basic steps of the nutrition care process. 2. Describe tools used in the assessment of nutritional status, such as: a. dietary history and recalls b. diagnostic tests (radiologic/laboratory data). c. anthropometric measurements. d. physical findings and sociological data. 3. Recognize some common nutrition problems, and propose corrective measures. 4. Formulate A personalized health care plan, evaluation, and follow-up care guide actions to promote healing and health. 5. Be familiar with the roles & responsibilities of the health care team in educating clients about nutritional needs. INTRODUCTION Nutrition support is fundamental for the successful treatment of disease, and it is often the primary therapy. To meet individual needs, a broad knowledge of nutrition status, requirements, and ways of meeting the identified needs is essential. Each member of the health care team plays an important role in developing and maintaining a person-centered health care plan.  THE THERAPEUTIC PROCESS SETTING AND FOCUS OF CARE Nutrition support may take place in a variety of settings and in a variety of forms. The ultimate goal of nutrition support is to establish nutritional balance according to specific needs of the individual. Health care providers such as the nurse and the dietitian provide essential support and personalized care. Nutrition care must be based on individual needs and be person-centered. Figure 4.1 demonstrates the nutrition care process model, with the person-centered approach defining the relationship between the patient and the dietetic professional. Needs must constantly be updated with the patient’s status. Such personalized care demands great commitment from the health care team. The 4 quadrants around the core represent the four steps of the nutrition care process:  NUTRITION ASSESSMENT  NUTRITION DIAGNOSIS  NUTRITION INTERVENTION  NUTRITION MONITORING AND EVALUATION Each of the steps is preceded by the word nutrition. This was a conscious decision to make the Nutrition Care Process unique and specific to dietetics professionals Even though each step builds on the previous one, the process is not linear. HEALTH CARE TEAM In the area of nutrition care, the registered dietitian nutritionist (RDN), also known as a registered dietitian(RD), carries the major responsibility of medical nutrition therapy. Working closely with the physician, the dietitian determines individual nutrition therapy needs and a plan of care. Team support is essential throughout this process. Nurses are in a unique position to provide additional nutrition support by referring patients to the dietitian when necessary. Of all the health care team members, nurses are in the closest continuous contact with hospitalized patients and their families. Such a relationship is important to ensure the most beneficial health care approach. ROLES OF THE NURSE AND THE CLINICAL DIETITIAN DIETITIAN  Determines nutrition needs, plans and manages nutrition therapy, evaluates the plan of care, and documents results  May only see the patients twice or thrice during hospital stay NURSE  helps to develop, support, and carry out the plan of care  have constant contact with the patient and will often be the person dealing with immediate nutrition-related questions because of his or her frequent contact.  The nursing process is a specific process by which nurses deliver care to patients and includes the following steps: assessment, diagnosis, outcome/planning, implementation, and evaluation. Nursing Diagnosis  is the nurse’s clinical judgment about a client’s response to actual or potential health conditions or needs  may include several issues that are nutrition related, such as diarrhea, malnutrition, failure to thrive, and fluid volume deficit NURSES  Coordinators and advocate  Interpreters  Teachers and counselors PHASES OF THE CARE PROCESS  The Academy of Nutrition and Dietetics has developed a standardized Nutrition Care Process for RDNs. The Nutrition Care Process is “a systematic problem-solving method that dietetics professionals use to critically think and make decisions to address nutrition-related problems and provide safe and effective quality nutrition care.” It is composed of the following four distinct and interrelated nutrition steps: (1) assessment; (2) diagnosis; (3) intervention; and (4) monitoring and evaluation.  The Nutrition Care Process provides a consistent structure and framework for nutrition professionals to use to provide individualized care for patients. This process is used for patients, clients, and groups that have identified nutrition risk factors and that need assistance to achieve or maintain health A. NUTRITION ASSESSMENT  To assess nutrition status and provide person-centered care, as much information as possible about the patient’s situation is collected.  Data obtained during the nutrition assessment are organized into five categories: 1.Food- and Nutrition-Related History 2.Anthropometric Measurements 3.Biochemical Data, Medical Tests, and Procedures 4.Nutrition- Focused Physical Findings 5.Client History. FOOD- AND NUTRITION-RELATED HISTORY  In most cases, the Registered Nutritionist-Dietitian is responsible for evaluating the diet. Knowledge of the patient’s basic eating habits may help to identify possible nutrition deficiencies.  A variety of methods are used to collect dietary intake, all of which have strengths and weaknesses. Table 4.A.2 Strengths and Limitations of Techniques Used to Measure Dietary Intake TECHNIQUE BRIEF STRENGTHS LIMITATIONS DECRIPTION Fast, inexpensive, and easy to One 24-hour recall cannot 24-hour A trained interviewer asks the administer illustrate typical dietary food respondent to Can provide detailed intake recall recall, in detail, all information Underreporting and over food and drinks about the types of foods reporting are common consumed during consumed Depends on respondent’s the previous 24 Low respondent burden is not memory hours dependent on respondent’s level Accuracy is somewhat of education, literacy, or writing dependent upon the skill of skills the interviewer Does not alter respondent’s Omissions of sauces, usual intake dressings, and beverages can  Table 4.A.2 Strengths and Limitations of Techniques Used to Measure Dietary Intake TECHNIQUE BRIEF STRENGTHS LIMITATIONS DECRIPTION Multiple- The respondent records, at the Does not rely on Requires high degree time of consumption, the memory since the of cooperation day food identities and amounts of all participant’s record Client/patient must be record foods and beverages intake immediately literate and able to consumed for 3 to 7 days following write consumption Takes more time to Can provide detailed obtain data intake data Analysis is labor Multiple-day data are intensive more representative Act of recording food of usual intake intake often alters Reasonably valid for usual intake up to 5 days Underreporting and inaccurately estimating portion sizes are common Respondent burden can result in low response rates Table 4.A.2 Strengths and Limitations of Techniques Used to Measure Dietary Intake TECHNIQUE BRIEF STRENGTHS LIMITATIONS DECRIPTION Food The respondent Can be self- Modest demand on indicates how many administered Machine Respondent frequency times a day, week, readable Relatively May not represent usual Questionnair month, or year that he inexpensive food or portion sizes es or she usually May be more typically chosen by consumes specific representative of Respondent foods by using a usual intake over Cultural/ethnic specific questionnaire longer periods of time foods are often not consisting of hundreds than a few days of included of foods or food groups diet records Intake data can be Does not alter compromised when multiple respondents usual foods are grouped within intake single listings Requires literacy and good long-term memory Table 4.A.2 Strengths and Limitations of Techniques Used to Measure Dietary Intake TECHNIQUE BRIEF STRENGTHS LIMITATIONS DECRIPTION A trained nutrition Assesses usual Lengthy interview Diet history professional interviews the nutrient intake process patient about the number of Can detect seasonal Requires highly meals eaten per day; his or changes trained interviewers her appetite and food Data about all May overestimate dislikes; the presence or nutrients can be nutrient intake absence of gastrointestinal obtained Requires the distress; the use of dietary Can correlate well cooperation of a supplements; and other with biochemical respondent with the lifestyle choices measures ability to recall his or her usual diet Difficult and expensive to code for group analysis ANTHROPOMETRIC MEASUREMENTS Height  should be measured using a wall-mounted measuring tape, if possible, or the moveable measuring rod on a platform clinic scale. Have the person stand as straight as possible, without shoes or a hat. Children who are younger than 2 years old should be measured while they are lying down with a stationary headboard and a movable footboard. Weight and body mass index  For accurate results, patients should be weighed at consistent times (e.g., early morning after the bladder is emptied and before breakfast)  If the patient is wearing the same clothing each time that he or she is weighed (e.g., an examination gown), a more consistent weight measurement will be obtained.  The body mass index is calculated by using both weight and height measurements and it is a helpful assessment tool throughout the life cycle BMI COMPUTATION Example: Height = 5’ 3” tall, Formula: BMI= Actual Weight = 55kg Weight Ht Computation: m² 1. Compute for Ht m². 2. BMI = Actual Weight 5ft x 12inches = 60inches + 3 Htm² BMI = 55kg inches 2.56 =63inches BMI = 21.48 63inches x 0.0254m = 1.6002 m BMI Classification = NORMAL (1.6002m)² = 2.56 Body composition The dietitian may measure various aspects of body size and composition to determine relative levels of lean tissue compared to fat mass. Some methods include a skin fold thickness measurement with: Caliper Bioelectrical impedance analysis BOD POD body composition tracking Dual-energy x-ray system Hydrostatic weighing absorptiometry Waist circumference  Waist circumference assessment and waist-to-height ratio are important considerations for both overweight and normal- weight individuals, because they indicate the risk for chronic diseases (e.g., type 2diabetes, cardiovascular disease, hypertension, cancer, overall mortality), even among individuals of normal weight. BIOCHEMICAL DATA, MEDICAL TESTS, AND PROCEDURES Examples of biochemical tests pertinent to nutrition include, but are not limited to, the following: Plasma proteins: serum albumin and pre-albumin evaluate for protein status Liver enzymes: evaluate liver function Blood urea nitrogen and serum electrolytes: evaluate renal function Urinary urea nitrogen excretion: estimate nitrogen balance Creatinine height index: evaluate protein tissue breakdown Complete blood count: evaluate for anemia Fasting glucose: evaluate for hyper- and hypoglycemia Total lymphocyte count: evaluate immune function The medical tests that are used for nutrition assessment are generally reliable for people of any age, but some conditions may interfere with test results and should be considered when regarding laboratory values. Depending on the patient, some additional medical tests or procedures may be warranted, such as the following:  Skeletal system integrity. Several tests may be used, especially with older patients, to determine the status of bone integrity and possible osteopenia or osteoporosis. Some tests that are commonly used are x-rays, dual-energy x-ray absorptiometry, and bone scans.  Gastrointestinal function. Medical procedures are also useful to evaluate function, disease, or malfunction along the gastrointestinal tract (e.g., disturbances in gastric emptying time, peptic ulcer disease, and inflammatory bowel disease).  Resting metabolic rate. Evaluating a patient’s resting metabolic rate helps to establish total energy needs. NUTRITION-FOCUSED PHYSICAL FINDINGS TABLE 4.A.3 Physical Indicators of Nutritional Status Body Area Signs of Good Nutrition Signs of Malnutrition 1. Head to neck a. Hair a. shiny, lustrous; smooth a. dull, dry, thin, wirelike, sparse, brittle; scalp healthy scalp rough, flaky b. Face b. Smooth skin, moist with b. Paled or mottled, dark under eyes, swollen, uniform color scaling or flakiness, lumpiness c. Eyes c. bright, clear, moist c. Dry membranes, redness, fissures at corners, red rimmed, fine blood vessel or scars at cornea d. Lips d. smooth, pink d. red, swollen. Lesions or fissures e. Tongue e. Deep red, slightly rough e. Scarlet or purplish color, raw, swollen, surface smooth f. Teeth f. straight; none missing, no f. cavities, black or gray spots, erupting overlap, without cavities abnormally, missing g. Gums g. Firm, pink, smooth, no g. spongy, bleed easily, inflammation, recede, bleeding atrophied  TABLE 4.A.3 Physical Indicators of Nutritional Status Body Area Signs of Good Nutrition Signs of Malnutrition 2. Skin Smooth, ,moist, uniform in color Dry, flaky, scaling, “gooseflesh”, swollen 3. Glands No thyroid enlargement: no Front of neck and cheeks become lumps at parotid juncture swollen lumps visible at parotid; goiter 4. Nails Pink nail beds, smooth, firm, Brittle, ridged, pale nail beds, flexible, uniform shape clubbed, spoon shaped 5. Muscle and Good posture, firm, well- Flaccid, wasted muscles, weakness, skeletal developed muscles, good tenderness, decreased reflexes System mobility; no malformation of skeletons 6. Internal Systems a. a. Flat abdomen, liver not a. distended, enlarged abdomen, Gastrointestinal tender to palpate, normal size ascites, hepatomegaly (enlarged liver) b. b. Normal pulse rate, normal b. Pulse rate exceeds 100 Cardiovascular blood pressure beats/min, abnormal rhythm, blood CLIENT HISTORY  Guided questioning helps clients to identify and remember elements of their histories that may be pertinent.  As mentioned previously, dietary supplements such as herbs are often not mentioned unless they are specifically addressed. Other complementary and alternative medicine use should be identified during this stage.  Many elements of a client’s personal history can affect his or her current nutrition status and help to guide the plan of care; such elements include socioeconomic status, religion, culture, ethnicity, family interactions, living situation, education level, and employment status.  The gathering of nutrition assessment data, health care providers must distinguish relevant from irrelevant data, validate the data, and then determine whether there is a need to obtain additional information. B. NUTRITION DIAGNOSIS  A nutrition diagnosis involves the “identification and labeling of an existing nutrition problem that the food and nutrition professional is responsible for treating independently.”  A careful study of all information that has been gathered thus far reveals basic patient needs.  A nutrition diagnosis statement will have three distinct and concise elements: Problem Etiology Signs/symptoms This is often referred to as a PES statement. Problem  After the careful assessment of nutrition indices, data are analyzed, and a nutrition diagnostic category is assigned. The nutrition diagnostic statement identifies nutrition problems, which may include nutrient deficiencies (e.g., iron-deficiency anemia) or underlying disease that requires a modified diet (e.g., renal disease, liver disease). Etiology  The causes or contributing risk factors are identifiable factors that are directly leading to the stated problem. The Academy of Nutrition and Dietetics defines etiology as “a factor gathered during the nutrition assessment that contributes to the existence or the maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems.”  Correctly identifying the etiology is the only way to adequately design an intervention plan. Within the nutrition diagnostic PES statement, the etiology should be preceded by the words related to. Signs and Symptoms  Signs and symptoms of nutrition problems are an accumulation of subjective and objective changes in the patient’s health status that indicate a nutrition problem and that are the results of the identified etiology. Within a nutrition diagnostic PES statement, the signs and symptoms should be preceded by the words as evidenced by.  The nutrition diagnosis will change as the patient’s nutrition needs change.  The following is an example of a nutrition diagnostic PES statement: Excessive caloric intake (problem) related to frequent consumption of large portions of high-fat meals (etiology) as evidenced by average daily intake of calories exceeding recommended amount by 500 kcal and 12-pound weight gain during the past 18 months (signs). C. NUTRITION INTERVENTION Nutrition interventions are “purposefully planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, target group, or the community at large.”  Objectives of the care plan are client driven, thus focusing attention on personal needs and goals as well as on the identified requirements of medical care for the patient.  Suitable and realistic actions then carry out the personal care plan. Such activities ideally include family members and caretakers as well. THE NUTRITION INTERVENTION STRATEGIES ARE ORGANIZED INTO THREE CATEGORIES: 1. Food and/or Nutrient Delivery  Personal adaptation. Successful nutrition therapy can occur only when the diet is personalized to meet individual needs. This can be done best by planning with the patient and his or her family. The following four areas must be explored together: 1. Personal needs: What personal desires, concerns, goals, or life situation needs must be met? 2. Disease: How does the patient’s disease or condition affect the body and its normal metabolic functions? 3. Nutrition therapy: Prioritize diagnoses on the basis of urgency, impact, and resources. How and why must the diet change to meet the needs created by the patient’s particular disease or condition? 4. Food plan: How do these necessary nutritional modifications affect daily food choices? Write a nutrition prescription that is focused on the etiology to meet these needs. Mode of feeding. The primary principle of diet therapy is based on a patient’s normal nutrition requirements, and it is only modified as an individual’s specific condition requires. Nutrition components of the oral diet may be modified in the following ways: 1. Energy: The total energy value of the diet, expressed in kilocalories, may be increased or decreased. 2. Nutrients: One or more of the essential nutrients (i.e., protein, carbohydrate, fat, minerals, vitamins, and water) may be modified in amount or form. 3. Texture: The texture or seasoning of the diet may be modified (e.g., liquid and low-residue diets). In the event that nutrient needs cannot be adequately satisfied through oral intake, other methods of nutrient delivery must be considered. When a patient’s gastrointestinal tract is functioning but he or she cannot consume food orally, enteral feedings are an option.  Enteral feedings are administered by a tube and make use of the digestion and absorption functions of the gastrointestinal tract at some point below the mouth. Feeding tubes are placed within the gastrointestinal tract at the point at which the patient is able to tolerate introduction of food or nutrients. If patients are unable to tolerate any nutrient delivery into the gastrointestinal tract, health care providers must consider parenteral nutrition therapy.  Parenteral nutrition therapy is administered intravenously and thus carries risks associated with its invasive nature. However, it is an effective way of meeting the nutrient needs of a patient whose gastrointestinal tract is not functioning. 2. Nutrition Education and Counseling  Communicating with a patient about his or her specific nutrition intervention plan is a critical step in the potential success of the treatment. Patients and families who understand the necessary changes to food or nutrient delivery methods are able to appreciate the benefit from such adjustments and are more likely to be compliant. Education may be a one-on-one experience with the dietitian, or it may occur in a group setting. Initial education and counseling interactions during inpatient stays can continue through outpatient appointments, when necessary.  Nutrition interventions plans are generally long term lifestyle modifications that are meant to promote and improve health. Some patients will have more changes to make than others, and they will need continued nutrition counseling support to reach one goal at a time. Establishing a long-term plan to make such changes takes a commitment to education, counseling, and both professional and personal support. The plan of care will be modified over time as needed and in response to intervention. 3. Coordination of Nutrition Care  Several health care providers may be involved in a nutrition intervention plan. For example, enteral tube feedings will require the coordination of dietitians, nurses, the prescribing physician, and possibly the clinical pharmacist.  Interdisciplinary connections within health care make the coordination of nutrition care possible and more effective.  In addition, family, friends, care providers, and other members of the patient’s personal support group may be helpful during the coordination of the patient’s care.  All professional and personal resources and referrals necessary to carry out and maintain the intervention should be identified during this step. D. NUTRITION MONITORING AND EVALUATION Nutrition monitoring and evaluation identifies patient outcomes relevant to the nutrition diagnosis and the intervention plan. This step measures progress toward the patient’s goals. The three components of this process are as follows: (1) monitor progress (2) measure outcomes (3) evaluate outcomes Outcome measures that are used during this step are organized into the same categories as the nutrition assessment categories, excluding client history.  Table 4.D.1 Nutrition Assessment Categories FOOD-/ ANTHROPOMETRIC BIOCHEMICAL NUTRITION- NUTRITION- MEASUREMENT DATA, MEDICAL FOCUSED RELATED OUTCOMES TESTS, AND PHYSICAL FINDING HISTORY PROCEDURE OUTCOMES OUTCOMES OUTCOMES Food and nutrient Height Lab data (e.g., Physical intake Weight electrolytes, appearance Food and Body mass index glucose) and tests Muscle and fat nutrient (e.g., gastric wasting Growth pattern administration emptying time, Swallow function Medication, indices and percentile ranks resting metabolic Appetite complementary/alt rate ernative medicine Weight history use Knowledge and beliefs Availability of food and supplies Physical activity, nutrition SUMMARY  The basis for effective nutrition care begins with the patient’s nutrition needs and must involve the patient and his or her family. Such person-centered care requires initial assessment and planning by the dietitian and continuous close teamwork among all team members who are providing primary care.  Nutrition therapy is based on the personal and physical needs of the patient. Successful therapy requires a close working relationship among dietetic, medical, and nursing staff in the health care facility. The nurse is in a unique position to reinforce the nutrition principles of the diet.