Diagnosis, Intervention, Evaluation,

and Documentation
 ADA NUTRITION CARE PROCESS AND MODEL
Screening & Referral
System
 Identify risk factors
 Use appropriate tools
and methods
 Involve
interdisciplinary
collaboration Nutrition Diagnosis
 Identify and label problem
Nutrition Assessment  Determine cause/contributing risk
 Obtain/collect timely and
factors
appropriate data  Cluster signs and symptoms/
 Analyze/interpret with defining characteristics
evidence- based standards
Document
 Document

Relationship
Between
Patient/Client/Group Nutrition Intervention
& Dietetics  Plan nutrition intervention
Professional  Formulate goals and
determine a plan of action
Implement the nutrition intervention
Nutrition Monitoring and  Care is delivered and actions
-
Evaluation are carried out
 Monitor progress  Document
 Measure outcome indicators
 Evaluate outcomes
 Document

Outcomes
Management System
 Monitor the success of the Nutrition Care
Process implementation
 Evaluate the impact with aggregate data
 Identify and analyze causes of less than
optimal performance and outcomes
 Refine the use of the Nutrition Care
Process
Nutrition Assessment Leads to
Nutrition Diagnosis

• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring and Evaluation
Nutrition vs Medical Dx

Medical Dx Nutrition Diagnosis

Diabetes Excessive CHO intake related to evening

visits to Coldstone Creamery as
evidenced by diet hx and high hs blood
glucose
Trauma and Increased energy expenditure related to
closed head multiple trauma as evidenced by results
injury of indirect calorimetry
Liver failure Altered gastrointestinal function related to
cirrhosis of the liver as evidenced by
steatorrhea and growth failure
Nutritional vs Medical Dx
Medical Dx Nutrition Diagnosis
Obesity Excessive energy intake related to lack
of access to healthy food choices
(restaurant eating) as evidenced by diet
history and BMI of 35.
Dependence Excessive energy intake related to high
mechanical volume PN as evidenced by RQ >1
ventilation
Anorexia Inappropriate food choices related to
nervosa history of anorexia nervosa and self-
limiting behavior as evidenced by diet
history and weight loss of 5 lb
PES Statement
• Problem: nutrition diagnosis label
• Etiology: the focus of the intervention
• Signs and symptoms: change when nutrition
problems are successfully treated; the focus
of monitoring and evaluation
Problem (Diagnostic Label)
Falls into three general domains:
• Intake (NI)
• Excessive or Inadequate intake compared to
requirements
• Clinical (NC)
• Medical or physical conditions that are
outside normal
• Behavioral/environmental (NB)
• Knowledge, attitudes, beliefs, physical
environment, access to food, food safety
Etiology
• Etiology (Cause/Contributing Factors)
• Related factors that contribute to problem
• Identifies cause of the problem
• Helps determine whether nutrition
intervention will improve problem
• Linked to problem by words “related to”
(RT)
• Note: etiology may not always be clear
Etiology
• Etiology (Cause/Contributing Factors)
• Excessive energy intake (problem)
“related to” regular consumption of large
portions of high-fat meals (etiology)…
• Swallowing difficulty (problem) RT
recent stroke (etiology)…
• Involuntary wt gain RT decrease in
exercise…
Diagnostic Labels Can Be Problems
or Etiologies
• Inadequate energy intake (NI-1.4) related to food-
nutrition knowledge deficit (NB-1.1)
• Food-nutrition knowledge deficit (NB-1.1) related
to lack of previous nutrition education
• Involuntary weight loss (NC-3.2) related to
inadequate energy intake (NI-1.4)
• Inadequate oral food-beverage intake (NI-2.1)
related to swallowing difficulty (NC-1.1)
Signs and Symptoms

• Signs/Symptoms (Defining characteristics)

• Evidence that problem exists
• Linked to etiology by words “as
evidenced by”
• Evaluation and monitoring of effectiveness
of intervention is done by reviewing signs
and symptoms
Nutrition Dx with S/S
• Excessive energy intake (NI-1.5) (P)
• “related to” regular consumption of large
portions of high-fat meals (E)
• “as evidenced by” diet history & 12 lb wt
gain over last 18 mo (Signs)
Nutrition Assessment Identifies
Etiology and S/S
• Problem: excessive energy intake
• Etiology: reviewing the diet history, we
learn that
• Patient eats in fast food restaurants 2x
day
• Patient supersizes portions because it’s a
bargain
• Patient has only 15 minutes for lunch
PES Statement
Excessive energy intake P

Related to eating frequently in fast food E

restaurants

As evidenced by BMI of 30 and diet S

history
Etiology Guides Intervention!

• The clinician determines what the

intervention is by looking at the root cause
of the nutrition problem.
• If the cause of excessive energy intake is
eating frequently in fast food restaurants,
how would you intervene?
Signs and Symptoms Direct
Intervention and Evaluation
Intervention/ Eval

P Excessive energy
intake
E RT eating Intervention: Counsel
frequently in fast patient about best choices
food restaurants in fast food restaurants (C-
2.4)
S As evidenced by Eval: Recheck weight (S-
BMI and diet 1.1.4) and diet history (BE-
history 2.1.1.) at next visit
PES Statements
• Excessive fat intake (NI-5.6.2) related to high
intake of fried foods and bakery goods as
evidenced by diet history and hyperlipidemia
• Excessive energy intake (NI-1.5) related to high
intake of fried foods and snack items as evidenced
by diet history and BMI
• Food/nutrition related knowledge deficit (NB-1.1)
related to lack of education on cholesterol
lowering diet as evidenced by history and patient
self-report
 Nutrition Diagnosis Statement
Should Be
• Clear, concise
• Specific
• Related to one problem
• Accurate – related to one etiology
• Based on reliable, accurate assessment
data
Evaluating Your PES Statement
• There are no right or wrong PES statements
• But some are better than others
Evaluating Your PES Statement
• Can the RD resolve or improve the nutrition
diagnosis?
• Can your intervention address the etiology
and thus resolve it or improve the problem?
• Or can your intervention address the signs
and symptoms?
Evaluating Your PES Statement
• Ex: Inadequate energy intake related to
decreased taste perception as evidenced by
diet history, medical dx and weight loss of
10 lb. during cancer tx
• Cannot treat the etiology (decreased taste
perception) but can treat S&S by
recommending foods with stronger flavors
Evaluating Your PES Statement
• Altered nutrition-related labs related to GI
bleed as evidenced by medical hx and
decreased hgb/hct in medical record
• Labs likely won’t improve until GI bleed
is addressed; the etiology is not a
nutritional deficit
• CAN address inadequate intake of iron,
copper, B12, protein, etc.
Evaluating Your PES Statement
• When all things are equal and there is a choice
between two nutrition diagnoses from different
domains, consider the Intake domain diagnosis as
the one more specific to the role of the RD
• Instead of Altered nutrition-related labs related to
GI bleed as evidenced by medical hx and
decreased hgb/hct in medical record
• Consider Inadequate intake of iron (NI-5.10.1)
related to increased needs due to GI bleed as
evidenced by medical history, blood count, diet
history, and serum ferritin
Evaluating Your PES Statement
• Will measuring the signs and symptoms tell
you if the problem is resolved or improved?
• Ex: If nutrition dx is excessive energy
intake, can do another diet history at next
visit and see if intake has changed; can also
check weight
NCP Example: Long Term Care
• 85 y.o. resident of LTC facility has lost
>10% weight in the last 6 months
• Medical workup negative
• Oral supplement is ordered but patient
continues to lose weight
• Nutrition professional is consulted for
enteral feeding recommendations
NCP Example: LTC
• On assessment, it is found that patient’s
teeth no longer fit and she cannot chew
regular meats and vegetables; patient is
storing oral supplement in drawer as she
worries about the cost
Write a PES statement for this
patient!
NCP Example: LTC
• Diagnosis: Inadequate energy intake (NI-
1.4) related to poorly fitting dentures and
hoarding of oral supplement as evidenced
by observation and pt interview
Etiology Guides Intervention

• Intervention: Nutrition professional orders

dental consult (RC-1.3) to reline dentures
and chopped diet (ND-1.2); puts resident on
Medpass supplement (ND-3.1.1)
Diagnoses Apply to All Settings
Long term Inadequate energy intake (NI-1.4) related to
care patient refusal of pureed diet as evidenced by
intake records, pt self-report and 8% weight
loss/3 months

Long term Inadequate fiber intake (NI-5.8.5) related to

care patient avoidance of fruits and vegetables as
evidenced by chronic constipation and diet
history
Ambulatory Not ready for diet/lifestyle change (NB-1.4)
Care related to social/environmental issues as
evidenced by pt verbalization and continued
weight gain
 ADA’s Nutrition Care
Process Steps

• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring and Evaluation
Nutrition Intervention
• Should be targeted at etiology
• If not etiology, then signs and symptoms
Nutrition Interventions
Four categories of nutrition interventions:
• Food and/or nutrient delivery (ND)
• Nutrition education (E)
• Nutrition counseling (C)
• Coordination of nutrition care (RC)
Food and/or Nutrient Delivery
• Meals and snacks (ND-1)
• Enteral/parenteral nutrition (ND-2)
• Medical food supplements (ND-3.1)
• Vitamin and mineral supplement (ND-3.2)
• Bioactive substance supplement (ND-3.3)
• Feeding assistance (ND-4)
• Feeding environment (ND-5)
• Nutrition-related medication management (ND-6)
Nutrition Education (E)
• Initial/brief nutrition education (E-1)
• E.g. survival skills on discharge
• Comprehensive nutrition education (E-2)
• Purpose
• Recommended modifications
• Result interpretation
• Other
Note: Education is appropriate for food and nutrition-related knowledge
deficit. If the client knows the content, more education probably won’t help
Nutrition Counseling (C)
• Theory or approach
• Strategies
• Phase
Nutrition Counseling:
Theory or Approach
The theories or models used to design and
implement an intervention; provide a research-
based rationale for designing and tailoring
nutrition interventions
• Cognitive-behavioral therapy (C-1.2)
• Health belief model (C-1.3)
• Social learning theory (C-1.4)
• Transtheoretical Model/Stages
of Change (C-1.5)
• Other (C-1.6)
 Nutrition Counseling: Strategies*
• Motivational • Cognitive
interviewing (C-2.1) restructuring (C-2.8)
• Goal setting (C-2.2) • Relapse prevention
• Self-monitoring (C-2.3) (C-2.9)
• Problem solving (C-2.4) • Rewards/contingency
• Social support (C-2.5) mgt (C-2.10)
• Stress management (C- • Other
2.6)
• Stimulus control (C-2.7)
*Selectively applied evidence-based method or plan of action designed to
achieve a particular goal
Coordination of Care (RC)
• Coordination of other care during nutrition care
(RC-1)
• Team meeting
• Referral to RD
• Collaboration with other providers
• Referral to community agencies/programs
• Discharge and transfer of nutrition care to new
setting/provider (RC-2)
• Collaboration
• Referral to community agencies/programs
 ADA’s Nutrition Care
Process Steps

• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring and Evaluation
Nutrition Monitoring and Evaluation
• Monitor progress and determine if goals are
met
• Identifies patient/client outcomes relevant
to the nutrition diagnosis and intervention
plans and goals
• Measure and compare to client’s previous
status, nutrition goals, or reference
standards
Nutrition Outcomes – 4 Categories
• Nutrition-Related Behavioral and Environmental
Outcomes (BE)—Nutrition-related knowledge,
behavior, access, and ability that impact food and
nutrient intake
• Food and Nutrient Intake Outcomes (FI)—Food
and/or nutrient intake from all sources
• Nutrition-Related Physical Signs and Symptom
Outcomes (S)—Anthropomorphic, biochemical,
and physical exam parameters
• Nutrition-Related Patient/client centered
Outcomes (PC)—perception of patient/client’s
nutrition intervention and its impact
Nutrition-Related Behavioral and
Environmental Outcomes (BE)
• Knowledge/beliefs (1)
• Behavior (2)
• Access (3)
• Physical activity and function (4)
Behavior-Environmental Outcomes
Domain: Beliefs and Attitudes (BE-1.1)
Definition: beliefs/attitudes about and/or readiness to
change food, nutrition, or nutrition-related
behaviors
Potential indicators (BE-1.1)
• Readiness to change
• Perceived consequences of change
• Perceived costs versus benefits of change
• Perceived risk
• Outcome expectancy
• Conflict with patient/family value system
• Self efficacy
Beliefs and Attitudes (BE-1.1)

Measurement methods or data sources

• Patient self-report, client/patient
assessment questionnaire or interview
Typically used to monitor and evaluate
change in the following domains of
nutrition intervention:
• Nutrition education, nutrition counseling
Beliefs and Attitudes (BE-1.1)
Typically used to monitor and evaluate change in the
following nutrition diagnoses
• Harmful beliefs/attitudes about food- or
nutrition-related topics
• Not ready for diet/lifestyle change
• Inability to manage self-care
• Excess or inadequate oral food/beverage,
energy, macronutrient, micronutrient, or
bioactive substance intake
• Imbalance of nutrients
• Inappropriate fat foods
Beliefs and Attitudes (BE-1.1)
Typically used to monitor/evaluate change in the
following nutrition diagnoses (cont)
• Inappropriate intake of amino acids
• Underweight
• Overweight/obesity
• Disordered eating pattern
• Physical inactivity
• Excess exercise
Behavior-Environmental Outcomes Domain:
Food and Nutrition Knowledge (BE-1.2)

Definition: Level of knowledge about food,

nutrition and health, or nutrition-related
information and guidelines relevant to
patient/client needs
Food and Nutrition Knowledge (BE-1.2)
Potential Indicators
• Level of knowledge (e.g. none, limited, minimal,
substantial, and extensive
• Areas of knowledge:
• Food/nutrient requirements
• Physiological functions
• Disease/condition
• Nutrition recommendations
• Food products
• Consequences of food behavior
• Food label understanding/knowledge
• Self-management parameters
Food and Nutrition Knowledge (BE-1.2)
Measurement methods or data sources
• Pre and post-tests administered orally, on paper, or
by computer
• Scenario discussions
• Patient/client restate key information
• Review of food records
• Practical demonstration/test
Typically used to monitor and evaluate change in the
following domains of nutrition intervention:
• Nutrition education, nutrition counseling
Food and Nutrition Knowledge (BE-1.2)

Typically used to monitor and evaluate

change in the following nutrition diagnoses:
• Food- and nutrition-related knowledge
deficit
• Limited adherence to nutrition-related
recommendations
• Intake domain
Ability to Plan Meals/Snacks (BE-2.1)

• Definition: Patient/client ability related to

planning healthy meals and snacks, which
are compatible with dietary goals
• Potential indicator: Meal/snack planning
ability (e.g. may include ability to use
planning tools, plan a menu, create/tailor a
meal plan, create/use a shopping list
Ability to Plan Meals/Snacks (BE-2.1)

• Measurement methods/data sources: food

intake records, self-report or caregiver
report, 24-hour recall, menu review,
targeted questionnaire
• Typically used to measure outcomes for
these domains of nutrition interventions:
• Nutrition education
• Nutrition counseling
Ability to Plan Meals/Snacks (BE-2.1)

Typically used to monitor and evaluate change in the

following nutrition diagnoses:
• Excessive or inadequate oral food/beverage intake
• Underweight
• Overweight/obesity
• Limited adherence to nutrition-related
recommendations
• Inability or lack of desire to manage self-care
Other BE Nutrition Outcomes
Behavior (2)
• Ability to select healthful
food/meals
• Ability to prepare
food/meals
• Adherence
• Goal setting
• Portion control
• Self-care management
• Self-monitoring
• Social support
• Stimulus control
Access (3)
• Access to food
Physical activity and function
(4)
• Breastfeeding success
• Nutrition-related ADLs
and IADLs
• Physical activity
Other Outcomes
Food and Nutrient Intake (FI)
• Energy intake (1)
• Food and Beverage (2)
• Enteral and parenteral (3)
• Bioactive substances (4)
• Macronutrients (5)
• Micronutrients (6)
Physical Signs/Symptoms (S)
• Anthropometric (1)
• Biochemical and medical
tests (2)
• Physical examination (3)
Patient-Client Centered
Outcomes (PC)
Outcomes Based Practice
• Underlays Performance Improvement
and Management
• Meets accreditation standards (TJC,
American Diabetes Association)
• Supports value of nutrition providers
in health delivery system
• Enhances reputation/ties with medical
staff and other colleagues
NCP Example: Acute Care
• Mr. D. is a 73 y.o. white male admitted with L leg
fx after fall. He lives with his son and daughter in
law. Per his son, Mr. D’s appetite has been poor
the past 6 months, his dentures are very loose and
he refuses to wear them. He also refuses pureed
foods. Ht: 6 ft.; weight 133 lb; usual weight 1 year
ago 165 lb. Meds: milk of magnesia, Pepcid, Di-
Gel. No significant medical hx save progressive
dementia;labs after hydration serum alb 2.4 g/dL;
Hgb 10.6 g/dL; HCT 35.3%; BUN, Cr, liver fxn
tests WNL
Write a PES statement for this
patient!
NCP Example: Acute Care
Nutrition Diagnosis
• Inadequate energy intake (NI-1.4) related to
dementia and poor appetite as evidenced by
diet history and recent unintentional weight
loss
• Chewing difficulty (NC-1.2) related to ill-
fitting dentures as evidenced by diet history
• Increased energy expenditure (NI-1.2)
related to long bone fx as evidenced by
medical history
How would you intervene with this
patient?
Intervention
• Dental consult to have dentures relined for better
fit (RC - coordination of care)
• Try oral supplements to determine patient
preference and evaluate acceptance (ND-3.1.1
food-nutrient delivery)
• Consider move to assisted living (RC -
coordination of care)
• Educate patient’s family on nutrient-dense choices
for supplemental feedings (E - nutrition education)
Monitoring and Evaluation
• Initiate calorie count while patient is
hospitalized to evaluate acceptance of oral
supplements
• Weigh patient weekly after discharge
• Evaluate patient’s ability to chew textured
foods after dentures are replaced
• Evaluate patient in Geriatric Clinic in one
month
The Diet Prescription
• Designates type, amount, frequency of
feeding based on pt’s needs, care goals
• May specify calorie goal
• May limit or increase various
components of the diet
• Each institution usually has specific
diets that have been approved by
committee that are used at that
institution
Modifications of the Normal Diet
• Normal nutrition is foundation of
therapeutic diet modifications
• Based on DRIs
• Based on Food Guide Pyramid
• Purpose of diet is to supply needed
nutrients
Modifications of the Normal Diet
• Change in consistency
• Increase/decrease energy value of diet
• Increase/decrease type of food or nutrient
consumed
• Elimination of specific foods or components
• Adjustment in level, ratio, balance of protein,
fat, CHO
• Change in number, frequency of meals
• Change in route of delivery of nutrients
Basic Hospital Diets
Basic Hospital Diets —cont’d
“Surgical” Soft Diet
Clear Liquid Diet
Full Liquid Diet
Full Liquid Diet –cont’d
House or Standard Diet
Controversies
• Should the house diet be low in fat,
saturated fat, sodium, and sugar to conform
with the U.S. dietary guidelines?
• Should the house diet be intended to
maximize the nutritional intake of sick
people, featuring familiar, comfort foods
and fulfilling patient preferences and
expectations, regardless of conformity to
dietary guidelines designed for healthy
people?
Consistency Diet Controversies
• Soft Diet: what should be included or excluded? Is
the diet ‘dental” soft, “surgical” soft, mechanical
soft; the needs of dysphagia patients and dental
patients are different
• Full liquid diet: there is no evidence that it has a
role as part of a surgical progression; many of the
foods included are poorly tolerated by persons
immediately post GI surgery (dairy products, fats,
etc.) May be useful as a source of nutrition for
persons with mouth pain or dental surgery
Consistency Diet Controversies
• Thickened liquids: when speech
pathologists recommend specific liquid
consistencies, they may be using a
different standard than is used in the food
and nutrition department
• There is no generally-accepted standard for
nectar thick, honey thick, etc. Often these
foods vary greatly among and within
institutions and depending on where and by
whom the thickening is done
Therapeutic Diet Controversies
• Should patients with
chronic diseases who
are hospitalized with
acute illnesses be
placed on the
restricted diet that is
appropriate for them
long term?
Therapeutic Diet Controversies
• Should residents in
long term care
facilities have the
same right as home-
based clients to decide
whether or not to
follow a restricted
diet?
Nutritional Care of the
Terminally Ill Patient
• Maintenance of comfort and quality of life
are the main goals of nutritional care for
terminally ill patients = “palliative care”
• Dietary restrictions and aggressive nutrition
care that negatively impacts quality of life
are rarely appropriate.
Palliative Care
• Encourages the alleviation of physical
symptoms, anxiety, and fear while
attempting to maintain the patient’s ability
to function independently
Continuity of Care
• Due to shortened length of stay, more nutritional
care is being provided in alternative settings (long
term care, home care, ambulatory clinics and
community programs)
• Nutrition counseling and education in acute care is
often limited to survival skills
• Nutritional counseling should be provided in a
setting conducive to long term behavior change
• The acute care stay can be an opportunity to
identify nutritional problems and devise a plan for
follow-up care
Discharge 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 Planning

Courtesy University of Washington Medical Centers, Seattle.