Nutrition Care Process

Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention

Ms. Ailyn Kuan-Del Rio, RND, MSCN

 NUTRITION ASSESSMENT
• “A systematic process of obtaining, verifying, and
interpreting data in order to make decisions about
the nature and cause of nutrition-related problems.”

• Initiates the data collection process that is

continued throughout the NCP and forms the
foundation for reassessment and reanalysis of the
data in Nutrition Monitoring and Evaluation (Step
4).

SOURCES: Lacey and Pritchett, JADA 2003;103:1061-1072. &ACADEMY OF NUTRITION AND DIETETICS
NUTRITION ASSESSMENT DOMAINS
• 1. Food/Nutrition Related History
• 2. Anthropometric Measurements
• 3. Biochemical Data, Medical Tests, Procedures
• 4. Nutrition-Focused Physical Findings
• 5. Client History
• 6. Comparative Standards

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

CRITICAL THINKING
• Observing verbal and non-verbal cues to guide
interviewing methods
• Determining appropriate data to collect
• Selecting assessment tools and procedures and
applying in valid and reliable ways
• Distinguishing relevant from irrelevant data
• Organizing data to relate to nutrition problems
• Determining when problems require referral

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 RESULTS OF NUTRITION ASSESSMENT
• Leads to appropriate initial determination that a nutrition
diagnosis/problem exists
• If a nutrition problem is not identified, further information or
testing may be necessary to make a determination
• If the assessment indicates that no nutrition problem
currently exists that warrants a nutrition intervention, the
term “No nutrition diagnosis at this time” may be
documented
• If a nutrition diagnosis can be made, the RND labels the
problem and creates a PES* statement in Step 2 of the
Nutrition Care Process

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

SUMMARY
• Nutrition Assessment is the first step of the NCP
• Dynamic process that develops throughout the NCP
• Data is used for all other steps of the NCP
• New information may provide reason for
reassessment or change in approach and
intervention

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS
• New concept for dietetics profession
• The act of identifying a disease or condition from
it’s signs and symptoms
• Investigation or analysis of the cause or nature of a
condition, situation, or problem.
• Standardized terminology for nutrition diagnosis
has been developed to facilitate this step.

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS
• Critical step between nutrition assessment and
nutrition intervention.
• Identification of an existing nutrition problem, by
using the data collected in the nutrition assessment
that the Dietitian is responsible for treating.
• Creates a standardized nutrition diagnosis language
to describe nutrition problems consistently.
• Different from a medical diagnosis.

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Nutritional vs Medical Dx

Medical Diagnosis Nutritional Diagnosis

Diabetes Excessive CHO intake r/t visits to Coldstone Creamery

as evidenced by diet hx and high hs blood glucose

Trauma and closed Increased energy needs r/t multiple trauma as

head injury evidenced by results of indirect calorimetry

Liver failure Altered gastrointestinal function r/t cirrhosis of the liver

as evidenced by steatorrhea and growth failure
 Nutritional vs Medical Dx

Medical Dx Nutritional Diagnosis

Obesity Excessive energy intake r/t lack of access to healthy food

choices (restaurant eating) as evidenced by diet history
and BMI of 35.

Dependence mechanical Excessive energy intake r/t high volume PN as evidenced

ventilation by RQ >1

Anorexia nervosa Undesirable food choices r/t history of anorexia nervosa

and self-limiting behavior as evidenced by diet history
and weight loss of 5 lb
 NUTRITION DIAGNOSIS DOMAIN
• Intake
– Excessive or Inadequate intake compared to
requirements (actual or estimated)
• Clinical
– Medical or physical conditions that are outside normal
• Behavioral-Environmental
– Relate to knowledge, attitudes, beliefs, physical
environment, access to food, or food safety

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS DOMAIN: INTAKE
Defined as “actual problems related to intake of
energy, nutrients, fluids, bioactive substances
through oral diet or nutrition support (enteral or
parenteral nutrition)
• Class: Calorie energy balance
• Class: Oral or nutrition support intake
• Class: Fluid intake balance
• Class: Bioactive substances balance
• Class: Nutrient balance

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Bioactive compounds
• tiology:

• Food and nutrition related knowledge deficit

• Contamination, misname, mislabel, misuse, recent brand change, recent dose increase, recent formulation change of substance consumed

• Frequent intake of foods containing bioactive substances

• Altered GI function, eg pain or discomfort

• S/S

• Lab values indicating excessive intake of the specific substance, such as rapid decrease in cholesterol from intake of stanol or sterol esters and a statin drug
and related related dietary changes or medications

• Increased hepatic enzyme reflecting hepatocellular damage

• Weight loss as a result of malabsorption or maldigestion

• Neurologic changes, eg anxiety, mental status changes

• Cardiovascular changes, eg heart rate, EKG changes, blood pressure

• Reports or observations of:

• High intake of plant foods containing soy protein, beta glucan, plant sterol and stanol esters, eg fortified margarines, or other foods based on dietary
substance, concentrate, metabolite, constituent, extract, or combination

• Substances that interfere with digestion or absorption of foodstuffs

• Ready access to available foods/products with bioactive substance, eg from dietary supplement vendors

• Attempts to use supplements or bioactive substances for weight loss, to treat constipation, or to prevent/cure chronic or acute disease

• Conditions associated with diagnosis or treatment, eg cardiovascular disease, elevated BP, HTN

• Discomfort or pain associated with intake of foods rich in bioactive substances, eg soluble fiber, beta glucan, soy protein
NUTRITION DIAGNOSIS DOMAIN: CLINICAL
Defined as “nutritional findings/problems identified that relate
to medical or physical conditions
• Class: Functional Balance
Change in physical or mechanical functioning with nutritional
consequences
• Class: Biochemical Balance
Change in capacity to metabolize nutrients as a result of
medications, surgery, or as indicated by altered lab values
• Class: Weight Balance
Chronic weight or changed weight status when compared with
usual or desired body weight

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS DOMAIN: Behavioral
Defined as “nutritional findings/problems identified
that relate to knowledge, attitudes/beliefs, physical
encironment, or access to food and food safety
• Class: knowledge and beliefs
• Class: physical activity, balance and function
• Class: food safety and access

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS: PES
• This statement has 3 distinct components:
Ø P (Problem)
Ø E (Etiology)
Ø S (Signs and Symptoms)

This information is obtained during the nutrition

assessment phase of the Nutrition Care Process

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 PES STATEMENT
This statement has a distinct format:

Nutrition Problem related to Etiology as

evidenced by Signs and Symptoms

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS COMPONENT
• Problem (Diagnostic Label)
• Etiology (Cause/contributing risk factors)
• Signs/Symptoms (Defining characteristics)
• Signs = objective data = observable, measurable
changes
• Symptoms = subjective data = changes pt feels
and expresses

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

PES Statement
• Clear and concise
• Specific to the patient
• Limited to a single problem
• Accurately related to one etiology
• Based on signs and symptoms from the assessment
data

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

PES STATEMENT: Problem
• Problem (Diagnostic Label)
• Describes alterations in pt’s nutritional status
• Diagnostic labels
• Impaired (nutrient utilization…)
• Altered (GI function…)
• Inadequate/excessive (calorie intake…)
• Inappropriate (intake of types of
carbohydrate)
• Swallowing difficulty

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

PES STATEMENT: 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)

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 PES STATEMENT: ETIOLOGY
• Etiologies are grouped by the type of cause or contributing risk factor.
Ø Beliefs-Attitudes
Ø Cultural
Ø Knowledge
Ø Physical Function
Ø Physiologic
Ø Psychological
Ø Social-Personal
Ø Treatment
• For the following, the category alone may be the cause or contributing risk factor of
the Nutrition Dx (diagnosis)
Ø Access
Ø Behavior

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

PES STATEMENT: Signs and Symptoms
• Signs/Symptoms (Defining characteristics)
• Evidence that problem exists
• Linked to etiology by words “as evidenced by”

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

PES STATEMENT: Signs and Symptoms
• PES statement components:
• (P) Problem or Nutrition Diagnosis Label: Describes
• alterations in the patient’s nutritional status.
• (E) Etiology: Cause/Contributing risk factors linked to
• the nutrition diagnosis label by the words “related to.”
• (S) Signs/Symptoms: Data used to determine that the
• patient has the nutrition diagnosis specified. Linked to
• the etiology by the words “as evidenced by.”

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Evaluating your PES
• P (Problem): Can the Dietitian resolve or improve the
nutrition diagnosis? Consider the “intake” nutrition
diagnosis as the one more specific to the role of the RND.
• E (Etiology): Determine if this is the “root cause” for the
problem. If addressing the etiology will not resolve the
problem, can the RND intervention lessen the signs and
symptoms?
• S (Signs and Symptoms): Will measuring the signs and
symptoms indicate if the problem is resolved or improved?
Are the signs and symptoms specific enough that the RND
can monitor and document resolution or improvement of
the nutrition diagnosis?

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Evaluating your PES
• Does the nutrition assessment data support the
specific nutrition diagnosis, etiology, and signs and
symptoms?

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 PRIORITIZING PES
• Rank the diagnoses in order of urgency
• Assess the impact of the problem to the health status
• Patient's personal needs and understanding
• Patient's preferences
• Likelihood for significant improvement

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

NUTRITION DIAGNOSIS
• Identifying the etiology leads to selection of the
nutrition intervention aimed at resolving the
underlying cause of the nutrition problem.
• If the intervention cannot be aimed at resolving the
underlying cause, as is the case in Physiologic-
Metabolic etiologies, then the nutrition
intervention is targeted at minimizing the
signs/symptoms of the nutrition problem

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Sample PES statements
• Excessive calorie intake (problem) “related to”
regular consumption of large portions of high-
fat meals (etiology) as evidenced by diet history
and weight status
• Swallowing difficulty (problem) related to
stroke (etiology) as evidenced by coughing
following drinking of thin liquids (signs and
symptoms)

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Sample PES statements
• Food, nutrition and nutrition-related knowledge
deficit (P) R/T lack of education on infant feeding
practices (E) as evidenced by infant receiving
bedtime juice in a bottle (S)
• Altered GI function (P) R/T ileal resection (E) as
evidenced by medical history and dumping
syndrome symptoms after meals (S)

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Sample PES statements
• •Excessive Fat Intake related to limited access to healthful
options – frequent consumption of high-fat, fast-food meals as
evidenced by serum cholesterol level of 230 mg/dL and patient
report of 10 meals per week of hamburgers and fries
• •Excessive Energy Intake related to unchanged dietary intake and
restricted mobility while fracture heals as evidenced by 5lb
weight gain during last 3 weeks due to patient report of
consumption of 500 kcal/day more than estimated needs
• •Swallowing Difficulty related to post stroke complications as
evidenced by results of swallowing tests and reports of choking
during mealtimes

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Sample PES statements
A. Inconsistent carbohydrate intake related to poor diet
choices as evidenced by A1C.

B. Inconsistent carbohydrate intake related to poor

diet choices as evidenced by consumption of 180%
more carbohydrate than recommended.

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Sample PES statements
A. Altered GI function related to short bowel syndrome
as evidenced by hypoalbuminemia and parenteral
nutrition.

B. Altered GI function related to short bowel

syndrome as evidenced by 7 watery stools per day
for previous 5 days.

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

PES CHEAT SHEET
PES CHEAT SHEET
Sample Case: Mr. Brightside
PROBLEM

ETIOLOGY

SIGNS and SYMPTOMS

Next meeting
LECTURE
§1st Hour: Asynchronous
§ 2nd hour: Discussion on Nutrition Intervention
§ Weekly formative activity on Common medical
abbreviations. Refer to Appedix N of Nutrition and
Pathophysiology Book by Nelms
LAB
§ Reporting of Group 1 Case A Nutrition Assessment
§Group 2 Case B Nutrition Assessment
 Nutrition Intervention
Nutrition intervention is purposeful planned actions intended to positively
change a nutrition related behavior, environmental condition, or aspect of
health status
• Directed to the etiology or cause of the problem identified in the PES
statement
• Sometimes the intervention must be directed toward the signs and
symptoms if the RDN cannot impact the etiology

The key element is that the RD improves the issue by creating a rational
plan with the help of the whole family including the individual

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Nutrition Intervention
Two interrelated components

• Planning

• Implementation

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Nutrition Intervention: PLANNING
Planning the nutrition intervention involves:
• Prioritizing nutrition interventions based on urgency, impact, and available
resources/ guidelines
• Collaborating with the client to identify goals of the intervention for each
diagnosis
• Writing a nutrition prescription based on a client’s customized recommended
dietary intake of energy and/or selected food or nutrients based on current
reference standards and dietary guidelines and a client’s health condition and
nutrition diagnosis
• Selecting specific nutrition intervention strategies that are focused on the
etiology of the problem and that are known to be effective based on best current
knowledge and evidence
• Defining the time and frequency of care, including intensity, duration, and
follow-up
SOURCE: ACADEMY OF NUTRITION AND DIETETICS
Nutrition Intervention: IMPLEMENTATION
Implementation is the action phase and involves:
• Collaborating with the client to carry out the plan of
care
• Communicating the nutrition care plan
• Modifying the plan of care as needed
• Following up and verifying that the plan is being
implemented
• Revising strategies based on changes in condition

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Critical Thinking Skills
• Setting goals and prioritizing
• Defining the nutrition prescription or basic plan
• Making interdisciplinary connections
• Initiating behavioral and other nutrition interventions
• Matching nutrition intervention strategies with client
needs, nutrition diagnosis(es), and values
• Choosing from among alternatives to determine a
course of action
• Specifying the time and frequency of care

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Nutrition Intervention
Four Domains

• Food and/or Nutrient Delivery

• Nutrition Education
• Nutrition Counseling
• Coordination of Nutrition Care

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Nutrition Intervention

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Use of Nutrition Interventions Based on practice setting
Food and/or Nutrient Delivery:
• institutional settings (hospitals, long-term care)
• home care

Nutrition Education-Content:
• institutionalized settings

Nutrition Education-Application:
• outpatient/non institutionalized settings
• private practice
• community

Nutrition Counseling:
• outpatient/non institutionalized settings
• private practice
• community

Coordination of Nutrition Care:

• all practice settings

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Nutrition Intervention
Intervention 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?

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Nutrition Intervention Prescription and Plan
The patient/client’s individualized
recommended dietary intake of energy
and/or selected foods or nutrients based on
current reference standards and dietary
guidelines and the patient/client’s health
condition and nutrition diagnosis (specify).

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

 Nutrition Intervention Terminology

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Nutrition Intervention Terminology

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Nutrition Intervention

SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Case of Mr. Brightside
 Nutrition Diagnosis and Intervention
Excessive energy intake related to overconsumption of
energy dense, high fat, sugary and convenient food items
as evidenced by 200% above his recommended energy
intake

Prescription: 2500 kcal low fat diet, less simple sugars in 3

meals and 2 snacks
 Nutrition Diagnosis and Intervention
Next Week: Sept. 22

Start of oral exam (ST2)

3N1- Abanilla to Cruz, Abigail
3N2- Afundar to Caballero
3N3- Ambray to Cua

Start with the AT1 for both lec and laboratory