12/3/2012 1 Nutrition Care Process Jane McClinchy 2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 1 Learning outcomes At the end of the session, you should be able to: • Describe the main steps of the NCP • Be able to write a nutrition diagnosis • (note I will not be covering groups) 2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 2 Content • Explore why a process is needed in dietetics • Look at the stages of the Process • Workshop with case studies 2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 3 Time Activity 13.00 Introduction to the process 13.45 Workshop 14 30 Feedback 14.30 Feedback 15.00 Finish 2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 4 Need for a process • Uncertainties in health care funding • Electronic health records • SNOMED: SNOMED: • Systematized Nomenclature of Medicine 2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 5 EFAD competencies Dietetics process and professional reasoning • 3.1 Meet the needs of clients in complex situations related to health, social situations and the environment. Clients may be individuals, groups, organisations or populations • 3.2 Implement the Dietetic process, including screening, assessment, identifying needs, formulating goals, planning, implementing interventions and evaluating outcomes, in order to enable client choice. • 3 3 Implement theories and models nutritional and activity analysis in order 3.3 Implement theories and models, nutritional and activity analysis in order to integrate reasoning related to the dietetic process with client need. (This guides the selection and provides best possible practice for individuals and groups). • For the Clinical Dietitian • 3.4 Make a dietetic/nutrition related diagnosis. • 3.5 Treat and counsel a client/patient using special dietetic/nutritionally modified products. • European Federation of the Associations of Dietitians (EFAD) and Thematic Network Dietitians Improving Education and Training Standards in Europe (DIETS) (2009) European Dietetic Competences and their Performance Indicators attained at the point of qualification and entry to the profession of Dietetics retrieved from http://efad.topshare.com/iextranet/1468/5/0/70 2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 6
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12/3/2012
1
Nutrition Care Process
Jane McClinchy
2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 1
Learning outcomesAt the end of the session, you should be able to:
• Describe the main steps of the NCP
• Be able to write a nutrition diagnosis
• (note I will not be covering groups)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 2
Content
• Explore why a process is needed in
dietetics
• Look at the stages of the Process
• Workshop with case studies
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 3
Time Activity 13.00 Introduction to the process13.45 Workshop 14 30 Feedback14.30 Feedback 15.00 Finish
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 4
Need for a process
• Uncertainties in health care funding• Electronic health records• SNOMED:SNOMED:• Systematized Nomenclature of Medicine
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 5
EFAD competencies Dietetics process and professional reasoning• 3.1 Meet the needs of clients in complex situations related to health, social
situations and the environment. Clients may be individuals, groups, organisations or populations
• 3.2 Implement the Dietetic process, including screening, assessment, identifying needs, formulating goals, planning, implementing interventions and evaluating outcomes, in order to enable client choice.
• 3 3 Implement theories and models nutritional and activity analysis in order3.3 Implement theories and models, nutritional and activity analysis in order to integrate reasoning related to the dietetic process with client need. (This guides the selection and provides best possible practice for individuals and groups).
• For the Clinical Dietitian• 3.4 Make a dietetic/nutrition related diagnosis.• 3.5 Treat and counsel a client/patient using special dietetic/nutritionally
modified products.
• European Federation of the Associations of Dietitians (EFAD) and Thematic Network DietitiansImproving Education and Training Standards in Europe (DIETS) (2009) European Dietetic Competences and their Performance Indicators attained at the point of qualification and entry to the profession of Dietetics retrieved from http://efad.topshare.com/iextranet/1468/5/0/70
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 6
Others?2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 7
Process- pros and cons
Pros• Problem solving-scientific
• Provides security
Cons• Less flexible
• May mask creativityy
• Sequential/cyclical
• Patient centred
y y
• ? The unexpected
• Not patient centred
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 8
Barriers
• Lack of knowledge• Time• Need for training and support• Difficulty in determining nutritional
diagnosis statements
• Ferguson et al. (2012) Personal communication
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 9
Benefits of using a process?Using a process leads to:
• Consistent quality of practice• Evidence of professional clinical decision
making• Autonomy of practice• Autonomy of practice• Consistent record keeping and therefore
improved care • Key step in determining and measuring
outcomes of dietetic care • Can be used to promote the profession
• (Source BDA 2012)2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 10
Structural framework
• ‘…which helps us to inform what the [nutritional] diagnosis is, which helps to inform what intervention we’re going to plan which helps us inform whatplan, which helps us inform what outcomes we’re going to consider’ (FG2-P1)
• (Aylesbury and McClinchy, 2012 in press)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 11
MDT Communications
• ‘…that we’re efficient, precise and concise and methodical in what we write…I think it is an important part of MDT communications’ (FG3-P1)( )
• ‘what’s important in terms of the profile of the profession is that what’s written is concise and neat and to the point…doctors want the nitty gritty’ (FG1-P1)
•
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 12
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3
Transfer of patients between..
‘when patients are transferred…you get the notes with the patient sometimes it can take a while trying to figure out what thea while trying to figure out…what the intervention has been whereas if it was all standardised…it would be more focussed’ (FG2-P4)
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 13
Monitor/
Assessment
Nutritional
The NCP follows the
steps…
evaluate Diagnosis
Plan Implement intervention
2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 14
The spiral
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 15 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 16
Nutrition assessment in the NCP …Food/Nutrition-related history
Food and nutrient intake, usual diet, medications, food availability, knowledge/beliefs about food, physical activity level
Anthropometric measurements
Height, weight, body mass index, growth velocity, circumferences etcg y,
Biochemical data, medical tests and procedures
Lab data such as electrolytes, glucose, lipids, tests such as resting metabolic rate, abdominal x-rays etc
Nutrition-focused physical findings
Skin turgor and integrity, dentition, appearance of subcutaneous fat/muscle mass etc
Client history Medical/surgical/family history/social2nd Dec 2012 Jane McClinchy University of Hertfordshire
behaviour based counselling for self-efficacy and self management
Coordination of nutrition care Team meetings, referral to experts or outside agencies
Intervention
• Planning• Implementation
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 56
Components of the PlanComponent Definition Links with
NDOutcomes measurable and specific Signs and
symptomsIntermediate goals
which will achieve the outcomes
Problem
Plan provision of food Aetiology
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 57
Plan provision of food, provision of nutrition support, education package, counselling, coordination of care, social marketing campaigns, food availability, food shopping and cooking skills
Aetiology
Planning nutrition intervention Outcomes Examples (use info from S&S)
Anthropometric change
Weight, MUAC, waist:hip ratio
Biochemical indicators Lab values, indicators of nutritional status
Client-focussed outcomes: quality of life, client identified outcomes, satisfaction, self-efficacy, self-ural/ Social identified outcomes, satisfaction, self efficacy, selfmanagement, functional ability
Behavioural Food related behaviour, physical activity
Psychological Self-efficacy, self management, mental health state
Healthcare utilisation and cost outcomes
Medication changes, special procedures, planned/unplanned clinical visits, preventable hospitalisations, length of hospitalisation, prevent or delay nursing home admission 2nd Dec 2012 58Jane McClinchy University of Hertfordshire
NCP
Planning nutrition intervention Goals
Area Examples:
Diet and nutrition goals (changes)
Reduced energy intake by 600 kcalsReduce fat intake
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 59
(changes) Reduce fat intake
Environment/behavioural/social Increase physical activity by 30 minutes 5 times per week
Plan -designed to meet the outcomesand goals
Plan Examples
Dietetic prescription for an individual
Xx kcals reducing dietXxmls of xx feed at xx mls per hourHigh protein and high energy diet
Education plan for an individual Specifics of education e.g. which foods are
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 60
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: weight maintained at xxGoal? Plan?
Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Patient will choose lower energy foodsGoal?Plan?
Outcome: weight loss 05.-1 kg per weekGoal?Plan?2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 61
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 62
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 min 5 x per week Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 63
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week Outcome:
Planning links with ND
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 64
Nutrition intervention -implementation
Activities
• Communication and negotiation
• Education
• Collaboration with other health care professionals
• Use of behavioural change strategy or approach e.g. use
of SMART goals
• Use of educational tool e.g. diet sheet/food models
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 65
Diagnosis:Patient is obese caused by excessive energy intake of 25% above estimated requirements as evidenced by raised BMI and diet history
Interventions• Diet information • Sample meal plan with
600 kcal energy deficit • Smart goals enabling
Nutrition intervention – implementation
Intervention planning:Outcome : 0.5-1 kg loss of weight per week Goal: Consume 600 Kcal less Plan: 600 kcal energy deficit diet prescription
achievement of 600 kcal energy deficit
• Agree ‘episode of care’ and review timescale
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 66
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12
Nutrition intervention -implementation
Collaboration with other health care professionals
• Information for carers
• Asking Nurse to weigh
• Ward staff implement food record chart
• MDT home visit team implement
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 67
Problem Caused by
Evidenced by
Intake: Energy balanceEnergy intake greater than expenditure
caused by reduced activity
as evidenced by weight gain
Intake: Food
Plan Intervention Implementation Intervention
Outcome: Goal: Energy expenditure meet energy intakePlan: Increase activity by 30 mins5 time per week
SMART goal on the length/frequency of a specific exercise
Outcome:
Link with intervention
Intake: Food intakeExcessive intake of energy dens e foods
Lack of knowledge about appropriate foods
Diet history and patient reporting
Clinical: ObesityOverweight
Excessive energy intake
High BMI
Outcome: Goal: patient will know which foods are low in energy Plan: Educate patient on lower energy foods
SMART goals on selection of lower energy foods
Outcome: Goal: Consume 600 Kcal less Plan 600 kcal energy deficit diet prescription
SMART goals enabling 600 kcal energy deficit
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 68
Nutrition monitoring and review
Definition:• The review and measurement of the client, group or
population’s nutritional status at planned intervals with regard to the nutrition diagnosis, intervention plan, goals and outcomes
Components:• Check understanding or compliance• Determine if the intervention is being implemented as
prescribed• Obtain evidence that the plan is/is not changing
behaviour, nutrition or health status• Identify other positive or negative outcomes
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 69
Nutrition monitoring & review
Review and measurement of status at scheduled times
Nutritional diagnosis Plan ImplClinical: ObesityOverweight
Excessive energy intake
High BMI
a pG: weight loss 05.‐1 kg per weekP: 600 kcal energy deficit
SMART goals enabling 600 kcal energy deficit
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 70
Nutrition monitoring & review
• For the patient what will you measure or monitor?
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 71
Nutrition monitoring & review
• Or ABCDE
Parameter What will you measure?AnthropometryAnthropometry
Biochemistry
Clinical
Dietary
Environmental
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 72
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Evaluation
DefinitionSystematic comparison of current findings against previous
status, intervention goals and outcomes
To enable for example decisions about p• Discharge• Continuation of intervention• Reassessment
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 73
Monitor/
Assessment
Nutritional
The NCP follows the
steps…
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 74
Nutritional diagnosisPatient is obese caused by excessive energy intake of 25% above estimated requirements as evidenced by raised BMI and diet history
Planning intervention Outcome: weight loss 05.-1 kg per week Outco e e g t oss 05 g pe eeGoal: 600 kcal energy deficit Plan: Dietetic prescription and education
Implementation of intervention SMART goals enabling 600 kcal energy deficit
Evaluation against original outcome measure and decision about the future
Jane McClinchy University of Hertfordshire NCP 752nd Dec 2012
Workshop
Spend 15 mins on each activity• ND ‘fill in the blanks’ sheet• Writing a NCP statement case 1a or 1b• Your own action plan for implementing the
NCP in your work
• 14.30-15.00 Feedback • 15.00 Finish 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 76
Feedback
2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 77
Weight loss • Problem• Inadequate energy Intake (or could have food
intake) • Aetiology (Cause)Aetiology (Cause)• Energy intake not meeting needs to prevent
weight loss(food refusal-could be a meal/specific food items/snacks)
• Signs (Objective)/Symptoms (Subjective)• Xkg lost in y days, low BMI
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 78
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• Problem• Self –feeding difficulty (behavioural)• Aetiology (Cause)• Impaired ability to place food in mouth (spillage• Impaired ability to place food in mouth (spillage
of ____ % during meals)• Signs (Objective)/Symptoms (Subjective)• • X kg weight loss in Y days/ Rapid weight loss• • Advanced stages of Parkinson’s/MS/
Excessive shaking of hands2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 79
• Low Iron, HgB/HCT• Signs and symptoms-low haemoglobin• Abnormal Lab Values• Aetiology-change in ability to eliminate by products of
metabolism/metabolise/absorb• Diabetes• Problem-Inconsistent carbohydrate intake• Tube Feeding• Signs Symptoms -X kg lost in y days• Dysphagia• Aetiology- Impaired movement of food/fluid from mouth
to stomach• Problem-Inadequate food/beverage intake
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 80
Nutritional diagnosis P-Energy and protein intake below estimated requirements A-Increased requirements and reduced appetiteS-Medical notes report sepsis, weight loss 4% and food record chart shows intake of 600 kcals and 20g protein
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 81
Intervention Planning Outcome: Maintain current weight of 72 kgPatient reports improved appetiteGoal: Increase nutritional intake initially by 600 kcals and 24g proteinPlan:Plan: High protein, high energy diet including prescription of oral nutritional supplements which provide 600kcals and 24g proteinImplementation SMART goal with patient on consumption of ONSWork with nursing staff on help with menu selections (favourite foods to help with appetite) 2nd Dec 2012 Jane McClinchy University of Hertfordshire
NCP 82
Monitoring Monitor appetite and weightEvaluationIntake will be lower than requirements initially, so increase energy prescription once appetite has improved
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 83
Learning outcomesAt the end of the session, you should be able to:
• Describe the main steps of the NCP
• Be able to write a nutrition diagnosis
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 84
12/3/2012
15
Feedback
• Implementation of NCP• Try to use PAS• SMART goals• Step wise approach• Try to see the problem first• Identify the most important problem•
2nd Dec 2012 Jane McClinchy University of Hertfordshire NCP 85
Further reading
Resources on the Academy of Nutrition and Dietetics http://www.eatright.org/
Search Nutrition Care Process and a number of accessible pdfs are available
Resources on the BDA website are available to members only:
BDA (2012) Model and Process for Nutrition and Dietetic Practice