Nutrition Education and Counseling: Nutrition Care Process Presentation 4

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Goal Setting
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Goal Setting
Key strategy in the Nutrition Care Process
Review

SMART Goals
Specific
Measurable
Attainable
Rewarding
Time Bound
Define Measurable Goals
Identify when, where, how often under what conditions the new behavior will occur

Realistic, reasonable, desirable
Perceived as important

Do not set too many goals at once-overwhelming
--1-3 goals
--Client is the best judge
Measurable Goals
Good, try, better, more, less-not measurable

Need to produce outcome data

For funding agencies increases, you will have a hard time reporting your results if you do not have well-defined outcomes (numbers or time frames)
-Eat two servings of vegetables at dinner
-Eat one whole grain at breakfast
-Take a fruit to work each day to eat at break
-Prepare a vegetable based recipe this week
Goals which Client Has Control
Goal should depend on action of the client, not another person
--"I want my husband to..."
--is not a good goal
Does not mean the person can not seek the support of another person
State Positive Goals
Do not state goals as taking away a pleasurable pastime
--"I won't eat ice cream this week while watching TV"

Rather state goals as a positive change
--"Four days a week I will eat low fat yogurt while watching TV"
Design a Plan of Action
Investigate Physical Environment
-Is there anything that will get in the way of the client physically help/hinder achieving the goal?
-Example: can they afford food?
-Can they get to the store?
-Where will they purchase the fruit?

Investigate Cognitive Environment
-Does it seem achievable?
-What will you be saying to yourself if you miss a day?

Examine Social Support
-Explore if there is anyone in client's environment who will help/hinder achieving goal

Modify Goal if Necessary

Select a tracking technique
-How will you measure the plan?
--Check sheet for each time they eat 2 fruits at breakfast
--Check sheet for each cup of water

Verbalize the Goal
-When you believe the goal is defined, ask client to verbalize it

WRITE DOWN THE GOAL!
-Write it down and give it to client
-"Goals that have not been written
Nutrition Care Process
1. A-Assessment
Dietary Assessment
- Food Intake Data collection
- Data Analysis
- Interpretation of Analysis

Energy Determinations
- Determining Resting Energy Expenditure
- Select a Physical Activity (PA) Factor
- Determine TEE
- Adjust for Weight Loss

Physical assessment and Healthy Weight Standards
-Documentation and Charting

2. D-Diagnosis

3. I-Intervention

4. M-Monitoring&
E-Evaluation
NCP Step 1: ASSESSMENT
Dietary Assessment
Will vary according to the characteristics of the intervention
Most contain the following features:
--Dietary Evaluation and Nutrition Related History
--Anthropometrics
--Biochemical data and Medical Test Results
--Medical and Clinical history
--In some instances Functional Capacity Assessment
--Vision/Dexterity to evaluate food preparation capacity
Nutrition Assessment Data Domains and Examples
Food and Nutrition Related History
-Food intake
-Medication and/or herbal supplement intake
-Physical activity and function

Anthropometrics
-Ht, Wt, BMI, Waist circumference

Biochemical Data, Medical tests, Procedures
-Lab data
-Tests such as metabolic rate, DEXA scan

Nutrition Focused Physical Findings
-Loss of appetite, blood pressure

Client History
-Age, gender, medical history
-Social history, socioeconomic factors
Dietary Assessment
After accurately gathering all assessment information and analyzing results and relationships between data, compare findings to criteria such as
-A goal
-Nutrition prescription
-Standard

Then makes a meaningful evaluation

Used to accomplish
-Furnish baseline parameters
-Determine health and nutrition risks
-Set priorities for making dietary changes
-Ascertain feasible alternatives for making dietary changes and planning interventions
NCP Step 1: ASSESSMENT Step 1: Food intake data collectionMethods and tools to collect data to aid in understanding the kinds and amounts of food consumed and factors influencing choice include -Client assessment questionnaire -Food diary and daily food record -Usual diet -Diet history interview -Food frequency -24 hour recall Vary in purpose, length and complexity When collecting data be careful not to give advice, preach or condemn. Even words of approval should be avoided, as this could encourage client to give information perceived as a good answer Useful tell client there is no wrong answer, no one has a perfect diet, give example of a low nutrient dense food you enjoyClient Assessment Questionnaire (historical data form)Sometimes referred to as an intake form Contain several divisions addressing information about historical data Questions not asked for the purpose of making a diagnosis; asked to ascertain medical factors that could have nutritional impact Forms can be tailored to meet counseling needs for specific clientelePortion SizeMany of the following methods require estimation of portion sizes Several aids can be used to help respondents recall portion sizes for data collection -Two and three dimensional food models -Various shapes of cardboard or plastic household cups, bowls, plates, glasses, spoons -Life-size photos -Measuring spoons, cups -RulerFood diary and Food RecordClient records food and liquid intake Preparation method Food intake as it occurs for a specific period Sometimes additional information is recorded such as time, place, activities, social setting, degree of hunger, emotional state *Limited by impact of recording on food intakeUsual Intake FormGives counselor idea of typical daily pattern of food intake Simple and generally not as time consuming to complete Limited usefulness for clients with varied intake from day to day If client have a varied diet another intake method should be usedDiet History InterviewSimilar to asking about usual diet Emphasis on allowing client to "tell their story" Invited to give account of normal day's eating pattern "Typical day"Food Frequency ChecklistList of foods grouped together according to similarity in nutrient quality and quantity Read to client by interviewer or self-administered Set of responses to be checked off that indicate how often certain foods are consumed -Day, week, month Vary in amount of detail -Too short; knowledge gained is limited -Too long; tedious to complete, accuracy declines Evaluates how often certain foods and food groups are eaten or food groups not eaten24 hour recallAsk client to recall foods, beverages and supplements consumed including amounts and preparation methods over 24 hour period Midnight to midnight of the previous day or 24 hours Starting point most recent or most distant Easy to administer with little effort on part of client Accuracy increases if counselor assists clients in recalling food consumption and portion sizesComponents of Effective 24hour RecallDo not ask leading questions -Do not assume a meal was eaten (what did you eat for breakfast) Ask probing questions -You said you had a lot of butter on your toast, how much is a lot? Ask sequential questions about the day's activities, travels, encounters to recall food consumed Use portion size estimation tools Research shows certain foods are frequently missed -crackers, bread, rolls, toppings on vegetables, chips, nuts, calorie containing drinks, review list for these items24 hour recall Multiple pass 5 step procedurea)quick list client recalls all foods eaten in 24 hours b)asked about frequently forgotten foods c)probed to recall time and occasions of foods consumed d)detail cycle, clients asked to provide descriptions of foods/amounts with aid of models and measures Final probe review regarding type, amounts, additions and toppings, preparation methodNCP Step 1: ASSESSMENT Dietary Assessment Step 2: Data AnalysisAfter dietary information is collected, the data must me analyzed for food groups and components of food such as -Energy -Nutrients -Phytochemicals Food group evaluations generally quick Food component analysis can be time consuming, feedback generally not given same day. Food composition tables, Nutrient databases, nutritional analysis softwareCP Step 1: ASSESSMENT Dietary Assessment Step 3: Interpretation of AnalysisCompare data to a standard Computer programs automatically do both Commonly used standards -MyPlate for food groups -DRI's or specific nutrients --EAR'S --RDA's --AI's --UL's -DASHNCP Step 1: ASSESSMENT Energy Determinations Step 1: Determining Resting Energy Expenditure (REE)REE is energy needed to sustain life functions --Respiration --Heart beat --Kidney function --Over a 24 hour period of time Indirect Calorimetry Standard Equations AND suggests for obese individuals indirect calorimetry; if not available use Mifflin St. JeorStandard Equations Resting Energy Expenditure (REE)Mifflin-St Jeor Men: REE=[10XWt in kg]+[6.25XHt in cm]-(5Xage)+5 Women: REE=[10XWt in kg]+[6.25XHt in cm]-(5Xage)+161 Harris Benedict Equation Men: REE=[66.5+13.8XWt in kg]+[5.0XHt in cm]-6.8Xage Women: REE=[665.1+9.6XWt in kg]+[1.9XHt in cm]-4.7Xage To convert inches to cm, multiply by inches by 2.54 To convert pounds to kg, divide pounds by 2.2NCP Step 1: ASSESSMENT Energy Determinations Step 2: Select a Physical Activity (PA)FactorActivity level PA Typical Daily Activity Sedentary 1.2 Only activities of daily living Low active 1.375 30-60 min of moderate activity Active 1.55 >=60min of moderate activity Very active 1.725 >=60min of moderate activity plus 60 min vigorous or 120 min moderate activity Extreme Active 1.9 Daily vigorous activityNCP Step 1: ASSESSMENT Energy Determinations Step 3: Determine Total Energy Expenditure (TEE)REEXPA=TEENCP Step 1: ASSESSMENT Energy Determinations Step 4: Adjust for weight lossIf weight loss is desired subtract 500 kcal/day For approximately 1pound weight loss per weekPhysical Assessment and Healthy weight Standards: Should you adjust for weight loss?Healthy Weight standards BMI Waist Circumference Waist to Hip ratioBody Mass Index (BMI)BMI Standards: <18.5 Underweight 18.5-24.9 Healthy weight 25-29.9 Overweight >30 ObeseWaist CircumferenceNormal: Men: <=40 inches Women: <=35 inches High risk: Men: >40 inches Women: >35 inchesWaist to Hip RatioWaist (inches) = WHR Hip (inches) Same calculation for Men and Women Waist to Hip Ratio (WHR); Recommended: 1.0 or less for Men 0.8 or less for Women **Numbers higher than this=Increase risk.Documentation and ChartingIf it's not documented, it didn't happen! Legal document Well written, JCAHO standards Evidence of care Demonstration of accountability A basis of evaluation and planning to ensure quality of care Documentation for legal protection of clients, practitioners and facility **Tool for communication among health care team **Justification for reimbursement for third-party reimbursementDocumentationWhether computerized or handwritten notes should be Concise-Goals/Plans easily identified Clear, legibly written in black ink if handwritten Accurate for ongoing referencing Appropriate and pertinent, no personal opinions/criticisms Chronological order Entries should be made as soon as possible after encounter All entries dated and signed with full name and credentialsTypes of DocumentationSOAP ADIMENCP Step 2: Nutrition DiagnosisThe purpose of the nutrition diagnosis is to "identify and describe a specific problem that can be resolved or improved through treatment and nutrition intervention by a dietetics practitioner" For example: Nutrition diagnosis: excessive sodium intake Differs from Medical diagnosis: HypertensionProcedure for Defining DiagnosisUsing data collected during ASSESSMENT procedure, you are ready to define NUTRITION DIAGNOSIS Using standardized terminology found in AND reference manual, International Dietetics & Nutrition Terminology (IDNT) Frequently more than one problem exists RD needs to critically analyze which one or two are most likely to improve with nutrition interventionNutrition Diagnosis DomainsOver 100 nutrition diagnosis available Grouped together in three domains Intake -Includes definers such as inadequate, excessive, or inappropriate to describe an altered intake of a particular nutrient or substance Clinical -Relates to physical or medical conditions such as swallowing, chewing, digestion, absorption, appropriate weight Behavioral-environmental -Includes various cognition designation and environmental factorsWriting a Nutrition Diagnosis Statement-PES STATEMENTP-Problem: Diagnosis label. Comes from one of the standardized terms used to describe a diagnosis. Should provide a guidance for formulating nutrition interventions, allow collection of data to monitor and evaluate change and to identify realistic and measurable outcomes E-Etiology: Root cause or contributing risk factor. Factors can be pathophysiological, psychosocial, situational, developmental, cultural, environmental. Etiology is linked to diagnosis label by the words related to S-Signs/Symptoms: Defining characteristics used to determine that the client has the nutrition diagnosis specified. Measurable objective data, such as decreased oral intake , consuming <25% of meals or obesity, BMI >30, or subjective (but quantifiable) symptoms including observations and statements from client or caregiver (number of bowel movements). These will be the basis for setting ideal measurable goals in Step 3 and providing outcome measures in Step 4Examples: PES statementsMedical Diagnosis: T2DM Nutrition Diagnosis: inconsistant CHO distribution related to lack of meal planning as evidence by diet history and high blood glucoseEvaluating PES StatementsP Can the RD resolve or improve the nutrition diagnosis? Consider the intake domain as the preferred problem E Is the etiology the 'root' cause Will the intervention eliminate the problem by addressing the etiology? If not, Can the RD intervention alleviate signs/symptoms? S Will measuring sign/symptom indicate if problem is resolved? Are signs/symptoms specific enough to monitor and document? PES Overall: Does the nutrition assessment data support the diagnosis, etiology, and signs and symptoms?NCP Step 3: InterventionPurpose is to "resolve or improve the identified nutrition problem by planning and implementing appropriate nutrition interventions that are tailored to the client's needs" Specific set of activities/materials to address the problem Selection based on nutrition assessment and needs to be directed to the root cause (etiology) with the objective of relieving signs and symptoms of the diagnosis If the intervention cannot be directed at etiology (depression) then intervention should focus on reducing signs/symptoms Planning and implementation of nutrition intervention are neededPlanning Nutrition InterventionPrioritize diagnoses Consult AND Evidence Based Nutrition Practice Guidelines Jointly determine patient-focused expected outcomes with the client and relevant caregivers Develop nutrition prescription and recommended specific strategies for altering dietary intake of energy and selected foods, nutrients, or activity Work collaboratively with clients and caregivers to develop well defined measurable/achievable goals and expected outcomes Determine time and frequency of intervention activitiesImplementation of InterventionCommunicate nutrition care plan to all relevant individuals Carry out the nutrition intervention Collaborate with other professionals Continue data collection and monitor progress of intervention Revise intervention strategies as neededNutrition Intervention Domains4 Domains of nutrition intervention strategies Over 60 terms to choose from that address -Alerting nutritional intake -Nutrition related knowledge or behavior -Environmental conditions -Access to supportive care and services You can choose from more than one strategyNutrition Intervention Domains TypesFood and Nutrition Delivery: Individualized approach to providing food and nutrients including meals, snacks, food, vouchers, enteral and parenteral feeding, and supplements Nutrition Education: Formal process to instruct or train patient/clients in a skill or impart knowledge to help voluntarily manage or modify food, nutrition and physical activity choices and behavior to maintain or improve health Nutrition Counseling: A supportive process characterized by a collaborative counselor/client relationship to establish food, nutrition and physical activity priorities, goals, and individualized action plans that acknowledge and foster self care to treat existing conditions and promote health. Coordination of Nutrition Care: Entails "consultation" with, referral to, or coordination of nutrition care with other providers, institutions, or agencies that can assist in treating or managing nutrition related problems" Includes discharge planningNCP Step 4: Monitoring and Evaluation (M&E)Practitioner evaluates the effectiveness of the nutrition intervention Determine how much progress is being made Involves 3 activities: -Nutrition Monitoring -Measuring outcomes -Nutrition evaluationNutrition MonitoringPeriodic reviews and measurement of nutritional status as a result of intervention Determine if goals have been achieved or further intervention is needed Possible activities include: -Checking for understanding -Recording all evidence of behavior change indicators, including signs/symptoms identified in PES statement -Making conclusions based on evidence -Include any positive/negative factors that may have altered due to the nutrition interventionMeasuring OutcomesIncludes selecting appropriate nutrition care indicators to measure and using standardized indicators to increase validity and reliability of findings The measure should interface with electronic charting and codingNutrition EvaluationSystematic comparison of current data collection and measurements against criteria, which could be - The clients previous nutritional status - Intervention goals - A standard - Should also evaluate an assessment of the overall impact of the total nutritional intervention on patient outcomesDocumentationNCP can be incorporated into facility charting guidelines or ADIME format may be followed Every facility will have their own plan that they will follow *Just remember; you know how to be an RD and know the steps, you just may need to learn how to follow their system of documentation....