ADA NUTRITION CARE PROCESS AND MODEL
Screening & Referral
System
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Identify risk factors
Use appropriate tools
and methods
 Involve
interdisciplinary
collaboration
Nutrition Assessment
 Obtain/collect timely and
appropriate data
 Analyze/interpret with
evidence- based standards
Document
Nutrition Diagnosis
 Identify and label problem

Determine cause/contributing risk
factors
 Cluster signs and symptoms/
defining characteristics
 Document
Relationship
Between
Patient/Client/Group
& Dietetics
Professional
Nutrition Monitoring and
Evaluation

Monitor progress

Measure outcome indicators

Evaluate outcomes
 Document
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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 Intervention
 Plan nutrition intervention

Formulate goals and
determine a plan of action
Implement the nutrition intervention
 Care is delivered and actions
are carried out
 Document
Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation
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“A systematic process of obtaining,
verifying, and interpreting data in order
to make decisions about the nature and
cause of nutrition-related problems.”
› Lacey and Pritchett, JADA 2003;103:1061-
1072.
Gather data, considering
 Compare to relevant standards
 Identify possible problem areas

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Observe
› Verbal and nonverbal cues

Determining appropriate data to collect
› Only key information to be recorded
Selecting assessment tools
 Distinguishing relevant from irrelevant data
 Organizing data to relate to the nutrition
problem
 Determining when problems require referral

Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation

Nutritional problem
 Names and describes the problem
 Problem may already exist, or may be at
risk of occurring
 Not a medical diagnosis

Defined as “actual problems related to
intake of energy, nutrients, fluids,
bioactive substances through oral diet or
nutrition support (enteral or parenteral
nutrition)
 Class1: Calorie energy balance
 Class2: Oral or nutrition support intake
 Class3: Fluid intake balance
 Class4: Bioactive substances balance
 Class5: Nutrient balance
Defined as “nutritional findings/problems
identified that relate to medical or physical
conditions
 Class1: functional balance
 Class2: biochemical balance
 Class3: weight balance
Defined as “nutritional findings/problems
identified that relate to knowledge,
attitudes/beliefs, physical environment,
or access to food and food safety
 Class1: knowledge and beliefs
 Class2: physical activity, balance and
function
 Class3: food safety and access
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Problem
Etiology
Signs/Symptoms
› Signs
› Symptoms

Problem
› Describes alterations in pt’s nutritional status
› Diagnostic labels
 Impaired
 Altered
 Inadequate/excessive
 Inappropriate
 Swallowing difficulty

Etiology
› Related factors that contribute to problem
› Identifies cause of the problem
› Helps determine whether nutrition
intervention will improve problem
› Linked to problem

Etiology
› Excessive calorie intake related to regular
consumption of large portions of high-fat
meals
› Swallowing difficulty related to stroke

Signs/Symptoms
› Evidence- that the problem exists
› Linked to etiology- “as evidence by”

Etiology
› Excessive calorie intake “related to”
regular consumption of large portions of
high-fat meals as evidenced by diet
history and weight status
› Swallowing difficulty related to stroke as
evidenced by coughing following drinking
of thin liquids
Excessive calorie intake
 “related to” regular consumption of large
portions of high-fat meals
 “as evidenced by” diet history & 12 lb wt
gain over last 18 mo

Food, nutrition and nutrition-related
knowledge deficit R/T lack of education on
infant feeding practices as evidenced by
infant receiving bedtime juice in a bottle
 Altered GI function R/T ileal resection as
evidenced by medical history and dumping
syndrome symptoms after meals

Nutrition Diagnosis Statement should be:

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clear, concise
specific
related to one problem
Accurate- related to E
based on reliable, accurate assessment
data
Medical Diagnosis
Nutritional Diagnosis
Diabetes
Increased blood glucose level, excess calorie intake
Trauma and closed
head injury
TPN, IV hydration line, increase energy needs (state of
catabolism) R/T the trauma, as evidence by weight
Liver failure
No insulin, blood glucose stability, R/T fact that the liver
is not functioning, as evidence by increased blood
glucose levels.
Medical Dx
Nutritional Diagnosis
Obesity
Intake energy imbalance or calorie increase R/T
increased calories or obesity or lack of healthy foods or
SES, AEB weight, BMI
Dependence mechanical
ventilation
Increased carbohydrates, excessive calories R/T high
TPN, AEB vent settings
Anorexia nervosa
Decreased calorie intake, R/T history of anorexia and self
limiting behavior, AEB weight and diet history
Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation


“Purposely-planned actions designed
with the intent of changing a nutritionrelated behavior, risk factor,
environmental condition, or aspect of
health status for an individual, a target
group, or population at large.” –
› Lacey and Pritchett, JADA 2003;103:1061-
1072

Directed at the etiology or effects of a
diagnosis
Should be patient-centered
Must be achievable
 Stated in behavioral terms, quantifiable
terms
 Pt and counselor must establish goals
together
 What will the patient do or achieve if
objectives met

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SMART goals!

Problem 1: Involuntary weight loss
› Objectives:
 1. Increase calorie intake, very specific
 2. Gain X pounds in X month

Problem 2: Inadequate protein-energy
intake 2° poor appetite
› Objectives:
1.Increase nutrient dense foods high in
protein
2.Divide up protein rich foods throughout
the day
3.Improve socialization of eating foods
 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

Problem 1: Involuntary Weight loss
› Intervention:
1. Instruct client on (high protein, high calorie
feeding)
2. Gradually increase plan
3.
4.

Problem 2: Inadequate protein-calorie
intake 2° poor appetite
› Intervention:
1. Begin with nutrient dense foods
2.
3.
Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Nutrition Monitoring and Evaluation

Evaluate outcomes
Compare current findings
with previous status,
intervention goals,
and/or reference
standards
Nutrition
Monitoring
and Evaluation
Types of Outcomes
•Direct nutrition outcomes
•Clinical and health status outcomes
•Patient/client-centered outcomes
•Healthcare utilization
Intermediate-result outcome
End-result outcome
Are necessary in order to evaluate
 Should be achievable- and based on
scientific evidence
 Should be directly or indirectly related to
nutrition care

Nutrition Assessment
 Medical hx: 72 y.o. female admitted with
decompensated CHF; heart failure team consulted;
has been admitted with same dx x 2 in past month;
meds: Lasix and Toprol; current diet order: 2 gram
sodium; has lost 5 pounds in 24 hours since admission;
Output > input by 2 liters
 Nutrition history: has been told to weigh self daily but
has no scale at home. Does not add salt to foods at
the table. Noticed swollen face and extremities on
day prior to admission. Day before admission ate
canned soup for lunch and 3 slices of pizza for dinner;
does not restrict fluids; has never received nutrition
counseling
Nutrition Diagnosis- PESS
1. Fluid intake concerns, R/T dietary discretion
AEB symptoms
2. Excessive Na intake R/T foods eaten AEB diet
history
3. Knowledge deficit R/T no previous nutritional
education AEB inability to name Na foods
4. Self monitoring deficit R/T
Nutrition Intervention
 1. Low Na diet
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2. Go to senior center to eat
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3. Attend diet program
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4. Find someone to help the woman to get scale
Monitoring and Evaluation
1. Monitor BP and tell her to keep a weight log and food log
2. Case manager will monitor readmissions
3.