Chapter 21
The Nutrition
Care Process
Nutrition Care Process

Assess nutritional status.

Analyze data to identify nutritional needs.

Plan and prioritize nutritional care
objectives to meet these needs.

Implement strategies necessary to meet the
objectives.

Evaluate the nutritional care outcomes.
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Nutrition Care Process
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Nutrition Care Process –cont’d
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Nutrition Care Process –cont’d
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Patient/Nutrition Care Process

Admission

MD orders: PE, Dx, PMHx, Diet order,
Labs, Tests/Procedures, Consults, Meds
RN Assessment: Ht, Wt, I/Os, Vitals, PO,
FPG, Allergies, GI Status, Feeding
ability/Dentition, Wounds

Nutrition Screen: Age, Dx, Diet Rx,
Anthros, Labs, Oral intake, GI, Meds
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Nutriton Assessment
Gather & evaluate/analyze data
Update screen info from MR
Interview pt/family
D/w staff
Document assessment & plan
SOAP, PIE, DAR, Narrative
Paper vs. computer chart
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
Implement Strategies (Interventions)
– Education, Referrals, Food Preferences,
snacks/supplements

Nutrition F/U Assessments
– Evaluate outcomes, Document assessment,
– Implement further strategies PRN
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Nutritional Assessment

The process by which the nutritional
status of an individual is determined

Usually includes dietary history and
intake data, laboratory data, clinical
examination and health history,
anthropometric data, and
psychosocial data
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Nutritional Screening Information
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Nutrition Screening and Assessment Tool
Courtesy Carolinas Medical Center, Charlotte, N.C.
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Development of a Plan for
Nutritional Care

Prioritize problems

Client and counselor must jointly
establish achievable goals

Express objectives in behavioral terms

State objectives in quantifiable terms
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Implementation of Nutritional Care

Implementation is the component of the
nutritional care process that 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?
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Evaluation of Nutritional Care

Evaluate care provided

Review plan frequently

Reassess plan—may be new needs

Identify any new needs

Formulate a new nutritional care plan
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Nutritional Care Record

Written documentation of the nutritional
care process, including the interventions
and activities used to meet the nutritional
objectives
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Care Record
Courtesy St. John’s Hospital, Springfield, Ill.
© 2004, 2002 Elsevier Inc. All rights reserved.
Documentation Style

DAP (diagnosis, assessment, plan)

PIE (problem, intervention, evaluation)

PES (problem, etiology, symptoms)

IER (intervention, evaluation, revision)

HOAP (history, observation, assessment, plan)

SAP (screen, assess, plan)

SOAPIER (subjective, objective, analysis/assessment,
plan, intervention, evaluation, revisions)

SOAP (subjective, objective, assessment, plan)
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SOAP Notes
S: Subjective

Info provided by patient, family, or other

Pertinent socioeconomic, cultural info

Level of physical activity

Significant nutritional history
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SOAP Notes—cont’d
O: Objective

Factual, reproducible observations

Diagnosis

Height, age, weight—and weight gain patterns

Lab data

Clinical data (nausea, diarrhea)

Diet order

Medications
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SOAP Notes—cont’d
A: Assessment

Interpretation of patient’s status based on
subjective and objective info

Evaluation of nutritional history

Assessment of laboratory data and medications

Assessment of diet order

Assessment of patient’s comprehension and
motivation
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SOAP Notes—cont’d
P: Plan

Diagnostic studies needed

Further workup, data needed

Medical nutrition therapy goals

Recommendations for nutritional care
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Basic Hospital Diets
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Basic Hospital Diets —cont’d
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Soft Diet
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Clear Liquid Diet
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Full Liquid Diet
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Full Liquid Diet –cont’d
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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.

Dietary restrictions are rarely appropriate.
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Palliative Care

Encourages the alleviation of physical
symptoms, anxiety, and fear while
attempting to maintain the patient’s
ability to function independently
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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
© 2004, 2002 Elsevier Inc. All rights reserved.
Discharge Planning
Courtesy University of Washington Medical Centers, Seattle.
© 2004, 2002 Elsevier Inc. All rights reserved.