Nutrition Diagnosis and Intervention - 茨城県栄養士会

1 Nutrition Diagnosis and Intervention : Standardized Language for the Nutrition care Process Nutrition Diagnosis and Intervention : Standardized Language for the Nutrition care Process ISBN: 978-0-88091-366-9 Copyright 2007, American Dietetic Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written consent of the publisher. Printed in the United States of America. The views expressed in this publication are those of the authors and do not necessarily reflect policies and/or official positions of the American Dietetic Association. Mention of product names in this publication does not constitute endorsement by the authors or the American Dietetic Association.

2 The American Dietetic Association disclaims responsibility for the application of the information contained herein. 10 9 8 7 6 5 4 3 2 1 Nutrition Diagnosis and Intervention : Standardized Language for the Nutrition care Process Table of Contents Edition: 2007 iv Publication 1 Introduction Nutrition Diagnosis and Intervention Nutrition care Process and Model Step 1. Nutrition Assessment 19 Nutrition Assessment and Diagnosis Matrix ..22 Food/ Nutrition History Data ..22 Anthropometric Data ..28 Biochemical Data, Medical Tests, and Physical Examination Data ..32 Client History Data ..35 Step 2. Nutrition Diagnosis 42 Nutrition Diagnosis Terminology ..49 Nutrition Diagnosis Terms and Definitions ..50 Nutrition Diagnosis Reference Sheets ..59 Step 3. Nutrition Intervention Introduction.

3 186 Nutrition Intervention Terminology ..197 Nutrition Intervention Terms and Definitions ..198 Nutrition Intervention Reference Resources Case Study A and Examples of Charting in Various 227 Case Study B and Examples of Charting in Various Formats ..233 Implementing Nutrition Diagnosis Article ..241 Scope of Dietetics Practice Framework Standards of Practice in Nutrition care and Updated Standards of Professional Performance Article ..253 Standards of Practice in Nutrition care Appendix ..258 Appendix Procedure for Nutrition Controlled Vocabulary/Terminology 268 Acknowledgments Task 278 Staff Liaisons, Consultants ..279 Expert Reviewers ..280 Nutrition Diagnosis and Intervention : Standardized Language for the Nutrition care Process Table of Contents Edition: 2007 vFeedback Camera-Ready Pocket Guide Nutrition Diagnosis .

4 285 Nutrition Intervention ..287 Please check the ADA Web site ( ) for additional materials. Sign in as a member and select Research from the sidebar or Practice from the sidebar and then Quality Management. Nutrition Diagnosis and Intervention : Standardized Language for the Nutrition care Process Publication Highlights PUBLICATIONS RELATED TO THE Nutrition care PROCESS Since its development, several publications related to the Nutrition care Process have been developed by the American Dietetic Association (ADA). In addition to this publication, there are two articles published in the Journal of the American Dietetic Association and one publication available regarding the Nutrition care Process and Model. The original article published in the 2003 Journal described the complete Nutrition care process (1).

5 Another 2005 Journal article described the implementation of Nutrition Diagnosis , Step 2 in the Nutrition care process (2). Similarly, the first publication, entitled Nutrition Diagnosis : A Critical Step in the Nutrition care Process, examined only Nutrition Diagnosis (3). This publication is intended to illustrate the evolution of the Nutrition care process since its introduction in 2003 and provide tools for practitioners to implement the Nutrition care process into their practice. NEW IN THIS PUBLICATION This publication addresses the first three steps in the Nutrition care process: Nutrition Assessment, Nutrition Diagnosis , and Nutrition Intervention . The Nutrition Assessment section is NNEEWW and provides a matrix illustrating the Nutrition assessment data associated with the Nutrition diagnoses.

6 It is beyond the scope of this publication to define the Nutrition assessment data with a standard taxonomy, as this has been done elsewhere in the dietetics literature. The Nutrition Diagnosis section reflects the CCHHAANNGGEESS to the Nutrition diagnoses since the publication of the book Nutrition Diagnosis : A Critical Step in the Nutrition care Process introduced at ADA s 2005 Food and Nutrition Conference and Exhibition. The Nutrition Intervention section is NNEEWW and uses a standard taxonomy to describe the Nutrition interventions performed by dietetics professionals. A research study is underway to assess the usability and validity in clinical settings of the terms. The taxonomy is grouped into four classes of Nutrition interventions : Food and/or Nutrient Delivery, Nutrition Education, Nutrition Counseling, and Coordination of care .

7 The terminology used is defined and reference sheets for each specific Nutrition Intervention are available for use now by the profession. A practitioner will note that while some interventions are very closely related ( , education and counseling), the terms are intentionally separated to distinguish between them. Further, it is believed that the information necessary for medical record documentation, billing, and the description of the Nutrition interventions for research are included in the terminology. Edition: 2007 1 The Nutrition Intervention section describes the two interrelated components of Nutrition Intervention planning and implementation. It also illustrates how the Nutrition Diagnosis statement, also called the PES (problem, etiology, signs/symptoms) statement, labels the problems and identifies where the Nutrition Intervention is aimed to address the problem.

8 Specific descriptors ( , individuals or groups, face to face or electronically) of a Nutrition Intervention encounter ( , interactions, visits, contacts, sessions) are also provided. NOT INCLUDED IN THIS PUBLICATION The Nutrition Monitoring and Evaluation (Step 4) section was deliberately omitted from this publication since a great deal of research is underway regarding the Nutrition Diagnosis and Nutrition Intervention terminology that may impact the Nutrition monitoring and evaluation component of the Nutrition care process. Therefore, the research data will be examined before terms are defined and categorized for this step. Future publications will provide updates to the first three steps and examine the fourth and final step, Nutrition monitoring and evaluation. REFERENCES 1.

9 Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103:1061-1072. 2. Mathieu J, Foust M, Ouellette P. Implementing Nutrition Diagnosis , step two in the Nutrition care process and model: Challenges and lesions learned in two health care facilities. J Am Diet Assoc. 2005;105:1636-1640. 3. American Dietetic Association. Nutrition Diagnosis : A Critical Step in the Nutrition care Process. Chicago, IL: American Dietetic Association; 2006. Edition: 2007 2 Nutrition Diagnosis and Intervention : Standardized Language for the Nutrition care Process INTRODUCTION Continually emerging from the American Dietetic Association s (ADA) strategic plan are priority actions that guide work groups and taskforces in creating tools to advance the dietetics profession.

10 In 2002, to achieve the Association s strategic goals of promoting demand for dietetic professionals and help them be more competitive in the marketplace, the ADA Quality Management Committee appointed the Nutrition care Model Workgroup. This Workgroup developed the Nutrition care Process and Model, a systematic process describing how dietetics professionals provide care with patients/clients (1). The Nutrition care process is designed to improve the consistency and quality of individualized patient/client care and the predictability of the patient/client outcomes. It is not intended to standardize Nutrition care for each patient/client but to establish a standardized process for providing care . Of note, the terms patient/client are used in association with the Nutrition care process; however, the process is also intended for use with groups.