The Nutrition Care Process, Dietary Screening, & Dietary Assessment

PHRM 3540

What is the importance of implementing standardized processes in health care?

less variation & more predictability of outcomes occur

What is quality in health care?

the degree to which health services for individuals & populations increase the likelihood of desired health outcomes & are consistent with current professional knowledge

How can quality performance of providers be assessed?

by measuring patients’ outcomes & the degree to which providers adhere to an accepted care process

What is done during the COLLECT part of the Pharmacists’ Patient Care Process (PCP)?

pharmacists gather current & past medication use history for prescription & nonprescription medications, herbal products, & dietary supplements

What is relevant information to gather & notate during the COLLECT part of the Pharmacists’ Patient Care Process (PCP)?

medical history, health & wellness information, biometric test results, physical assessment findings, lifestyle habits, preferences & beliefs, heath & functional goals, & socioeconomic factors

What is done during the ASSESS part of the Pharmacists’ Patient Care Process (PCP)?

pharmacists analyze each medication for appropriateness, effectiveness, safety, & adherence

What is relevant information to analyze & evaluate during ASSESS part of the Pharmacists’ Patient Care Process (PCP)?

health & functional status, risk factors, cultural factors, health literacy, immunization status, & need for preventative care or other health care services

What part of the Nutrition Care Process (NCP) includes pharmacists?

screening & referral system

What is included under the SCREENING & REFERRAL SYSTEM part of the Nutrition Care Process (NCP)?

risk factor identification, appropriate tools & methods use, & interdisciplinary collaboration involvement

Who was the Nutrition Care Process (NCP) developed to be used by?

board certified registered dietitian nutritionists (RD, RDN)

What is recommended during the SCREENING & REFERRAL SYSTEM part of the Nutrition Care Process (NCP)?

interdisciplinary collaboration

What is indicated in the REFERRAL SYSTEM part of the Nutrition Care Process (NCP)?

Nutrition Care & Medical Nutrition Therapy (MNT) provided by a registered & licensed dietetics professional

What is included in the reimbursable Medicare Part B Medical Nutrition Therapy (MNT) for eligible patients?

• an initial nutrition & lifestyle assessment

• individual/group nutrition therapy services

• follow-up visits to check on progress in managing diet

• services for specific patient groups (those w/ diabetes, ERSD, or who have received a kidney transplant w/in the last 36 months)

What can also happen when discussing referrals with a patient?

sometimes there is no dietician available, the patient cannot afford “extra” dietetic services, patient may not adhere to referral, or only has a “simple” question

What is nutritional screening?

a first-line process of identifying patients who are at risk or are currently malnourished/not meeting dietary needs

What is a nutritional assessment?

a detailed investigation to identify & quantify specific nutritional problems

Information from a number of indicators must be collected & analyzed to determine nutrition status.

true

Who can provide nutrition care in the state of GA?

• licensed dieticians

• those with a Masters or above in human nutrition, food & nutrition, dietetics, food systems management, or nutrition education

• those with a doctorate in nutritional biochemistry

• those who are licensed to practice dentistry, medicine, osteopathy, chiropractic, nursing, or pharmacy

A pharmacist without an accepted degree can use the dietician title since they are licensed.

false

What is the rationale for using nutrition screening?

it is not practical, cost-effective, or clinically warranted to conduct a comprehensive nutrition assessment on every individual; thus, nutrition screening provides a reliable, systematic method to identify persons for who a detailed nutrition assessment is needed

What are the GOALS of a nutrition screening?

• to detect those who are: overweight, obese, malnourished, or at risk for malnutrition

• to predict health outcomes as a results of nutrition-related factors

• to identify those who would benefit from nutritional intervention

What are the joint commission standards for nutrition screening & assessment?

• performance standard for accredited healthcare institutions

• in hospitals, a nutrition screening must be completed w/in 24 hours of admission on all patients

• for patients who are determined to be nutritionally-at-risk by the screening criteria, a comprehensive nutrition assessment must be completed w/in 48 to 72 hours

• periodic re-screening should occur every 3 to 7 days

• most nutrition assessments are completed by dietitians but may be completed by pharmacists

There are different dietary & nutrition screening tools, but it is best to use validated ones rather than those provided by a workplace.

true

What are the validated dietary & nutrition screening tools?

• Malnutrition Universal Screening Tool (MUST)

• Mini Nutritional Assessment (MNA)

• Nutritional Risk Screenings (NRS 2002)

• Short Nutritional Assessment Questionnaire (SNAQ)

• Malnutrition Screening Tool (MST)

• Subjective Global Assessment (SGA)

Which validated dietary & nutrition screening tool(s) were(was) developed ONLY for use in a hospital setting?

• Nutritional Risk Screenings (NRS 2002)

• Short Nutritional Assessment Questionnaire (SNAQ)

• Malnutrition Screening Tool (MST)

• Subjective Global Assessment (SGA)

Which validated dietary & nutrition screening tool(s) were(was) developed for MULTIPLE care settings?

• Malnutrition Universal Screening Tool (MUST)

• Mini Nutritional Assessment (MNA)

In which dietary & nutrition screening tool does a higher score equate to being worse off?

Malnutrition Universal Screening Tool (MUST)

In which dietary & nutrition screening tool does lower score equate to being worse off?

Mini Nutritional Assessment (MNA)

What are the GOALS of a comprehensive nutrition assessment?

• identification of risk factors associated with malnutrition

• determination of the risk of nutrition-related complications

• estimation of nutrition needs

• establishment of baseline nutrition parameters against which to measure nutrition therapy outcomes

Who is especially important to complete a comprehensive nutrition assessment on?

• elderly

• irregular exercise regime, sedentary lifestyle

• alcoholism

• infection, fever, trauma

• malabsorption syndromes, draining abscesses, renal dialysis

• IV solution w/o oral intake for >10 days

What relevant information should a pharmacist gather to understand a patient’s underlying pathology?

• inflammatory states, chronic infections, hypermetabolic states

• neoplastic diseases, endocrine disorders, hyperlipidemia

• digestive or absorptive dieases

• GI surgery

What relevant information should a pharmacist gather to complete a patient’s comprehensive medical history?

• immunizations, hospitalizations, chronic & acute diseases

• past & current prescription & non prescription medications, herbal products, & supplements

• food allergies or lactose intolerance

What relevant information should a pharmacist gather to complete a patient’s comprehensive family history?

• history of cancer, diabetes, heart disease, HTN, obesity, & osteoporosis

• parents, siblings, children, spouse: ages, current health status, & cause of death if deceased

What relevant information should a pharmacist gather to complete a patient’s comprehensive social history?

• occupation, daily exercise pattern, marital & family status

• economic status, educational level, residence

• duration & frequency of substance use: tobacco, alcohol, illegal drugs, caffeine

What findings of a GENERAL examination are suggestive of malnutrition?

edema, cachexia or obesity, ascites, dehydration, muscle wasting, fever, tachycardia, alopecia

What findings of a SKIN & MUCOUS MEMBRANES examination are suggestive of malnutrition?

thin, shiny, dry, or scaly skin, decubitus ulcers, poor healing of surgical or traumatic wounds, pallor or redness of gums or fissures at mouth edge, glossitis, stomatitis, or cheilosis

What findings of a MUCULOSKELETAL examination are suggestive of malnutrition?

retarded growth or short stature, bone pain or tenderness or epiphyseal swelling, muscle mass less than expected for habitus, exercise level

What findings of a NEROLOGIC examination are suggestive of malnutrition?

ataxia, nystagmus, seizures or paralysis, encephalopathy

What findings of a HEPATIC examination are suggestive of malnutrition?

jaundice, hepatomegaly

What are anthropometric & other nutritional status measurements used to assess patients for malnutrition?

• weight, structure, & head circumference

• BMI

• waist circumference

• waist-to-hip & waist-height ratios

• body composition

• skinfold thickness, mid-arm & calf muscle circumference

• bioelectrical impedance

• visceral proteins → lean body mass

• immune function tests

What methods can be used to assess a patient’s dietary intake?

• 24-Hour Dietary Recall

• Diet Record

• Food Frequency Questionnaire

• Brief Dietary Assessment Instruments

What is indicative of the 24-Hour Dietary Recall method?

• patient interviewed via telephone or face-to-face and asked to report all foods & beverages consumed in the past 24 hours

• pharmacist prompts for details

What are advantages of the 24-Hour Dietary Recall method?

• intake is quantified

• less patient burden

• does not alter eating behaviors

• does not require literacy

What are disadvantages of the 24-Hour Dietary Recall method?

• relies on patient recall

• requires multiple recalls over several months to capture habitual intake

What is indicative of the 3-Day Diet Record method?

• patients record all food & beverages consumed over 3 consecutive days (2 weekdays & 1 weekend day)

• consumed items can be measured using a scale or other household items or estimated using a portion-size guide

What are advantages of the 3-Day Diet Record method?

• intake is quantified

• does not require recall

• allows self-monitoring which can influence patient behavior change

• provides typical meal & food pattern information

What are disadvantages of the 3-Day Diet Record method?

• high patient burden (training required)

• can alter eating behaviors

• requires literate population

• requires multiple records over several months to capture habitual intake

What is indicative of the Food Frequency Questionnaire (FFQ) method?

• patients report how frequently certain food & beverage items from a checklist were consumed over a specific period of time (typically 1 year)

• takes about 1 hour to complete; software calculates nutrient intake y multiplying the reported frequency of each food by the amount of nutrient in a serving

What are advantages of the Food Frequency Questionnaire (FFQ) method?

• less patient burden

• less interviewer burden

• does not alter eating behaviors

• captures habitual intake

What are disadvantages of the Food Frequency Questionnaire (FFQ) method?

• relies on patient recall

• not as quantifiably precise

• requires patient literacy

• does not provide meal pattern information

• cannot be used over short time periods

What are factors to consider when choosing the appropriate method to assess a patient’s dietary intake?

• setting, time, & feasibility for the patient interaction

• type of information wanted: exact dietary intake over past 24 hours or dietary patterns?

• suspected issues with specific foods/nutrients related to a disease?

• availability & cost of the questionnaire & software program