Nutrition Care Process Study Guide

Purposes of ADIME/NCP

• Provides framework for individualized care with standardized language and structure

• Leads to more efficient and effective care

• Standardized language allows for more effective communication and comparison across systems

Cognitive Behavioral Therapy & Cognitive Model

• assumes behavior is directly related to internal factors (i.e. cognition, thoughts) and external factors (i.e. environment)

• effective in targeting dietary habits and lifestyle risk factors

Health Belief Model

• developed in the 1950’s to explain why individuals don’t adopt disease prevention strategies or get screened

• focused on beliefs about disease/conditions ( beliefs predict behaviors)

• Strategies focus on reducing barriers to behavior change and emphasizing benefits of behavior change

Constructs in Health Belief Model

1. Perceived susceptibility

2. Perceived severity

3. Perceived benefits (of risk reduction behaviors)

4. Perceived barriers (to behavior change)

5. Cue to action (prompt to behavior change; e.g. symptoms, family illness, media)

6. Self-efficacy (confidence in ability to perform health action)

Transtheoretical Model (Stages of Change)

• theoretical model of intentional health behavior change that describes a sequence of cognitive and behavioral steps taken in successful change

• measured outcomes: self-efficacy and decision balance

Stages of Change

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

6. Relapse (or termination)

Precontemplation (stage of change)

• Unaware that problem exists, potentially in denial

• No intention of changing behavior and not considering change

• RD Actions: raise awareness, educate, point out cognitive dissonance, highlight risks/benefits

Contemplation (stage of change)

• Aware of change but no firm commitment to change behavior; ambivalent or uncertain

• Plans to make a change within 6 months

• RD Actions: resolve ambivalence, provide education and instruction, help client gain confidence

Preparation (stage of change)

• Intent on making action to address problem within 30 days

• Convinced that change is good and believe they can do it

• Committed but still deciding what to do

• May still lack confidence

• RD Actions: help identify appropriate strategies and gain confidence; listen, encourage, support

Action (stage of change)

• Actively modifying behavior or problem

• Taking steps toward change but not yet stabilized (< 6 months)

• RD Actions: help implement strategies, anticipate challenges, relapse prevention, encourage and support skills

Maintenance (stage of change)

• Sustained change with new behaviors replacing old behaviors

• Achieved goals and maintained change (> 6 months)

• RD Actions: work on skills to maintain; relapse prevention; listen, encourage, support

RD Actions in Stages of Change

• Low levels of readiness: instruct, advise, coach, listen

• Moderate levels of readiness: listen, encourage, support

Social Cognitive Theory (SCT)

• Related CBT; both recognize role of thoughts in mediating processes

• Learning through observation; mental state is important to learning behaviors; learning does not necessarily lead to behavior change

• Does not account for relationship between biology and environment

Social Cognitive Theory (SCT) Components

• Attention - is behavior observed?

• Retention - is behavior remembered?

• Reproduction - ability to perform behavior

• Motivation - will or desire to perform behavior

Motivational Interviewing (MI)

• Built on idea that clinician and patient are equal partners; honors patient autonomy

• Designed to strengthen personal motivation by exploring patient’s reasons for change with acceptance and compassion

• **Collaboration, not confrontation

• **Evocation of ideas, not imposing ideas

• **Autonomy, not authority

Principles of Motivational Interviewing (MI)

1. Express empathy

2. Support self-efficacy

3. Roll with resistance

4. Develop discrepancy (between current and ideal)

OARS (MI)

• Open-ended questions

• Affirmations

• Reflections

• Summaries

Change Talk

• indicates patient’s readiness/willingness to change

• DARN CAT

DARN CAT (Change Talk)

• Desire

• Ability

• Reason

• Need

• Commitment

• Activation

• Taking Steps

Fundamental MI Processes

• Engaging

• Focusing

• Evoking

• Planning

Engaging (MI)

Build rapport, establish relationships

Focusing (MI)

establish goals and expectations

Evoking (MI)

explore ambivalence and identify reasons for change

Planning (MI)

develop plan based on patient’s insights and skills

Nutrition Education

Reinforcement of basic or essential nutrition-related knowledge

Medical Nutrition Therapy (MNT)

Nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by an RD or nutrition professional

Screening & Referrals

• Often entry point into NCP

• Identify and refer individuals (or populations) who already have or are at risk for nutrition-related problems, who would benefit from NCP, and who are appropriate for nutrition care services

• May be done by RD or other health professionals

• Common tools include MUST, MNA, GNRI

• May occur at admission and throughout stay

Malnutrition Universal Screening Tool (MUST)

Screening tool assessing height, weight, BMI, unintentional weight loss, changes in nutritional intake (> 5 days)

Mini Nutrition Assessment (MNA)

Screening tool assessing oral intake, weight loss, mobility, neurological and psychological state, current stress levels, and BMI

Geriatric Nutritional Risk Index (GNRI)

Screening tool for older adults assessing weight and weight history and albumin

Assessment Domains

1. Food & Nutrition-Related History

2. Anthropometrics

3. Biochemical data

4. NFPE Findings

5. Patient History

Food & Nutrition-Related History (Assessment Domain)

Intake, medications, knowledge/beliefs, availability of food/tools/supplies, physical activity, nutrition-related quality of life; 24-hour recall, FFQ, food records

Anthropometrics (Assessment Domain)

Height, weight, BMI, waist-to-hip ratio, growth pattern indices, growth percentile, weight history, body fat percent

Biochemical data (Assessment Domain)

Medical tests, procedures, lab values, gastric emptying time, RMR, swallow study, KUB X-ray, volume loss I/O’s

NFPE Findings (Assessment Domain)

Physical appearance, edema, ascites, pallor, jaundice, wounds, hair/nails, mouth, eyes, muscle or fat wasting, swallow ability, appetite, affect

Patient History (Assessment Domain)

Personal medical and social history, family medical history, treatment history

WHO Growth Chart

• Exclusively used for breastfed infants

• Shows optimal growth patterns from birth to 2 years

CDC Growth Charts

Shows typical growth patterns from birth to 3 years

Head circumference

Reflects non-nutritional abnormalities or very severe long-term malnutrition

Short Stature

• (0-2yo) Length-for-Age < 2%ile

• (>2yo) Height-for-Age <3%ile or <5%ile

Underweight in Infants/Toddlers

• (0-2yo) Weight-for-Length < 2%ile

• (>2yo) BMI-for-Age <3%ile or <5%ile

Overweight in Infants/Toddlers

• (0-2yo) Weight-for-Length > 98%ile

• (>2yo) BMI-for-Age 85-95%ile

Obesity in Toddlers

BMI-for-Age > 95%ile

Z-score Mild Malnutrition

-1 to -1.9

Z-score Moderate Malnutrition

-2 to -2.9

Z-score Severe Malnutrition

> -3

Hamwi IBW for Men

106 lbs + (6 lbs x inches over 5ft)

-/+ 10% for small vs large frame

Hamwi IBW for Women

100 lbs + (5 lbs x inches over 5 ft)

-/+ 10% for small vs large frames

Arm Amputation

5% total BW

Forearm Amputation

2.3% BW

Hand Amputation

0.7% BW

Leg Amputation

16% BW

Lower Leg Amputation (BKA)

5.9% BW

Foot Amputation

1.5% BW

Underweight BMI

< 18.5

Normal BMI

18.5-24.9

Overweight BMI

25-29.9

Obesity I BMI

30-34.9

Obesity II BMI

35-39.9

Obesity III BMI

> 40

BOD-POD

body composition measured by air displacement; suitable in conditions that affect body water content (e.g. ESRD)

Bioelectrical Impedance Analysis

non-invasive, safe, and rapid measure of body composition; dependent on water content and less reliable in fever, electrolyte imbalances, dehydration, and extreme obesity

Dual Energy X-ray Absorptiometry (DEXA)

Measures bone, muscle, and fat; May be impacted by hydration or any calcified soft tissue

Underwater weighing

water displacement used to estimate body volume; patients must be submerged and motionless

Indirect Body Composition Measures

Triceps skinfold, midarm muscle circumference, midarm circumference

Nitrogen Balance

• Net change in body mass protein

• Indicates catabolism or anabolism

• Calculated using nitrogen intake and urine urea nitrogen (requires 24 hr urine collection)

• Nitrogen Intake - Nitrogen Output

Non-urea nitrogen losses (unaccounted for in UUN)

Wound leakage, stressed cells diarrhea

Nitrogen Intake

(Protein g consumed in 24 hrs) / 6.25

Nitrogen Output

• 24 hr urinary urea nitrogen (g) + 4 g (UUN)

• 24 hr total urea nitrogen (g) + 2 g (TUN)sd

Positive Nitrogen Balance

• Anabolism (building)

• Occurs in childhood, adolescence, pregnancy, weight gain, excess protein intake

Negative Nitrogen Balance

• Catabolism (breaking down)

• Occurs in weight loss, severe trauma and burns, chronic conditions (cancer, HIV, AIDS)

Patient/Client History Topics

Allergies and intolerances, food avoidances, appetite, food attitudes, chronic diseases and treatments, culture and background, dental and oral health, SES, GI factors, food access

Food Security

Access at all times by all people to safe, appropriate, nutritionally-adequate food; no indication of problems or limitations

Marginal Food Security

Anxiety over food sufficiency or shortage in household but no diet changes or reduced intake

Low Food Security

Food quality , variety, or diet desirability reduced because of lack of resources; little to no indication or reduced intake

Very Low Food Security

Intake reduced and normal eating patterns disrupted multiple times per year due to lack of money or resources for food

Hunger

uneasy or painful sensation caused by a lack of food

Nutrition Diagnosis

• Nutrition problem treated independently by RD with nutrition intervention; May change as pt responds to treatment

• Identification of a nutrition problem and labeling with standardized terminology, including investigation of root causes and etiology

Nutrition Diagnosis Domains

1. Intake

2. Clinical

3. Behavioral

Intake (Diagnosis Domain)

Excessive or inadequate intake compared to requirements (e.g. energy, fluid, macro- and micronutrients, EN intake, bioactive substances)

Clinical (Diagnosis Domain)

Medical or physical conditions outside normal; May be functional (e.g. swallow, GI function), biochemical (e.g. altered lab values, drug interaction), or weight-related

Behavior (Diagnosis Domain)

Problems relating to knowledge, attitudes, beliefs, physical environment, access to food, food safety, physical activity

Diagnosis Prioritization

If a patient has multiple nutrition diagnoses, they should be ranked in order of importance, urgency, and ability to intervene with nutrition care

Etiology Categories

• Beliefs and attitudes

• Cultural

• Knowledge

• Physical function

• Physiologic-Metabolic

• Psychological

• Social-Personal

• Treatment

• Access

• Behavior

Beliefs & Attitudes (Etiology Category)

related to conviction of truth of nutrition statement (e.g. “Keto is best for weight loss”)

Cultural (Etiology Category)

Related to values, social norms, customs, religion, political beliefs (e.g. “Beef tallow is healthier” or “Coffee is bad”)

Knowledge (Etiology Category)

Related to levels of understanding about food, nutrition, health, or related information (e.g. “Raw milk is better for you” or “Bone broth will cure cancer”)

Physical Function (Etiology Category)

Related to physical ability to engage in tasks (may include cognitive function) (e.g. ADLs, food prep, self-feeding)

Physiologic-Metabolic (Etiology Category)

related to medical or health status that may have a nutrition impact (e.g. DM, CKD)

Psychological (Etiology Category)

Related to diagnosed or suspected mental health or psychological problem (e.g. ARFID)

Social-Personal (Etiology Category)

Associated with patient’s personal and social history

Treatment (Etiology Category)

Related to medical or surgical treatment or other therapies and management of care (e.g. chemo side effects)

Access (Etiology Category)

Affecting intake and availability of safe and healthful food, water, and related supplies (e.g. food security status)

Behavior (Etiology Category)

Influencing achievement of nutrition-related goals

Signs

objective information including lab values, anthropometrics, physical observations

Symptoms

subjective observations including what the patient feels (e.g. nausea, pain)

Intervention (ADIME)

• Purposefully planned actions intended to positively change a nutrition-related behavior, environmental condition, or aspect of health status

• Based on diagnosis to address etiology; may reduce signs and symptoms but primary target is the nutrition diagnosis

Intervention Domains

1. Food and/or Nutrient Delivery

2. Nutrition Education

3. Nutrition Counseling

4. Coordination of Nutrition Care

Food/Nutrient Delivery (Intervention Domain)

Customized approach for food or nutrition provision (meals & snacks, EN/PN, supplements, feeding assistance)

Nutrition Education (Intervention Domain)

formal process to instruct or train patient in skill or choices and behavior to maintain or improve heath, includes both content and application