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CHARNEY
FOR THE NUTRITION AND DIETETICS
Pamela Charney
HEALTH PRACTICE COLLECTION
It has long been known that nutritional deficiencies are associated with
LIBRARY morbidity and mortality in hospitalized patients. Registered dietitians
Katie Ferraro, Editor
(RDs) are responsible for the diagnosis and treatment of malnutrition
Create your own in all practice settings. Accurate diagnosis of malnutrition depends
Customized Content on the skills of RDs in completing the nutrition assessment combined
Bundle the more with critical thinking skills. There are five components of the nutrition
assessment; they are as follows:
books you buy,
the higher your
Nutrition-focused physical exam
discount! Client history
Food and nutrition history
Nutrition
RDs must consider each component in order to accurately diagnose
Psychology nutrition problems.
Health, Wellness, The Nutrition Care Process (NCP) provides RDs with a solid
Nutrition Assessment
and Exercise framework that describes the critical thinking process that RDs use
Assessment
Science in all practice settings. The four steps of the NCP include nutrition
Health Education assessment, nutrition diagnosis, nutrition intervention, and nutrition
monitoring/evaluation. While the NCP applies to all practice settings,
the dietetics terminology gives RDs an agreed upon set of terms that
THE TERMS describe the work of the clinical RD.
Perpetual access for
a one time fee Pamela Charney, PhD, RD is a registered dietitian with over 20 years
No subscriptions or experience. She has a great deal of experience in all care settings,
ranging from 30 bed critical access hospitals to 500 bed academic
access fees
medical
centers. She received her baccalaureate degree from the
Unlimited
University of West Florida, completed a dietetic internship at W alter
concurrent usage
Reed Army Medical Center, and is a US Army veteran. She has masters
Downloadable PDFs degrees in nutritional sciences and clinical informatics and patient
Free MARC records centered technology from the University of Washington and a PhD in
health sciences from Rutgers University. Dr. Charney has a long record
of professional service and was a charter member of the Academy
For further information,
of Nutrition and Dietetics Nutrition Care Process and Dietetics
a free trial, or to order,
Terminology Committees. She is also a sought-after speaker at local,
contact:
national, and international levels and has written extensively on the
sales@momentumpress.net
nutrition care process, critical thinking in dietetics practice, nutrition
assessment, and evaluation of quality of nutrition care. Pamela Charney
ISBN: 978-1-60650-751-3
Nutrition Assessment
Nutrition Assessment
10 9 8 7 6 5 4 3 2 1
Keywords
care process, critical thinking, dietetics, dietetics practice, nutrition assess-
ment, nutrition diagnosis, nutrition intervention, nutrition monitoring/
evaluation, registered dietitian or nutritionist
Contents
Chapter 1 Relationship Between Nutrition and Health......................1
Chapter 2 Nutrition Care Process and Model.....................................5
Chapter 3 Nutrition Assessment.......................................................11
Chapter 4 Nutrition Diagnosis.........................................................29
Chapter 5 Nutrition Intervention.....................................................41
Chapter 6 Nutrition Monitoring and Evaluation..............................55
References67
Index77
CHAPTER 1
Relationship Between
Nutrition and Health
Introduction
History is replete with references to the strong connection between
nutrition and health (Cannon 2005). Hippocrates was among the first
to describe nutritional therapy as primary treatment for disease (Cross
2010). Multiple descriptions of the role of diet in maintaining health can
be found in manuscripts from the Middle Ages and Renaissance periods
(Cannon 2005). While most agree that this connection exists, modern
health systems often place insufficient emphasis on the identification and
treatment of nutrition problems.
It has long been known that hospitalized patients who have inadequate
intake, weight loss, and other signs that are often associated with malnu-
trition may have more complications and longer length of stay than nor-
mally nourished patients. During the Crimean War, Florence Nightingale
noted that wounded soldiers who had access to a healthy diet were more
likely to survive their injuries than soldiers who had a poor diet. In her
Notes on Nursing, she discussed the importance of nutrition to recovery
and carefully described aspects of meal service that might enhance food
intake (Nightingale 1860).
In the 1930s, Hiram Studley, a gastrointestinal surgeon, noticed that
patients who had lost weight prior to surgery for peptic ulcer had more
complications and higher mortality than those who had not lost weight
2 NUTRITION ASSESSMENT
(Studley 1936). The connection between weight loss and outcome was
clearthe mortality rate for those who lost less than 20 percent of their
usual weight before surgery was less than 5 percent, while more than 30
percent of those who lost more than 20 percent of their usual weight
before surgery died. Parekh and Steiger provided a description of the rel-
evance of Studleys work in modern surgery (Parekh and Steiger 2004).
More recently, it was found that loss of more than 10 percent of
usual weight was associated with significantly higher risk for postop-
erative complications in adolescents undergoing spinal fusion surgery
(Tarrantetal.2015). Thus, the connection between weight loss and sur-
gical outcome appears to remain strong in spite of advances in surgical
technique and postoperative care.
Further evidence supporting the importance of nutrition assessment
to dietetics practice was provided in the mid-1970s when a series of arti-
cles focused on the discovery that many hospitalized patients suffered
from malnutrition (Bistrian et al. 1974, 1976; Bistrian 1977; Weinsier
etal. 1979). The best known of these publications has been since cited by
thousands of other publications, thus, indicating the interest that health
care providers have in the role of nutrition status in health outcomes
(Butterworth 1974).
In the past 30 years, researchers have focused on determining the
precise nature of the relationship between nutritional status and health
outcomes. While most agree that there is a strong connection between
unintentional weight loss and health outcomes, there is less agreement
on the mechanism(s) involved. It does appear that insufficient nutrient
intake over time is related to loss of muscle mass and decreased func-
tional status (Windsor and Hill 1988). Therefore, until recently, the focus
of nutrition interventions was to ensure adequate protein intake. More
recently, knowledge of the metabolic response to stress has resulted in
a broader focus that includes protein and other nutrients that support
recovery (Turner 2010).
Older Adults
At the beginning of the 20th century, life expectancy in the United States
was approximately 50 years. By the end of the 20th century, life expectancy
Relationship Between Nutrition and Health 3
had risen to more than 70 years. Along with increasing life expectancy,
there was also a shift from an agricultural to urban society, making it more
difficult for extended families to provide support for aging parents and
grandparents. Long-term care (LTC) facilities were expected to provide
care for older adults who could no longer care for themselves. High costs
and concerns regarding quality of care have driven a recent shift away
from LTC to aging in place, resulting in greater numbers of older adults
living in the community.
One benefit of LTC facilities was the ability to monitor health status
on a regular basis. Older adults living in the community must balance the
social benefits of remaining in familiar surroundings with the absence of
continual health monitoring. Changes in appetite associated with aging
may lead to gradual decrease in nutrient intake with subsequent weight
loss. Sporadic health visits mean that weight loss may go undetected until
there is a health crisis.
Weight loss is strongly associated with mortality in older adults.
Unintentional weight loss is a strong predictor of mortality in commu-
nity-dwelling older adults (Landi, Onder, and Cesari 2004; Olin et al.
2005; Reynolds et al. 1999). Poor nutritional status is also associated with
poor psychological well-being in older adults with dementia (Muurinen
et al. 2015).
Chronic Conditions
Historical Perspective
To begin to understand the Nutrition Care Process (NCP) and how to
use it in practice, it is important to step back and look at how and why
the NCP came about. In a nutshell, the NCP is the dietetic professions
answer to a larger question in health care: How can health outcomes be
improved? Improved health outcomes are defined by overall improve-
ment in the cost, quality, and efficiency of health care. For the dietetics
profession, demonstrating the impact of nutrition care as a component
of improved health outcomes provides an opportunity to prove the value
of what we do.
Health outcomes can be thought of as the product of the care pro-
vided along with how the care was provided. The vast majority of health
care providers want to give their patients the highest quality of care pos-
sible. In order to do so, care processes are needed to support high-quality
care. For example, if it is thought that high-quality care for patients who
have experienced a cardiac event includes echocardiography, then health
care systems that do not have access to echocardiography make it difficult,
if not impossible, to provide high-quality care. Deficiencies in care are
not related to the clinician who wants the patient to have the study;
6 NUTRITION ASSESSMENT
instead, the care process (lack of access to the test) impedes p rovision of
high-quality care.
Avedis Donabedian is considered by many to be the father of health
care quality. Prior to the 1960s, many felt that it was impossible to measure
the process by which health care is provided. Donabedian noted that it
was entirely possible to measure the quality of health care by observing
its structure, its processes and its outcomes (Donabedian 1966). More
recently, the Institute of Medicines definitions of quality health care
incorporate an evaluation of the care process as an important addition in
the determination of how well care provided meets current professional
standards (Palmer 1997).
Nursing
The first modern discussions on nursing care processes were seen in the
mid-1950s (Wright 1992). There are now several models used to describe
the nursing care process. Interestingly, all are similar to the NCP in that
the patient or client is at the center of the process. Nursing care processes
also tend to have steps similar to the four steps of the NCPassessment,
diagnosis, intervention, and monitoring and evaluation.
Occupational Therapy
As with the Nursing and Nutrition Care Processes, the OT care pro-
cess included the relationship between the therapist and client as central
to the OT care process (AOTA Inc. 2002).
Physical Therapy
It appears that there are more similarities than differences among allied
health professional care processes. Each stresses a focus on the relationship
between the therapist and the patient or client. All healthcare professional
care processes include a mechanism to describe how the allied health pro-
fessional identifies a need for intervention (assessment and diagnosis), to
determine the most appropriate course of action (the intervention), and
to determine if the intervention was successful (monitoring and evalua-
tion). Thus, it can be seen that dietetics practice is not unique in utilizing
a care process that provides a framework for critical thinking supported
by evidence.
8 NUTRITION ASSESSMENT
The United States has one of the most complex health care systems in the
world. Dietetics practice may be impacted by social and economic factors
that the dietetics professional has little control over. In spite of this lack
of control, the registered dietitians (RDs) must be aware of and acknowl-
edge these factors in order to plan nutrition interventions that are realistic
for the situation. For example, an RD working in a neonatal intensive
care unit follow-up clinic in an economically challenged area must take
financial resources into account when recommending discharge infant
formulas. In this situation, it would be important to consider which
formulas are supplied by the Women, Infants, and Children (WIC) pro-
gram. While the desired outcomes would be the same regardless of the
care setting, the RD considers external factors so that interventions can
be flexible and adjusted to meet patient or client needs.
Dietetics knowledge
Critical thinking skills
Nutrition Care Process andModel 9
Thus, the inner ring describes characteristics that are unique to the
RD. It is important to remember that while the RD has little to no con-
trol over the concepts in the outer ring, the individual RD has the ability
to influence and change concepts in the inner ring.
Of the four concepts, critical thinking is probably most difficult to
define. Health professionals have long struggled with defining critical
thinking (Riddell 2007). Research in nursing describes critical thinking
as an organized, purposeful way of thinking that is applied to a situation
or problem. A nurse who uses critical thinking skills is open to new pos-
sibilities and experiences (Wilkinson 2007). There is no reason to think
that these definitions would not apply to dietetics practice.
Patient-Centered Care
The past decade has seen a shift in health care from an expectation
that providers direct all aspects of care to an atmosphere that encour-
ages patients and their families to be active participants in their care.
Patient-centered care requires that all members of the health care team
change their focus so that patients have the information they need to be
primary decision-makers instead of relying on providers to make deci-
sions for them. Patient-centered care is thought to be associated with
improvements in quality of care (Aboumatar et al. 2015).
As members of the health care team, RDs must be familiar with
the tenets of patient-centered care. The shift to focus on patient needs
requires strong communication skills and an ability to move from pro-
viding simple diet instructions to working as partners with patients to
develop workable lifestyle changes.
Nutrition Screening
is positive, further testing can be done. For example, health fairs often
include capillary cholesterol measurement. Elevated cholesterol acts as a
screening test for lipid abnormalities.
Nutrition risk screens are used to identify risk for nutrition diagnoses
in individuals who do not appear to have a nutrition problem. Regula-
tory agencies such as the Joint Commission require that nutrition risk
screening be completed shortly after patients are admitted to a health care
facility. When nutrition risk screening is done as part of the admission
assessment, it is not possible for dietetics practitioners to complete every
nutrition screen. Therefore, most facilities utilize nursing staff to com-
plete nutrition risk screening.
Nutrition screening identifies risk for nutrition problems, while
nutrition assessment identifies the problem and determines the severity
of the problem. While most nutrition screens focus on identifying risk for
malnutrition, it is important to have mechanisms in place to identify risk
for other nutrition diagnoses.
Nutrition assessment
Nutrition diagnosis
Nutrition intervention
Nutrition evaluation/monitoring
Nutrition Assessment
As described earlier, nutrition assessment is the process by which dietetics
professionals collect and analyze data about an individual, group, or pop-
ulation in order to determine if a nutrition diagnosis is present. Data
collected during the assessment typically fall into one of the following five
categories identified by the Nutrition Care Process (NCP):
Anthropometric measurements
Biochemical data, medical tests, and procedures
Food- and nutrition-related history
Client history
Nutrition-focused physical examination findings
methodologies for doing assessment have been as varied as the skills and
the knowledge of the individual RD until the development of the nutri-
tion assessment portion of the NCP.
(Continued)
16 NUTRITION ASSESSMENT
used, it is not known whether this method would be useful in acute care
settings (Martin et al. 2014).
The scenario here demonstrates the need for strong critical think-
ing skills when evaluating nutrition history information. Inaccura-
cies in reporting food and nutrient intake occur for many reasons
(Fisheretal.2008; Lissner et al. 2007). For instance, the patient or client
might have distorted views of portion sizes or might want to please the
interviewer by reporting intake that is much different from actual intake
in order to better meet perceived normal or good diets (Heitmann, Lissner,
and Osler 2000). Therefore, whenever possible, more than one method
should be used to gather and compare data that allow for cross-check-
ing and verification. Information should be evaluated in context of other
data gathered. For example, reports suggesting very low intake might be
questioned if the patient or client is significantly overweight and has not
lost weight. Conversely, reports suggesting excessive intake might need
re-evaluation if the information does not match other assessment infor-
mation indicating a weight loss.
Nutrition Assessment 19
Client History
How would you describe your current health? Would you say
you feel well on most days? Are you able to do the things you
want or need to do every day?
Have you been feeling ill lately? If so, how often and for how
long? Describe what you feel like.
Do you have any problems chewing or swallowing? If so, have
these problems made you change the type and amount of
food that you eat?
Do you have any chronic health conditions that impact your
ability to eat the foods you want to eat?
Is there anything else about your health status that you want
me to know?
The final component of the patient history is the social history. When
obtaining a social history, the RD must focus on issues surrounding
educational level, housing situation, economic concerns, family or social
support, spiritual concerns, and beliefs and attitudes surrounding food.
Anthropometric Measurements
clinician are often recorded. There are known inaccuracies when height
and weight are estimated in an acute care setting (Beghetto etal.2006;
Determann et al. 2007). However, stated height and weight provided
by healthy adults less than 60 years of age was found to be sufficiently
accurate for use in research and community settings (Kuczmarski,
Kuczmarski, and Najjar 2001). When admission height and weight are
estimated rather than actually measured, a notation should be included
in the documentation. This can serve as a reminder to obtain actual
measurements as soon aspossible.
Even when actual measurements are obtained, there is still no guaran-
tee that they will be accurate. Infants and toddlers can be very difficult to
weigh and measure, and skilled personnel might not always be available
to complete the measurements. Patients might have a significant degree
of edema or may not be able to completely follow instructions for height
measurements. For these reasons, even measured height and weight should
be evaluated in conjunction with other information. For example, loss of
height or major deviations from an established growth curve in infants
and children should be a red flag that there might have been an inaccurate
measurement at some point. A large change in weight over a short time
period is another warning of problems. Finally, even when meticulous
attention is given to measurement techniques, errors in documenting
results can occur. For example, the medical record might include a weight
measurement of 150 kg for a patient who actually weighs150lbs. For
these reasons, the RD should compare the documented height and weight
to a visual inspection of the patient to further verify the data.
Reference standards for the comparison of anthropometric informa-
tion exist for some populations. RDs must be able to determine which
standard to use for evaluation in the clinical setting. Various height and
weight tables exist for adults, along with the BMI. In pediatric prac-
tice, growth charts are used to determine adequacy of growth. Accurate
plotting of height and weight in pediatric practice has been noted to be
problematic; one study in a tertiary pediatric acute care facility found
that less than 25 percent of admissions had height measurements that
were correctly plotted on growth charts (Lipman et al. 2009). There
are also many condition-specific growth charts that can be used to plot
Nutrition Assessment 25
or have not been fully validated. RDs in pediatric practice must know
which chart to use as well as how to plot height and weight correctly.
The domain covers a number of biochemical indices that are often used to
evaluate nutrition status in all care settings. While some of these tests may
be useful, each laboratory test carries a risk to the patient or client (from
the needle stick, psychological impact related to worrying about results)
and adds to the cost of care provided. Also, many of these tests have not
been adequately validated as markers of nutrition status and should be
used with caution. For example, levels of the serum hepatic transport
proteins, particularly serum albumin and prealbumin (transthyretin) are
often used as measures of visceral protein status in acute care. This concept
is not supported when critically evaluated (Friedman and Fadem 2010;
Fuhrman, Charney, and Mueller 2004).
Nutrition Assessment 27
Nutrition Diagnosis
The most controversial component of the Nutrition Care Process (NCP)
is the second step, that is, nutrition diagnosis. Why is it so controversial?
Traditionally, registered dietitians (RDs) have not considered themselves
to be members of a diagnosing profession. Many dietetics professionals were
trained to focus first and foremost on the nutrition assessment and then
the intervention. But the act of diagnosingthe process of discerning or
distinguishing the nature of a disease or problemhas always been a part
of the process, but it was never codified until the development of the NCP.
The Academy of Nutrition and Dietetics (AND) defines nutrition
diagnosis as the identification and labeling of the specific nutrition prob-
lem that dietetics practitioners are responsible for treating independently
(Lacey and Pritchett 2003). While RDs are trained to assess nutrition
status, to develop plans to do something for the patient, client, or group
(intervention), and to monitor the results of the intervention, most have
no formal training in the diagnostic process. It is incorrect to think that
only physicians can diagnose. Each of the health professions is responsible
for diagnosing health conditions that are within the scope of practice for
the profession. Therefore, RDs must take responsibility for diagnosing
nutrition problems. Taking responsibility for the diagnosis and treatment
of nutrition problems ensures that dietetics gains respect of a health care
system that values the diagnostic thought process.
Historically, the goal of nutrition assessment was to find a problem.
Once the problem was identified, RDs took action to solve the problem,
but never used the word diagnosis. There was clearly a diagnosis involved,
but it was usually never specified or codified as such. Why does this mat-
ter? Well, if the process moves right from assessing to intervention with-
out calling and naming the intermediate process the nutrition diagnosis,
we lose the chance to demonstrate the full scope and breadth of dietetics
practice. Omitting to pointing out the diagnostic phase implies that we
30 NUTRITION ASSESSMENT
can define how we assess nutrition status and what we do for patients and
clients, but we cannot describe why we do those things. More importantly
perhaps, we cannot really demonstrate the impact of RD-directed inter-
ventions if we do not diagnose or clearly indicate that we have diagnosed
the nutrition problem that led to the intervention. And, if we focus on
or use diagnoses from the domain of another health profession, that is,
cancer, type 2 diabetes mellitus, or failure to thrive, as the driving force
behind the work of dietetics and not the diagnoses developed from the
domain of the dietetics profession, then we lose important information
that answers the question Why is it vital that the RD provide nutrition
care? What was the nutrition problem that necessitated the RDs presence
in the care of this patient?
U.S. Bureau of Labor Statistics that classifies several health care profes-
sions as diagnosing professions (Bureau of Labor Statistics 2008). While
no one but the licensed physician can make a medical diagnosis, each
diagnosing professional is responsible for making diagnoses within his or
her own professional scope of practice. A brief description of some of the
diagnosing health professions is included in the following.
Physicians
Nurses
Physical Therapists
Occupational Therapists
get closer to the correct diagnosis without unnecessary labs or lab tests
that might not provide additional information.
Now, how would the RD without extensive experience diagnose
this patients nutrition problems? He or she might request lab testing
to evaluate protein stores, forgetting that changes in functional capacity
might be a good indicator of muscle function since protein stores are not
the problem, it is how protein functions in the body. Or, the RD with less
experience might even skip the detailed weight history and simply jump
into an intervention for involuntary weight loss without bothering to verify
that there actually was involuntary weight loss. Thus, at the next visit, there
might be no change in weight because the nutrition intervention that was
implemented did not focus on the correct diagnosis.
was first published less than 10 years ago (Lacey and Pritchett 2003).
Therefore, many educators may not be prepared to teach diagnostic skills
since they have had no exposure to diagnostic thought processes them-
selves. Preceptors in supervised practice sites may not have strong diag-
nostic skills. There is also the perception held by some that RDs do not
need diagnostic skills to pick a nutrition diagnosis. Some RDs are reluc-
tant to diagnose nutrition problems because they are not confident in
their diagnostic skills. Additionally, there is sometimes a misperception
by some outside dietetics that RDs cannot diagnose at all!
On the other hand, many RDs who have developed the necessary
skill set needed to diagnose nutrition problems are wondering what they
ever did before developing these skills. These pioneer nutrition diagnosti-
cians typically are those who work closely with colleagues from the other
health diagnosing professions. Those working in facilities that train other
health professionals have been able to witness those students being taught
diagnostic skills and have successfully applied those skills to their own
practice.
Nutrition Intervention
As defined by the Nutrition Care Process (NCP), dietetics profession-
als are responsible for independent treatment of health problems related
to nutrition. Nutrition intervention is defined as purposefully planned
actions intended to positively change a nutrition-related behavior, envi-
ronmental condition, or aspect of health status for an individual (and his/
her family or caregivers), target group, or the community at large (The
American Dietetic Association 2007). The intervention phase of the NCP
includes two componentsplanning the intervention and implementing
the intervention. During the planning phase, the registered dietitian (RD)
identifies the nutrition intervention that has the best chance of success-
fully treating the nutrition problem. Goal setting is also done during the
planning phase of nutrition intervention. Goals should be realistic and
achievable. The implementation phase is where the action takes place. In
some cases, the RD might be responsible for carrying out the intervention
independently. In other situations, the RD will collaborate with others to
ensure that the intervention is carried out.
Nutrition interventions must be focused on the nutrition diagnosis.
For example, if a knowledge deficit is diagnosed, then the proper inter-
vention would be related to education or counseling. If the RD diagno-
ses a knowledge deficit and then changes the diet order, no education is
provided and there is no demonstrable link between the diet order and
the patient or clients knowledge deficit. This is the equivalent to a physi-
cian prescribing an antibiotic (intervention) to resolve a wound infection
(diagnosis).
Another way of thinking focuses on documentation of the nutrition
diagnosis to help identify the correct intervention. Using this approach,
it can be seen that an appropriate nutrition intervention will eliminate or
reduce the severity of the etiology of the nutrition diagnosis. Going back
to the example from medicine, the antibiotic will eliminate the source of
42 NUTRITION ASSESSMENT
Dietetics knowledge
Skills and competency
Critical thinking
Collaborative ability and network
Communication skills
Use of evidence-based practice
Application of American Dietetic Associations Code of Ethics
RDs working in community and public health settings can utilize the
NCP and nutrition intervention terminology to gather the type of data
needed to demonstrate the impact of nutrition interventions.
When the desired intervention focuses on the timing, amount, and type
of foods/nutrients provider, as well as the environment in which foods/
nutrients are provided, the nutrition intervention most likely falls into
the Food and Nutrient Delivery Class. This class includes the following:
Nutrition Education
Nutrition Counseling
Theoretical basis/approach
Strategies (The American Dietetic Association 2009)
Nutrition Intervention
As mentioned earlier, nutrition interventions have two components:
planning and implementation. While planning and implementation are
distinct actions included in a nutrition intervention, they are interrelated
and often flow together. For example, the RD might be in the implemen-
tation phase of a discharge planning nutrition intervention when new
information becomes available that requires revisiting the planning phase
of this intervention and, thus, a quick adjustment of the implementation.
Nutrition prescriptions must be formulated and communicated to the
patient or client and other members of the health care team as part of goal
setting and documentation of the nutrition intervention. Once plans for
the intervention are complete and the nutrition prescription is in place,
RDs implement the nutrition intervention.
Planning
should be realistic and achievable; while its ideal that the patient or client
be involved in the goal setting, in some care settings, patient or client
involvement is not feasible. Goal setting is integral to the monitoring and
evaluation step of the NCP as its not possible to determine the success of
the intervention if there was no initial goal set!
Implementation
After the nutrition prescription has been developed, goals set, and an
intervention(s) selected, the nutrition intervention is implemented. The
terminology used to describe the intervention may depend on the type
of prescriptive authority held by the RD. Those RDs with the ability to
implement a nutrition intervention might order a change in meal timing
directed toward those responsible for meal delivery, while those who do
not have the ability to implement a nutrition intervention might recom-
mend a change in meal timing.
was determined that the RD would be consulted only for those patients
who had lost weight or had documented poor intake for three to four
days prior to admission. Changing policy from consult based on medical
diagnosis to consult based on nutrition diagnosis resulted in a significant
savings in time and effort by the RD and allowed the staff to concentrate
on enhancing services provided to the outpatient oncology clinic.
Conclusion
Nutrition intervention is the third step of the NCP. Using a care pro-
cess like the NCP along with a standardized terminology like the IDNT
to describe nutrition interventions done by RDs has a positive impact
on nutritional on health and well-being in all care settings. Nutrition
interventions that have been defined by the IDNT include four distinct
categories: meal/nutrient intake, nutrition education, nutrition counsel-
ing, and coordination of nutrition care. Each of these categories includes
descriptors providing further detail regarding the intervention. Utilizing
the intervention terminology along with the NCP allows RDs to clearly
describe what was done for a patient or client or group, why the inter-
vention was done, and what the expected goal of the intervention is.
Data gathered from use of the intervention terminology in multiple sites
can then be used to convince all stakeholders of the need for enhanced
nutrition services in all care settings.
CHAPTER 6
Nutrition Monitoring
andEvaluation
Monitoring and evaluation (M/E) is the fourth step of the Nutrition Care
Process (NCP) (Lacey and Pritchett 2003). If the nutrition diagnosis was
correct, the correct intervention implemented, and appropriate indica-
tors of progress toward goals selected, then M/E should demonstrate that
goals set during nutrition intervention have been met. Errors in any of the
preceding steps of the NCP might result in M/E data that are confusing
or lacking connection to the nutrition diagnosis or intervention. Before
beginning the M/E step, registered dietitians (RDs) should ensure that
goals set during nutrition intervention are appropriate and meaningful
and that indicators of progress toward goals are monitored in a reason-
able time frame so that outcomes of care can be correctly interpreted and
reported. Therefore, the M/E step of the NCP really involves monitoring
of indicators and evaluation of outcomes. Given the importance of the
M/E step, it is important to completely define M/E as well as the impor-
tance of selecting the best indicators of progress toward outcome goals.
Then it can be seen how M/E relates to all areas of dietetics practice.
Monitoring and evaluating the results of nutrition interventions pro-
vides the link that allows RDs to demonstrate the value of nutrition care.
A successful M/E system would identify and measure outcomes that are
meaningful to all stakeholders, including patients, referring providers,
administrators, and policy makers. Therefore, it is imperative that out-
comes that will be monitored are carefully selected.
Outcomes selected might vary depending on the situation or care
setting. Administrators might be interested in differences in length of
hospital stay or patient satisfaction with RD services. The patient or cli-
ent wants to know if the intervention will resolve the nutrition problem
and how long that will take. Decisions regarding the best outcomes to
56 NUTRITION ASSESSMENT
evaluate should take into account the care setting, time available for mon-
itoring, organizational or patient goals and objectives, and the ability to
gather the needed data.
The importance of M/E outcomes is not limited to the NCP. Let us
think about the importance of M/E in other aspects of our daily life. Any
time we try something new or different, we monitor results and evalu-
ate the usefulness of the change. For example, let us say that a colleague
suggests a different route to drive to school or work. Your goal is to save
five or more minutes over your current route. The new route saves five
minutes driving time, but has a number of turns and might be difficult
to navigate in the dark. When trying the new route, the driving time
and difficulty of navigation is monitored. Following several attempts at
the new route, evaluation shows that the attention needed to navigate is
simply not worth the potential for saving five minutes.
Which Indicators
When evaluating potential indicators for use in the M/E step of the NCP,
the need to select indicators that are valid and reliable cannot be over-
stated (Higgins and Straub 2006). Reliability refers to the reproducibility
of data, while validity describes the truthfulness of data. Indicators that
are both reliable and valid are referred to as precise (Fitzner 2007). It is
important to remember that an indicator that is reliable but not valid pro-
duces consistent results when repeated, but these results do not measure
the true value of the measure. The validity of an indicator is more com-
plex, but basically is an attempt to determine if the indicator in question
is actually measuring the concept that it is intended to measure (Roberts
and Priest 2006).
Intake Terms
Anthropometric Terms
2007). RDs must use critical thinking skills to determine how accurate
estimates of height and weight are as well as use methods to ensure that
actual height and weight are measured when needed.
Conclusion
M/E is the fourth step of the NCP. It can be argued that M/E is the most
important step of the NCP. While each of the other steps is integral to
the NCP, patients, other health care providers, and administrators rely on
results of M/E in order to determine the worth of nutrition services. RDs
are responsible for gathering data needed to demonstrate the effective-
ness of nutrition interventions in the treatment of nutrition diagnoses.
Thus, it is vital that M/E be done appropriately. M/E involves monitor-
ing, measuring, and evaluating indicators that change as a direct result of
a nutrition intervention.
Although not specifically addressed in descriptions of M/E, RDs must
also have the ability to clearly and effectively communicate the results of
M/E.
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Dietary Supplements
by B. Bryan Haycock and Amy A. Sunderman
Sports Nutrition
by Kary Woodruff
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EBOOKS Nutrition Assessment
CHARNEY
FOR THE NUTRITION AND DIETETICS
Pamela Charney
HEALTH PRACTICE COLLECTION
It has long been known that nutritional deficiencies are associated with
LIBRARY morbidity and mortality in hospitalized patients. Registered dietitians
Katie Ferraro, Editor
(RDs) are responsible for the diagnosis and treatment of malnutrition
Create your own in all practice settings. Accurate diagnosis of malnutrition depends
Customized Content on the skills of RDs in completing the nutrition assessment combined
Bundle the more with critical thinking skills. There are five components of the nutrition
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RDs must consider each component in order to accurately diagnose
Psychology nutrition problems.
Health, Wellness, The Nutrition Care Process (NCP) provides RDs with a solid
Nutrition Assessment
and Exercise framework that describes the critical thinking process that RDs use
Assessment
Science in all practice settings. The four steps of the NCP include nutrition
Health Education assessment, nutrition diagnosis, nutrition intervention, and nutrition
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the dietetics terminology gives RDs an agreed upon set of terms that
THE TERMS describe the work of the clinical RD.
Perpetual access for
a one time fee Pamela Charney, PhD, RD is a registered dietitian with over 20 years
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