Saturday, August 9, 2014

How specific should PES be??...Like Goldilocks....just right

Like the childhood story of Goldilocks and the three bears, Nutrition Diagnoses and PES statements can be TOO BROAD, or they can be TOO SPECIFIC, or they can be "JUST RIGHT".

Broad Nutrition Diagnoses such as excessive oral intake or inadequate (suboptimal) oral intake are useful when the situation warrants where the intervention is targeted to either less or more of EVERYTHING.  If the intervention is not targeted to one or two specific nutrients, then a broader nutrition diagnosis is warranted.  The nutrition assessment would not need to have as detailed a nutritional analysis of current dietary intake vs estimated requirement that document gaps in specific nutrients when this diagnosis is used.  You may simply have recorded # servings in food categories and use the Pyramid or dietary guideline as the comparative standard.

One example of an appropriate use of a broad nutrition dia
gnosis might be in a long term residential care facility where a resident has consumed one or two teaspoon of each meal for the past two days, Inadequate oral intake might be the best choice.  Since it isn't a long term problem, but one that has just emerged, it may be reflected by a broad Nutrition diagnosis.  This nutrition diagnosis would lead to an intervention focused on increasing intake of ANYTHING.  It would not be reasonable to have multiple nutrition diagnoses, although it would not be technically 'inaccurate', e.g. inadequate energy, inadequate protein, inadequate fat, inadequate carbohydrate, inadequate calcium, inadequate Vitamin C, etc.

 On the other hand, if this were a long term situation where the resident had not been eating over a long period of time and had signs of malnutrition, then this situation would warrant a more specific nutrition diagnosis that reflects the seriousness of the situation, such as malnutrition, or protein-energy.  The nutrition assessment data and comparative standards would need to document the severity of the signs and symptoms that document the discrepancy between estimated requirements and estimated intake which would now lead to an intervention that focused on energy dense and protein rich foods.

Another situation where it may be logical to use a broad nutrition diagnosis might be for a person who has been consuming very large quantities of virtually everything,  The dietitian may choose a broad nutrition diagnosis of excessive oral intake that would lead to an intervention that focused on smaller portions of everything that was consumed.   Again the nutrition assessment data would only need to document portsion sizes or number of servings from pyramid or dietary guideline food categories

However, if you are targeting a specific nutrient with your intervention the it is logical to expect that the nutrition diagnosis would reflect this specific nutrient.  For example if you are modifying protein, sodium, potassium, Vitamin E, or fluid, then your assessment would logically have to include an analysis of that particular nutrient and you would want to use the appropriate comparative standard or nutrient prescription  as the basis to determine whether there is "excessive" or "inadequate" content in the current intake/diet order. In these situations your intervention would the focus on providing or restricting the targetted nutrient.

Bottom line:
The choice of a broad general nutrition diagnosis (suboptimal oral intake) versus a more specific nutrition diagnosis (suboptimal protein intake) is related to the nutrition assessment data available, the intended focus for the nutrition intervention, and corresponding nutrition monitoring and evaluation indicators.

Wednesday, August 6, 2014

Four steps, but an integrated whole

Although we have the Nutrition Care Process divided into 4 distinct steps, we must always view them as a whole unit, and realize that they do not necessarily happen in tidy neat sequences. 

Dr Kight refered to the "dance" of the nutrition session with a patient/client.  The dance was two steps forward, one step backwards, two steps forward, one step backwards: repeat....

She was referring to the way we have a discussion with a client during a typical dietitian/client encounter.  We gather some information, begin to formulate our preliminary thoughts about what nutrition diagnoses we are dealing with, then we go back into data gathering mode again and gather some more information to confirm our previous thinking, or in some cases decide that perhaps it is actually a different nutrition diagnosis.  In some cases we may already be into providing the nutrition intervention, when the client offers some more information that causes us to re-think our intervention, and perhaps even the nutrition diagnosis that we should be addressing. 

The Nutrition Care Process may be depicted as separate steps, but having all the steps connected is critical to optimizing out ability to help our patients achieve positive nutrition outcomes.