Are Goals, Expected Outcomes, Indicators and Criteria all the same??

In the Nutrition Care Progress notes, Evidence-Based Practice Guidelines, and references about nutrition care we have several terms that are all used to describe the outcome of our nutrition care.

It can be confusing when trying to discern what is a goal, expected outcome or indicator and criteria.

For each of these terms there are varying definitions, however as we think about how they are being used in the context of nutrition care we can determine how to incorporate them into our work as dietitians.

To illustrate how these might be similar or different we are going to follow the wording used to reflect sodium intake and energy (calories) through one specific condition, Heart Failure.

GOAL
For example within Evidence-Based Nutrition Practice Guidelines (EBNPG) the word "goal" is used generally to refer to the broad statements used to reflect the purpose of the EBNPG.

Example:  In the Heart Failure EBNPG Toolkit it states:
"The goals of nutrition care include a reduction in sodium and fluid intake and the monitoring of calories, protein and nutrient needs."  

The components of the nutrition prescription may also serve as a more specific articulation of these goals. The completed example of a progress note shows the nutrition prescription as 1800 KCal, 2 Gm Na, 2 gm Potassium diet, 65 Gm protein with 1900 ml fluid.

GOAL/EXPECTED OUTCOME
The EBNPG Toolkit in the Intervention step description indicates that the "Goal/Expected Outcome" should include the amount of change anticipated, the timeline for change, they should be clear and concise, client-centered, tailored to what is reasonable and reflect appropriate expectations based on treatment.

Within this context, the sodium level specified in the Nutrition Prescription is a more specific articulation of the broader goal statement.  Thus the goal/expected outcome  for the intervention of either education or counselling is to achieve this specific level of sodium.  In other words, the reason we educate the patient/client is to provide them with the necessary knowledge to select foods that were within the sodium level specified in the nutrition prescription.

 The Heart Failure EBNPG toolkit identifies the following as examples of what could be included as Goal/Expected outcomes for the overall nutrition therapy:

• "Biochemical (sodium and potassium, fasting glucose within normal levels, and creatinine and BUN at upper limits.
• B12, B5, folate, thiamine and magnesium
• Weight change less than 2 lbs overnight or 5 lbs gain in one week
• Physical activity within New York Heart Association (NYHA) functional classification established for patient
• Intake with sodium no more than 2 Gm and fluid intake within 48-64 fluid ounces per day"

Example:  In an actual progress note, the goal listed in the intervention section might be as follows:

"Goal/Expected Outcome:  Increase dietary intake to 90% of estimated energy and protein within  fluid and sodium limits"

INDICATORS/CRITERIA
In the Heart Failure EBNPG toolkit discussion on potential monitoring indicators, the following items are included as examples that might be used from the Food and Nutrition-Related Outcomes.  (Note:  Other potential indicators are included from the other Nutrition Assessment/Monitoring and Evaluation Domains)

"Food and Nutrition-Related Outcomes

• Fluid/beverage intake
• Food intake
• Alcohol intake
• Protein intake
• Carbohydrate intake
• Vitamin intake
• Mineral intake
• Food and nutrition knowledge
• Beliefs and attitudes
• Adherence (self reported adherence score)
• Physical Activity and function"

The Heart Failure toolkit text also lists the Nutrition Prescription as providing the specifics for the goal  as well as being used when identifying the criteria to be used for the indicators.  i.e.you would compare the actual intake against the criteria of the nutrition prescription/goal or reference standard.

Example:  In this case the following might be included as the indicators and criteria.

• Indicator (energy) and criteria (1620 KCal which is 90% of the estimated requirement of 1800)
• Indicator (sodium) and criteria (2 Gm sodium)
• Indicator (Fluid intake) and criteria (between 1900 - 2000 ml per day)

References:

Heart Failure Evidence-Based Nutrition Practice Guideline Toolkit, 2011, Available at:  https://www.eatright.org/shop/product.aspx?id=6442472073