DECIDING WHAT TO DO IS AS IMPORTANT AS DECIDING WHAT NOT TO DO. Steve Jobs
One type of critical thinking that occurs during the Nutrition Diagnoses step is to identify the most important Nutrition Diagnoses. When the dietitian identifies the nutrition diagnoses that exist, in many cases there may be too many to address all of them immediately. Some nutrition diagnoses require immediate attention and some can be addressed later over time. Deciding which Nutrition Diagnoses to start with is truly part of the "art" of dietetics.
Some of the general criteria that might be useful when making these decisions are:
Reason for Referral
If the patient was referred to you, priority should be given to the specific problem identified on the referral.
In a few situations, additional information that you collect during the nutrition assessment step may cause you to consider a different intervention than the original request. If this is the case, it is essential that you communicate your rationale for taking or recommending a slightly different approach. As a member of the healthcare team it may be optimal to do this verbally as well as include information in the Nutrition Progress Note.
Impact on Medical Condition or Health Status
The medical condition(s) also are key considerations. You want to select the nutrition diagnosis that if addressed is most likely to either improve the medical condition or stop/slow the deterioration of the medical condition(s). This is based on the pathophysiology of the medical condition. This may vary depending on the stage or severity of the medical condition.
Knowing the current and as well as likely progression of health status (overall health of the individual) will allow you to predict which of the nutrient shortfalls or excesses are likely to have immediate high impact and need addressing now versus those that are likely to be less severe or only have impact after a prolonged time and can wait for addressing at a later time.
Strength of Evidence
Evidence-based dietetics means basing decisions on the best evidence available. How strong the evidence is for the relationship of a nutrition diagnosis to the current medical condition or health status on is an important consideration. You may choose one nutrition diagnosis over another because the science may be emerging for one but the evidence is STRONG for the other (has been confirmed through repeated studies).
Patient Preference
We are a patient/client centered profession. As a dietitian we bring the science "to the table" but in the outpatient setting the patient is the one that has the final decision about what they wish to address at this time. The dietitian may propose suggestions with data on why they would recommend addressing a particular nutrition diagnosis, but the decision should be made jointly with input from the patient. When the patient is hospitalized, it is usually the physician who is the "captain of the team" that considers the various options, including patient preferences.
There may also be patient specific or condition specific criteria in addition to the more general criteria discussed here.
Bottom Line: Consider the referral, impact on medical condition or health status, strength of evidence, and patient preference to select the most important Nutrition Diagnosis to start with during the patient encounter.
