Deciding on which nutrition diagnosis will best describe the problem/issue that you are addressing is one aspect of the critical thinking and clinical judgement used by dietitians.
The whole purpose of identifying the most accurate nutrition diagnosis is to BEST describe your assessment of the client condition that needs nutritional care. The nutrition diagnosis and etiology chosen will lead to the most appropriate nutrition intervention and the signs and symptoms listed usually lead to appropriate monitoring and evaluation indicators.
Our documentation in the nutrition progress is a key way to communicate with the rest of the healthcare team. Your choice of nutrition diagnosis should allow them to understand your logic and ensure that all the healthcare team interventions are consistent and working together.
Lets consider the initial evaluation of a patient on a ventilator where the diet order has been NPO for 4 days and patient is unable to eat due to being on a ventilator.
Following are the types of questions that you may want to ask yourself as you make the decision about a more general nutrition diagnosis (e.g. Inadequate oral intake) versus a more specific nutrition diagnosis (Inadequate energy intake).
The table below also includes some thoughts on what the implications of a general versus more specific nutrition diagnosis might be:
|
Question to ask your self |
Some implications of general
nutrition diagnoses (e.g. Inadequate Oral Intake) |
Some implications of a more
specific nutritional diagnosis (e.g. Inadequate Energy Intake) |
|
Will it make a difference in the nutrition intervention that I choose? |
Inadequate oral intake might suggest that the intervention focus
is on getting oral food and beverage intake. |
Inadequate energy would indicate an intervention focus on high
energy foods and or beverages. |
|
Will it make a difference in the Monitoring and Evaluation (M&E) indicators that I choose? |
M&E Indicators would most likely focus on estimates of % food
on trays, or number of servings of food groups (e.g. those used in My Plate,
diabetic exchanges, or renal exchanges). |
M&E Indicators will likely be energy targets, e.g. 85% of estimated
energy requirements. |
|
Am I concerned about lack of intake - all nutrients, or am I
really only focused on a specific nutrient or only focused only on energy? |
Inadequate oral intake indicates that ALL nutrients plus energy are
inadequate. Your intervention focus will likely be on increasing all nutrients. |
Inadequate energy intake could represent an intake that is
adequate in some nutrients, but not adequate in energy. Your intervention focus will be first and foremost on providing energy. |
|
Do I have the data necessary or is it worth the extra effort to
calculate the additional data?
|
If you are in a nursing home, and the resident is no longer eating (meals or snacks) as per the nursing staff. They may report…"she is leaving almost everything on the tray". You may not have a good estimate of the actual intake, and you do not need to calculate the specific energy requirements to know that she is not consuming enough food and beverages. There is no additional benefit to converting this to a more specific nutrient(s) or energy nutritional diagnosis. The intervention will be the same, provide frequent small quantities of foods/beverages with high nutrient/energy density according to preferences You are not
likely to need the estimated energy or nutrient needs to guide your
intervention. |
If you are in acute care setting and the intervention that you are considering is going to be based on a specific energy level or specific protein level, then you may decide that it IS worth taking the extra time and energy to estimate the energy and protein requirements. You will most likely need
this information to guide enteral feeding or very specific nutrition intervention. The intervention is very specifically designed to meet specified targets. If it is enteral or parenteral the rate and type of formula is based on estimated requirement. |
|
Should I start with Inadequate Oral Intake and change to more
specific as I gain more information and get a clearer picture of the
patient/client's condition or as the situation becomes more critical?
|
In some cases, the inadequate oral intake may be a preliminary nutrition diagnosis while you gather more specific information. This may be especially appropriate if the duration of being on the ventilator is uncertain (only 1 more day vs at least another week). If the patient remains on the ventilator and you are ready to change to a more specific
nutrition diagnosis (e.g. Inadequate Energy Intake which you will intervene via enteral nutrition) you can indicate that Inadequate Oral Intake is no longer relevant and
replace it with Inadequate Energy Intake. |
In some cases it may be more appropriate to go directly to a specific nutrition diagnosis. Especially if you have the necessary data and you are ready
for a specific nutrition intervention targeted to the nutrient or energy used as the signs and symptoms in
the more specific nutrition diagnosis. |
|
Is there something unique to the issue that deals with ORAL
intake? Do you want to focus on the
oral aspect of inadequate intake?
|
In some circumstances, the focus may be on ORAL intake. For example in a residential care setting, the goal may be to enhance the resident's independence and ability to self feed. The intervention may be to enter the resident into restorative dining. In this case the Oral intake really is the focus of the intervention and appropriate to be used as the nutrition diagnosis |
However in some situations the problem is that adequate ORAL intake is likely impossible (e.g. patient is on ventilator). In this case, this PES statement could incorporate the inability of maintaining volitional oral intake as an etiology and statement may signal that oral intake is the issue and alternative means of providing nutrition is needed (e.g.enteral tube feeding). In this case, your etiology would likely be tied to justifying why oral intake is not possible. For example with a patient on a ventilator, the etiology could be inability to maintain volitional oral intake while on ventilator. |
|
Does a more general nutrition diagnoses accurately describe the
level of concern to the rest of the healthcare team. Does the situation require a more
compelling nutrition diagnosis? |
Inadequate oral intake related to inability to maintain volitional oral intake while on ventilator AEB no nutritional intake for 4 days- Diet order of NPO vs recommendations for early enteral nutrition in ventilator patients. This PES statement would be most appropriate as a preliminary nutrition diagnosis where the duration of the ventilator has not been determined and there is a possibility that the ventilator will be discontinued soon.
|
Inadequate
energy related to inability to maintain volitional oral intake while on ventilator as evidenced by 0 energy
intake for the past 4 days (Diet order NPO) compared to recommendations for early enteral nutrition with estimated requirements of 2000
kcal per day with cumulative energy deficit of 8,000 kcal You could also keep it simpler as follows:
|
BOTTOM LINE: Neither is technically "WRONG", but depending on your situation one may fit better than the other. Your decision should be based on what best describes your clinical judgement of the situation and what you want to convey to the rest of the healthcare team.
Usually simpler is better, as long as it accurately describes the situation.
References:
Inadequate Oral Intake NI-2.1. Reference Sheet. Electronic Nutrition Care Process Terminology (eNCPT). Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-2-1. Accessed Nov 14 2020.
Inadequate Energy Intake NI-1.2. Reference Sheet. Electronic Nutrition Care Process Terminology (eNCPT). Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-1-2. Accessed Nov 14 2020.
Myers EF, Orrevall Y. Using the Nutrition Care Process: Critical Thinking Vignettes From Eight Clinical Cases. St Louis, Mo. EF Myers Consulting. 2018
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