Criteria for identifying the most important Nutrition Diagnoses

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.

One of the key outcomes---Change in status of Nutrition Diagnoses?

Documenting the status of Nutrition Diagnoses as patient care continues

One of the key decisions that you will make is determining the appropriate method for documenting progress in nutrition diagnoses based upon your patient/client population. 

The choices for documenting the status of a nutrition diagnosis included in the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) are as follows:

•        New

•        Continued

•        Resolved

•        Removed

However, in some cases the dietitian may want to know more than just whether it was continued or resolved, they may want to indicate directionality for a continued nutrition diagnoses for example, using a three way description of  improved, declined/worsened, or no change.

One approach, developed by UPMC Presbyterian Shadyside that accomplishes this directionality uses these terms:

•        “Resolved”—nutrition diagnosis no longer exists because it has been addressed

•        “Improvement shown/unresolved”—nutrition diagnosis still exists but signs/symptoms showing improvement. Patient/client making progress

•        “No improvement/unresolved”—nutrition diagnosis still exists, little to no improvement shown, still appropriate for patient/client’s condition

•        “No longer appropriate”—nutrition diagnosis is no longer exists because patient/client’s condition or situation has changed. The focus of nutrition interventions no longer supports the nutrition diagnosis

At this point, there is no clear right or wrong answer to how your institution chooses to record the current status of a nutrition diagnosis.

As you are considering how you want to record your status, you may want to be thinking about the end result or type of reports that you want.   With the increased use of electronic health records any data recorded in a systematic way can be pulled into a report with the assistance of information technology experts.

 With either the system begin tested in the ANDHII or some other method such as that which was originally designed by UPMC Presbyterian Shadyside  you will be able to generate a numerical percent of the number of nutritional diagnoses that were "resolved" and the number that were removed due to the change in patient condition.  

However if you use the ANDHII system it will be difficult to know how to characterize those that are "continued" , e.g. whether they improved, stayed the same, or worsened.

Your report using the ANDHII data might look like:
       Month_____
              Total number of Nutrition Diagnoses identified ________
                                                                       (Sum of all notes/records)
              Total number of Nutrition Diagnoses resolved _________ 
                                                                      (Sum of all notes/records
              Average nutrition diagnoses per patient ______
                                                                      (Sum/patients with notes/records)
              % patients with at least one Nutrition Diagnoses resolved 
              Narrative list of TOP 10 nutrition diagnoses identified
              Narrative list of TOP 5 nutrition diagnoses resolved
              Narrative list of TOP 10 MEDICAL Diagnoses with nutrition diagnoses
                   May want to show Top 10 Medical Dx matched with top 1-2 Nutrition 
                   Diagnoses for Medical diagnoses

 Or it could be something like the following table which shows a total of those that improved added plus that were resolved and situations where the nutrition diagnoses was no longer appropriate (removed) where it was impossible to resolve/improve.
   

               

Etiologies--Are we missing the point? Just Ask Why 5 times???

Using the etiology (root cause) to guide the nutrition intervention is often not fully explored in  nutrition care
process discussions...other that to mention that you should ask "why?" five times to get to the root cause (or lowest level that the dietitian can impact).  More focus has been placed on correctly naming the problem as the Nutrition Diagnoses.

This example that shows the impact of varying etiologies on the choice of nutrition interventions.

Assume the Nutrition Assessment clearly indicates that there is a problem with Excessive Energy Intake (NC 3.3.1).  The person has consistently gained weight for past 2 years, the dietary history shows that the person has routinely consumed MORE than his estimated needs, and the weight status meets the criteria for being overweight.  There is no medical reason to avoid addressing his weight gain/status at this time.

Excessive Energy Intake (NC3.3.1) was selected as the problem/diagnosis.  But let's look at the difference in intervention based on varying etiologies. (See Etiology Matrix in ENCPT website)  In the ENCPT there are 28 different types of etiologies related to knowledge, beliefs and attitudes alone!!.

If the etiology for Excessive Energy Intake is identified as

• "Food and nutrition knowledge deficit" concerning identifying foods/beverages that are highest in energy or being able to identify intake that would be within optimal energy levels (plus BMI or weight data).  
• Then a logical intervention might be providing tailored Nutrition Education - Content-Recommended Modifications to help increase knowledge and understanding.  

However if the etiology is identified as

• "Lack of confidence in ability to make change" 
• Then an intervention providing knowledge/information would not likely change confidence.   However,the intervention most likely to be successful would be a Nutrition counselling approach, perhaps using an Motivational Interviewing strategy based on Stages of change to facilitate the person being able to clearly identify other situations when he/she has been successful, what the barriers are to making these changes, and exploring problem solving for the patient to discuss ways he/she can overcome the barriers and thus be more confident that they can be successful.  

OR

• "Cultural or religious practices that affect ability to" make changes
• Perhaps a Nutrition Counselling approach based on Cognitive-behavioral theory is appropriate, but not focused on changing the religious or cultural beliefs, but Problem solving to identify ways to accommodate the changes within the existing belief structure.  

OR

• "Denial of need to change"  
• Again a nutrition intervention with Nutrition counselling is appropriate, however the focus would likely be on using the Health Belief Model and perhaps Motivational interviewing to facilitate a discussion where the individual came to the realization that there were consequences likely associated with continuing in present course/not making changes that are outweighed by the benefits of making the effort to make changes.

OR

• "Food and nutrition related knowledge deficit concerning" how to prepare appropriate foods based upon nutrition prescription
• Here a nutrition education intervention would be appropriate, however it would not be the "content" of the diet it would likely need to focus on Nutrition Education-Application, Skill Development, and might involve Collaboration and Referral of Nutrition Care to community agencies/programs to find a suitable cooking course that would meet their needs.

It isn't until a person has started working with the NCP and terminology that you truly come to realize that while naming the problem is important, it is even MORE important to properly understand the etiology, the underlying cause.  Only by understanding the WHY the nutrition problem exists can the dietitian design the optimal nutrition intervention to correct the problem.  The same holds true for other types of etiologies (Access, Behavior, Physical Function, Physiologic-Metabolic, Psychological, Social-Personal, and Treatment).  

Citations:

Etiology Matrix in ENCPT, available at https://ncpt.webauthor.com (Available by subscription)

For student assignments that specifically guide students in making the connection between the etiology and the intervention see the Nutrition Care Process and Terminology:  A Practical Approach.  

Cascade of Nutrition Outcomes - One Thing Leads To Another!!

The critical thinking involved in Monitoring and Evaluation, the last step in the Nutrition Care
Process, is the identification of indicators and criteria that will provide evidence that the nutrition intervention of the dietitian is effective.

Outcomes can be thought of as occurring in a cascade, each level of outcome leading to outcomes in the next layer, until you reach the ultimate outcome desired.  This may be visualized as shown using the domains of terminology.

For example, let's take a case of a person with Diabetes Mellitus who received both nutrition education related to how to choose foods according to plan and counselling to ensure readiness to change.
Then one short term  indicator of success for this nutrition intervention may be a change in knowledge about optimal food choices and change in readiness to change that could be measured at the end of the nutrition consultation and again at the beginning of the next appointment.  This change in knowledge and beliefs and attitudes would be expected to lead to a change in behavior around food choices, perhaps in adherence with meal planning/food choice guidance and types of food/meals consumed.  That change would then lead to a change in food or nutrient intake, perhaps change in total carbohydrate intake or total energy intake.  This change over time would likely lead to changes in self monitored blood glucose levels and eventually to change in HBA1C.  These changes could then lead to changes in quality of life measures, perhaps health related quality of life scores or disease specific quality of life scores.

Dietitians often look at the biochemical measures or anthropometric measures and overlook the more immediate short term measures that are related to their intervention  or overlook the more global quality of life measures.

If we miss the opportunity to document  immediate short term measures that are specific to our intervention (changes in knowledge, behavior, and dietary intake), we don't really know if the changes in laboratory values are related to our intervention or whether they are coming from other interventions such as medication changes.

While dietitians do not claim full responsibility for changes in biochemical or anthropometric measures, without the immediate short term measures we lack any evidence that we even contributed to the outcomes!!

Bottom line:  Using the cascade of outcomes diagram helps dietitian think of a range of outcomes that demonstrate effectiveness of nutrition interventions and create a logical argument that nutrition interventions are related to positive health outcomes.

Want to practice NCPT, but not impact patient care??? Case simulations may be part of the answer

As more people both in the US and internationally are exploring and implementing both the Nutrition Care Process and using standardized terminology (eNCPT), more demonstration cases are being developed for use.

Is there a way to develop some common guidelines that can assist those developing cases to make their cases as effective as possible?  And assist educators in selecting the right resource for their needs?

After having the recent experience of  developing the five in-depth cases using two "standardized patients" for our new text, Nutrition Care Process and Terminology:  A Practical Approach, here are some starting thoughts.  Some of these are pretty basic, but it is amazing how they stand the test of time.

• Cases developed to demonstrate the use of the Nutrition Care Process and the Nutrition Care Process Terminology need to reflect the most current terminology.  
• Much to our chagrin, the minute we released our text in early October 2015, there was an update to the ENCPT.  This caused several months of intense review to update the terms used in our cases and activities and publication of an update to address new terms.

• A clear articulation of the exact skills to be learned in a case is essential.  Attention is needed to reflect  all aspects of the interaction between the patient and dietitian to maximize the learning from a case study/simulation.  To help educators select resources, attention to clear learning objectives are essential.  

• Different types of cases needed for different skills
• Starting with a written story that provides all the key elements of the patient's life is entirely appropriate for an objective that deals only with how the dietitian uses data/information to evaluate the situation.  But this would not be sufficient to address the skills needed to review a medical record to extract data nor the interviewing skills necessary to elicit the information from the patients or the communication skills needed to verbally summarize nutrition care.   
• We decided to supplement the written story with a Virtual Learning Environment with video clips and the opportunity for student so submit videos where they "asked" the patent questions, or recorded their opening comments or summary to the patient, or discussed patient progress with the physician.  These types of additional components take a written case a step closer to "real life".  Karen Lacey's forward summarized her opinion on this aspect.  

• The eNCPT Student Companion Guide created by the Academy also includes a basic patient scenario and may be appropriate for the very first introduction to the process and terminology. However the first printing of the Instructor Solution Manual had some information that needed to be more clearly presented (e.g. regarding what was being shown as "prescription"  and "intervention" in the answer keys in the solution manual were co-mingled creating confusion about what the Nutrition Prescription was, what the Nutrition Intervention was, and how to appropriately use the terminology.  The examples provided were not consistent with the descriptions on the eNCPT.)  This guide also includes sample exam questions that can be used to test content knowledge.  It provided a framework for identifying ALL potential nutrition diagnoses based on existence of nutrition assessment signs and symptoms that may be useful as a starting point for less advanced students.  

• There are other aspects of nutrition care that can also be incorporated into different types of simulation.  For example, a simulation that allows the practitioner to explore whether they should be performing a specific task is also needed.  Especially for students who are still learning what is within and what is outside their scope of care.  The "cases" provided by the Academy address some common situations e.g. writing PN and EN orders, ordering laboratory tests, making physical activity recommendations, screening for swallowing difficulties.  These are available to members and for sale to non members addresses this need.   The cases developed by Quality Management from the Academy include the eNCPT as a resource for the cases. 

• Cases are also available that demonstrate various ethical situations, e.g. social media and applying the code of ethics to decisions.  Whenever appropriate these cases should also integrate the framework of the nutrition care process and terminology.  

• Technology continues to evolve at a dizzying pace.  Harnessing the latest to effectively provide learning experiences will be key.  
• The use of Second Life Avatars to allow the students to more fully "experience" doing a Subjective Global Assessment is certainly a unique way used by Dr Alison Steiber.  
• Work completed by Dr Pattie Landers to develop case studies that include the experience of using electronic medical records also provides a different type of simulation experience.   While we know that each electronic medical records is quite unique, being able to see and experience the potential features is essential to ensuring a smooth transition from paper cases/medical records into the world of electronic documentation.

While we know that experiential learning is essential, it will be a challenge to keep these simulations current and to curate the resources available to continually select the most appropriate for the stated objective for the cases.  Just as the case study developers are challenged, so are the educators challenged to continually review and select the materials that most closely meets their classroom/educational program needs.

Anticipatory guidance...Identifying nutrition problems that don't yet exist??

A key concept in the Nutrition Care Process is that dietitians identify an existing nutrition problem, called a nutrition diagnosis, by clustering existing signs and symptoms from the nutrition assessment that shows that the nutrition diagnoses exists.  So doesn't that eliminate the possibility of prevention and anticipatory guidance??


Nutrition Diagnoses/Problems
In 2011 (Third Edition International Dietetics & Nutrition Terminology) the nutrition diagnostic terminology was expanded to identify four nutrition diagnoses that provide the ability to "predict" future nutrition problems, thus supporting the concept of prevention and anticipatory guidance.

• Predicted inadequate energy intake (NI-1.4)
• Predicted excessive energy intake (NI-1.5)
• Predicted inadequate nutrient intake  (NI-5.11.1)
• Predicted excessive nutrient intake  (NI-5.11.2)
• Predicted food-medication interaction (NC-2.4)
• Predicted breast-feeding difficulty (NC-1.5)

The definition of these terms indicate that they are used to reflect future problems, e.g. intake of one or more nutrients that is anticipated  (predicted based on observation, experience, or scientific reason) to fall short of or exceed estimated nutrient requirements, established reference standards, or recommendations based on physiological needs.  

Etiology
The types of etiologies that would be the "cause" of these nutrition diagnoses could be scheduled or planned medical therapy or medication that is predicted (based on research, experience or scientific reason) to either increase or decrease nutrient requirements, or change the ability to consume, absorb, or utilize nutrients.  In some cases cultural or religious practices could also be the "cause" of predicted problems.   In other cases etiology may be social issues such as housing or living conditions or potential for environmental emergency or catastrophe/disaster shown through research to be risk factors for intake problems.  

Signs and Symptoms
But what about the need to have signs and symptoms to document the presence of the nutrition diagnosis?  In the case of "predicted" nutrition diagnoses the reference sheets  indicate that you may use "estimated" needs or "estimates" of future intake.  

 The data used for these estimates may be findings of research projects as opposed to actual patient data.  History or presence of a condition for which research shows an increased prevalence of insufficient nutrient(s) intake in a similar population may be used as a sign and symptom.  For example the post surgery predicted energy needs for someone that is scheduled to undergo major surgery for cancer may be based on research findings related to the energy needed for future wound healing combined with research that documents a simultaneous decrease in intake could document a predicted gap between future intake and requirements.   This would then be used to set the stage for anticipatory guidance prior to surgery about coping with the future situation.

PES Statements might be:
Predicted excessive energy intake related to future immobilization of leg and lack of awareness of changes needed as evidenced current PAL of 1.8 expected to go to 1.2 and estimated current intake of 2800 kcal compared to reduced energy requirements of 1800 kcal during restricted mobilization scheduled for 4 weeks in December.
    ( intervention might be nutrition education on energy balance and meal planning for lower energy intake.)

Predicted suboptimal energy intake related to scheduled head and neck radiation therapy, lack of awareness of future dietary requirements, and anticipated changes in appetite as evidenced by scheduled radiation for next 3 months and usual weight loss of 5-10 KG/month for other patients receiving similar treatment (reference as appropriate).
    ( Intervention might be nutrition education on principles.) 

Predicted excessive carbohydrate intake  or Excessive carbohydrate intake related to strong family history of diabetes and lack of perceived susceptibility as evidenced by reports of all siblings and parents with Type 2 DM and current carbohydrate intake inconsistent with principles of diet for prevention of Type 2 DM.
     (Intervention might be nutrition counseling using health belief model and education on principles of prevention of DM EBNPG recommendations.)

Predicted excessive intake of nutrients in foods not tolerated related to potential diagnosis of food intolerances/allergies as evidenced by history of gastrointestinal distress and pain.
    ( Intervention might be nutrition education and use of self monitoring to test tolerance of foods.)

Full descriptions of the "predicted" nutrition diagnoses are available in the electronic NCPT.  Available at:  https://ncpt.webauthor.com/.  

Is that all there is??? Getting beyond knowledge deficit diagnoses for IBD.

What about conditions where the focus of the nutrition care is to help the patient learn to identify foods that are tolerated so future dietary intake can be planned to avoid them, but still be nutritionally adequate??

One of the conditions that would likely lead to this type of nutrition care may be Inflammatory Bowel Diseases (IBD).  In this case the focus of the dietitian's care is often to guide the patient in effectively use self-management skills.  They may need to have a systematic way to monitor their dietary intake, identify signs and symptoms as they begin to emerge and more effectively identify what dietary components are likely to be connected to the GI disturbances.  The self-management skills would also include helping the patient identify when they need to seek medical/dietetics follow-up care vs when they can/should manage the issue themselves.

Depending on the focus of the dietitian's intervention nutrition diagnoses could range from:

Concerns over Knowledge

• Food and Nutrition-Related Knowledge Deficit - most appropriate when the patient is newly diagnosed or when patient acknowledges lack of knowledge about the principles and food tolerances.  

This type of nutrition diagnosis is easiest to document, justify and support with nutrition assessment data (statement from patient about desire to know more, or documentation that patient could not accurately respond to questions) and will easily lead to an intervention of nutrition education.  The nutrition education intervention can focus on principles of planning intake during times of remission (content) as well as how to identify "flare" and how to adjust dietary intake during those periods (application).  The education can also identify the content of "when should the patient seek additional health care vs when can they manage the situation themselves" (application)

However the experienced dietitian may not be satisfied with this level of sophistication and wish to more clearly describe their nutrition care.  Other types of nutrition diagnoses can be added that are likely appropriate to more fully describe the range of nutrition problems (diagnoses) that are being addressed and a more full range of interventions used by the dietitian.  Following are the types of issues that are likely to be encountered:

Concerns over intake issues:
These issues could be ones that already exist or predicted for the future.  Often there are intake issues likely to be of concern, for example energy, fat soluble vitamins, B12, soluble vs insoluble fiber, and Calcium.  

These could be identified either as existing problems (intake that is already compromised) or those that are likely to be compromised in the future with repeated flares or by elimination of foods that have been identified as not being well tolerated.

• Predicted suboptimal* energy intake - if they are concerned about a future problem that could result from a combination of reduced intake due to trying to avoid food caused GI disturbances combined with decreased absorption which could be supported by research/experience with other patients with similar IBD diagnoses and symptoms.
• Predicted suboptimal* nutrient intake - if the concern is about a specific nutrient or nutrients that are likely to be unavailable due to malabsorption, perhaps fat soluble vitamins which could be supported by research/experience with other patients experiencing compromised intake or absorption.
• Predicted excessive intake may be used if the concern if over nutrients in foods not tolerated related to potential diagnosis of food intolerances/allergies which could be supported with nutrition assessment data about their history of gastrointestinal distress and pain.

Concerns over other behavioral/environmental issues
In most cases the individuals with IBD also are coping with behavioral and attitudinal issues.  For example they may not be keeping adequate food journals to identify which food items are trigger foods for flares. They may also be denying that they have a chronic condition that will need long term management on their part.  These types of nutrition diagnoses will often lead to more nutrition counseling types of intervention in addition to the knowledge needed.  Following are some of the types of other nutrition diagnoses likely to be addressed:

• Self-monitoring deficit related to need to rule in and rule out specific food as evidenced by history of GI disturbances, medical diagnosis of inflammatory bowel, and unverified or changing food tolerances
• Unsupported beliefs/attitudes about food and nutrition-related topics -  related to not ready for lifestyle change and denial of impact of diagnosis as evidenced by expression of reluctance to implement self-monitoring or other lifestyle changes necessary to manage the IBD.
• Inability to manage self-care  related to newly diagnosed IBD and lack of previous exposure to information about IBD nutrition care as evidenced by new medical diagnoses in medical record and referral for initial evaluation for nutrition therapy for IBD.  This may be an appropriate nutrition diagnoses if the dietitian is focusing on helping the patient learn the principles as well as developing the skills to apply the principles in self-management.  This would also include helping the patient identify when they need to seek medical assistance and when they can manage on their own.  
• Not Ready For Diet/Lifestyle Change related to unsupported beliefs/attitudes about whether the IBD will resolve without lifestyle changes as evidenced by patient's ability to verbalize knowledge, but providing reasons why changes in lifestyle are not necessary/possible at this time.  This would be used when the patient is experiencing a conflict between "knowing" what to do and actually planning and making the lifestyle changes necessary to manage their condition

Concerns over GI tract functioning

In some cases the dietitian may want to focus on the GI malfunctioning.  However this may or may not be useful to effectively direct the nutrition intervention chosen.  If this option is chosen, the dietitian may choose:

• Altered GI function related to unspecified food tolerances as evidenced by flares of GI symptoms (diarrhea, bloating) and patient verbalizing not knowing which foods precede flares.

Concerns over food/medication interactions

In many cases patients are managed by medications that also have nutritional implications for increased appetite, decreased absorption of fat soluble nutrients, or bone demineralization.  In these cases, the dietitian may also want to address either existing or predicted food/medication interactions.  

• Food-Medication Interaction or Predicted food-medication interactions would be appropriate diagnoses to use in these situations  

Specific nutrition diagnoses reference sheets are available to help the dietitian decide which best describes their thinking about the types of nutrition issues they have chosen to address.

BOTTOM LINE:  Dietitians have many choices of nutrition diagnoses that can be used to  fully describe the focus and nature of the nutrition care provided.  Some are based on existing situations and some based on predicting future situations that are likely to emerge.

Academy of Nutrition and Dietetics, E Nutrition Care Process and Terminology (ENCPT) available at:   https://ncpt.webauthor.com/pubs/idnt-en/file.cfm?item_type=xm_file&id=88978.  Accessed December 26, 2015

*If a synonym for the term “inadequate” is helpful or needed, an approved alternate is the word “suboptimal.”