Domain II: Nutrition Care for Individuals and Groups: Nutrition Diagnosis Flashcards
A nutrition ____ requires the identification and labeling of a nutrition problem that dietetics professionals are responsible for treating independently; will change as the patient’s response changes
Diagnosis
A ____ diagnosis is a disease or pathology that can be treated or prevented; it does not change as long as the condition exists (ex: Type 1 Diabetes)
Medical
____ is the disruption of normal body functions that is seen in disease
Pathophysiology
____ ____ is the process of determining which of many problems with similar symptoms is the correct diagnosis
Differential diagnosis
A diagnosis links the ____ to the ____ and sets realistic and measurable outcomes
Assessment; intervention
The Academy’s NCP ____ language is the basis for collecting evidence that nutrition care can improve outcome
Standardized
What are the three domains of nutrition diagnostic labels?
-Clinical
-Intake
-Behavioral-environmental
Clinical diagnoses are nutritional findings/problems that relate to ___/___ condition
Medical/physical
What are three categories of clinical nutrition diagnoses?
-Functional balance
-Biochemical balance
-Weight balance
Function balance diagnoses refer to ____ or ____ changes that interfere or prevent desired nutritional results (Ex: chewing/swallowing difficulty, altered GI function)
Physical or mechanical
Biochemical balance diagnoses refer to change in the capacity to metabolize nutrients due to…
-Medications
-Surgery
-specific lab values
Weight balance diagnoses refer to chronic or changed weight status when compared with ___ ___ ___ (underweight, involuntary weight loss, overweight)
Usual body weight
Intake diagnoses are actual problems related to ____ ____
Nutrient intake
____ energy balance diagnoses refer to actual or estimated changes in energy
Caloric
Oral or nutrition support intake diagnoses refer to ___ or ____ intake compared to the goal
Inadequate or excessive
Fluid intake balance diagnoses refer to ____ and ____ intake compared to the goal
Inadequate or excessive
A diagnosis related to bioactive substance refers to…
-Supplements
-Alcohol
-Functional foods
Nutrient balance diagnoses refer to intake of nutrients compared with ____ levels
Desired
Behavioral-environmental diagnoses are problems related to…
-Knowledge and beliefs
-Access to food
-Food safety
What are some examples of knowledge and beliefs diagnoses?
-Knowledge deficit
-Harmful beliefs
-Disordered eating pattern
-Undesirable food choices
Behavioral-environmental diagnoses can also be related to ___ ___ and functionality (inactivity, excessive exercise, impaired ability to prepare food
Physical activity
PES statement formula:
(Problem) related to (etiology) as evidenced by (signs and symptoms)
When writing PES statements, it is important to ____ by selecting the most important and urgent problem to be addressed
Prioritize
If you have diagnoses from two domains, consider the ____ diagnosis, as it is more specific to the nutrition professional and it is more likely to facilitate a nutrition-directed intervention
Intake
You should evaluate the PES statement by asking what questions?
-Can you resolve or improve the nutrition diagnosis for this person/group?
-Is the etiology you selected the “root cause” that can be addressed with nutrition intervention, or can you at least lessen the signs and symptoms?
-Will measuring the signs and symptoms indicate if the problem is resolved or improved and are the signs and symptoms specific enough that you can monitor and document resolution or improvement of the diagnosis?
-Does the nutrition assessment data support a particular nutrition diagnosis with typical etiology and signs and symptoms?
Identifying the etiology leads to the selection of nutrition _____ aimed at resolving the underlying cause of the nutrition problem when possible; if that is not possible, it should be targeted at minimizing symptoms as much as possible
Interventions
If the assessment indicates that no nutrition problem currently exists that warrants a nutrition intervention, what should be written?
No nutrition diagnosis at this time
What critical thinking skills are needed when writing a nutrition diagnosis?
-Finding patterns and relationships among data and possible causes
-Making inferences (if ____ continues, then ____ is likely to happen)
-Stating the problem clearly and being objective
-Rule in or out specific diagnoses; prioritize the relative importance of problems
A nutrition ____ is a purposely planned action designed with the intent of changing a behavior, risk factor or condition for an individual, group, or community
Intervention
Nutrition interventions are based on the nutrition ____ and provide the basis upon which outcomes are measured and evaluated
Diagnosis
What are the four categories of nutrition interventions?
-Food delivery
-Education
-Counseling
-Coordination of care with other providers
_____ cultural knowledge is an essential element in program planning
Institutionalized
What should be done when planning a nutrition intervention?
-Prioritize nutrition diagnosis
-Consult EAL and other practice guidelines
-Determine patient-focused outcomes for each diagnosis
-Confer with caregivers
-Define time and frequency of care
-Identify resources needed
____ is the action phase when the intervention is communicated and carried out
Implementation
The ___ ___ ___ contains systematically reviewed scientific evidence used in making food and nutrition practice decisions; integrates the best available evidence with professional expertise and client values to improve outcomes; explains what interventions are most effective
Evidence Analysis Library
What critical thinking skills are needed to plan and carry out a nutrition intervention?
-Setting goals and prioritizing
-Defining nutrition prescriptions or plan
-Making interdisciplinary connections
-Initiating interventions
-Specifying time and frequency of care
___ prevention programs work to reduce exposure to a promoter of disease (early screening for risk factors like diabetes)
Primary
Primary prevention programs are also known as ____ ____
Health promotion
_____ prevention programs require recruiting those with elevated risk factors into a treatment program to reduce impact of a condition that has already occurred
Secondary
Secondary prevention programs are ___ ___ programs and slow the progress of a condition to restore health
Risk reduction
_____ prevention programs intervene to reduce severity of a condition and/or manage complications as disease progresses
Tertiary
Tertiary prevention programs are ____ efforts
Rehabilitation
The Federal Trade Commission is responsible for regulating the information on…
-Internet
-TV
-Radio
What is another agency that is responsible for monitoring health fraud?
The National Council Against Health Fraud
When evaluating information, ask questions based on the _____ checklist
CARS
What is included in the CARS checklist?
-Credibility (check credentials of the author)
-Accuracy (info is current, factual, and comprehensive)
-Reasonableness (info is fair, balanced, and consistent)
-Support (is supporting documentation cited for scientific statements)
What are some different formats for notes in medical records?
-POMR (problem-oriented medical record)
-PES (problem, etiology, symptoms)
-SAP (screen, assessment, plan)
-ADIME (assessment, diagnosis, intervention, monitoring, and evaluation)
HIPAA stands for…
Health Information Portability and Accountability Act
HIPPA requires that all permanent legal documents be written in ____ pen or types
Black
HIPPA guidelines require that documentation is…
-Complete
-Clear
-Concise
-Objective
-Legible
-Accurate
HIPPA requires that ____ entries are identified and the actual date/time be recorded, as well as the time it should have been documented
Late
When ___ ____ are not chosen correctly, contact the person who wrote order corrections
Diet orders
How should an error be fixed in medical charts?
-Draw a single line through the error, enter the data and initials
-Write the correction, date, and initial
-Never use white-out, thick markers, or remove and original and replace it with the copy
-For the omitted information, beside the original entry, write “see addendum”, enter date and initial
Discharge plans begin on day ____ of a hospital stay
1
All patient information is ____
Confidential