Exam 1: Nutrition Diagnosis and Intervention Flashcards
Purpose of nutrition assessment
assess, identify, verify malnutrition signs
Domains of nutrition assessment
Purpose of nutrition diagnosis
Domains of nutrition diagnosis
- Intake
- Clinical
- Behaviors
Describe the components of a PES statement
Problem
Etiology
Signs/Symptoms
Purpose of nutrition intervention
Steps of nutrition intervention
- Planning
- Implementation
Nutrition Intervention should
target etiology, be specific and include goals/objectives
Types of nutrition interventions
⚬ Food and/or nutrient
delivery
⚬ Nutrition education
⚬ Nutrition counseling
⚬ Coordination of care
⚬ Population-based
nutrition action
Purpose of monitoring and evaluation
steps of monitoring and evaluation
- Provide evidence
- Compare findings
- Resolve or revise
categories of monitoring and evaluation
⚬ Food/nutrition-
related history
⚬ Biochemical data,
medical tests and
procedures
⚬ Anthropometric
measurements
⚬ Nutrition-focused
physical findings
What is evidence-based practice?
“the conscientious, explicit and judicious use of current best
evidence in making decisions about the care of individual
patients.”
how to recognize resources for practice using evidence baed guidelines
properly designed and executed prospective
randomized controlled trials, systematic reviews of literature, and
meta-analysis
how to utilize resources for practice using evidence baed guidelines
Conducting systematic review and using conclusion to develop
practice guidelines
* Academy of Nutrition and Dietetics Evidence Analysis Library
Evidence-Based Nutrition Practice Guidelines
CMS
Centers for Medicare and Medicaid Services regulate and review subacute facilities
role of the joint commission and CMS in regulating healthcare institutions
characteristics of nutritional care record
- Legal document
- Identifies problems and sets criteria to evaluate care
- Allows entire health care team to understand the rationale for
nutrition care, how it will be provided, and the role of each team
member - Communication tool
- Important for accreditation and peer review
list of guidelines for charting and documentation
- Health Insurance Portability and Accountability Act (HIPAA)
- Standards to maintain privacy and security of personal health
information - Paper-based or electronic
- Black pen or typewritten
- Complete, clear, concise, objective, legible, and accurate
- Include date, time, and service
- Complete sentences are not necessary but use correct spelling and
grammar - Entries should be consistent and noncontradictory
- Sign all entries and include credentials
- No personal opinions or criticism
- Document at the time of service, never in advance
- Identify late entries
- Do not correct errors with correction tape, correction fluid, or self-
adhesive labels; thick pen lines to obliterate the error, or replacing
original with a copy - Correct minor errors with a single line through the error and initialed
correction - For omissions, write “see addendum,” date, and initial
explain CMS final rule related to therapeutic diet orders
- Qualified dietitians will be permitted to become
privileged by the hospital staff to: - Order patient diets
- Order lab tests
- Make subsequent modifications to diets based
on lab test results - Subject to state laws governing licensing and
scope-of-practice
explain nutrition care considerations for hospitalized
- Honor patient preferences
- Imagination and ingenuity in menu planning
- Attention to color, texture, composition, and temperature of foods
- Sound knowledge of therapeutic diets
- Patient selection of menus increases consumption
explain nutrition care considerations for terminally ill/hospice patient
- Main goals: maintain comfort and quality of life
- Dietary restrictions are rarely appropriate
- Palliative/comfort care
- Advanced directive: legal document specifying decisions regarding
end-of-life issues
