Applying the Nutrition Care Process Nutrition Diagnosis and

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Applying the Nutrition Care Process Nutrition Diagnosis and Powered By Docstoc
					Support Line December 2007 Volume 29 No. 6

Applying the Nutrition Care Process:
Nutrition Diagnosis and Intervention
Annalynn Skipper, PhD, RD, FADA

Abstract                                     nutrition (PN). The dynamic nature of         consistent documentation of care
   The Nutrition Care Process (NCP)          the critical care unit and sheer volume       delivered, communication between
was accepted by the dietetics profession     of data that RDs incorporate into the         health-care professionals, and continuity
in 2003 and is being implemented in all      decision making process present               as patients move from one location to
settings where dietitians provide direct     challenges in identifying the nutrition       another. Such vocabularies clearly
patient care. Standardized terminology       diagnosis, describing the intervention,       distinguish the unique activities of
is being developed to describe the           and determining the monitoring and            each profession, thereby reducing the
activities of registered dietitians (RDs)    evaluation using the standardized lan-        opportunities for miscommunication,
within each of the four steps of the NCP:    guage of dietetics. The purpose of this       overlapping activities, and interprofes-
Nutrition Assessment, Nutrition              article is to illustrate how the nutrition    sional conflict.
                                             diagnosis, intervention, and monitoring         Widespread implementation of the
Diagnosis, Nutrition Intervention, and
                                             steps of the NCP can be applied to a          NCP and use of standardized language
Nutrition Monitoring and Evaluation.
                                             critically ill patient.                       also should aid benchmarking data
RDs providing nutrition support to
                                                                                           collection and may serve as the basis
complex or critically ill patients have      Background                                    for identifying homogenous populations
questions about how to apply the NCP
                                                Standardized or controlled vocabular-      for research. A standardized approach
and standardized language to their
                                             ies are used in medicine and nursing to       to describing care is especially valuable
patients. This article provides a brief
                                             describe diagnosis and treatment for          to RDs working in nutrition support
overview of the NCP and a case illus-
                                             those within and outside the medical          where the multifaceted nature of the
trating how standardized language can
                                             profession. Examples of controlled            data evaluated may be underappreciated
be applied to a postoperative intensive
                                             vocabularies familiar to dietitians include   by those who focus on the number of
care unit (ICU) patient whose course
                                             the Common Procedure Terminology              patients seen rather than the complexity
changes over time.
                                             (CPT) and the International Classifica-       of care delivered.
                                             tion of Diseases (ICD-9) terminologies
                                                                                           Nutrition Diagnosis
Introduction                                 developed for use by physicians (5,6).
                                             Nurses may use one of several standard-          The most unique feature of the NCP
   The NCP is a four-step approach to        ized languages, and physical therapists       is the nutrition diagnosis. The 60
nutrition problem solving and care that      have also developed a controlled              nutrition diagnosis terms and definitions
is designed to guide and illuminate the      vocabulary to describe their patient          were developed to describe nutrition
work of RDs. Since its adoption by the       care activities (7,8). All of these termi-    problems that can be treated indepen-
dietetics profession in 2003, three of the   nologies ultimately should combine to         dently by the dietitian (4). Thus, they
fours steps of the process — diagnosis,      identify the contributions of health          are distinct from the terms physicians
intervention, and monitoring and             professionals within the electronic           use to describe medical diagnoses.
evaluation — have been elaborated in         medical record. The International             However, RDs and physicians use a
book form (1). Standardized terminol-        Dietetics and Nutrition Terminology is        similar process of diagnostic reasoning
ogy describing nutrition diagnosis was       being developed to identify the unique        to derive diagnoses from their respective
introduced in 2005 (2). A second book        contributions of RDs within the               domains (9). Like medical diagnoses,
that included nutrition diagnosis and        universal electronic medical record.          nutrition diagnostic terms have a specific
intervention terminology was released           Controlled vocabularies serve several      definition; unique etiologies, signs,
in 2006 (3). A third book, International     important purposes besides their role         and symptoms; and a code number
Dietetics and Nutrition Terminology          in meeting the federal mandate for            that may be used for linking to data in
Reference Manual, which includes the         electronic medical records. The terms         an electronic medical record. Unlike
monitoring and evaluation step of the        and codes are easily incorporated into        medical diagnoses, nutrition diagnoses
NCP, was released in 2007 (4).               laws and regulations. Because they are        typically resolve following intervention
   Many RDs are familiar with the NCP,       uniform descriptors, they may facilitate      by the dietitian.
and some are incorporating standardized      productivity, efficacy, and reimbursement        Once the RD “makes” a nutrition
language into medical record documen-        data collection. In educational settings,     diagnosis, the term is incorporated
tation. As a result, nutrition support       controlled vocabularies are used to           into a nutrition diagnosis statement or
dietitians have questions about how to       organize information presented to             PES statement composed of three parts:
apply the NCP to critically ill patients     students. In the clinical environment,        a problem (P), etiology (E), and signs
receiving enteral (EN) and parenteral        standardized language facilitates clear,      and symptoms (S) (Table 1). Within

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                                                                                          Support Line December 2007 Volume 29 No. 6

the PES statement, the diagnosis is              on best available evidence and the             which they individualize to meet the
a nutrition problem that will resolve            clinical judgment of the RD. It is not         nutrition prescription by manipulating
with the dietitian’s intervention. The           the current nutrition order, but rather        formula volume and composition.
etiology is the “root” cause of the              an individualized statement of the needs       Nutrition support dietitians may also
nutrition problem. It may be improved            of the patient at a given moment in            prescribe medical food supplements
or eliminated with the nutrition                 time. In critically ill patients, the          (ND-3.1) and participate in nutrition-
intervention. The signs and symptoms             nutrition prescription may be adjusted         related medication management
are monitored by the dietitian to deter-         frequently as medical diagnoses (e.g.,         (ND-6). The purpose of the nutrition
mine progress toward resolving the               acute renal failure, hepatic encephalopa-      intervention ultimately is to correct
nutrition diagnosis. For example, the            thy), treatments (e.g., surgical procedures,   the nutrition diagnosis, remove the
nutrition support dietitian may calculate        medications), and the patient’s condition      etiology, or reduce the signs and
the carbohydrate intake of a critically          (e.g., wound healing, weaning from             symptoms.
ill patient with hyperglycemia, rule             the ventilator) change.
out excessive carbohydrate intake as a              An example of a nutrition prescription      Nutrition Monitoring and
nutrition diagnosis, and suggest the             for a critically ill patient might be as       Evaluation
need for an increased insulin dose.              simple as 1,800 kcal and 65 g protein.            The monitoring and evaluation step
   Diagnosing nutrition problems and             It might be expanded to include specific       of the NCP is defined as the review
writing a PES statement that is both             amounts of fat, vitamins, minerals,            and measurement of the patient/client’s
correct and meaningful is a rigorous             fluids, and bioactive substances. Ideally,     status at a scheduled or preplanned
task. It involves validating assessment          the nutrition prescription is based on         follow-up point with regard to the
data, clustering and comparing signs             the latest evidence-based standards, but       nutrition diagnosis, intervention/plans
and symptoms to develop differential             where data are lacking, the RD applies         goals, and outcomes (1). Evaluation is
diagnoses, and systematically eliminating        clinical judgment and institutional            the systematic comparison of current
them until a diagnosis is derived from           tradition to the nutrition prescription.       findings with previous status, interven-
the signs and symptoms.                             The RD implements one of 13                 tions, goals, or a reference standard.
                                                 nutrition interventions that are designed      Almost 50 monitoring and evaluation
Nutrition Intervention
                                                 to reduce the gap between the patient’s        strategies have been identified in the
  The nutrition intervention is defined          current and ideal intake. Each nutrition       nutrition monitoring and evaluation
as a specific action that remedies a             intervention consists of a definition, a       step of the NCP. Effectiveness of the
nutrition diagnosis and consists of two          unique number, and a reference sheet           intervention is monitored by changes
components: the plan and the imple-              describing the details of the intervention     in the signs and symptoms listed in the
mentation. The first step in planning            and usual application. Nutrition support       PES statement. In Table 1, the inter-
nutrition intervention is the nutrition          dietitians are strongly identified with        vention (potassium supplementation
prescription. The prescription is based          enteral and parenteral nutrition (NC-2),       ND-3.2) should resolve the nutrition
                                                                                                diagnosis and can be monitored using
  Table 1. General Format for the Three-part Nutrition Diagnostic                               the sign (serum potassium level) in the
  Statement (PES Statement) With a Sample Statement                                             PES statement.
                                                                                                   For critically ill patients or others
  General Format                                                                                receiving nutrition support, the diag-
  problem (P) related to etiology (E) as evidenced by signs and symptoms (S)                    nosis may resolve, but the monitoring
  Sample PES statement                                                                          and evaluation portion of the NCP
  (P) Inadequate intake of potassium (NI 55.1) related to (E) increased urinary                 continues for the duration of the
  losses with amphotericin B administration, as evidenced by (S) declining serum                nutrition intervention. The monitor-
  potassium levels.                                                                             ing and evaluation step incorporates
                                                                                                changes from baseline in biochemical
  Sample Nutrition Prescription                                                                 and medical tests, anthropometric
  Increase potassium intake to 2 mEq/kg each day.                                               data, intake and output, and other
  Sample Nutrition Intervention                                                                 familiar nutrition support monitoring
  Mineral (potassium 40 mEq/day) supplements (ND-3.2) as needed to maintain                     parameters. Thus, the fourth step of
  serum potassium levels within normal limits.                                                  the NCP incorporates the familiar
                                                                                                components of the nutrition support
  Sample Nutrition Monitoring and Evaluation
                                                                                                dietitian’s assessment in a more
  Monitor potassium intake (FI-6.2); serum potassium level (S-2.2)
                                                                                                systematic approach that enables
  Note: The (P), (E), (S) and numbers for the nutrition diagnostic term (NI 55.1),              measurement of nutrition outcomes
  nutrition intervention term (ND-3.2), and nutrition monitoring and evaluation                 and ultimate demonstration of the
  terms (FI-6.2 and S-2.2) are included for the convenience of the reader; they are
  not necessarily recorded in the medical record.                                               RD’s effectiveness.
                                                                                                                     (Continued on page 16)

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Application                                    Terminology Reference Manual (4).            parameters selected reflect the author’s
  The NCP is designed for use with             These terms should not be adapted            personal practice philosophy, which
individual patients as well as groups and      or modified because they are designed        includes an evidence-based approach
populations. The remainder of this             to describe and capture the RD’s             to patient management. Of course,
article illustrates how the NCP and            activities related to the NCP.               nutrition support practice varies widely
standardized language may be applied             The following case provides an             and others might use a different approach
over several days. The case is presented       example of how the standardized              to problems presented. The reader is
using the assessment, diagnosis, inter-        language of dietetics and the ADIME          encouraged to set aside differences in
vention, monitoring, and evaluation            format can be used for medical record        opinion on how the patient is managed
(ADIME) format. Table 2 contains               documentation. The author appreciates        and focus on how the standardized
general guidelines for incorporating           that some RDs would provide a much           terminology may be applied.
key features of the NCP into some              more detailed note, while others would
                                               limit their documentation to information     Case
popular documentation formats. The
examples of chart notes also contain           unavailable elsewhere in the medical           HF is a 27-year-old previously
diagnostic, intervention, and monitor-         record. The intent is not to specify a       healthy male who was admitted to the
ing and evaluation terms from the              level of detail, but to provide sufficient   intensive care unit (ICU) following
International Dietetics and Nutrition          detail to describe the case. The inter-      emergency surgery for a ruptured
                                               ventions and monitoring and evaluation       appendix. He weighed 82 kg on
                                                                                            admission and was at ideal weight for
                                                                                            his height of 6 ft 1 in. His temperature
  Table 2. General Guidelines for Incorporating the Nutrition Care
                                                                                            was 100.4°F, and his white blood cell
  Process Into Six Common Documentation Formats
                                                                                            count was elevated (14×103/mcL) on
  ADIME                                     PGIE                                            admission. Other laboratory findings
  A = Assessment                            P = Problem                                     were unremarkable. On hospital day 2,
  D = Diagnosis or                              Diagnosis or                                HF was being weaned from the ventila-
      PES* statement                            PES* Statement                              tor and expected to transfer out of the
  I = Intervention                          G = Goal                                        ICU later in the day. The intravenous
      Nutrient Prescription                     Nutrient Prescription                       (IV) fluids of D5.45 saline were run-
      Nutrition Intervention                I = Intervention                                ning at 125 mL/h. Because all patients
      Goal                                      Nutrition Intervention                      admitted to the ICU are automatically
  M = Monitoring                                Goal                                        seen by an RD, a note must be entered
  E = Evaluation                            E = Evaluation                                  into his medical record before the
                                                                                            patient is transferred to the floor.
  SOAP                                      DAR                                             Cumulative patient data are shown
  S = Subjective                            D = Data                                        in Table 3.
  O = Objective                                 Diagnosis or
  A = Assessment                                PES* Statement                              Initial Assessment and Diagnosis
      Diagnosis or                          A = Action                                         As part of the initial assessment, the
      PES* Statement                            Nutrient Prescription                       RD reviewed the medical record for
      Nutrient Prescription                     Nutrition Intervention                      biochemical data, the results of medical
                                                                                            tests and procedures, and anthropomet-
  P = Plan                                      Goal
                                                                                            ric measures. Because HF was on a
      Nutrition Intervention                R = Response
                                                                                            ventilator, the food/nutrition and
                                                                                            client history was limited to a brief
  PIE                                       DAR-O                                           conversation with family members,
  P = Problem                               D = Data                                        who stated that he was eating well
      Diagnosis or                              Diagnosis or                                until 2 days prior to admission. Given
      PES* Statement                            PES* Statement                              the elevated blood glucose value, the
  I = Intervention                          A = Action                                      RD inquired about a history of
      Nutrition Intervention                    Nutrient Prescription                       diabetes, which was negative.
  E = Evaluation                                Nutrition Intervention
                                                                                            Nutrition Diagnostic Reasoning
                                            R = Response                                      The RD reviewed the assessment
                                            O = Output                                      data and compared the findings with
                                                                                            potential nutrition diagnoses. Because
  *PES=Problem, Etiology, Signs and Symptoms where Problem is a diagnostic term and
   Etiology, Signs and Symptoms are derived from the corresponding reference sheet for      of the elevated blood glucose value,
   the diagnostic term.                                                                     the RD evaluated the dextrose content
                                                                                            of the IV fluids and determined that it

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  Table 3. Cumulative Patient Data From Admission Through Hospital Day 10
                                  Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital
                                   Day 1    Day 2    Day 3    Day 4    Day 5    Day 6    Day 7    Day 8    Day 9   Day 10
  Sodium (mEq/L)                    135      134      132       132       130        132     133       133       137        135
  Potassium (mEq/L)                 3.4      4.1      4.8       3.2        4.4       3.9     3.7       4.6        4.7       4.6
  Chloride (mEq/L)                           111      113       102       103        101     102       100       100         99
  Carbon dioxide (mEq/L)                     17        17        23        21        20       18        17        18         19
  Blood urea nitrogen (mg/dL)                                    21        24        26       25        31        37         46
  Creatinine (mg/dL)                                            0.8        0.7       1.1     1.2       1.5        1.7       2.0
  Blood glucose (mg/dL)                      184      136       237       140        132     125       145       130        136
  Magnesium (mEq/L)                 1.9      2.1      2.4       1.6        1.7       1.6     1.2       1.4        1.8       2.0
  Phosphorus (mg/dL)                4.3      4.2      4.0       3.9        4.0       4.1     4.2       4.0        3.8       2.6
  Calcium (mg/dL)                   8.1      7.9      8.0       7.8        7.6       8.1     8.2       8.0        7.9       7.8
  Intake and Output
  Weight (kg)                       83       86        87        94        96        100      99        98        97         97
  Intake (L) (all sources)          5.1      3.4      7.8       4.7        3.0       3.6     2.8       2.4        2.4       2.4
  Output (L) (all sources)          1.8      2.0      1.0       1.6        1.6       2.5     3.1       3.0        3.0       1.6
  Vancomycin 1 g q12 h IV                     •        •         •          •         •       •         •          •         •
  Insulin drip (titrate to keep
  blood glucose <150 mg/dL)                                                 •         •       •         •          •         •
  Propofol 20 mcg/kg/min IV                                                 •         •       •         •          •
  Amphotericin B 50 mg qd IV                                                •         •       •         •          •         •

was likely insufficient to contribute to     data from the nutrition assessment,           Determining the Nutrition Prescription
hyperglycemia. The elevated blood            then writing “the patient has no                 The nutrition prescription concisely
glucose concentration appeared to be a       nutrition diagnosis at this time.” This       states individualized recommended
transient stress response following          statement would be substantiated by           dietary intake. It is based on current
surgery, and the RD confirmed that           published guidelines that clearly state       reference standards and dietary guide-
the surgeons had addressed the hyper-        that a previously healthy patient could       lines adjusted for the patient’s health
glycemia by ordering insulin coverage.       easily tolerate up to 7 days without          condition and nutrition diagnosis (3).
Because the hyperglycemia was not            nutrient intake (10). However, the            The level of detail for the nutrient
nutrition-related, the dietitian ruled       ruptured appendix made HF a candi-            prescription can be adjusted based on
out excessive carbohydrate intake            date for postoperative complications,         the patient’s condition as well as practice
(NI-53.3).                                   and a return to the ICU was a reason-         standards, institutional convention, and
  Clearly, HF was well nourished. The        able expectation. Because HF had              clinical judgment. Thus, the require-
RD did not identify any significant          been eating well prior to admission           ments for lipid, carbohydrate, and
nutrition problems except that he was        and had been NPO for less than 24             individual nutrients could be specified
NPO. However, the patient would              hours, the RD diagnosed inadequate            as needed. For HF, the RD based the
have a diet ordered in time for the          protein-energy intake (NI-5.3),               calorie and protein prescription on
evening meal. In this case, the RD           primarily because the definition of the       published standards (10). The recently
could simply decline to diagnose a           diagnosis refers to changes in physiologic    released evidence-based guideline for
nutrition problem by recording the           needs of short or recent duration (3).        critically ill patients also could be used,
                                                                                                              (Continued on next page)

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Support Line December 2007 Volume 29 No. 6

especially if a long-term ICU stay was             etiology. In this case, inadequate protein-          tered (DTR) can verify that the patient
anticipated (11).                                  energy intake will be alleviated with                is eating and report any identified
                                                   a general diet (ND-1), which will be                 problems to the RD. Table 4 illustrates
Nutrition Intervention                             ordered as soon as the patient is weaned             a sample initial note in the ADIME
  The nutrition intervention is designed           from the ventilator. Once the diet is                format that incorporates the nutrition
to treat the nutrition diagnosis or its            ordered, the dietetic technician regis-              diagnosis, prescription, nutrition

  Table 4. Initial Note Hospital Day 2
  Biochemical Data, Medical Tests and Procedures                              Anthropometric Measurements
  WNL except blood glucose of 184 mg/dL and WBC                               Ht. 6'1"; current weight is 86 kg; up from
  of 10,000 cells/mm3                                                         82 kg on admission.
  134 | 111 | 21 / 184
   4.1 | 17 | 0.8 \
  Physical Exam Findings                                                      Food and Nutrition History
                                                                              Eating well prior to admission; no known nutrient
  Deferred                                                                    modifications. Currently NPO; receiving D5.45
                                                                              saline at 125 mL/hr providing 510 calories and
                                                                              210 mEq Na. I&O + 6 L since admission.
  Client History
  Medical history: negative for diabetes. Surgical history: appendectomy for ruptured appendix last PM. Per MD, patient to
  wean from ventilator and transfer from ICU today. Regular diet to be ordered on extubation.
  #1 Problem Inadequate calorie and protein intake (NI-5.3)___________________________________________________
     Etiology related to insufficient GI access__________________________________________________________________
     Signs/Symptoms as evidenced by calorie intake 35% of required and no protein intake ___________________________
  #2 Problem ______________________________________________________________________________________________
     Etiology ______________________________________________________________________________________________
     Signs/Symptoms _______________________________________________________________________________________
  #3 Problem ______________________________________________________________________________________________
     Etiology ______________________________________________________________________________________________
     Signs/Symptoms _______________________________________________________________________________________
  Nutrition Prescription
  The patient/client’s individualized recommended                             Intervention #1 Order general diet (ND-1) _________
  dietary intake of energy and/or selected foods or                           Goal (s) Adequate PO intake_______________________
  nutrients based upon current reference standards
  and dietary guidelines and the patient/client’s                             Intervention #2__________________________________
  health condition and nutrition diagnosis. (specify)                         Goal (s)_________________________________________

  General diet providing 2,050 calories and 100 grams                         Intervention #3__________________________________
  of protein.________________________________________                         Goal (s)_________________________________________
  Indicator, e.g., self-monitoring ability                                    Criteria, e.g., intake amount, mg/dL
  #1 Energy intake (F1.1.1) _________________________                         #1 Consumes >2,000 kcal/day______________________
  #2 Protein intake (FI-5.2.1) _______________________                        #2 Consumes >90 grams of protein per day___________
  #3_______________________________________________                           #3 _____________________________________________
  Note: Terms in bold text are drawn directly from the International Dietetics and Nutrition Terminology Reference Manual. They are defined
  within the language and should not be modified. The codes (numbers in parenthesis) are included for the convenience of the reader, but
  it is not necessary to include them in the medical record.

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                                                                                 Support Line December 2007 Volume 29 No. 6

intervention, and monitoring and            had a cumulative input and output that     Nutrition Intervention
evaluation.                                 was positive by almost 15 L, no extra-        Consistent with unit protocol and
                                            ordinary sodium losses, and a sodium       an evidenced-based guideline, the RD
Follow-up on Hospital Day Four
                                            intake from his IV fluids in excess of     continued to restrict HF to 14 to
   HF was transferred to the floor as
                                            his requirements (3,10). The RD            18 kcal/kg/day for the first week in the
planned, but on hospital day 3, his
                                            attributed the hyponatremia to the         ICU (15). During the second week, the
temperature reached 102°F, and he
                                            cumulative input and output, which         RD might recalculate energy require-
complained of abdominal pain. That
                                            resulted from medically necessary IV       ments based on the Penn State Equation:
afternoon, he underwent small bowel
                                            fluids administered during surgery and     (HB (0.85)+VE(33)+Tmax(175)-6433),
resection for ischemic necrosis. Results
                                            the postoperative stress response. She     as recommended in the evidence-based
of the operation included a temporary
diverting ileostomy. His ileocecal valve    elected to monitor the serum sodium,       guide for critically ill patients (16).
and colon were intact, with about 200       which she knew would normalize with        This information would be incorpo-
cm of small bowel in continuity and         postoperative diuresis. She suggested      rated into the nutrition prescription.
the remaining segment excluded by           on rounds a reduction in the current          In this setting, the RD had obtained
the diverting colostomy.                    IV fluid rate, documented the positive     clinical privileges to place the feeding
   On hospital day 4, the RD found          cumulative input and output in the         tube and write orders for EN and PN
that HF weighed 94 kg. His skin was         assessment, and adjusted the nutrition     and monitoring if consulted by the
warm and dry to the touch, and he had       intervention to reflect the need for       physician to do so. The RD reviewed
+2 pedal edema. Bowel sounds were           maximally concentrated formula.            the assessment data and developed a
inaudible, and an ileostomy bag was in         The RD also noticed the sharp           plan of care with the surgeons. The
place, but there was no drainage.           increase in serum glucose concentration    decision was made to initiate a small
Nasogastric (NG) tube output was            and evaluated HF for a diagnosis of        bowel feeding tube because the NG
about 100 mL over the previous              altered nutrition-related laboratory       suction would interfere with gastric
8-hour shift. Ventilator settings were      value, glucose (NC-2.2) (3). However,      feedings. In another patient, the RD
intermittent ventilation of 24 breaths/     the carbohydrate intake of 150 g           might have placed an NG tube based
min, FiO2 of 80%, and 6 cm of posi-         (1.2 mg/kg/min) was far below the          on recent evidence denying a clear
tive end-expiratory pressure. The max-      recommended maximum of 472 g               advantage of small bowel over NG
imum temperature was 100.6°F. Blood         (4 mg/kg/min per day) (14), and this       feeding (11). The RD selected a stan-
cultures were positive for Staphylococcus   diagnosis was ruled out. A diagnosis of    dard formula with the highest possible
epidermis and Escherichia coli. He was      excessive carbohydrate intake (NI-53.2)    protein content to balance the dextrose
receiving D5.45 lactated Ringer at          was ruled out for the same reason. The     calories from the IV fluids and the fat
125 mL/hr. Vancomycin and ampho-            elevated blood glucose was attributed      calories from the propofol. Additional
tericin B were started postoperatively.     to impaired glucose metabolism com-        protein could be added if the propofol
An insulin drip was started according       monly seen in sepsis, and the amount       and IV fluids continued. The RD did
to unit protocol, and a multiple            of insulin administered via a continuous   not select an immune-enhancing formula
vitamin infusion was ordered.               insulin infusion (insulin drip) was        because such formulas are not recom-
                                            increased per unit protocol.               mended for routine use (15). Table 5
Nutrition Diagnostic Reasoning                 The RD also noticed the magnesium       shows a sample nutrition progress note.
  The RD recognized that HF had             value of 1.6 mg/dL. She evaluated the
                                            patient’s recent magnesium intake and      Follow-up on Hospital Days Eight
developed sepsis, according to the
                                            noted that HF had not received             and Ten
widely used criteria of the American
                                            magnesium supplementation since               On hospital day 8, HF weighed 98 kg.
Academy of Chest Physicians (12), and
                                            admission. He was asymptomatic, but        His blood glucose values were within
considered a second nutrition diagnosis:
                                            likely had increased urinary losses of     the acceptable range established by the
increased nutrient needs (NI-5.1) (3).
                                            magnesium associated with ampho-           team managing his blood glucose and
However, the definition of increased                                                   insulin. However, his renal function
needs is “increased need for a specific     tericin administration, which would
                                            continue for several more days. The        was declining, consistent with his
nutrient compared to established ref-                                                  clinical course of sepsis and antibiotic
erence standards.” Because there was        RD added inadequate mineral intake
                                            (magnesium) (NI-55.1) to the list of       administration. His IV fluids were
no evidence that HF required more                                                      0.45 saline at 80 mL/hr. Enteral feed-
calories or protein than specified in       diagnoses because HF had a lower-
                                            than-recommended intake based on           ings were held because he had 2 L of
reference standards for a critically ill                                               liquid stool in a 24-hour period. Stool
patient with sepsis, that diagnosis was     physiologic needs, which is consistent
                                            with the diagnostic criteria for inade-    output had decreased sharply since
rejected (13).                                                                         cessation of feeding 8 hours earlier. The
  The RD noticed a marginally low           quate mineral intake. She spoke with
                                            the surgeon, who ordered 2 g of            physicians attributed the stool output
serum sodium concentration, but                                                        to the length and/or condition of his
quickly rejected inadequate mineral         magnesium sulfate IV to correct
intake (sodium) (NI-55.1) because HF        the intake deficit.                                          (Continued on page 21)

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 Table 5. Follow-up Note for Hospital Day 4
 Biochemical Data, Medical Tests and Procedures                            Anthropometric Measurements
 Labs:                                                                     Ht. 6'1"; current weight is 94 kg; up from
 132 | 102 | 21 / 237                                                      82 kg on admission. 82 kg is dosing weight.
  3.2 | 23 | 0.8\
 calcium: 7.8; phosphorus: 3.9; magnesium: 1.6
 Physical Exam Findings                                                    Food and Nutrition History
 + 2 edema of lower extremities                                            Diet NPO; 24 hour I&O + 4 L.
 NG tube to intermittent suction                                           Cumulative I&O + 14.6 L.
 No bowel sounds                                                           Receiving D5.45 saline at 125 mL/hr. and propofol
 Ileostomy without drainage                                                at 10 mL/hr providing 774 calories & 210 mEq Na.
 T max 100.6
 Client History
 Medications: vancomycin, amphotericin B, propofol, insulin drip, potassium chloride; multiple vitamin infusion. Bowel
 resection last PM with diverting ileostomy; intact ileocecal valve and colon.
 #1 Problem Inadequate protein-energy intake (NI-5.3) ______________________________________________________
    Etiology related to insufficient GI access__________________________________________________________________
    Signs/Symptoms as evidenced by calorie intake 35% of required and no protein intake ___________________________
 #2 Problem Inadequate mineral intake (magnesium) (NI-55.1) _______________________________________________
    Etiology related to magnesium losses with amphotericin_____________________________________________________
    Signs/Symptoms as evidenced by serum magnesium of 1.6 mg/dL ____________________________________________
 #3 Problem ______________________________________________________________________________________________
    Etiology ______________________________________________________________________________________________
    Signs/Symptoms _______________________________________________________________________________________
 Nutrition Prescription
 The patient/client’s individualized recommended                           Intervention #1 Dietitian will insert enteral feeding
 dietary intake of energy and/or selected foods or                         tube (ND-3.1)___________________________________
 nutrients based upon current reference standards                          Goal (s) Enteral access_____________________________
 and dietary guidelines and the patient/client’s
 health condition and nutrition diagnosis. (specify)                       Intervention #2 Dietitian will initiate enteral feedings
                                                                           with standard 2 kcal/mL feeding at 25 mL/hr when tube
 Based on 82-kg dosing weight, permissive underfeeding                     placed (ND-2) and decrease IV fluids accordingly______
 with 2 kcal/mL feeding at 25 mL/hr to provide 1,230 kcal                  Goal (s) Optimum nutrient intake by 10 PM today _____
 and 55 g protein in minimal volume. Supplement vitamins,
 minerals, and electrolytes to meet needs._________________                Intervention #3 Dietitian will order enteral nutrition
 ___________________________________________________                       monitoring protocol______________________________
 ___________________________________________________                       Goal (s) Identify feeding intolerance_________________
 ___________________________________________________                       Intervention #4 Recommend 2 g of Mg sulfate IV as
 ___________________________________________________                       discussed with surgery_____________________________
 ___________________________________________________                       Goal (s) Replete serum Mg_________________________
 Indicator, e.g., self-monitoring ability                                  Criteria, e.g., intake amount, mg/dL
 #1   Enteral access (FI-3.1.1) _________________________                  #1   Placement confirmed by radiograph ______________
 #2   Enteral formula (FI-3.1.2)________________________                   #2   Recorded intake of 25 mL/hr of feeding___________
 #3   Energy intake (F1.1.1) ___________________________                   #3   Recorded intake of 25 mL/hr of feeding___________
 #4   Protein intake (FI-5.2.1) _________________________                  #4   Recorded intake of 25 mL/hr of feeding___________
 #5   Total carbohydrate intake (FI-5.3.1)_______________                  #5   Carbohydrate intake from all sources <472 g/day____
 For dietitians without privileges to insert the feeding tube, order the formula, and provide the monitoring protocol, the wording
 “Recommend post-pyloric feeding tube, etc.” may be substituted.

                                                                 – 20 –
                                                                                   Support Line December 2007 Volume 29 No. 6

remaining bowel and recommended that       feedings. Inadequate mineral intake           identify and document nutrition-
feedings be held. The RD recognized        (magnesium) resolved with ongoing             related problems and their resolution.
that HF had altered gastrointestinal       magnesium supplementation in the              The anticipated result is improved
(GI) function (NC-1.4), but also con-      PN. Altered GI function persisted. The        communication with other profession-
tinued to have inadequate intake from      decline in serum phosphorus values            als, increased visibility of the dietitian’s
enteral/parenteral nutrition (NI-2.3).     suggested to the RD the possibility of        role, and clearer documentation of the
The RD could revise the PES statement      an altered nutrition-related laboratory       dietitian’s unique contribution to
for the inadequate enteral/parenteral      value (phosphorus) (NC-2.2) (3).              patient care.
intake to include altered GI function      However, she rejected the diagnosis
                                                                                         Readers are encouraged to log in to the DNS
as an etiology. However, the altered       because the decrease in phosphorus
GI function was the nutrition diagnosis                                                  listserve to discuss this article with the author.
                                           concentrations likely represented
driving a change in therapy, and two       refeeding hypophosphatemia, which is          Annalynn Skipper, PhD, RD, FADA, has
separate diagnoses were recorded.          not included in NC-2.2. The diagnosis         more than 25 years experience as a nutrition
   The RD and the surgeons were con-       also could have been inadequate mineral       support dietitian. She is an author and
cerned that HF had suboptimal intake       intake (NI-55.1) (phosphorus). How-           consultant in Oak Park, Ill.
for most of the 8 days since admission.    ever, the RD selected imbalance of
In some instances, the feeding would       nutrients (NI 5.5) to describe more           References
be held and subsequently restarted.        precisely the relationship between             1. Lacey K, Pritchett E. Nutrition care
However, in light of this patient’s                                                          process and model: ADA adopts road
                                           phosphorus and carbohydrate. After
                                                                                             map to quality care and outcomes
deteriorating condition, marginal GI       discussion with the surgeons, the RD              management. J Am Diet Assoc. 2003;
function, and an accumulating calorie      supplemented the PN with an additional            103:1061–1071.
deficit, the decision was made to start    20 mEq of sodium phosphate and                 2. Nutrition Diagnosis: A Critical Step in
PN and reinitiate enteral feedings as      anticipated resolution of hypophos-               the Nutrition Care Process. Chicago, Ill:
tolerated. The surgeons changed the                                                          American Dietetic Association; 2005.
                                           phatemia the next day (Table 7). The           3. Nutrition Diagnosis and Intervention:
central line, and the RD ordered 1 L       RD also informed the nurse of an                  Standardized Language for the Nutrition
of PN containing 60 g amino acids          increase in dextrose intake and the               Care Process. Chicago, Ill: American
(0.7 g/kg) and 200 g (1.6 mg/kg/min)       potential for an increased insulin                Dietetic Association; 2006.
dextrose to be administered over 24                                                       4. International Dietetics and Nutrition
                                           requirement.                                      Terminology Reference Manual. Chicago,
hours daily with electrolytes, decreased      On hospital day 14, HF was stable              Ill: American Dietetic Association; 2007.
potassium, and increased acetate to        and weaned off the ventilator. A general       5. American Medical Association. CPT®
accommodate declining renal function.      healthful diet was ordered (ND-1),                2007 Professional Edition. Chicago, Ill:
She ordered a 250-mL bottle of 20%                                                           American Medical Association; 2007.
                                           and HF was transferred out of the ICU          6. American Medical Association. AMA
lipids to be administered as an IV rider   to the care of another RD. The ICU                Physician ICD-9-CM 2007, Volumes 1 &
over 12 hours daily. She planned to        RD signed off and transferred care to             2. Chicago, Ill: American Medical
increase the feeding to goal the follow-   the RD on the floor (RC-2).                       Association; 2007.
ing day and checked to ensure that                                                        7. NANDA International. Nursing
laboratory tests were ordered for          Conclusion                                        Diagnosis: Definitions and Classification
                                                                                             2005-2006. Philadelphia, Pa: NANDA
monitoring. Sample follow-up                 The NCP is a four-step problem-                 International: 2006.
documentation is found in Table 6.         solving process that can be used to            8. American Physical Therapy
   On hospital day 10, HF weighed 97 kg.   identify nutrition problems that the              Association. Guide to Physical Therapist
The RD had decreased his IV fluids to                                                        Practice. 2nd ed. Fairfax, Va: American
                                           RD can treat independently. The stan-             Physical Therapy Association; 2003.
20 mL/hr and increased his PN to goal      dardized language is used to describe          9. Bowen JL. Educational strategies to
the day before. Despite declining renal    nutrition diagnoses, interventions, and           promote clinical diagnostic reasoning.
function, phosphorus concentrations        monitoring and evaluation. The NCP                N Engl J Med. 2006;355:2217–2225.
declined from 4.0 to 2.6 mg/dL. His                                                      10. A.S.P.E.N. Board of Directors and the
                                           and standardized language are                     Clinical Guidelines Task Force. Guide-
stool output had slowed to 1 L/24 hr.      designed for use by RDs caring for                lines for the use of parenteral and enteral
Blood glucose control was acceptable       patients or clients of all ages and levels        nutrition in adult and pediatric patients.
on the insulin drip. If blood glucose      of complexity. Critically ill patients            JPEN J Parenter Enteral Nutr. 2002;
values remained below 150 mg/dL, the                                                         26(suppl):1SA–138SA.
                                           with myriad intercurrent medical and          11. Critical Illness Evidence-Based
surgeons would consider administering      nutritional problems present chal-                Nutrition Practice Guideline. Available
octreotide for the diarrhea, but PN        lenges in applying the NCP that can               at: http://www.adaevidencelibrary.
was scheduled to continue until the        be overcome with clear thinking that              com/topic.cfm?cat=2799. Accessed
diarrhea was better controlled.                                                              November 20, 2006.
                                           clusters detailed information used to         12. Bone R, Balk R, Cerra F, et al.
Nutrition Diagnostic Reasoning             manage critically ill patients. The               Definitions for sepsis and organ failure
                                           NCP and standardized language of                  and guidelines for the use of innovative
  The inadequate EN and PN has             dietetics is designed to describe the             therapies in sepsis. The ACCP/SCCM
resolved with the achievement of goal      nutrition problems that the RD can                                  (Continued on page 23)

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Support Line December 2007 Volume 29 No. 6

 Table 6. Follow-up Note for Hospital Day 8
 Biochemical Data, Medical Tests and Procedures                     Anthropometric Measurements
 Labs:                                                              Ht. 6'1"; current weight is 98 kg; up from
 133 | 100 | 31 / 145                                               82 kg on admission. 82 kg is dosing weight.
  4.6 | 17 | 1.5\
 calcium: 7.6; phosphorus: 4.0; magnesium: 1.7
 Physical Exam Findings                                             Food and Nutrition History
 + 2 edema of lower extremities                                     Feedings held for 2 L stool output. Diet NPO; 24 hour
 + NG tube to drainage                                              I&O – 1.4 L; Cumulative I&O +16.6 L; 0.45 saline at
                                                                    80 mL/hr. Propofol at 10 mL/hr. Total intake over last
                                                                    24 hours is approximately 400 kcal & 150 mEq Na
 Client History
 Medications: vancomycin, amphotericin B, propofol, insulin drip.

 #1 Problem Inadequate intake from enteral nutrition infusion (NI-2.3)________________________________________
    Etiology related to feeding intolerance____________________________________________________________________
    Signs/Symptoms as evidenced by intake less than needs______________________________________________________
 #2 Problem Altered GI function (NC-1.4)___________________________________________________________________
    Etiology related to bowel resection_______________________________________________________________________
    Signs/Symptoms as evidenced by 2 L stool output that declined when enteral feedings discontinued________________
 #3 Problem ______________________________________________________________________________________________
    Etiology ______________________________________________________________________________________________
    Signs/Symptoms _______________________________________________________________________________________

 Nutrition Prescription
 The patient/client’s individualized recommended dietary            Intervention #1 Initiate parenteral nutrition (ND-2)___
 intake of energy and/or selected foods or nutrients                Goal (s) 1 L of PN containing 60 g amino acids and
 based upon current reference standards and dietary                 200 g dextrose over 24 hours. Administer 250 mL of
 guidelines and the patient/client’s health condition               20% lipids over 12 hours separately with reduced
 and nutrition diagnosis. (specify)                                 potassium (20 mEq) and increased (maximum)
                                                                    acetate relative to baseline._________________________
 1.5 L PN providing 100 g of protein and 340 g of dextrose
 over 24 hours daily with an IV rider of 250 mL of 20% lipids       Intervention #2 Order parenteral nutrition
 daily over 12 hours. Electrolytes to meet baseline needs are       monitoring protocol______________________________
 80 mEq Na, 30 mEq K, 20 mmol phosphorus, 10 mEq                    Goal (s) Identify feeding intolerance_________________
 calcium, 8 mEq Mg (with 1/3 chloride and 2/3 acetate).
 Will also give 10 mL MVI, 3 mL trace elements, and                 Intervention #3__________________________________
 40 mg famotidine daily_______________________________              Goal (s)_________________________________________
 Indicator, e.g., self-monitoring ability                           Criteria, e.g., intake amount, mg/dL
 #1   Parenteral access (FI-3.1.1) ______________________           #1   Parenteral access patent_________________________
 #2   Parenteral formula (FI-3.1.2)_____________________            #2   Parenteral formula administered as ordered________
 #3   Parenteral formula rate/schedule (FI-3.1.5)________           #3   Parenteral formula administered as ordered________
 #4   Energy intake (F1.1.1)___________________________             #4   Parenteral formula contains 1420 calories__________
 #5   Protein intake (FI-5.2.1)_________________________            #5   Parenteral formula contains 60 g/protein__________
 #6   Total carbohydrate intake (FI-5.3.1)_______________           #6   Carbohydrate intake from all sources <472 g/day____

                                                          – 22 –
                                                                                                 Support Line December 2007 Volume 29 No. 6

    Consensus Conference Committee.                14. Wolfe R, O'Donnell T Jr, Stone M,                       feedings for critically ill patients. J Am
    American College of Chest Physicians/              Richmand D, Burke J. Investigation of                   Diet Assoc. 2006;102:1226–1241.
    Society of Critical Care Medicine.                 factors determining the optimal glucose             16. Frankenfield D, Smith J, Cooney R.
    Chest. 1992;101:1644–1655.                         infusion rate in total parenteral nutrition.            Accelerated nitrogen loss after traumatic
13. Cerra FB, Benetiz MR, Blackburn GL,                Metab Clin Experiment. 1980;29:892–900.                 injury is not attenuated by achievement
    et al. Applied nutrition in ICU patients:      15. Kattelmann KK, Hise M, Russell M,                       of energy balance. JPEN J Parenter
    a consensus statement of the American              Charney P, Stokes M, Compher C.                         Enteral Nutr. 1997;21:324–329.
    College of Chest Physicians. Chest. 1997;          Preliminary evidence for a medical
    111:769–777.                                       nutrition therapy protocol: enteral

  Table 7. Follow-up Note for Hospital Day 10
  Biochemical Data, Medical Tests and Procedures                                 Anthropometric Measurements
  Labs:                                                                          Ht. 6'1"; current weight is 97 kg; up from
  135 | 99 | 46 /                                                                82 kg on admission. 82 kg is dosing weight.
   4.6 | 19 | 2.0\
  calcium: 7.6; phosphorus: 2.6; magnesium: 2.0
  Physical Exam Findings                                                         Food and Nutrition History
  + 2 edema of lower extremities                                                 NPO; Receiving PN as ordered. 24 hour I&O + 0.8 L;
  + NG tube to drainage                                                          cumulative I&O + 15.2; 0.45 saline at 20 mL/hr
                                                                                 provides 35 mEq/day of Na
  Client History
  Vancomycin, amphotericin B, propofol, insulin drip.
  #1 Problem Inadequate intake from enteral nutrition infusion (NI-2.3) has resolved_____________________________
     Signs/Symptoms _______________________________________________________________________________________
  #2 Problem Altered GI function (NC-1.4)___________________________________________________________________
     Etiology related to bowel resection_______________________________________________________________________
     Signs/Symptoms as evidenced by 2 L stool output, which declined when enteral feedings discontinued ______________
  #3 Problem Imbalance of Nutrients (NI-5.5) _______________________________________________________________
     Etiology related to insufficient phosphorus to balance carbohydrate intake ______________________________________
     Signs/Symptoms as evidenced by a decline in serum phosphorus level__________________________________________
  Nutrition Prescription
  The patient/client’s individualized recommended                                Intervention #1 Dietitian will order 1.5 L of PN with
  dietary intake of energy and/or selected foods or                              65 g amino acids and 340 g dextrose over 24 hours
  nutrients based upon current reference standards                               daily with 250 mL of 20% lipids daily plus additional
  and dietary guidelines and the patient/client’s                                acetate and reduced potassium.______________________
  health condition and nutrition diagnosis. (specify)                            Goal (s) PN to meet goal needs as BUN corrects______

  1.5 L parenteral nutrition providing 100 g of protein and                      Intervention #2 Dietitian will order parenteral
  340 g of dextrose over 24 hours daily with an IV rider of                      nutrition monitoring protocol_______________________
  250 mL of 20% lipids daily over 12 hours. Electrolytes to                      Goal (s) Identify feeding intolerance_________________
  meet baseline needs are 80 mEq Na, 30 mEq K, 20 mmol
  phosphorus, 10 mEq calcium, 8 mEq Mg (with 1⁄3 chloride                        Intervention #3 Dietitian will increase the phosphorus
  and 2⁄3 acetate), 10 mL MVI, 3 mL trace elements, and                          in the PN to 39 mmol_____________________________
  40 mg famotidine daily _______________________________                         Goal (s) Serum phosphorus level of 4.0 mg/dL________
  Indicator, e.g., self-monitoring ability                                       Criteria, e.g., intake amount, mg/dL
  #1 Parenteral formula rate/schedule (FI-3.1.5) ________                        #1 I&O sheet reflects PN administered as ordered_____
  #2 ________________________________________________                            #2 Serum phosphorus within normal limits___________
  #3 ________________________________________________                            #3 ____________________________________________

                                                                      – 23 –

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