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NCP A Brief Overview SOMC

NCP A Brief Overview SOMC. BY: Stephanie Yednak And Cheryl Muller. NCP. Assessment Diagnosis Intervention Monitoring and Evaluation ADIME Notes can be organized in ADIME fashion to ensure compliance to NCP. Assessment Food and Nutrition Related History. What should be included:

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NCP A Brief Overview SOMC

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  1. NCPA Brief OverviewSOMC BY: Stephanie Yednak And Cheryl Muller

  2. NCP • Assessment • Diagnosis • Intervention • Monitoring and Evaluation • ADIME • Notes can be organized in ADIME fashion to ensure compliance to NCP

  3. AssessmentFood and Nutrition Related History What should be included: • Intake • Mode of administration (mouth, tube) • Nutrition knowledge/beliefs • Physical activity • Supplement use • Nutrition quality of life

  4. Assessment:Anthropometric Measurements • Height • Weight • BMI • Weight history

  5. Assessment:Biochemical Data, Tests, Procedures • Lab values • Pertinent tests (endo, swallow, ect)

  6. Assessment:Nutrition Focused Physical Findings • Physical appearance • Muscle and fat wasting • Swallow function • Appetite

  7. Assessment: Client Hx • Personal history • Medical and family history • Past treatments • CAM • Social history

  8. NUTRITION Diagnosis • Can be related to: • Intake (poor po, too much sat fat, ect) • Clinical (nutrition problems that relate to medical problems (lab values, swallowing difficulty, obesity, unintended wt loss) • Behavioral-environmental (poor adherence to diet, not ready to make lifestyle changes, inactive PA, poor food choices)

  9. PES • P- problem • Describes alterations in nutrition status • Malnutrition, altered GI function • E-etiology • Cause/contributing factors (related to) • Increased energy needs, inappropriate food choices • S- Signs/symptoms • Data used to determine the diagnosis (as evidenced by) • Low BMI, hyperglycemia, jaundice

  10. PES:Putting it all together • Inadequate vitamin intake (N1-5.9.1) related to limited access to food as evidenced by low serum levels of folate • Inadequate oral intake (NI-2.1) related to swallowing difficulty as evidenced by significant weight loss of >10% BW in 6 months. • Food and nutrition related knowledge deficit (NB-1.1) related to harmful beliefs about food and nutrition as evidenced by pt verbalizes disinterest in complying with diet or learning accurate information.

  11. Intervention • Food and or Nutrient Delivery (meals, snacks, delivery, supplements, PN infusion) • Nutrition Education (cholesterol, fiber, K) • Nutrition Counseling (establish goals, facilitate change) • Coordination of Nutrition Care (other health care providers)

  12. Intervention examples • Enteral Nutrition (ND-2.1) • Insert enteral feeding tube (ND-2.1.2) • Medical food supplements (ND-3.1) • Ensure bid • Vitamin and Mineral Supplements (ND-3.2) • Increase calcium intake, decreases vitamin K

  13. Nutrition Prescription • Different than medical • What you recommend • Protein needs, fluid • Modified diet • Fat/ salt restriction

  14. Monitoring & EvaluationOUTCOME • Food and Nutrition Related History Outcomes • Intake increased, PA, better compliance • Anthropometric Measurement Outcomes • Pt gained/lost weight, BMI • Biochemical Data, tests, outcomes • BG stabelized, no ulcers in endo • Nutrition Focused Physical Finding Outcomes • Physical appearance, swallow function, appetite

  15. M&E example • Patient consuming ~ 2600 kcal/day, 144% recommended intake of 1800 kcal, will continue to monitor and encourage compliance

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