Dietetic and Nutrition

Case Studies

Judy Lawrence, Pauline Douglas, Joan Gandy

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781118898246
• Edition: 1
• Topic: Medicine
• Subtopic: Nutrition, Dietics & Bariatrics

The ideal companion resource to 'Manual of Dietetic Practice', this book takes a problem-based learning approach to dietetics and nutrition with cases written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge

• Each case study follows the Process for Nutrition and Dietetic Practice published by the British Dietetic Association in 2012
• Includes case studies in public health, an increasingly important area of practice

Part I

Chapter 1
Model and process for nutrition and dietetic practice

Judy Lawrence

The nutrition care process and model was first conceived by the Academy of Nutrition and Dietetics (Lacey & Pritchett, 2003). Since then it has evolved and been adapted and is now used by dietitians and nutritionists worldwide. The case studies in this book are written with the nutrition and dietetic care process in mind. The process can be used in any setting including clinical dietetics and public health. Although case studies in this book are based around the British Dietetic Association's (BDA) (2012) model and process (Figure 1.1) used by dietitians in the United Kingdom, they can be used alongside other versions of the process and model as well. The model starts with the identification of nutritional need, followed by six stages, namely, assessment, identification of the nutrition and dietetic diagnosis, planning the nutrition and dietetic intervention, implementing the intervention, monitoring and reviewing the intervention and finally evaluating the intervention.

Figure 1.1 Nutrition and dietetic process (BDA (2012), p. 7. Reproduced with permission of British Dietetis Association).

The case studies use the ABCDE approach (Gandy, 2014), were A is for anthropometry, B stands for biochemical and haematological markers, C for clinical, D for dietary and E is used to include economic, environmental and social issues that may be relevant. Information collected during the assessment is used to make the nutrition and dietetic diagnosis. More details of the assessment can be found in Chapter 4.

Identifying the nutrition and dietetic diagnosis

The nutrition and dietetic diagnosis is the nutritional problem that is assessed using the dietitian's clinical reasoning skills and resolved or improved by dietetic intervention. The nutrition and dietetic diagnosis is a key part of the care process, and once the correct diagnosis has been made the intervention and the most appropriate outcomes to monitor will fall into place. The nutrition and dietetic diagnosis is written as a structured sentence known as the PASS statement, where P is the problem, A the aetiology and SS the signs and symptoms. The PASS statement should describe the ‘Problem’ related to ‘Aetiology’ as characterised by ‘Signs/Symptoms’, for example; inadequate energy intake (problem) related to an overly restrictive gluten free diet (aetiology) as characterised by weight loss of 4 kg and anxiety regarding appropriate food choices (signs and symptoms). A well-written PASS statement is one where the dietitian or nutritionist can improve or resolve the problem, the intervention addresses the aetiology and the signs and symptoms can be monitored and improved. The nutrition and dietetic diagnosis can be broken down into the three steps; problem, aetiology and signs and symptoms.

Problem

This is the nutritional (dietetic) problem not the medical problem; it is the problem that can be addressed by dietetic intervention. In these case studies, the problems are expressed using the diagnosis terms as approved by the BDA. More details about the terminology can be found in Chapter 2 on international language and terminology. The problem is the change in the nutrition state that is described by adjectives such as decreased/increased, excessive/inadequate, restricted and imbalanced. In the United Kingdom, nutrition and dietetic diagnosis terms fall into one of the following seven categories:

• Energy balance;
• Oral or nutritional support;
• Nutrient intake;
• Function, for example, swallowing;
• Biochemical;
• Weight; and
• Behavioural/environmental.

There may be more than one problem, so a number of nutritional and dietetic diagnoses may be possible but these can often be consolidated into one diagnosis or one diagnosis may be prioritised, using clinical judgement and the client's wishes. Some nutrition and dietetic diagnosis may be more appropriate than others; practice and experience will hone this skill.

Aetiology

The aetiology is the cause of the nutritional problem. Causes may be related to behavioural issues such as food choices, environmental issues such as food availability, knowledge such as not knowing which foods are gluten free, physical such as inability to chew food, or cultural such as beliefs about foods. There may be more than one cause for the problem that a client has but the dietitian should be able to identify the basis of the problem using the information gained during the assessment process. For example, a client may have an incomplete knowledge of their gluten-free diet and this may be caused by:

• Missing a dietetic appointment;
• Not appreciating that all gluten-containing foods need to avoided;
• A misconception that the diet was not important; and
• A lack of awareness of the gluten content of many manufactured foods.

It is also important that the aetiology identified in the PASS statement is one that the dietitian can influence because the aetiology forms the basis of the intervention. It may be difficult to identify the cause of the problem and in such circumstances the pragmatic approach may be to identify the contributing factors. Once identified, the aetiology may be linked to the problem using the phrase ‘related to’.

Signs and symptoms

Signs are the objective evidence that the problem exists; they may be from anthropometric measurements, biochemical or haematological results. Symptoms are subjective: they may be things that the patient/client has talked about such as tiredness, clothes being too tight or loose, difficulty swallowing and lack of understanding. Signs and symptoms gathered during the assessment process can be used to quantify the problem and indicate its severity. Signs and symptoms may be linked to the aetiology using the phrase ‘characterised by’. It is not necessary to have both signs and symptoms in the diagnostic statement; one or the other is adequate.

Alternative diagnoses may be made when answering the questions in the case studies. It does not necessarily mean that your statement is incorrect; it may be a reasonable alternative or less of a priority. Check that your PASS statement describes a problem that can be altered by dietetic intervention and that the evidence collected during the assessment process suggests that it is important. The signs and symptoms should ideally be ones that can be measures to help advance the progress in alleviating the problem.

Nutrition intervention

The nutrition intervention is the action taken by the dietitian to address the diagnosis. Ideally, the intervention should be aimed at the cause of the problem, the aetiology, but if this is not possible then the intervention should address the signs and symptoms of the problem. In some cases, the intervention may be to maintain a current situation, for example, adult PKU. The intervention may involve the dietitian in delegating or co-ordinating the nutrition care done by others. The intervention has two stages: planning and implementation. For each PASS statement it is necessary to establish a goal based on the signs and symptoms (planning) and an approp...