This book is dedicated to Pat Judd (1947–2015), inspirational dietitian and educator.
Registered Dietitian, the Research Officer for the BDA, and Visiting Researcher,
Nutrition and Dietetics, King's College London, England
Registered Dietitian, a Senior Lecturer and Clinical Dietetic Facilitator,
Northern Ireland Centre for Food and Health (NICHE), Ulster University,
Northern Ireland
Registered Dietitian, a Freelance Dietitian and Visiting Researcher in Nutrition and Dietetics,
University of Hertfordshire, England
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Library of Congress Cataloging-in-Publication Data
Names: Lawrence, Judy, 1960- , editor. | Gandy, Joan, editor. | Douglas, Pauline, 1961- , editor.
Title: Dietetic and nutrition case studies / edited by Judy Lawrence, Joan
Gandy, Pauline Douglas.
Description: Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons, 2016.
| Complemented by: Manual of dietetic practice / edited by Joan Gandy in conjunction with the British Dietetic Association. Fifth edition. 2014. |
Includes bibliographical references and index.
Identifiers: LCCN 2015040817 (print) | LCCN 2015042999 (ebook) | ISBN 9781118897102 (pbk.) | ISBN 9781118898239 (pdf) | ISBN 9781118898246 (epub)
Subjects: | MESH: Dietetics. | Nutritional Physiological Phenomena. | Diet
Therapy. | Problem-Based Learning.
Classification: LCC RM216 (print) | LCC RM216 (ebook) | NLM WB 400 | DDC
615.8/54–dc23
LC record available at http://lccn.loc.gov/2015040817
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Ellie Allen
Barbara Martini Arora
Eleanor Baldwin
Julie Beckerson
Kathleen Beggs
Helen Bennewith
Sarah Bowyer
Rachael Brandreth
Elaine Cawadias
Alison Culkin
Rachael Donnelly
Pauline Douglas
Hilary Du Cane
Alastair Duncan
Mary Flynn
Caroline Foster
Lisa Gaff
Joan Gandy
Elaine Gardner
Susie Hamlin
Nicola Henderson
Sandra Hood
Nicola Howle
Bushra Jafri
Yvonne Jeanes
Sema Jethwa
Susanna Johnson
Natasha Jones
Ruth Kander
Joanna Lamming
Anne Laverty
Judy Lawrence
Julie Leaper
Sian Lewis
Sherly X. Li
Seema Lodhia
Julie Lovegrove
Marjorie Macleod
Paul McArdle
Angela McComb
Caoimhe McDonald
Jennifer McIntosh
Yvonne McKenzie
Kirsty-Anna McLaughlin
Kassandra Montanheiro
Eileen Murray
Mary O'Kane
Sian O'Shea
Sue Perry
Gail Pinnock
Vicki Pout
Louise Robertson
Juneeshree S. Sangani
Nicola Scott
Ella Segaran
Reena Shaunak
Bushra Siddiqui
Isabel Skypala
Alison Smith
Chris Smith
Clare Stradling
Carolyn Taylor
Lucy Turnbull
Evelyn Volders
Kirsten Whitehead
Kate Williams
E. Mark Windle
Problem-based learning (PBL) is increasingly becoming the preferred method of teaching in health care. There is currently a dearth of appropriately written case studies. This book takes a PBL approach to dietetics and nutrition and aims to address this gap. It has been written to complement the Manual of Dietetic Practice (MDP) (5th edition), and the case studies are cross-referenced accordingly. Uniquely, the case studies are written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge. This book has been written and edited with many readers in mind. Lecturers and staff in universities with courses in dietetics and nutrition will undoubtedly find it relevant although it will be useful to many other health care students and professionals. The case studies are also aimed at qualified dietitians and nutritionists as a tool to enhance their continuing professional development. Readers will be able to work through the case studies individually and in groups in different settings including dietetic departments. It will also help dietetic students and dietitians to identify further areas of practice that may be of interest to them.
Each case study follows the Process for Nutrition and Dietetic Practice (PNDP) that was published by the British Dietetic Association (BDA) in 2012. While throughout the world there are slight variations in nutrition and dietetic models and processes, the case studies can be successfully used alongside these. In addition, the Nutrition Care Process Terminology (NCPT), formally known as International Dietetics and Nutrition Terminology (IDNT), is used throughout the case studies – a feature practitioners worldwide will find useful.
Each case study starts with a scenario, which will enable the reader to identify the need for a nutritional intervention. This is followed by the assessment step of the PNDP and is standardised by the use the ABCDE format in most cases. Questions are posed about the assessment, the intervention and evaluation and monitoring steps. Some case studies also include further questions to stretch more newly qualified and more experienced practitioners. The PNDP is central to all areas of practice although it may be easier to identify each step in clinical areas than in other areas such as public health. This book includes real life case studies in public health, an increasingly important area of practice, and although they may be more detailed by carefully working through the case study and answers, it is possible to identify each and every step of PNDP. Questions on ethical issues are included in some case studies; however, ethics should always be of prime importance to any health care professional and is central to practice.
The book is split into two parts; firstly to reinforce keys areas of practice pertinent to this book it starts with the following introductory chapters:
This is followed by the case studies and separate answers. To avoid duplication the references for both the case studies and the answers are given at the end of each case study regardless of where they are cited. For completeness and to aid readers, many appendices from the Manual of Dietetic Practice are reproduced in the book. They include dietary reference values, weight and measures, dietary data, anthropometric data, energy prediction equations and so on and clinical chemistry.
Many of the case studies also have a link to a relevant PEN, Practice Based Evidence in Nutrition (PEN), practice question or resource. Dietitians in Australia, Canada, the United Kingdom and Ireland will be familiar with this global resource for nutrition practice.
We hope that readers enjoy using this book as much as we have enjoyed compiling it. Finally, we would like to thank the contributors and reviewers who have been invaluable when compiling this book.
Judy Lawrence
Pauline Douglas
Joan Gandy
Additional resources, which may be of interest to readers of this book, can be found on the companion website for the Manual of Dietetic Practice, 5th Edition, edited by Joan Gandy.
http://www.manualofdieteticpractice.com/
The website includes
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.
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.
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:
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.
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:
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 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.
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 appropriate intervention based on the aetiology (implementation). The intervention should of course be evidence based. Interventions may involve recommending, implementing, ordering, teaching or referring to other professionals.
Planning the intervention may involve collecting more information from the patient or from other sources. Planning should involve the patient/client/carer or group in agreeing and prioritising the necessary steps, to ensure that the care is patient centred.
Implementing the intervention is the phase of the nutrition and dietetic care process, which involves taking action. The intervention may involve the dietitian in training someone else to take action, or in supporting the patient/client to make behavioural changes. The dietitian may facilitate change through others, for example a dietetic assistant, nurse, care assistant, carer or teacher. The implementation may be something that is done to an unconscious patient such as the delivery of a prescribed total parenteral nutrition feeding regimen. Alternatively, the intervention may involve a community or group, for example a school meals project or lipid lowering group.
Monitoring focuses on changes in the signs and symptoms that were identified in the initial assessment to see if progress is being achieved and goals are met. The goals should be SMART:
SMART goals should make the monitoring process easier. Monitoring should be ongoing or carried out at planned intervals so that the results of the monitoring process can be used to review the intervention and modify it, if necessary. This may involve a new assessment and a new nutrition and dietetic diagnosis, which will in turn lead to new goals and additional monitoring. Some of the case studies in this book involve more than one nutrition and dietetic diagnosis.
Evaluation takes place at the end of the process. It involves collecting data about the current situation and comparing it with data from the assessment, with a reference standard such as BMI indicators of obesity or HbA1c measures of diabetes, or with goals that were established early in the planning process. The effectiveness of the evaluation can be judged by changes in the signs and symptoms identified in the nutrition and dietetic diagnosis.
The nutrition and dietetic care process may be an ongoing process where an individual patient is seen many times over a number of years for a chronic condition such as diabetes or it may be a short episode of care.
Pauline Douglas
The challenges for the nutrition and dietetic practitioner are to prevent and reduce the burden of nutrition related health problems for individuals or groups of people. Dietitians and nutritionists must advance practice from experience based to evidence based and demonstrate quality practice and optimise nutritional outcomes. To do this they must have a common language that they can benchmark their practice with other dietitians. They must demonstrate practice through the acquisition and use of complex systems of communication. This allows them to convey meaningful information to others. In addition:
With an increasing mobility of heath care professionals around the world the language needs to be standardised to convey meaningful information in a uniform way. This allows for the comparison of like messages in a logical process to facilitate the production of evidence-based practice. Also service users are travelling within countries and across borders for treatment and expect a consistent quality of care.
Using standard terminology:
It provides a common means of communication for healthcare professionals. Other healthcare professions, for example, nurses, physiotherapists, occupational therapists and so on have shown the benefits of having a standardised language. Making nursing practice count (Beyea, 1999) ensures that when a nurse talks about a stage three pressure area, another nurse fully understands what the first nurse is describing. An example from dietetics is that there are differing definitions and understanding of what is meant by nutritional support. In some countries this relates to enteral and parenteral nutrition and in others this also includes food fortification and oral nutritional supplementation.
A standardised language is complementary to a nutrition and dietetic process. It ensures that there is comparability in the terms used to describe diagnoses, interventions and outcomes of nutritional care. It is important to stress that this still ensures the dietitian provides individualised nutritional care for the patient or the population ensuring the patient/service user is at the centre of all care by taking into account their needs, values and culture.
Dietitians do not work alone. They are integral members of the inter-professional health team. As such communication of their work needs to be accessible to other healthcare professionals, commissioners of service or those reimbursing them for their services. The World Health Organization uses the International Classification of Diseases (ICD) as the standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to monitor the incidence and prevalence disease for general health and populations. Similarly the International Classification of Functioning, Disability and Health (ICF) is the WHO framework for measuring health and disability at both individual and population levels.
In 2003 the Academy of Nutrition and Dietetics (AND) published the concepts of a nutrition care process and model. Other professional bodies have now modified this to best meet the needs of their members and their healthcare provision, for example, BDA (2012). In 2008, AND defined the language to complement the process. This was called International Dietetic and Nutrition Terminology (IDNT) now known as the Nutrition Care Process Terminology (NCPT). In Europe, the Dutch Dietetic Association were also developing another dietetic language. This was modelled on the International Classification of Function (ICF) and is now recognised as the ICF – Dietetique. Now as the work of the National Dietetic Associations from across the world is being published, working groups are being established to facilitate international collaboration to further develop dietetic practice in this area.
The International Health Terminology Standards Development Organization (IHTSDO) is a not for profit organisation based in Europe. This organisation owns and administers the rights to health terminologies and related standards including Systematised Nomenclature of Medicine – Clinical Terms (SNOMED – CT). SNOMED – CT is a comprehensive medical terminology incorporating several terminologies from various healthcare disciplines. While being of international scope it can be adapted to each countries requirements. This international dietetic working group has been working closely to incorporate NCPT as an integral element of SNOMED. The WHO and IHTSDO have agreed to try to harmonise WHO classifications and SNOMED – CT terminologies to develop common terms used by both organisations. This has the potential to support further integration of different dietetic languages and thus enhance dietetic practice.
In Europe a key priority is ‘to support Member States in developing common identification and authentication measures to facilitate transferability of data across border healthcare’ (European Parliament and Council, 2011). As a result NCPT developments have facilitated eNCPT being available in several languages, for example, English, French, Italian, Spanish and Swedish again supporting international standards for dietetic practice and facilitating working across borders.
The NCPT is used alongside the Nutrition and Dietetic Care Process. In the diagnosis the PASS statement (problem, aetiology, signs and symptoms) the problem is the change in nutrition state that is described by adjectives such as decreased/increased, excessive/inadequate, restricted and imbalanced. In addition nutrition and dietetic diagnosis terms fall into one of seven categories:
The descriptors used in the different countries can challenge the dietitian to define the problem in a way that their service users may find acceptable. The interested professional bodies are collaborating on this to gain appropriate, relevant country specific additions and alternatives. Dietetic professional bodies need to continue to work collaboratively to ensure deititians have a standardised language.
It is important that the dietetic profession continue to engage with and use the NCPT. It should become an integral element of academic training, further developed within practice placement settings and then fully embraced by dietitians throughout their professional practice.
The Professional Practice Committee of the European Federation of Associations of Dietitians especially Constantina Papoutsakis, Ylva Orrevall, Lene Thorensen, Naomi Trostler, Remijnse Wineke and Claudia Bolleurs for their insight and knowledge.