Nursing Clinical Reference Group

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Here is the list of nutrition ICNP terms for discussion at the March 2021 Meeting

ICNP definitions

17 Comments

  1. William Swan

    What a very interesting discussion yesterday. I'm going into the ICNP browser today and make an initial pass at these terms. I will probably not go in order as listed. This my first time into the browser. I was notable to find the definition of "positive" that Kathy referred to. My recollection is that it is term used to embrace concepts like normal, within normal limits and similar. I could also not find a definition for "body mass" and am not assuming it is the same as body mass index.

    Risk for nutritional excess and Risk for excessive food intake are not differentiated in the browser only that the former is the parent of the later. These terms and their opposites, Risk for nutritional deficit and Risk for deficient food intake, correspond to IDNT terms Predicted Excessive Nutrient Intake and Predicted Inadequate Nutrient Intake. Noteworthy that in the IDNT only the parent concept is considered. IDNT would use the terms "nutrient" or " nutrition" not "nutritional" and would not differentiate between food and nutrition or nutrients since food is just one way to get nutrition or nutrients.

    There are 2 Positive Nutritional Status terms. They have differing codes, parents and children; but, they are similar. They also lie in different Axis. I'm not sure what that means. I think we are working on terms in the Diagnosis/Outcomes Axis

    Normal definition: Normality State: Conforming with a norm, typical, standard, the usual or expected state, https://neuronsong.com/_/_sites/icnp-browser/#/2019/concepts/en/10013295. Normal appetite would probably work for Positive appetite.

    There are number of references to judgement in the descriptions of terms that include Impaired. I assume this is referring to nursing judgment. Impaired Low Nutritional Intake almost seems like a double negative. I am having difficulty getting my head around this concept. Is an interpretation of this term, It is my negative judgement the patient has low nutritional intake? Is low the same as inadequate?

    Today's final thought: going back to body mass and the definition of nutritional status, nutritional status here seems to be solely a function of weight. I am not aware of weight standards by age. There are some weight standards that consider frame size (body build?). It is possible to have normal weight persons in poor nutritional status.

    Looking forward to our continued discussions. Is there a source document for the ICNP that goes into more detail than the browser?


  2. Nick Hardiker

    Sorry I missed the meeting yesterday. For some reason, I don't always get notified, even though I am watching.

    ICNP is represented under the Web Ontology Language. The information in the ICNP browser is derived from this source and has most of the associated information about individual concepts. It does however lack the formal OWL definition (which in some contexts is more important than the textual description). Other important information that is sometimes a little hidden in the browser is hierarchical placement, although parents and children are given. I don't want to go into the structure of ICNP here but there is often an apparent mirror concept - both a focus and a diagnosis/outcome that looks very similar. For this work, we are really only interested in the diagnosis/outcome and not in the focus. And finally, to avoid the proliferation of nuances of concepts such as impaired, altered, abnormal, etc. and their corresponding opposites, ICNP uses in its knowledge name negative and positive. This is interpreted into the preferred term 'Impaired Low Nutritional Intake' in its most natural or usual form. Impaired does not mean low - it means negatively judged - and conversely low does not necessarily imply negative.

    I hope this is helpful - or at least informative.

    1. William Swan

      Thanks for this information, it is helpful

  3. Kathy Molstad

     I understand all of these nutrition DC except: Impaired Low Nutritional Intake.  It does not make sense to me

  4. Nick Hardiker

    The 'impaired' is redundant here, other than to indicate that we judge the low nutritional intake to be a bad thing.

  5. Kathy Molstad

    ok Nick. But it is difficult to understand and even more difficult to translate. Is there a better way of stating this DC?

  6. Nick Hardiker

    Underernært?

  7. John Snyder

    Is there an opportunity for evaluation of current contextual usage of these concepts within the scope of an EHR implementation as well as current scope of practice for nurses versus dietitians? 

    While I understand that these concepts current exist in the diagnosis realm in ICNP, which at one time may have been appropriate, is it still appropriate for these concepts to remain in the diagnosis realm? The Positive Appetite and Positive Nutrition Status concepts appear to be something that would be contextually captured on a nursing documentation flow sheet which would be better represented as observable entities, rather than diagnosis. Additionally, the positive or conversely negative nutrition status may be based on a Nutrition Screening performed by a nurse that would then trigger a referral to nutrition services. Here again, this would be more of a total score from a screening assessment that may be better represented as observable entity concepts.

    I am open to being corrected, but I think it would be better to sort out the current contextual usage of the terms and inactivating or reclassifying terms within ICNP prior to replicating the content into SNOMED and then having to clean it up in both code systems at a future date.

  8. Nick Hardiker

    Hi John

    I agree that we should think about practical application and this is something that has almost certainly formed part of the mapping decision making process.

    In my mind once an Observable Entity is instantiated e.g. has a judgement applied, it is no longer an Observable Entity. The two examples that you have given (which equate to good appetite and good nutritional status) may be vague but they do have a positive judgement applied to them, and therefore I would not consider them to be observable Entities, but Clinical Findings. The Observable Entity part of these examples would be Appetite and Nutrition Status.

    Nick

    1. John Snyder

      HI Nick,

      I think I understand your perspective, however, wouldn't transitioning this into an observable entity allows these concepts to function the way an EHR documentation flow sheet works? Similar to a LOINC code, an observable entity may have a response value. Documentation flow sheets are necessarily in a question/answer format.

      In an EHR, which of the following would be preferred assuming that Appetite Status is either an observable entity in a non-LOINC country or is represented by a LOINC code in the US or in a country using LOINC.

      Appetite:Positive Appetite (finding)

      OR

      Appetite:

      Positive (qualifier value)

      Negative (qualifier value)

      Not assessed

      Unknown

      If we apply the finding concept to the observable entity format of a documentation flow sheet, it would seem to me we are redundantly stating what the positive assertion is being applied to. (in this case appetite).

      Sorry, I am not sure I follow the logic that once an observable entity has been instantiated with an applied judgement it is not longer an observable? I believe the qualifier value response would be the "applied judgement" being referred to. While the qualifier value response which is the "applied judgement" may change during each assessment, what is being observed doesn't change. I apologize if I am misunderstanding.

      Perhaps there are implementations that require the use of the clinical finding?

  9. Nick Hardiker

    Something for the next meeting perhaps?

  10. Cathy Richardson

    Thank you for the input so far. Below are some suggestions for five of the concepts mentioned above. I am following up on the remaining three. 

    I'd appreciate from input from both the Nursing CRG and Nutrition Project Group.

    • Positive Nutritional Status: https://neuronsong.com/_/_sites/icnp-browser/#/2019/concepts/en/10025002
      • In the previous equivalence work the concept 284670008 |Nutritionally compromised (finding)|was identified as an equivalence for the ICNP term Impaired Nutritional Status
      • The current concept exists 248324001 |Well nourished (finding)|- would this be suitable?

    Thank you.

    Cathy

    1. Jim Case

      We need to remember that current editorial policy regarding "risk" concepts specify the type of risk.  While most interpret the use of "Risk" to mean "increased risk", we need to be explicit so any "Risk for X" concepts need to state whether the risk is increased or decreased as Cathy mentioned.



      1. Elze de Groot

        I wonder what the difference is when to model a concept for at risk in the situations hierarchy and when in the findings. I would always model an at risk concept in the situation hierarchy, because there you can specify the 'at risk' component. Or is the difference that 'at increased or decreased risk should be a finding?

        1. Jim Case

          Elza,

          Good point.  Risk is a predisposition as opposed to a condition.  We have not yet looked at a modeling patten for these concepts as part of the QI project.  As we have currently modeled predispositions as clinical findings for allergies, "risk" seems to fit in the same bucket, but I do think we need to do some analysis.  We currently have almost 250 "at risk" findings, but only 4 "At risk" situations, but that may be more a of a legacy issue than a modeling decision. 


  11. Nick Hardiker

    From my perspective these would appear to be good matches

  12. Zac Whitewood-Moores

    Thanks Cathy

    For the penultimate one, would 278022001 | Neutral fluid balance (finding) | be suitable?  I am concerned that there may well be a proliferation of vocabularies for semantically almost equivalent which then makes concept selection for the average clinician far more challenging.  This may particularly be the case for some concepts which may need to be used by non-graduate staff who may not separate the nuances between some concepts.  This of course is far less problematic in querying if able to be fully modelled but sadly that is often not the case with some vocabularies being incorporated into SNOMED CT.

    The final one appears to exist, or potentially be retired ambiguous in favour of the new more explicitly worded one? 48501009 | Alteration in nutrition: potential for more than body requirements (finding) |

    Apart from these, the others seem to be consistent.  Many thanks