Prepared by Sandy Sarcona, MS, RD

Nutrition Care Process (NCP)

Steps of NCPA – Nutrition AssessmentD – Nutrition Diagnosis

I – Nutrition InterventionM – Nutrition MonitoringE – Evaluation

Problem, Etiology, Signs and Symptoms

Through nutrition reassessment, dietetics practitioners perform nutrition monitoring

and evaluation to determine if the nutrition intervention strategy is working to resolve the nutrition diagnosis, its etiology, and/or

signs and symptoms

Step 1: Nutrition Assessment Screening and referral are typical entrance

points into the NCPAssessment leads to determination that a

nutrition diagnosis/problem exists; it is possible that a nutrition problem does not existExample: LTC resident on tube feeding;

weight wnl and stable, Albumin wnl, labs wnl, good skin integrity and hydration status, feeding continues at recommended rate.

Nutrition Assessment DomainsFood/Nutrition-Related History: FH (diet hx,

energy intake, food and beverage intake, enteral and parenteral intake, bioactive substance intake, macronutrient/micronutrient intake, medication/supplement use, knowledge/beliefs/attitudes/behavior, etc)

Anthropometric Measurements: ADBiochemical Data, Medical Tests and

Procedures: BDNutrition Focused Physical Findings: PD

(appetite, edema, taste alterations, swallowing difficulty, etc)

Client History: CH (personal hx, PMH, social hx)

Nutrition Assessment, Monitoring and Evaluation Comparative Standards

Estimated Energy Needs (formula)Estimated Fat, Protein, and CHO needsEstimated Fiber Needs (AI)Estimated Fluid Needs (AI)Estimated Vitamin and Mineral Needs

(RDA…)Recommended Body Weight /BMI/Growth

(peds)

Example: Food IntakeIndications: amount of food, types of food/meals; meal/snack patterns, diet quality, food varietyMeasurement methods: food intake records, 24-hour recall, food frequency, MyPyramid Tracker

Typically used to monitor and evaluate change in the following nutrition dx: excessive or inadequate oral food/bev intake, underweight, overweight/obesity, limited access to food

Evaluation – comparison to goal or reference standard

1) Goal: Pt currently eats ~10% of kcal from saturated fat Goal to <7% of daily kcal

2) Reference standard: Pt’s current intake of fat not meeting AHA criteria to consume <7% of kcal from sat. fat

Step 2: Nutrition Diagnosis

1. Problem (Diagnostic Label) such as, Excessive oral food/beverage intake (NI-2.2)

2. Etiology (Cause/Contributing Factor) such as, related to lack of food planning, purchasing, and preparation skills

3. Signs/Symptoms defining characteristics) such as, as evidenced by BMI of 32, intake of high caloric-density foods/beverages at meals and snacks.

Nutrition Diagnosis - DomainsIntake (NI) – actual problems related to

intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support

Clinical (NC) – Nutritional finding/problems identified that relate to medical or physical conditions

Behavioral – Environmental (NB) – Nutritional findings/problems identified that related to knowledge, attitudes/beliefs, physical environment, access to food, or food safety

Nutrition Dx: Problem, Etiology, Signs and Symptoms

Inadequate energy

intake (NI-2.1) related to decreased ability to consume sufficient energy due to ESRD and dialysis as evidenced by significant weight loss of 5% in past month, and lack of interest in food

Involuntary weight gain (NC-3.4) related to antipsychotic medication as evidenced by increase weight of 11% in 6 months.

Self-feeding difficulty (NB-2.6) related to impaired cognitive ability as evidenced by weight loss of 6% in last month and dropping cups and food from utensil.

Step 3: Nutrition InterventionInvolves planning and implementation

Planning Prioritizing the nutrition diagnoses, setting goals

and defining the intervention strategy and Detailing the nutrition prescription (states

pt/client’s recommended dietary intake of energy, nutrients, etc)

Using the ADA’s evidence-based practice guidelines

Setting goals that are measurable, achievable and time-defined

Implementation – carrying out and communicating the plan of care

Nutrition Intervention – 4 categories

Food and/or Nutrient Delivery

Nutrition Counseling

Individualized approach for food/nutrient provision such as meals, snacks, supplements

Instruct a pt/client in a skill or to impart knowledge to help them manage or modify food choices and eating behavior to maintain or improve health

Collaborative counselor-patient relationship, to set priorities, establish goals and create action plans for self-care to treat an existing condition and promote health

Referral to or coordination of nutrition care with other health care providers, agencies etc. to assist in managing nutrition related problems

Nutrition EducationCoordination of Nutrition Care

Nutrition InterventionDirect the nutrition intervention at the

etiology of the problem or at the signs and symptoms if the etiology cannot be changed by the dietetics practitioner.

Nutrition interventions are intended to eliminate or diminish the nutrition diagnosis, or to reduce signs and symptoms of the nutrition diagnosis.

AssessmentDiagnosis InterventionMonitoring & Eval

Problem Etiology Signs &

Symptoms

Step 4: Monitoring and Evaluation

Determine the amount of progress made and whether goals/expected outcomes are being met

Follow-up monitoring of the signs and symptoms is used to determine the impact

of the nutrition intervention on the etiology /signs and symptoms of the

problem.

Monitoring and EvaluationFood/Nutrition –Related Hx Outcomes

Biochemical Data, Medical Tests & Procedure Outcomes

Food and nutrient intake, supplement intake, physical activity, food availability, etc.

Physical appearance, swallow function, appetite

Lab data and tests

Height, weight, BMI, growth pattern, weight hx

Nutrition-Focused Physical Finding Outcomes

Anthropometric Measurement Outcomes

Sample:PES: Self-monitoring knowledge deficit related to

knowledge deficit on how to record food and beverage intake as evidenced by incomplete food records at last two clinic visits and lab of HbA1c = 8.5mg/dL

Assessment Data:(sources of info): blood glucose self-monitoring records, food diary worksheets and meal records, blood glucose levels (Fasting, 2-hour postprandial and/or HbA1c levels)

Intervention: Teaching patient and family members about use of simple blood glucose self-monitoring records and meal records

Monitoring and Evaluation:HbA1c levels (goal <6.5mg/dL); other glucose labs, food diary and records, discussion about complications of using the records.

Sample:Dialysis Patient

PES: Excessive mineral intake of Phosphorus (NI-5.10.6) related to overconsumption of high Phosphorus foods and not taking Phosphate Binders as evidenced by hyperphosphatemia

Assessment Data:(sources of info): diet recall, monthly serum phosphorus level.

Intervention: Teaching patient about use of taking phosphate binders with meals and instruction on high phosphorus foods to limit to <1200mg/day

Monitoring and Evaluation: Phosphorus levels (goal ≤ 5.5mg/dL); keeping records of P intake from food and binders

Sample:Gastroesophagel reflux disease (GERD)

PES: Undesirable food choices (NB-1.7) related to lack of prior exposure to accurate nutrition-related information as evidenced by alcohol intake of ~10 drinks/week and high fat diet and complaints of heart burn.

Assessment: Diet recallIntervention: Educate and counsel patient on

dietary management of GERD and the role of alcohol and fat in promoting heart burn.

Monitoring and Evaluation: Report of decreased alcohol and fat consumption and less heart burn and discomfort.

Sample:Dialysis

PES: Excessive fluid intake (NI 3.2) related to kidney disease as evidenced by weight gain of 5kg between treatments

Assessment:Intervention:Monitoring/Evaluation:

Sample Case 158 year old female with Type 2 DM, ESRD 2

diabetic nephropathy; third month on dialysisLabs: K+ 5.8mEq/L; BUN 74mg/dL; Creat

5.51mg/dL; Albumin 3.6g/dL; FBS 289mg/dL; HbgA1c 9.4%; Phosphorus 5.3mEq/L

Rx: 2 PhosLo/meal, 2000IU cholecalciferol, Metformin, Lipitor

Adhering to phosphate binders. Diet hx – 60 gm protein (10%), 350gm CHO (65%), 61gm fat (25%) 2200 kcal, about 3gm K, 1000ml fluid: pt states she is okay with fluid restriction, but is overwhelmed with dialysis and new diet modifications; not sure what she is allowed to eat anymore; familiar with diet for diabetes but not renal; good appetite.

Ht. 5’6”, Wt. 160, BMI 25

PES for Case 1Excessive Carbohydrate Intake – NI

5.8.2 related to lack of willingness/failure to modify carbohydrate intake as evidenced by hyperglycemia, FBS 289 ; Hemoglobin A1c 9.4%, diabetes

Excessive Mineral Intake (Potassium) – NI 5.10.2 related to food and nutrition-related knowledge deficit as evidenced by serum K+ of 5.8

Sample Case 282 year old male, S/P CVA with right sided weakness 1

mos ago, HTN, ESRD on dialysis 2x/weekLives alone on 2nd floor of two family house; cannot

drive; use to walk to store prior to stroke but can’t anymore; depends on son to bring him food. Pt claims that his son does not visit regularly

Alb 2.9Ht 5’10’, UBW 165lbs prior to stroke; Present wt 154lbsDiet order: 80gm protein, 2gm Na, 2gm K, 1000ml fluidDiet hx: B – toast w/ butter and coffee, L – soup,

crackers and coffee, D-soup, sandwich (peanut butter and jelly) and tea; S – whole milk and 4 cookies

PES Case 2Limited access to food – NB-3.2

related to physical limitation to shop as evidenced by report of limited supply of food and variety of food in home; significant weight loss of 6% in one month.