NUTRITION

CARE
PROCESS
• A systematic problem- • A standardized model
solving method that intended to guide
food and nutrition Registered Dietitians
professionals use to and Registered
think critically and Dietetic Technicians,
make decisions that in providing high
address practice- quality nutrition care.
related problems.

WHAT IS THE NUTRITION

CARE PROCESS AND
• Developed by the Academy of Nutrition and Dietetics
(AND)

• Improve the consistency • Provide structure and

and quality of terminology for
individualized research studies and
patient/client care and the data
predictability of the • collection.
patient/client outcomes. Provide a
standardized
language.

WHY WAS THE NCP

DEVELOPED
1. Assessment: nutritional health status
2. Diagnosis: interpret data
3. Intervention: develop a plan of action
4. Monitor/Evaluate: monitor the effectiveness of
the plan

NUTRITION CARE PROCESS:

ADIM
AND NUTRITION CARE PROCESS AND MODEL
• Initiates the data collection process that is
continued throughout the NCP and forms the
foundation for reassessment and reanalysis of
the data in Nutrition Monitoring and
Evaluation (Step 4).

STEP 1: NUTRITION
ASSESSMENT
 For individuals:
• Patient/client through interview
• Observation and measurements
• Medical records
• Referring health care provider

For population groups:

• Data from surveys
• Administrative data sets
• Epidemiological or research studies
Nutrition Care Process Snapshot NCP step 1: Assessment [Link]

HOW DO FOOD AND NUTRITION

PROFESSIONALS DETERMINE WHERE
TO OBTAIN NUTRITION ASSESSMENT
Food and nutrition-related history:
• Food intake, nutrition and health awareness and
management, physical activity and exercise, and food
availability.

Biochemical data, medical tests and procedures

• Include laboratory data (e.g., electrolytes, glucose, lipid
panel, and gastric emptying time).

Anthropometric measurements
• Include height, weight, body mass index (BMI), growth
rate, and rate of weight change.

CATEGORIES OF NUTRITION
ASSESSMENT DATA
Nutrition-focused physical findings
• Include oral health, general physical appearance, muscle
and subcutaneous fat wasting

Client history
• Include medication and supplement history, social
history, medical/health history, and personal history.

…CATEG
ORIES OF NUTRITION
ASSESSMENT DATA
• Determining appropriate data to collect
• Determining the need for additional
• information
Selecting assessment tools and procedures that
match the situation
• Applying assessment tools in valid and reliable
• ways
Distinguishing relevant from irrelevant data
• Distinguishing important from unimportant
• data
Validating the data
Nutrition Care Process Snapshot NCP step 1: Assessment [Link]

NUTRITION ASSESSMENT:
CRITICAL THINKING
• Identification and labeling of a nutrition problem that the
RD is responsible for treating independently.
• Standardized terminology for nutrition diagnosis has
been developed to facilitate this step.
• It is suggested that the RD use a PES Statement to
communicate the nutrition diagnosis (problem, etiology,
and signs/symptoms).
Examples:
• “inadequate energy intake”, “overweight/obesity”, “food
and nutrition related knowledge deficit”, and “limited
access to food or water”

STEP 2. NUTRITION DIAGNOSIS

• Critical step between nutrition assessment and
nutrition intervention.
• Identification of an existing nutrition problem, by
using the data collected in the nutrition
assessment
that the RD is responsible for treating.
• Creates a standardized nutrition diagnosis
language to describe nutrition problems
consistently.
• Different from a medical diagnosis.

STEP 2. NUTRITION DIAGNOSIS

PURPOSE
 Medical Diagnosis Nutritional Diagnosis

Diabetes Excessive CHO intake r/t visits to Coldstone

Creamery as evidenced by diet hx and high hs
blood glucose

Trauma and closed head Increased energy needs r/t multiple trauma as
injury evidenced by results of indirect calorimetry

Liver failure Altered gastrointestinal function r/t cirrhosis of the

liver as evidenced by steatorrhea and growth
failure

NUTRITIONAL VS. MEDICAL

 Medical Diagnosis Nutritional Diagnosis

Obesity Excessive energy intake r/t lack of access to

healthy food choices (restaurant eating) as
evidenced by diet history and BMI of 35.

Dependence mechanical Excessive energy intake r/t high volume PN as

ventilation evidenced by RQ >1

Anorexia nervosa Undesirable food choices r/t history of anorexia

nervosa and self-limiting behavior as evidenced by
diet history and weight loss of 5 lb

NUTRITIONAL VS. MEDICAL

• Nutrition diagnosis is documented by writing a
PES statement.
• The format for the PES statement is:
“Nutrition problem label related to as
evidenced by .”
Example:
• Inadequate fiber intake (NI-5.8.5) related to lack of
nutritional knowledge about desirable quantities of
fiber as evidenced by patient’s intake of fiber that
is insufficient when compared to the RDA.

NUTRITION DIAGNOSIS COMPONENTS

PES statement should be:
• Clear and concise
• Specific to the patient
• Limited to a single problem
• Accurately related to one etiology
• Based on signs and symptoms from the
assessment data

NUTRITION DIAGNOSIS COMPONENTS

PES statement components:
(P) Problem or Nutrition Diagnosis Label: Describes
alterations in the patient’s nutritional status.

(E) Etiology: Cause/Contributing risk factors linked to

the nutrition diagnosis label by the words “related to.”

(S) Signs/Symptoms: Data used to determine that the

patient has the nutrition diagnosis specified. Linked to
the etiology by the words “as evidenced by.”

NUTRITION DIAGNOSIS COMPONENTS

(P) 1. Can the RD resolve or improve the nutrition diagnosis?
2. Consider the Intake Domain as the preferred problem type
(E) 1. Is the etiology listed the “root cause”?
2. Will RD intervention resolve or improve the problem by addressing
the etiology?
3. Can RD intervention at least lessen the symptoms?
(S) 1. Will measuring the signs and symptoms tell you if the problem
is resolved or improved?
2. Are the signs and symptoms specific enough?
PES Overall
Does nutrition assessment data support the nutrition diagnosis, etiology,
and signs and symptoms?

EVALUATING PES
• Intake

• Clinical
• Behavioral

NUTRITION DIAGNOSIS HAS THREE

GENARAL DOMAINS
Intake (NI)
• Excessive or Inadequate intake compared to requirements
(actual or estimated)

Composed of five categories:

1. Energy balance
2. Oral or nutrition support intake
3. Fluid intake
4. Bioactive substance
5. Nutrient

NUTRITION DIAGNOSIS HAS THREE

GENARAL DOMAINS
Clinical
• Medical or physical conditions that are abnormal

Composed of three categories:

1. Functional
2. Biochemical
3. Weight

NUTRITION DIAGNOSIS HAS THREE

GENERAL DOMAINS
Behavioral
• Environmental related to knowledge, attitudes, beliefs,
physical environment, access to food, or food safety

Composed of three categories:

1. Knowledge and beliefs
2. Physical activity and function
3. Food safety and access

NUTRITION DIAGNOSIS HAS THREE

GENERAL DOMAINS
• Focuses on the issue at hand taking a detailed course of
action and utilizing resources.
• Final goal is to modify an individual, a specific group, or
a community’s nutrition behavior.

Steps of Nutrition Intervention

1. Selecting
2. Planning
3. Implementing

STEP 3: NUTRITION
• The nutrition intervention chosen is based by
the nutrition diagnosis and uses:
1. team involvement
2. science based principles
3. additional research, if available.

• The key element is that the RD improves the

issue by creating a rational plan with the help of
the whole family including the individual

STEP 3: NUTRITION
• Food and/or Nutrient Delivery
• Nutrition Education
• Nutrition Counseling
• Coordination of Nutrition Care

NUTRITION
INTERVENTION
• Prioritize nutrition diagnoses
• Consult AND’s EBNPG
• Determine patient-focused expected outcomes
• Confer with family members/caregivers
• Define nutrition plan and strategies
• Define time and frequency of care

PLANNING THE NUTRITION

INTERVENTION
• Communicate the nutrition care plan
• Help carry out the plan

IMPLEMENTING THE
NUTRITION
The plan of action will be based on the patient's
diagnosis:
1. Select the appropriate strategy based on the
problem
2. Discuss the intervention to the patient (include
family)
3. Explain the plan ([Link] education)
4. Schedule of care (program duration follow-ups)
5. Additional materials, documentations, financial/food
resources

STEPS OF NUTRITION INTERVENTION

• An on-going course of action
• Accurate, timely, and applicable records
• Scrutiny of patient’s file should include:
1. Date and time
2. Goals and outcomes
3. Plan’s adjustments
4. Patient’s receptiveness
5. Resources and referrals
6. Follow-ups (observe progress) and frequency
7. Discharge (if applicable)

DOCUMENTATION OF
NUTRITION
• Critical step that defines the outcomes
specific
to nutrition care.

• Overlapping between nutrition assessment,

monitoring and evaluation terminology
client history).
(except

• Generating a standardization of evaluating

the effectiveness of nutrition intervention.

STEP 4:NUTRITION MONITORING

AND EVALUATIO
Purpose
• To determine whether progress made is related to the
patient’s nutrition intervention goals and/or desired
outcomes.
• To provide evidence if the intervention is/has been
effective in changing the behavior or status of the patient.
• To evaluate nutrition care outcomes.
• To create a standardized language for nutrition
intervention.

NUTRITION MONITORING
AND EVALUATIO
RELATIONSHIP BETWEEN
MONITORING & INTERVENTION
Monitoring provides findings that the nutrition
intervention has impacted the patient’s status
positively or negatively
Measuring outcomes by using data from the nutrition
care indicators*
Evaluate patient outcomes by comparing current findings
with previous status/behavior and patient’s
nutritional intervention goals
[Link]

MONITORING AND
EVALUATION
• Nutrition related behavioral and environmental outcomes
• Food and nutrient intake outcomes
• Nutrition related physical signs and symptoms
• Nutrition related patient/client centered outcomes

NUTRITION OUTCOME CATEGORIES

OF MONITORING AND
• Determine proper indicator/measures
• Determine suitable data for comparison
• Determine the process of the clients relating to expected
outcomes
• Determine why the patient outcomes are different from the
expected outcomes
• Determine issues that assist or hamper improvement
• Determine how long a patient needs to be under nutrition
care
Nutrition Care Process Snapshot NCP step 4: Assessment [Link]

NUTRITION MONITORING
AND EVALUATION
Patient outcomes
• Improved nutrition intakes Cost outcomes
• Changes in physical signs • Decreased cost to health
and symptoms care
• Increases patients quality of • system
Length of hospital stay
life • Outpatient visits
Health & disease outcomes • Procedures
• Prevention or maintenance • Medication and equipment
of health used
[Link]
• Changes in knowledge
• Changes in severity,
duration of disease

HEALTH CARE
OUTCOMES
Nutrition Assessment
• Medical hx: 72 y.o. female admitted with decompensated
CHF; heart failure team consulted; has been admitted with
same dx 2x in past month; meds: Lasix and Toprol;
current diet order: 2 grams sodium; has lost 5 pounds in
24 hours since admission; Output > input by 2 liters
• Nutrition history: has been told to weigh herself daily but has
no scale at home. Does not add salt to foods at the table.
Noticed swollen face and extremities on day prior to
admission. Day before admission ate canned soup for lunch
and 3 slices of pizza for dinner; does not restrict fluids; has
never received nutrition counseling

NCP EXAMPLE #1: ACUTE

CARE
Nutrition Diagnosis
• Excessive sodium intake r/t frequent use of canned
soups and restaurant foods as evidenced by diet history.
• Knowledge deficit r/t no previous nutrition education as
evidenced by frequent use of high sodium
convenience foods and inability to name high sodium
foods.
• Excess fluid intake r/t dietary indiscretions as evidenced
by diet hx and current fluid status.
• Self-monitoring deficit r/t lack of access to scale as
evidenced by patient self report.

NCP EXAMPLE #1: ACUTE

Nutrition Intervention
• Excessive sodium intake: Patient will attend Senior
Feeding site that provides low sodium meals; Patient will
implement survival skills low sodium diet principles and
attend heart failure diet program in heart failure clinic.
• Self-monitoring deficit: Patient will obtain free home
scale from CHF case manager; will limit fluids to 2 liters/
day per instructions in Heart Failure Clinic if adherence
to low sodium diet does not achieve appropriate fluid
balance.

NCP EXAMPLE #1: ACUTE

Monitoring and Evaluation
• Patient will weigh himself daily and keep log; report to
heart failure case manager if weight ↑ 2 lb in 24
• hours
Patient will bring 3 day diet record to heart failure clinic
for review by dietitian
• Heart failure case manager will track hospital
readmissions over 12 months

NCP EXAMPLE #1: ACUTE

Nutrition Assessment
• JW is a 70 yr. old white man admitted for cardiac bypass
surgery. The nutrition risk reveals that he has lost weight
without trying and has been eating poorly for several weeks
before admission, leading to referral to the RD for nutrition
assessment.
• Caloric intake: 1,200kcal/day (less than energy requirements as
stated in the recommended dietary allowances). Meals: irregular
throughout the day; drinks coffee frequently. History of
hypertension, thyroid dysfunction, asthma, prostate surgery. JW
lives alone in his own home. He lost his wife 3 months ago, and
for the past 6 months he rarely sits down to a cooked meal.

NCP EXAMPLE #2
Nutrition Diagnosis
• Involuntary weight loss related to missing meals as
evidenced by loss of 15 lbs over 3 months.
• Inadequate oral food and beverage intake

NCP EXAMPLE #2
Nutrition Intervention
••Diagnosis 1: Involuntary weight loss
During the hospitalization JW will maintain his current
weight, following discharge he will begin to slowly gain
weight up to a target weight of 145lb.
• JW will modify his diet to include adequate calories and
protein through the use of nutrient-dense foods to prevent
further weight loss and eventually promote weight gain.

NCP EXAMPLE #2
Nutrition Intervention
••Diagnosis 2: Inadequate oral food and beverage intake
While in the hospital JW will include nutrient-dense foods in
his diet, especially when his appetite is limited.
• Following discharge JW will attend a local senior center for
lunch on a daily basis to help improve his socialization and
caloric intake.

NCP EXAMPLE #2
Monitoring and Evaluation
• Monitoring will include weekly weight measurements and
nutrient intake analyses while he is in the hospital and
biweekly weight measurements at the senior center or clinic
when he is back at home.
• If nutrition status is not improving, such as JW’s weight
records and goals not being met, JW needs to be reassessed
and develop new goals and create plans for new interventions.

NCP EXAMPLE #2
American Dietetic Association. Frequently Asked Questions Regarding the Nutrition Care
Process and Model (2008). Retrieved November 2, 2009 from [Link]

Bueche, J., Charney, P., Pavlinac, J., Skipper, A., Thompson, E., & Myers, E. (2008). Nutrition
care process and model part I: The 2008 update. Journal of the American Dietetics
Association, 113-117. Retrieved November 13, 2010 from [Link]
HealthProfessionals/[Link].?id=7077&terms=NCP

Calhoun, J., Goukasian, C., Siritiranukul, j., & Young, R. Nutrition Care Process. November
2010. Retrieved November 2012

Leidys, L., Louisa, B., & Noura, A., & Star, E. Nutrition Care Process. November 2010.
Retrieved November 2012.

REFERENCES
Mahan, L.K., & Escott-Stump, S. (2008). Krause’s Food & Nutrition Therapy (12th ed.).
Philadelphia: Saunders.

Nutrition Care Process: Diagnosis, Intervention, Evaluation, and Monitoring. Retrieved from
[Link].

Nutrition Care Process Step 4: Nutrition monitoring and evaluation. On-line, International
Dietetics & Nutrition Terminology Reference Manual - Third Edition Retrieved November
13, 2010 from [Link]

Nutrition Diagnosis Snapshot (2009). In Pocket guide for International dietetics & nutrition
terminology (IDNT) reference manual (pp. 137-141). Chicago, IL: ADA

Nutrition Diagnosis Snapshot (2010). In Pocket guide for International dietetics & nutrition
terminology (IDNT) reference manual, ed. 3rd. (pp. 313- 314). Chicago, IL: ADA

REFERENCES
 THANK YOU!
NOVEMBER 21,
2012