PRACTICAL ASPECTS

Implementation and Practical Application of the Nutrition Care Process in the Dialysis Unit
Debra Memmer, MS, RD, LD
The Nutrition Care Process (NCP) was introduced in 2003 (Lacey and Pritchett, J Am Diet Assoc. 2003;103:10611071). Since then, dietitians have been encouraged to incorporate the NCP into their daily practice, yet it has not been totally adopted in all dialysis units (Dent and McDufe, J Ren Nutr. 2011;1:205-207). The renal dietitian has the benet of being able to follow-up with the dialysis patient on a monthly basis. During these monthly visits, as information unfolds, a unique relationship culminates with the dialysis patient. The NCP allows the dietitian to make precise nutrition diagnoses, which reect the complexity of the renal dietitians involvement with the dialysis patient. The purpose of this article is to provide a brief description of the NCP as it relates to dialysis, offer a framework on how to begin using the NCP in the dialysis unit, and provide an example of a monthly nutrition note. 2013 by the National Kidney Foundation, Inc. All rights reserved.

HEN THE NUTRITION Care Process (NCP) was introduced, the initial reaction of some registered dietitians was What do they want us to do now?As if we dont have enough to do already!dialysis is different! Although the NCP is intended for all areas of nutrition, the renal dietitian is able to use the NCP to its fullest potential. This process allows the renal dietitian to make precise nutrition diagnoses because of the relationship that develops between the patient and the dietitian. The American Dietetic Association (ADA) adopted the NCP and model in 2003.1 Since then, dietitians have been encouraged to incorporate the NCP into their daily practice, yet it has not been totally adopted in all dialysis units.2 The Nutrition Diagnosis was further dened in 2006.3 The International Dietetics and Nutrition Terminology (IDNT) Reference Manual was then introduced in 2008, bringing the standardSchool of Nutrition/Dietetics, University of Akron, Akron, Ohio. Financial Disclosure: The author declares that they have no relevant nancial interests. Address correspondence to Debra Memmer, MS, RD, LD, University of Akron, 215 Schrank Hall South, 240 Carroll Street, Akron, OH. E-mail: dmemmer@uakron.edu 2013 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 doi:10.1053/j.jrn.2012.01.025

ized language to fruition.4 Since the inception of the NCP, there have been many educational seminars on this subject at local, state, and national levels. The IDNT requires ongoing maintenance of the terminology to reect the varying population and settings of the profession, changes in practice, and clarications of terms. Many editions have been published with revised and updated information.3-7 Dietitians in various settings have adopted the IDNT. The usage of the NCP and the terminology continues to progress through the years. The ADA Nutrition Care Model Workgroup accepts comments from dietitians who are currently working with the NCP and IDNT. All of the comments shape the IDNT to allow the dietitians detailed work to be represented. Through the years, it has become clear that this is a comprehensive and adaptable tool to represent the patients nutrition course led by the dietitian.8 Because it is continually being revised during this implementation period, it seems advantageous for renal dietitians to incorporate it into their daily routines so they can have a voice as to what needs to be changed, added, or deleted in future editions. The purpose of this article is to provide a brief description of the NCP as it relates to dialysis, offer a framework on how to begin using the NCP in the dialysis unit, and provide an example of a monthly nutrition note.
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Journal of Renal Nutrition, Vol 23, No 1 (January), 2013: pp 65-73

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Brief Review of the NCP

The NCP is part of a larger model that cites the patients relationship with the dietetic professional at the core, with many surrounding processes that can have an effect on the patient. It was developed so the dietetic professionals can provide individualized nutrition care for patients and clients through a standardized process. It supports the critical thinking and problem solving that is necessary when treating the dialysis patient. The IDNT empowers the dietitian with precise terminology. As the importance of interdisciplinary health care teams continues to grow, standardized terminology can lead to efcient ways to record dietetic interaction and communicate effectively with other members of the health care team. Standardized terminology can also allow for more efcient ways to analyze patient outcomes.1 The NCP has been incorporated into the dietetics curriculum.9,10 The NCP can be considered a teaching tool because it is a stepwise approach to conducting a thorough nutrition assessment to provide individualized nutrition care. The author has the understanding that the reader is aware of the NCP. This article is not intended to introduce the reader to the NCP. Instead, the author intends to show how the NCP can be adopted into the dialysis unit, with a focus on Nutrition Diagnosis. For complete clarication of the NCP, the reader should refer to the most recent IDNT reference manual.7

SOAP Subjective Objective Assessment Plan

ADIME Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring & Evaluation

Figure 1. Relocation of information into the ADIME format.

strates where that same information can be included in the ADIME chart note. The reverse for documentation is also appropriate and accepted. Registered dietitians can document using either of the styles as well as any other (such as narrative).

Further Explanation of the ADIME Format

Nutrition Assessment The rst step in the NCP is Nutrition Assessment. This step lays the foundation for the remainder of the NCP. Here, the term assessment is used to represent all of the information that is gathered to proceed through the NCP. The information included focuses on details from the patient or the patients record: food history, biochemical data, medications, patient statements, opinions, anthropometric measurements, weight status, protein catabolic rate, total nitrogen appearance, glomerular ltration rate, urea reduction rate, kinetic modeling results, estimated calorie/ protein needs, enteral/parenteral nutrition order/delivery, and diet order/intake. As always, the nutrition professional investigates the information about the patient situation obtained from the many sources, including, but not limited to, the chart, patient, family, and physician. This section includes all of the pertinent information that is necessary to make clinical judgments to proceed through the NCP. The information gathered in the assessment guides the dietitian through the completion of the ADIME note. This information will help to arrive at the Nutrition Diagnosis, as the assessment details are used as the etiology, evidence/signs, and symptoms of the Nutrition Diagnostic Statement. Much of the subjective information (e.g.,

A Brief Review of Charting

Much complexity and variation evolve around the dietitians services in the dialysis unit. The NCP is not a way of charting, but it is a standardized approach to nutrition care. The IDNT is the language for documenting that care. In the dialysis unit, nutrition care consists of many nutritionrelated activities completed throughout a typical day. The NCP includes the following 4 steps: Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation (ADIME format). A popular way of charting has been the Subjective, Objective, Assessment, and Plan (SOAP) format.11 Figure 1 displays the opportunities for similarities among the SOAP and ADIME formats. The diagram considers information that is usually reported in the specic area of the SOAP chart note and demon-

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food history) will be supportive evidence in the Nutrition Diagnostic Statement. The assessment details, tailored through the Nutrition Diagnostic Statement, will help to determine the necessary intervention. Certain assessment indicators that were marked as needing improvement will then be monitored in the Monitor & Evaluation area of the ADIME note. Table 1 illustrates how the information gathered in the Nutrition Assessment can help form the Nutrition Diagnostic Statement. When compared with the SOAP format, the subjective and objective information is included within the Nutrition Assessment section of the NCP. Other functions that may have been performed in the SOAPs Assessment area may also be included here in the ADIMEs Nutrition Assessment area, such as body mass index interpretation and calorie/protein need estimations. All of this information is gathered here in the ADIMEs Nutrition Assessment area so the dietitian can extrapolate the information and critically decide what takes precedence within the Nutrition Diagnostic Statement.

Nutrition Diagnosis The Nutrition Diagnosis takes the medical diagnosis further and identies the nutrition component that requires the interaction of the dietitian. The Nutrition Diagnosis may be resolvable with some type of nutrition intervention, whereas the medical diagnosis may be treatable, yet ongoing. The list of acceptable Nutrition Diagnosis terms can be seen on the nutrition diagnostic terminology list (Fig. 2). This list has been reprinted with permission from the IDNT reference manual, in which the complete denitions for each Nutrition Diagnosis can be found.7 Table 2 lists descriptive nutrition diagnoses, with

specic nutrients, that are commonly used in the dialysis unit. The Nutrition Diagnostic Statement will be extracted after critically evaluating the subjective data, objective data, data from the chart, and that retrieved from the patients personal information (all of which have been included in the assessment section). It is after this careful attention to detail that the Nutrition Diagnosis emerges and allows for the specic function of the intervention to be identied. The dietitian can now identify a clear concise Nutrition Diagnosis with substantial qualiers to form the Nutrition Diagnostic Statement. This statement is linked by the connecting terms Problem/Nutrition Diagnosis related to etiology as evidenced by the signs and symptoms. Forming the statement can be crucial, as it informs the health care team of the focus in solving the nutrition problem. As the renal dietitian hands out the monthly laboratory results each month, the discussions with the patients evolve around specic interventions that address very specic problems. After thoroughly reviewing patient information, acceptable nutrition diagnoses can be evident. Examples of nutrition diagnoses that are commonly seen in the dialysis unit are listed in Table 3 on the right. The medical diagnoses that may have been used before implementation of the NCP are listed on the left. As the IDNT is incorporated into routine documentation, the Nutrition Diagnosis will be able to lead into the nutrition intervention that the dietitian needs to complete.

Nutrition Intervention The dietitians actions are considered the nutrition intervention. The nutrition interventions are intended to eliminate or diminish the Nutrition Diagnosis. It can range from providing supplements

Table 1. Example of Formulating a Nutrition Diagnostic Statement

Assessment Patient complained of difculty chewing due to loose-tting dentures. Albumin, 2.9. Diet recall taken and analyzed by computer program 5 20 g protein. Estimated needs at 1.2 g protein/kg 5 70 g/day. Inadequate protein intake Difculty chewing Diet recall analysis, 20 g of protein; patient complained of unable to chew meat due to loose-tting dentures; albumin of 2.9 mg/dL. Inadequate protein intake related to difculty chewing as evidenced by diet recall analysis of 20 g of protein intake compared with estimated needs of 70 g, albumin of 2.9 mg/dL, and patient complaint of loose-tting dentures.

Nutrition diagnosis/problem Related to/etiology Evidence/signs and symptoms Formulated nutrition diagnostic statement

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Figure 2. Nutrition Diagnostic Terminology list. Academy of Nutrition and Dietetics (formerly the American Dietetic Association). Reprinted with permission.

for increasing calories and protein to rening nutrients in an intradialytic parenteral nutrition solution. It can include, but is not limited to, educating/ counseling, contacting the doctor, referring to the social worker, ordering/adding nutritional supplements, recommending any nutrients intravenously, implementing any change that would

improve the patients nutritional status, or recommending any medications that have nutritional signicance, such as iron supplements, phosphorus binders, or lipid-lowering agents. All of these actions aim to reduce the signs and symptoms of the Nutrition Diagnosis. Table 4 summarizes verbs that are commonly used for the interventions.

NUTRITION CARE PROCESS IN THE DIALYSIS UNIT Table 2. Specic Nutrition Diagnoses
Commonly Used Descriptive Words for Nutrition Diagnoses Inadequate intake Excessive intake Increased nutrient needs Altered nutrition-related laboratory value Examples of Nutrition Diagnoses Specic to Dialysis Unit Inadequate protein intake Excessive mineral intake (phosphorus) Increased nutrient needs (protein) Altered nutrition-related laboratory value (albumin)

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of being a renal dietitian is that the dietitian will be able to determine whether the intervention is working, and if not, decide how it can be altered. Nutrition Monitoring & Evaluation can be summarized as the what, when, and by how much? as shown in Table 5.

Implementing the NCP

The Preliminary Steps First, the dietitian should be familiar with the NCP. He/she should obtain access to the IDNT reference manual to use as a reference. Then, inform the administration and the health care team. Administration needs to be aware of the changes that will be taking place. Explain why it is necessary to implement the NCP. Use of the NCP with the standardized language will improve communication and be able to provide statistics for quality improvement purposes. Obtain recommendations from the administration because they may have an idea regarding a time line that might work well. The administration will probably know the best time for an in-service. The nurses see the patients on a daily basis so the dietitian will want to keep the daily nurses/staff updated as to the

Nutrition Monitoring and Evaluation 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. Its purpose is to determine the amount of progress made and whether goals/expected outcomes are being met. The Nutrition Monitoring and Evaluation section is unique to any dietitian who is able to see the patient for follow-up on a regular basis, such as the renal dietitian. The renal dietitian is able to see the results of his/her work. One of the best parts

Table 3. Translating Previously Used Terms into Specic Nutrition Diagnoses

Previously Used Terms Hyperphosphatemia Nutrition Diagnoses that are Commonly Seen in the Dialysis Unit Excessive mineral intake (phosphorus) Decreased nutrient needs (phosphorus) Food- and nutrition-related knowledge decit Limited adherence to nutrition-related recommendations Undesirable food choices Increased nutrient needs (protein) Inadequate protein intake Altered nutrition-related laboratory values (albumin) Unintended weight gain Excessive carbohydrate intake Inappropriate intake of types of carbohydrates (sucrose) Inconsistent carbohydrate intake Foodmedication interaction Inadequate energy intake Inadequate oral intake Malnutrition Unintended weight loss Food- and nutrition-related knowledge decit Limited adherence to nutrition-related recommendations Undesirable food choices Not ready for diet/lifestyle change Excessive uid intake Excessive mineral intake (sodium) Self-monitoring decit Unintended weight gain

Hypoalbuminemia

Hyperglycemia, diabetes

Weight loss

New to dialysis Noncompliance

Increased interdialytic weight gain

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Table 4. Interventions: commonly used verbs
Recommend Implement Order Refer Educate Counsel Initiate

MEMMER Table 6. Consolidation of Information

Statement 1: Excessive mineral intake (sodium) related to patients increased intake of fast foods that are high in sodium as evidenced by diet recall and interdialytic weight gain of 8 kg. Statement 2: Unintended weight gain related to patients increased uid intake as evidenced by patients interdialytic weight gain of 8 kg. Clinical judgment should be used to conclude whether one of the diagnoses should take priority. A diagnostic statement that can combine the 2 issues and state it more concisely may be as follows: Unintended weight gain related to knowledge decit of low-sodium diet and uid restriction as evidenced by diet recall of excessive intake of fast foods that are high in sodium, uid intake .2 L/day, and interdialytic weight gain of 8 kg.

changes the dietitian will be making. It will be easier to make the change if everyone in the unit is aware of it. Involving everyone and allowing everyone to be part of the knowledge/awareness step is crucial. Finally, if there is a specic form that is currently being used, plan a meeting with the Forms committee so that the NCP can be put on their next agenda. Take support documents to the meeting. If the dietitian is not on the committee or not the person to actually present the format, he/she should ask to be a special guest at the meeting so that he/she can present the NCP and be available to promote the process. Simple questions will arise and can be answered by the dietitian who is currently working with and familiar with the changes. If the renal dietitian is not the person who will be presenting the change to the Forms committee, it is important to be sure to educate the person who will be presenting the proposal. The renal dietitian should be available by phone. Make it clear that if any concerns arise, they will be addressed.

laboratory results within the normal ranges for dialysis patients. The patient and the dietitian will decide how the patients habits and/or intake can be altered to benet the patient. Then, identify the information that can form the Nutrition Diagnosis. Refer to the nutrition diagnostic terminology list. Choose one of the three following ways to start working with the Nutrition Diagnosis:
Table 7. Use of Abbreviations and Emphasis of Specic Area
A. Patient eats fast foods daily (analysis, approximately 6 g of sodium), weight increased by 8 kg from last treatment, complains of being thirsty and unable to limit uid intake. D. Excessive mineral intake (sodium) related to (R/T) fast food intake as evidenced by (AEB) diet recall and excessive interdialytic weight gain (IDWG). D. (Abbreviated) excessive mineral intake (Na1) R/T fast-food intake AEB diet recall and [IDWG. I. Nutrition education: lower sodium choices at fast food restaurants, simple food preparation techniques for home use reviewed. M & E: Short-term goal: patient able to state acceptable lower-sodium food choices. At the completion of the preparation phase, patient will show evidence of progressing to action/ willpower phase by counter thinking and replacing past behaviors with positive thinking of lower sodium food choices. by counter-thinking and replacing past behaviors with positive thinking of lower-sodium food choices.12 Long-term goal: self monitoring: keep 2-day food record, to be reviewed at next treatment. Goal: improvement of sodium intake to ,3 g/day, interdialytic weight gain ,2-3 kg.

Putting the NCP into Action The typical routine of a renal dietitian is to obtain the monthly laboratory results that are drawn from all patients. Start by completing the monthly routine as usual. Prepare the monthly reports as usual; visit with the patient to explore and discuss what is needed to be able to work on achieving
Table 5. Examples of Monitoring and Evaluation
What? 3-day diet record of protein intake Serum albumin level Serum phosphorus level 3-day diet record of phosphorus intake Interdialytic weight gain When? 1 week By How Much?

Increase intake to 70 g protein/day 1 month .3.5 1 month ,6.5 1 month ,1 g phosphorus/ day 1 month ,5%

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1. Look at the nutrition problems that have been identied during this months laboratory reviews with the patients. Create a list of commonly used problems that were the focus of this months reviews. Identify the nutrition diagnoses that could have been incorporated into the monthly notes. 2. Identify one common problem (e.g., low albumin) that is normally seen and identify all of the possible nutrition diagnoses that could have been used with the information from this month. 3. Identify one common problem that is a Nutrition Diagnosis (e.g., inadequate protein intake) and continue to build on that Nutrition Diagnosis. Once the dietitian is comfortable with the Nutrition Diagnosis, the dietitian can create the Nutrition Diagnostic Statement. Although no changes will be made to the current action of the dietitian and the care given to the patient, the recording of the event may be charted in the IDNT standardized language with the ADIME format. This Nutrition Diagnostic Statement can give a clear picture of the dietitians involvement to anyone reading the chart. Concentrate on the nutrition problem that needs to be resolved. All of the information that was previously included in the monthly note will now be included as an ADIME note. Once the nutrition diagnoses are mastered, the information that belongs in the remainder of the note can be identied and included in the ADIME note. An example of an ADIME note is as follows: A: Patient states he has been eating lots of dairy products; phosphorus, 9.2 mg/dL. D: Excessive intake of phosphorus related to increased dairy intake as evidenced by serum phosphorus level of 9.2 mg/dL and analysis of patients diet recall indicates 1,586 mg of phosphorus intake when compared with estimated needs of 1,000 mg phosphorus/day. I: Nutrition prescription: 1,800 calories, 90 g protein, 2 g Na1, 2 g K1, 1 g phosphorus, 1,500 mL uid restriction. Nutrition education on low-phosphorus diet provided the list of high-phosphorus foods to be avoided and reviewed acceptable alternatives to high-phosphorus foods.

M&E: patient appeared to understand nutrition education well. Goal: Answered diet questions appropriately. Long-term: patient to keep a 3-day food record and monitor patients intake. Goal: achieve 1,000 mg phosphorus/day and achieve a serum phosphorus level ,6.0 mg/dL in 1 month.

Frequently Stated Comments Possible Barriers to Begin Using the NCP At several times, there can be more than one nutrition problem. In the renal area, a popular question is Can there be more than one Nutrition Diagnosis? Table 6 shows an example of starting out with 2 nutrition diagnoses and consolidating the information. This could be done because the 2 diagnoses were related. However, if they are not related, it is important to prioritize. A dialysis patient may have 2 or 3 Nutrition Diagnostic Statements. The renal dietitian can critically evaluate the information and decide which interventions are short-term and which are long-term. It Takes too Long, Im too Busy. I Dont Have Time to Incorporate the NCP! Continue to complete work as usual and incorporate the NCP one step at a time. Wait until you get used to one part and then adjust to another part. This article suggests that a starting point could be the Nutrition Diagnosis. The Documentation is too Long, the Others Wont Read What I Have Written! The NCP is the total picture with all of the details. Designate a part of the ADIME note that, as a dietitian, you feel will be the most important part for the health care team to read. This area should be communicated to the others who are responsible for reading these notes. In Table 7, the Intervention of nutrition education may be the most important part for the health care team to read. This may be indicated by a box drawn around this area on the note. Anyone can refer back to the total ADIME note, if desiring to nd more details. To physically shorten the ADIME note, use a list of the institutions approved abbreviations and eliminate extraneous information (which often clutters notes) unless it is necessary

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documentation consistent with the standard of care. Table 7 shows a suggested abbreviated Nutrition Diagnostic Statement.

Example of a Monthly Nutrition Note

In the online version of this article is an example of a form that can be used as a monthly nutrition note or worksheet in the hemodialysis unit (available at www.jrnjournal.org). This form can be adapted to accommodate any area where nutrition notes are needed. Commonly used terms were chosen to be written in a checklist format for ease of use. The assessment area contains details that are commonly reviewed each month. Each area of the form contains terms that have routinely been used during the monthly lab documentation. Each area also contains a comments or other section so the user can rene the notes being written. Notice the Nutrition Diagnosis area contains the standardized language of nutrition diagnoses that are most often seen in the dialysis unit. These are written in a list format so the user can check the Nutrition Diagnosis once it is identied.

individual unit is the time line that should be used to implement the NCP. As the electronic health record becomes more commonly used, a great way to proceed is to incorporate a checklist of commonly used nutrition diagnoses and interventions. A license to be able to use the NCP/IDNT through a computerized system is required and will need to be obtained from the Academy of Nutrition and Dietetics (formerly the ADA, Chicago, IL) through their Web site at www.eatright.org. Some electronic health record vendors already have a license for the IDNT, and this information can also be obtained by contacting the academy at ncpslpermissions@eatright.org. Renal dietitians are very resourceful with regard to the complexity of the renal diet. The reader is encouraged to pick a point in the NCP as a starting point and create a stepwise outline on how to proceed. The NCP can help the renal dietitian to describe the extended interaction between the patient and the dietitian. The reader is encouraged to refer to the Academy of Nutrition and Dietetics Web site at www.eatright.org/healthprofessionals to learn further about the resources available on the NCP.

Example A sample note could be as follows: inadequate protein intake related to chewing difculty as evidenced by lower albumin levels of 2.9, loosetting dentures, patient complaining of meat protein foods being too hard to chew, and intake estimated at 20 g of protein compared with estimated needs of 70 g/day.

Acknowledgments
The author would like to thank the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) Standardized Language Committee for reviewing the manuscript and providing appropriate comments prior to submission.

Summary
There are many ways to implement the NCP in the dialysis unit. These suggestions assist the dietitian in making concise statements to communicate the nutritional needs of the patient. The Nutrition Diagnosis is an essential component in the daily practice of the dietitian. The implementation process of the NCP should be tailored to the individual units, but hopefully some of the information in this article can make it simple to begin. It will take time to rene the implementation of the NCP and the IDNT. Time is needed to adjust to the changes and make alterations as needed. Because dialysis patients are seen monthly, allowing a month between changes may be helpful. The time line that ts the

Supplementary data Sample Monthly Dialysis Nutrition Note can be found in the online version, at doi:10.1053/j.jrn. 2012.01.025.

References
1. Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103:1061-1071. 2. Dent LA, McDufe I. A survey of the utilization of the nutrition care process for documentation in outpatient dialysis centers. meeting abstracts. J Ren Nutr. 2011;1:205-207. 3. American Dietetic Association. Nutrition Diagnosis: a Critical Step in the Nutrition Care Process. Chicago, IL: American Dietetic Association; 2006. 4. American Dietetic Association. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago, IL: American Dietetic Association; 2008.

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5. American Dietetic Association. Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process. Chicago, IL: American Dietetic Association; 2007. 6. American Dietetic Association. International Dietetics and Nutrition Terminology (IDNT) Reference Manual, Standardized Language for the Nutrition Care Process. 2nd ed. Chicago, IL: American Dietetic Association; 2009. 7. American Dietetic Association. International Dietetics and Nutrition Terminology (IDNT) Reference Manual, Standardized Language for the Nutrition Care Process. 3rd ed. Chicago, IL: American Dietetic Association; 2011. 8. Hakel-Smith L, Nancy M. A standardized nutrition care process and language are essential components of a conceptual

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model to guide and document nutrition care and patient outcomes. J Am Diet Assoc. 2004;104:1878-1884. 9. Commission on Accreditation for Dietetic Education: Eligibility Requirements and Accreditation Standards for Didactic Program in Dietetics, Knowledge Requirement 3.1. 2008:12. 10. Commission on Accreditation for Dietetic Education: Eligibility Requirements and Accreditation Standards for Dietetic Internship Programs, Dietetic Internship 3.1. 2008:13. 11. Nelms RG. Documentation of the nutrition care process. In: Nelms M, Sucher KP, Lacey K, Roth SL, eds. Nutrition Therapy and Pathophysiology. 2nd ed Belmont, CA: Wadsworth; 2011:106-117. 12. Prochaska JO, Norcross JC, DiClemente CC. Changing for Good. New York, NY: Avon Books; 1994. 180-188.