Nutrition Care Process (NCP)

Prepared by Sandy Sarcona, MS, RD

 Steps of NCP
 A – Nutrition Assessment
 D – Nutrition Diagnosis

Problem, Etiology, Signs and Symptoms
 I – Nutrition Intervention
 M – Nutrition Monitoring
 E – Evaluation

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
NCP
 Assessment leads to determination that a nutrition
diagnosis/problem exists; it is possible that a nutrition
problem does not exist
 Example: 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 Domains
 Food/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: AD
 Biochemical Data, Medical Tests and Procedures: BD
 Nutrition 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 needs
 Estimated Fiber Needs (AI)
 Estimated Fluid Needs (AI)
 Estimated Vitamin and Mineral Needs (RDA…)
 Recommended Body Weight /BMI/Growth (peds)
Example: Food Intake

Indications: amount of food, types of food/meals; meal/snack

patterns, diet quality, food variety
Measurement 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 - Domains
 Intake (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 Intervention
 Involves 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
 Individualized approach for
food/nutrient provision such
as meals, snacks, supplements
Nutrition Education
 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
Nutrition Counseling
 Collaborative counselor-
patient relationship, to set
priorities, establish goals and
create action plans for self-
care to treat an existing
condition and promote health
Coordination of Nutrition Care
 Referral to or coordination of
nutrition care with other
health care providers,
agencies etc. to assist in
managing nutrition related
problems
 Nutrition Intervention
 Direct 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.
Assessment Diagnosis Intervention Monitoring & Eval
 
Problem Etiology Signs & Symptoms
 Nutrition interventions are intended to eliminate or diminish
the nutrition diagnosis, or to reduce signs and symptoms of the
nutrition diagnosis.
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 Evaluation
Food/Nutrition –Related Hx Biochemical Data, Medical
Outcomes Tests & Procedure Outcomes
 Food and nutrient intake,
 Lab data and tests
supplement intake, physical
activity, food availability,
etc.
Nutrition-Focused Physical Anthropometric
Finding Outcomes Measurement Outcomes
 Physical appearance,  Height, weight, BMI,
swallow function, appetite growth pattern, weight hx
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 recall
 Intervention: 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 1
 58 year old female with Type 2 DM, ESRD 2 diabetic
nephropathy; third month on dialysis
 Labs: 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 1
 Excessive 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 2
 82 year old male, S/P CVA with right sided weakness 1 mos ago,
HTN, ESRD on dialysis 2x/week
 Lives 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 2.9
 Ht 5’10’, UBW 165lbs prior to stroke; Present wt 154lbs
 Diet order: 80gm protein, 2gm Na, 2gm K, 1000ml fluid
 Diet 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 2
 Limited 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.