Nutrition Diagnosis

:
A Critical Step in the Nutrition Care Process
Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
ISBN: 0-88091-358-4
Copyright 2006, American Dietetic Association. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means without the prior written consent of the publisher. Printed in the United
States of America.
The views expressed in this publication are those of the authors and do not necessarily
reflect policies and/or official positions of the American Dietetic Association. Mention of
product names in this publication does not constitute endorsement by the authors or the
American Dietetic Association. The American Dietetic Association disclaims
responsibility for the application of the information contained herein.
10 9 8 7 6 5 4 3 2 1
Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
Table of Contents
Section I: The Nutrition Care Process
Nutrition Care Process and Model Article....................................................................1
Section II: Development of Standardized Language
American Dietetic Association’s Standardized Language Model: Current Status.....13
Section III: Introduction to Nutrition Diagnosis
Introduction to Nutrition Diagnoses/Problems ...........................................................17
Section IV: Nutrition Diagnosis Reference Sheets
Single Page List of Nutrition Diagnostic Terminology................................................22
Section V: Nutrition Diagnosis Terms and Definitions
Nutrition Terms and Definitions ..................................................................................23
Section VI: Appendix
Procedure for NutritionControlled Vocabulary/Terminology Maintenance/Review154
Acknowledgements
Task Force Members..................................................................................................160
Consultants ................................................................................................................161
Research Reviewers ...................................................................................................162
Additional Reference on Implementation of Nutrition Care Process ....................................165
Feedback Form......................................................................................................................171
Camera Ready Pocket Guide.................................................................................................173
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iii
Nutrition Care Process and Model: ADA adopts road
map to quality care and outcomes management
KAREN LACEY, MS, RD; ELLEN PRITCHETT, RD
T
he establishment and implementation of a standardized
Nutrition Care Process (NCP) and Model were identified as
priority actions for the profession for meeting goals of the
ADA Strategic Plan to “Increase demand and utilization of ser-
vices provided by members” and “Empower members to com-
pete successfully in a rapidly changing environment” (1). Pro-
viding high-quality nutrition care means doing the right thing at
the right time, in the right way, for the right person, and achiev-
ing the best possible results. Quality improvement literature
shows that, when a standardized process is implemented, less
variation and more predictability in terms of outcomes occur
(2). When providers of care, no matter their location, use a
process consistently, comparable outcomes data can be gener-
ated to demonstrate value. A standardized Nutrition Care Pro-
cess effectively promotes the dietetics professional as the
unique provider of nutrition care when it is consistently used as
a systematic method to think critically and make decisions to
provide safe and effective nutrition care (3).
This article describes the four steps of ADA’s Nutrition Care
Process and the overarching framework of the Nutrition Care
Model that illustrates the context within which the Nutrition
Care Process occurs. In addition, this article provides the ratio-
nale for a standardized process by which nutrition care is pro-
vided, distinguishes between the Nutrition Care Process and
Medical Nutrition Therapy (MNT), and discusses future impli-
cations for the profession.
BACKGROUND
Prior to the adoption of this standardized Nutrition Care Pro-
cess, a variety of nutrition care processes were utilized by prac-
titioners and taught by dietetics educators. Other allied health
professionals, including nursing, physical therapy, and occupa-
tional therapy, utilize defined care processes specific to their
profession (4-6). When asked whether ADA should develop a
standardized Nutrition Care Process, dietetics professionals
were overwhelmingly in favor and strongly supportive of having
a standardized Nutrition Care Process for use by registered
dietitians (RD) and dietetics technicians, registered (DTR).
The Quality Management Committee of the House of Dele-
gates (HOD) appointed a Nutrition Care Model Workgroup in
May 2002 to develop a nutrition care process and model. The
first draft was presented to the HOD for member input and
review in September 2002. Further discussion occurred during
the October 2002 HOD meeting, in Philadelphia. Revisions
were made accordingly, and the HODunanimously adopted the
final version of the Nutrition Care Process and Model on March
31, 2003 “for implementation and dissemination to the dietetics
profession and the Association for the enhancement of the
practice of dietetics.”
SETTING THE STAGE
Definition of Quality/Rationale for a Standardized
Process
The National Academy of Science’s (NAS) Institute of Medi-
cine (IOM) has defined quality as “The degree to which health
services for individuals and populations increase the likelihood
of desired health outcomes and are consistent with current
professional knowledge” (7,8). The quality performance of pro-
viders can be assessed by measuring the following: (a) their
patients’ outcomes (end-results) or (b) the degree to which
providers adhere to an accepted care process (7,8). The Com-
mittee on Quality of Health Care in America further states that
it is not acceptable to have a wide quality chasm, or a gap,
between actual and best possible performance (9). In an effort
to ensure that dietetics professionals can meet both require-
ments for quality performance noted above, the American Di-
etetic Association (ADA) supports a standardized Nutrition
Care Process for the profession.
Standardized Process versus Standardized Care
ADA’s Nutrition Care Process is a standardized process for
dietetics professionals and not a means to provide standardized
care. A standardized process refers to a consistent structure
and framework used to provide nutrition care, whereas stan-
K. Lacey is lecturer and Director of Dietetic Programs
at the University of Wisconsin-Green Bay, Green Bay. She
is also the Chair of the Quality Management Committee.
E. Pritchett is Director, Quality and Outcomes at ADA
headquarters in Chicago, IL.
If you have questions regarding the Nutrition Care Pro-
cess and Model, please contact Ellen Pritchett, RD, CPHQ,
Director of Quality and Outcomes at ADA,
epritchett@eatright.org
Copyright © 2003 by the American Dietetic Association.
0002-8223/03/10308-0014$35.00/0
doi: 10.1053/jada.2003.50564
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dardized care infers that all patients/clients receive the same
care. This process supports and promotes individualized care,
not standardized care. As represented in the model (Figure 1),
the relationship between the patient/client/group and dietetics
professional is at the core of the nutrition care process. There-
fore, nutrition care provided by qualified dietetics profession-
als should always reflect both the state of the science and the
state of the art of dietetics practice to meet the individualized
needs of each patient/client/group (10).
Using the NCP
Even though ADA’s Nutrition Care Process will primarily be
used to provide nutrition care to individuals in health care set-
tings (inpatient, ambulatory, and extended care), the process
also has applicability in a wide variety of community settings. It
will be used by dietetics professionals to provide nutrition care
to both individuals and groups in community-based agencies
and programs for the purpose of health promotion and disease
prevention (11,12).
Key Terms
To lay the groundwork and facilitate a clear definition of ADA’s
Nutrition Care Process, key terms were developed. These def-
initions provide a frame of reference for the specific compo-
nents and their functions.
(a) Process is a series of connected steps or actions to
achieve an outcome and/or any activity or set of activities that
transforms inputs to outputs.
(b) Process Approach is the systematic identification and
management of activities and the interactions between activi-
ties. A process approach emphasizes the importance of the
following:
■ understanding and meeting requirements;
■ determining if the process adds value;
■ determining process performance and effectiveness; and
■ using objective measurement for continual improvement of
the process (13).
(c) Critical Thinking integrates facts, informed opinions, ac-
tive listening and observations. It is also a reasoning process in
which ideas are produced and evaluated. The Commission on
Accreditation of Dietetics Education (CADE) defines critical
thinking as “transcending the boundaries of formal education
to explore a problem and form a hypothesis and a defensible
conclusion” (14). The use of critical thinking provides a unique
strength that dietetics professionals bring to the Nutrition Care
Process. Further characteristics of critical thinking include the
ability to do the following:
■ conceptualize;
■ think rationally;
■ think creatively;
■ be inquiring; and
■ think autonomously.
FIG 1. ADA Nutrition Care Process and Model.
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(d) Decision Making is a critical process for choosing the best
action to meet a desired goal.
(e) Problem Solving is the process of the following:
■ problem identification;
■ solution formation;
■ implementation; and
■ evaluation of the results.
(f) Collaboration is a process by which several individuals or
groups with shared concerns are united to address an identified
problem or need, leading to the accomplishment of what each
could not do separately (15).
DEFINITION OF ADA’S NCP
Using the terms and concepts described above, ADA’s Nutri-
tion Care Process is defined as “a systematic problem-solving
method that dietetics professionals use to critically think and
make decisions to address nutrition related problems and pro-
vide safe and effective quality nutrition care.”
The Nutrition Care Process consists of four distinct, but in-
terrelated and connected steps: (a) Nutrition Assessment, (b)
Nutrition Diagnosis, (c) Nutrition Intervention, and d) Nutri-
tion Monitoring and Evaluation. These four steps were finalized
based on extensive review and evaluation of previous works
describing nutrition care (16-24). Even though each step
builds on the previous one, the process is not linear. Critical
thinking and problem solving will frequently require that die-
tetics professionals revisit previous steps to reassess, add, or
revise nutrition diagnoses; modify intervention strategies;
and/or evaluate additional outcomes. Figure 2 describes each
of these four steps in a similar format consisting of the follow-
ing:
■ definition and purpose;
■ key components or substeps with examples as appropriate;
■ critical thinking characteristics;
■ documentation elements; and
■ considerations for continuation, discontinuation, or dis-
charge of care.
Providing nutrition care using ADA’s Nutrition Care Process
begins when a patient/client/group has been identified at nutri-
tion risk and needs further assistance to achieve or maintain
nutrition and health goals. It is also important to recognize that
patients/clients who enter the health care system are more
likely to have nutrition problems and therefore benefit from
receiving nutrition care in this manner. The Nutrition Care
Process cycles through the steps of assessment, diagnosis, in-
tervention, and monitoring and evaluation. Nutrition care can
involve one or more cycles and ends, ideally, when nutrition
goals have been achieved. However, the patient/client/group
may choose to end care earlier based on personal or external
factors. Using professional judgment, the dietetics professional
may discharge the patient/client/group when it is determined
that no further progress is likely.
PURPOSE OF NCP
ADA’s Nutrition Care Process, as described in Figure 2, gives
dietetics professionals a consistent and systematic structure
and method by which to think critically and make decisions. It
also assists dietetics professionals to scientifically and holisti-
cally manage nutrition care, thus helping patients better meet
their health and nutrition goals. As dietetics professionals con-
sistently use the Nutrition Care Process, one should expect a
higher probability of producing good outcomes. The Nutrition
Care Process then begins to establish a link between quality
and professional autonomy. Professional autonomy results
from being recognized for what we do well, not just for who we
are. When quality can be demonstrated, as defined previously
by the IOM (7,8), then dietetics professionals will stand out as
the preferred providers of nutrition services. The Nutrition
Care Process, when used consistently, also challenges dietetics
professionals to move beyond experience-based practice to
reach a higher level of evidence-based practice (9,10).
The Nutrition Care Process does not restrict practice but
acknowledges the common dimensions of practice by the fol-
lowing:
■ defining a common language that allows nutrition practice to
be more measurable;
■ creating a format that enables the process to generate quan-
titative and qualitative data that can then be analyzed and in-
terpreted; and
■ serving as the structure to validate nutrition care and show-
ing how the nutrition care that was provided does what it in-
tends to do.
DISTINCTION BETWEEN MNT AND THE NCP
Medical Nutrition Therapy (MNT) was first defined by ADA in
the mid-1990s to promote the benefits of managing or treating
a disease with nutrition. Its components included an assess-
ment of nutritional status of patients and the provision of either
diet modification, counseling, or specialized nutrition thera-
pies. MNT soon became a widely used term to describe a wide
variety of nutrition care services provided by dietetics profes-
sionals. Since MNT was first introduced, dietetics professionals
have gained much credibility among legislators and other
health care providers. More recently, MNT has been redefined
as part of the 2001 Medicare MNT benefit legislation to be
“nutritional diagnostic, therapy, and counseling services for the
purpose of disease management, which are furnished by a reg-
istered dietitian or nutrition professional” (25).
The intent of the NCP is to describe accurately the spectrum
of nutrition care that can be provided by dietetics profession-
als. Dietetics professionals are uniquely qualified by virtue of
academic and supervised practice training and appropriate
certification and/or licensure to provide a comprehensive array
of professional services relating to the prevention or treatment
of nutrition-related illness (14,26). MNT is but one specific
type of nutrition care. The NCP articulates the consistent and
specific steps a dietetics professional would use when deliver-
ing MNT, but it will also be used to guide nutrition education
and other preventative nutrition care services. One of the key
distinguishing characteristics between MNT and the other nu-
trition services using the NCP is that MNT always involves an
in-depth, comprehensive assessment and individualized care.
For example, one individual could receive MNT for diabetes
and also nutrition education services or participate in a com-
munity-based weight loss program (27). Each service would
use the Nutrition Care Process, but the process would be im-
plemented differently; the components of each step of the pro-
cess would be tailored to the type of service.
By articulating the steps of the Nutrition Care Process, the
commonalities (the consistent, standardized, four-step pro-
cess) of nutrition care are emphasized even though the process
is implemented differently for different nutrition services. With
a standardized Nutrition Care Process in place, MNTshould not
be used to describe all of the nutrition services that dietetics
professionals provide. As noted above, MNT is the only appli-
cation of the Nutrition Care Process (28-31). This change in
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STEP 1. NUTRITION ASSESSMENT
Basic Definition &
Purpose
“Nutrition Assessment” is the first step of the Nutrition Care Process. Its purpose is to obtain
adequate information in order to identify nutrition-related problems. It is initiated by referral and/or
screening of individuals or groups for nutritional risk factors. Nutrition assessment is a systematic
process of obtaining, verifying, and interpreting data in order to make decisions about the nature and
cause of nutrition-related problems. The specific types of data gathered in the assessment will vary
depending on a) practice settings, b) individual/groups’ present health status, c) how data are related
to outcomes to be measured, d) recommended practices such as ADA’s Evidence Based Guides for
Practice and e) whether it is an initial assessment or a reassessment. Nutrition assessment requires
making comparisons between the information obtained and reliable standards (ideal goals). Nutrition
assessment is an on-going, dynamic process that involves not only initial data collection, but also
continual reassessment and analysis of patient/client/group needs. Assessment provides the
foundation for the nutrition diagnosis at the next step of the Nutrition Care Process.
Data Sources/Tools for
Assessment
Ⅲ Referral information and/or interdisciplinary records
Ⅲ Patient/client interview (across the lifespan)
Ⅲ Community-based surveys and focus groups
Ⅲ Statistical reports; administrative data
Ⅲ Epidemiological studies
Types of Data Collected Ⅲ Nutritional Adequacy (dietary history/detailed nutrient intake)
Ⅲ Health Status (anthropometric and biochemical measurements, physical & clinical conditions,
physiological and disease status)
Ⅲ Functional and Behavioral Status (social and cognitive function, psychological and emotional
factors, quality-of-life measures, change readiness)
Nutrition Assessment
Components
Ⅲ Review dietary intake for factors that affect health conditions and nutrition risk
Ⅲ Evaluate health and disease condition for nutrition-related consequences
Ⅲ Evaluate psychosocial, functional, and behavioral factors related to food access, selection,
preparation, physical activity, and understanding of health condition
Ⅲ Evaluate patient/client/group’s knowledge, readiness to learn, and potential for changing behaviors
Ⅲ Identify standards by which data will be compared
Ⅲ Identify possible problem areas for making nutrition diagnoses
Critical Thinking The following types of critical thinking skills are especially needed in the assessment step:
Ⅲ Observing for nonverbal and verbal cues that can guide and prompt effective interviewing
methods;
Ⅲ Determining appropriate data to collect;
Ⅲ Selecting assessment tools and procedures (matching the assessment method to the situation);
Ⅲ Applying assessment tools in valid and reliable ways;
Ⅲ Distinguishing relevant from irrelevant data;
Ⅲ Distinguishing important from unimportant data;
Ⅲ Validating the data;
Ⅲ Organizing & categorizing the data in a meaningful framework that relates to nutrition problems;
and
Ⅲ Determining when a problem requires consultation with or referral to another provider.
Documentation of
Assessment
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.
Quality documentation of the assessment step should be relevant, accurate, and timely. Inclusion of
the following information would further describe quality assessment documentation:
Ⅲ Date and time of assessment;
Ⅲ Pertinent data collected and comparison with standards;
Ⅲ Patient/client/groups’ perceptions, values, and motivation related to presenting problems;
Ⅲ Changes in patient/client/group’s level of understanding, food-related behaviors, and other clinical
outcomes for appropriate follow-up; and
Ⅲ Reason for discharge/discontinuation if appropriate.
Determination for
Continuation of Care
If upon the completion of an initial or reassessment it is determined that the problem cannot be
modified by further nutrition care, discharge or discontinuation from this episode of nutrition care
may be appropriate.
FIG 2. ADA Nutrition Care Process.
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STEP 2. NUTRITION DIAGNOSIS
Basic Definition &
Purpose
“Nutrition Diagnosis” is the second step of the Nutrition Care Process, and is the identification and
labeling that describes an actual occurrence, risk of, or potential for developing a nutritional problem
that dietetics professionals are responsible for treating independently. At the end of the assessment
step, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnostic category
from which to formulate a specific nutrition diagnostic statement. Nutrition diagnosis should not be
confused with medical diagnosis, which can be defined as a disease or pathology of specific organs
or body systems that can be treated or prevented. A nutrition diagnosis changes as the
patient/client/group’s response changes. A medical diagnosis does not change as long as the
disease or condition exists. A patient/client/group may have the medical diagnosis of “Type 2
diabetes mellitus”; however, after performing a nutrition assessment, dietetics professionals may
diagnose, for example, “undesirable overweight status” or “excessive carbohydrate intake.”
Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realistic
and measurable expected outcomes, selecting appropriate interventions, and tracking progress in
attaining those expected outcomes.
Data Sources/Tools for
Diagnosis
Ⅲ Organized and clustered assessment data
Ⅲ List(s) of nutrition diagnostic categories and nutrition diagnostic labels
Ⅲ Currently the profession does not have a standardized list of nutrition diagnoses. However ADA
has appointed a Standardized Language Work Group to begin development of standardized
language for nutrition diagnoses and intervention. (June 2003)
Nutrition Diagnosis
Components (3
distinct parts)
1. Problem (Diagnostic Label)
The nutrition diagnostic statement describes alterations in the patient/client/group’s nutritional status.
A diagnostic label (qualifier) is an adjective that describes/qualifies the human response such as:
Ⅲ Altered, impaired, ineffective, increased/decreased, risk of, acute or chronic.
2. Etiology (Cause/Contributing Risk Factors)
The related factors (etiologies) are those factors contributing to the existence of, or maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental
problems.
Ⅲ Linked to the problem diagnostic label by words “related to” (RT)
Ⅲ It is important not only to state the problem, but to also identify the cause of the problem.
▫ This helps determine whether or not nutritional intervention will improve the condition or correct
the problem.
▫ It will also identify who is responsible for addressing the problem. Nutrition problems are either
caused directly by inadequate intake (primary) or as a result of other medical, genetic, or
environmental factors (secondary).
▫ It is also possible that a nutrition problem can be the cause of another problem. For example,
excessive caloric intake may result in unintended weight gain. Understanding the cascade of
events helps to determine how to prioritize the interventions.
▫ It is desirable to target interventions at correcting the cause of the problem whenever possible;
however, in some cases treating the signs and symptoms (consequences) of the problem may also
be justified.
Ⅲ The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in order
of their importance and urgency for the patient/client/group.
3. Signs/Symptoms (Defining Characteristics)
The defining characteristics are a cluster of subjective and objective signs and symptoms
established for each nutrition diagnostic category. The defining characteristics, gathered during
the assessment phase, provide evidence that a nutrition related problem exists and that the
problem identified belongs in the selected diagnostic category. They also quantify the problem
and describe its severity:
Ⅲ Linked to etiology by words “as evidenced by” (AEB);
Ⅲ The symptoms (subjective data) are changes that the patient/client/group feels and expresses
verbally to dietetics professionals; and
Ⅲ The signs (objective data) are observable changes in the patient/client/group’s health status.
Nutrition Diagnostic
Statement (PES)
Whenever possible, a nutrition diagnostic statement is written in a PES format that states the
Problem (P), the Etiology (E), and the Signs & Symptoms (S). However, if the problem is either a risk
(potential) or wellness problem, the nutrition diagnostic statement may have only two elements,
Problem (P), and the Etiology (E), since Signs & Symptoms (S) will not yet be exhibited in the patient.
A well-written Nutrition Diagnostic Statement should be:
1. Clear and concise
2. Specific: patient/client/group-centered
3. Related to one client problem
4. Accurate: relate to one etiology
5. Based on reliable and accurate assessment data
Examples of Nutrition Diagnosis Statements (PES or PE)
Ⅲ Excessive caloric intake (problem) “related to” frequent consumption of large portions of high fat
meals (etiology) “as evidenced by” average daily intake of calories exceeding recommended
amount by 500 kcal and 12-pound weight gain during the past 18 months (signs)
FIG 2 cont’d.
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Ⅲ Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice in a
bottle
Ⅲ Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-pound
weight loss over past month
Ⅲ Risk of weight gain RT a recent decrease in daily physical activity following sports injury
Critical Thinking The following types of critical thinking skills are especially needed in the diagnosis step:
Ⅲ Finding patterns and relationships among the data and possible causes;
Ⅲ Making inferences (“if this continues to occur, then this is likely to happen”);
Ⅲ Stating the problem clearly and singularly;
Ⅲ Suspending judgment (be objective and factual);
Ⅲ Making interdisciplinary connections;
Ⅲ Ruling in/ruling out specific diagnoses; and
Ⅲ Prioritizing the relative importance of problems for patient/client/group safety.
Documentation of
Diagnosis
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.
Quality documentation of the diagnosis step should be relevant, accurate, and timely. A nutrition
diagnosis is the impression of dietetics professionals at a given point in time. Therefore, as more
assessment data become available, the documentation of the diagnosis may need to be revised and
updated.
Inclusion of the following information would further describe quality documentation of this step:
Ⅲ Date and time; and
Ⅲ Written statement of nutrition diagnosis.
Determination for
Continuation of Care
Since the diagnosis step primarily involves naming and describing the problem, the determination for
continuation of care seldom occurs at this step. Determination of the continuation of care is more
appropriately made at an earlier or later point in the Nutrition Care Process.
STEP 3. NUTRITION INTERVENTION
Basic Definition &
Purpose
“Nutrition Intervention” is the third step of the Nutrition Care Process. An intervention is a specific
set of activities and associated materials used to address the problem. Nutrition interventions are
purposefully planned actions designed with the intent of changing a nutrition-related behavior, risk
factor, environmental condition, or aspect of health status for an individual, target group, or the
community at large. This step involves a) selecting, b) planning, and c) implementing appropriate
actions to meet patient/client/groups’ nutrition needs. The selection of nutrition interventions is driven
by the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.
Dietetics professionals may actually do the interventions, or may include delegating or coordinating
the nutrition care that others provide. All interventions must be based on scientific principles and
rationale and, when available, grounded in a high level of quality research (evidence-based
interventions).
Dietetics professionals work collaboratively with the patient/client/group, family, or caregiver to
create a realistic plan that has a good probability of positively influencing the diagnosis/problem. This
client-driven process is a key element in the success of this step, distinguishing it from previous
planning steps that may or may not have involved the patient/client/group to this degree of
participation.
Data Sources/Tools for
Interventions
Ⅲ Evidence-based nutrition guides for practice and protocols
Ⅲ Current research literature
Ⅲ Current consensus guidelines and recommendations from other professional organizations
Ⅲ Results of outcome management studies or Continuous Quality Index projects.
Ⅲ Current patient education materials at appropriate reading level and language
Ⅲ Behavior change theories (self-management training, motivational interviewing, behavior
modification, modeling)
Nutrition Intervention
Components
This step includes two distinct interrelated processes:
1. Plan the nutrition intervention (formulate & determine a plan of action)
Ⅲ Prioritize the nutrition diagnoses based on severity of problem; safety; patient/client/group’s need;
likelihood that nutrition intervention will impact problem and patient/client/groups’ perception of
importance.
Ⅲ Consult ADA’s MNT Evidence-Based Guides for Practice and other practice guides. These
resources can assist dietetics professionals in identifying science-based ideal goals and selecting
appropriate interventions for MNT. They list appropriate value(s) for control or improvement of the
disease or conditions as defined and supported in the literature.
Ⅲ Determine patient-focused expected outcomes for each nutrition diagnosis. The expected
outcomes are the desired change(s) to be achieved over time as a result of nutrition intervention.
They are based on nutrition diagnosis; for example, increasing or decreasing laboratory values,
decreasing blood pressure, decreasing weight, increasing use of stanols/sterols, or increasing
fiber. Expected outcomes should be written in observable and measurable terms that are clear
and concise. They should be patient/client/group-centered and need to be tailored to what is
reasonable to the patient’s circumstances and appropriate expectations for treatments and
outcomes.
FIG 2 cont’d.
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Ⅲ Confer with patient/client/group, other caregivers or policies and program standards throughout
planning step.
Ⅲ Define intervention plan (for example write a nutrition prescription, provide an education plan or
community program, create policies that influence nutrition programs and standards).
Ⅲ Select specific intervention strategies that are focused on the etiology of the problem and that are
known to be effective based on best current knowledge and evidence.
Ⅲ Define time and frequency of care including intensity, duration, and follow-up.
Ⅲ Identify resources and/or referrals needed.
2. Implement the nutrition intervention (care is delivered and actions are carried out)
Ⅲ Implementation is the action phase of the nutrition care process. During implementation, dietetics
professionals:
▫ Communicate the plan of nutrition care;
▫ Carry out the plan of nutrition care; and
▫ Continue data collection and modify the plan of care as needed.
Ⅲ Other characteristics that define quality implementation include:
▫ Individualize the interventions to the setting and client;
▫ Collaborate with other colleagues and health care professionals;
▫ Follow up and verify that implementation is occurring and needs are being met; and
▫ Revise strategies as changes in condition/response occurs.
Critical Thinking Critical thinking is required to determine which intervention strategies are implemented based on
analysis of the assessment data and nutrition diagnosis. The following types of critical thinking skills
are especially needed in the intervention step:
Ⅲ Setting goals and prioritizing;
Ⅲ Transferring knowledge from one situation to another;
Ⅲ Defining the nutrition prescription or basic plan;
Ⅲ Making interdisciplinary connections;
Ⅲ Initiating behavioral and other interventions;
Ⅲ Matching intervention strategies with client needs, diagnoses, and values;
Ⅲ Choosing from among alternatives to determine a course of action; and
Ⅲ Specifying the time and frequency of care.
Documentation of
Nutrition Interventions
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.
Quality documentation of nutrition interventions should be relevant, accurate, and timely. It should
also support further intervention or discharge from care. Changes in patient/client/group’s level of
understanding and food-related behaviors must be documented along with changes in clinical or
functional outcomes to assure appropriate care/case management in the future. Inclusion of the
following information would further describe quality documentation of this step:
Ⅲ Date and time;
Ⅲ Specific treatment goals and expected outcomes;
Ⅲ Recommended interventions, individualized for patient;
Ⅲ Any adjustments of plan and justifications;
Ⅲ Patient receptivity;
Ⅲ Referrals made and resources used;
Ⅲ Any other information relevant to providing care and monitoring progress over time;
Ⅲ Plans for follow-up and frequency of care; and
Ⅲ Rationale for discharge if appropriate.
Determination for
Continuation of Care
If the patient/client/group has met intervention goals or is not at this time able/ready to make needed
changes, the dietetics professional may include discharging the client from this episode of care as
part of the planned intervention.
STEP 4. NUTRITION MONITORING AND EVALUATION
Basic Definition &
Purpose
“Nutrition Monitoring and Evaluation” is the fourth step of the Nutrition Care Process. Monitoring
specifically refers to the review and measurement of the patient/client/group’s status at a scheduled
(preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans/goals, and
outcomes, whereas Evaluation is the systematic comparison of current findings with previous status,
intervention goals, or a reference standard. Monitoring and evaluation use selected outcome
indicators (markers) that are relevant to the patient/client/group’s defined needs, nutrition diagnosis,
nutrition goals, and disease state. Recommended times for follow-up, along with relevant outcomes
to be monitored, can be found in ADA’s Evidence Based Guides for Practice and other evidence-
based sources.
The purpose of monitoring and evaluation is to determine the degree to which progress is being
made and goals or desired outcomes of nutrition care are being met. It is more than just “watching”
what is happening, it requires an active commitment to measuring and recording the appropriate
outcome indicators (markers) relevant to the nutrition diagnosis and intervention strategies. Data from
this step are used to create an outcomes management system. Refer to Outcomes Management
System in text.
FIG 2 cont’d.
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Journal of THE AMERICAN DIETETIC ASSOCIATION / 1067
Edition: 2006 7
Progress should be monitored, measured, and evaluated on a planned schedule until discharge.
Short inpatient stays and lack of return for ambulatory visits do not preclude monitoring, measuring,
and evaluation. Innovative methods can be used to contact patients/clients to monitor progress and
outcomes. Patient confidential self-report via mailings and telephone follow-up are some possibilities.
Patients being followed in disease management programs can also be monitored for changes in
nutritional status. Alterations in outcome indicators such as hemoglobin A1C or weight are examples
that trigger reactivation of the nutrition care process.
Data Sources/Tools for
Monitoring and
Evaluation
Ⅲ Patient/client/group records
Ⅲ Anthropometric measurements, laboratory tests, questionnaires, surveys
Ⅲ Patient/client/group (or guardian) interviews/surveys, pretests, and posttests
Ⅲ Mail or telephone follow-up
Ⅲ ADA’s Evidence Based Guides for Practice and other evidence-based sources
Ⅲ Data collection forms, spreadsheets, and computer programs
Types of Outcomes
Collected
The outcome(s) to be measured should be directly related to the nutrition diagnosis and the goals
established in the intervention plan. Examples include, but are not limited to:
Ⅲ Direct nutrition outcomes (knowledge gained, behavior change, food or nutrient intake changes,
improved nutritional status);
Ⅲ Clinical and health status outcomes (laboratory values, weight, blood pressure, risk factor profile
changes, signs and symptoms, clinical status, infections, complications);
Ⅲ Patient/client-centered outcomes (quality of life, satisfaction, self-efficacy, self-management,
functional ability); and
Ⅲ Health care utilization and cost outcomes (medication changes, special procedures,
planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, prevent or
delay nursing home admission).
Nutrition Monitoring
and Evaluation
Components
This step includes three distinct and interrelated processes:
1. Monitor progress
Ⅲ Check patient/client/group understanding and compliance with plan;
Ⅲ Determine if the intervention is being implemented as prescribed;
Ⅲ Provide evidence that the plan/intervention strategy is or is not changing patient/client/group
behavior or status;
Ⅲ Identify other positive or negative outcomes;
Ⅲ Gather information indicating reasons for lack of progress; and
Ⅲ Support conclusions with evidence.
2. Measure outcomes
Ⅲ Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms,
nutrition goals, medical diagnosis, and outcomes and quality management goals.
Ⅲ Use standardized indicators to:
▫ Increase the validity and reliability of measurements of change; and
▫ Facilitate electronic charting, coding, and outcomes measurement.
3. Evaluate outcomes
Ⅲ Compare current findings with previous status, intervention goals, and/or reference standards.
Critical Thinking The following types of critical thinking skills are especially needed in the monitoring and evaluation step:
Ⅲ Selecting appropriate indicators/measures;
Ⅲ Using appropriate reference standard for comparison;
Ⅲ Defining where patient/client/group is now in terms of expected outcomes;
Ⅲ Explaining variance from expected outcomes;
Ⅲ Determining factors that help or hinder progress; and
Ⅲ Deciding between discharge or continuation of nutrition care.
Documentation of
Monitoring and
Evaluation
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process
and is an integral part of monitoring and evaluation activities. Quality documentation of the
monitoring and evaluation step should be relevant, accurate, and timely. It includes a statement of
where the patient is now in terms of expected outcomes. Standardized documentation enables
pooling of data for outcomes measurement and quality improvement purposes. Quality
documentation should also include:
Ⅲ Date and time;
Ⅲ Specific indicators measured and results;
Ⅲ Progress toward goals (incremental small change can be significant therefore use of a Likert type
scale may be more descriptive than a “met” or “not met” goal evaluation tool);
Ⅲ Factors facilitating or hampering progress;
Ⅲ Other positive or negative outcomes; and
Ⅲ Future plans for nutrition care, monitoring, and follow up or discharge.
Determination for
Continuation of Care
Based on the findings, the dietetics professional makes a decision to actively continue care or
discharge the patient/client/group from nutrition care (when necessary and appropriate nutrition care is
completed or no further change is expected at this time). If nutrition care is to be continued, the nutrition
care process cycles back as necessary to assessment, diagnosis, and/or intervention for additional
assessment, refinement of the diagnosis and adjustment and/or reinforcement of the plan. If care does not
continue, the patient may still be monitored for a change in status and reentry to nutrition care at a later date.
FIG 2 cont’d.
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1068 / August 2003 Volume 103 Number 8
Edition: 2006 8
describing what dietetics professionals do is truly a paradigm
shift. This new paradigm is more complete, takes in more pos-
sibilities, and explains observations better. Finally, it allows
dietetics professionals to act in ways that are more likely to
achieve the results that are desired and expected.
NUTRITION CARE MODEL
The Nutrition Care Model is a visual representation that re-
flects key concepts of each step of the Nutrition Care Process
and illustrates the greater context within which the Nutrition
Care Process is conducted. The model also identifies other fac-
tors that influence and impact on the quality of nutrition care
provided. Refer to Figure 1 for an illustration of the model as
described below:
■ Central Core: Relationship between patient/client/group and
dietetics professional;
■ Nutrition Care Process: Four steps of the nutrition care pro-
cess (Figure 2);
■ Outer rings:
■ Middle ring: Strengths and abilities that dietetics profession-
als bring to the process (dietetics knowledge, skills, and com-
petencies; critical thinking, collaboration, and communication;
evidence-based practice, and Code of Ethics) (32);
■ Outer ring: Environmental factors that influence the process
(practice settings, health care systems, social systems, and
economics);
■ Supporting Systems:
■ Screening and Referral System as access to Nutrition Care;
and
■ Outcomes Management Systemas a means to provide contin-
uous quality improvement to the process.
The model is intended to depict the relationship with which
all of these components overlap, interact, and move in a dy-
namic manner to provide the best quality nutrition care possi-
ble.
Central to providing nutrition care is the relationship be-
tween the patient/client/group and the dietetics professional.
The patient/client/groups’ previous educational experiences
and readiness to change influence this relationship. The edu-
cation and training that dietetics professionals receive have
very strong components devoted to interpersonal knowledge
and skill building such as listening, empathy, coaching, and
positive reinforcing.
The middle ring identifies abilities of dietetics professionals
that are especially applicable to the Nutrition Care Process.
These include the unique dietetics knowledge, skill, and com-
petencies that dietetics professionals bring to the process, in
addition to a well-developed capability for critical thinking, col-
laboration, and communication. Also in this ring is evidence-
based practice that emphasizes that nutrition care must incor-
porate currently available scientific evidence, linking what is
done (content) and how it is done (process of care). The Code
of Ethics defines the ethical principles by which dietetics pro-
fessionals should practice (33). Dietetics knowledge and evi-
dence-based practice establish the Nutrition Care Process as
unique to dietetics professionals; no other health care profes-
sional is qualified to provide nutrition care in this manner. How-
ever, the Nutrition Care Process is highly dependent on collab-
oration and integration within the health care team. As stated
above, communication and participation within the health care
teamare critical for identification of individuals who are appro-
priate for nutrition care.
The outer ring identifies some of the environmental factors
such as practice settings, health care systems, social systems,
and economics. These factors impact the ability of the patient/
client/group to receive and benefit from the interventions of
nutrition care. It is essential that dietetics professionals assess
these factors and be able to evaluate the degree to which they
may be either a positive or negative influence on the outcomes
of care.
Screening and Referral System
Because screening may or may not be accomplished by dietet-
ics professionals, nutrition screening is a supportive system
and not a step within the Nutrition Care Process. Screening is
extremely important; it is an identification step that is outside
the actual “care” and provides access to the Nutrition Care
Process.
The Nutrition Care Process depends on an effective screen-
ing and/or referral process that identifies clients who would
benefit fromnutrition care or MNT. Screening is defined by the
US Preventive Services Task Force as “those preventive ser-
vices in which a test or standardized examination procedure is
used to identify patients requiring special intervention” (34).
The major requirements for a screening test to be considered
effective are the following:
■ Accuracy as defined by the following three components:
ᮀ Specificity: Can it identify patients with a condition?
ᮀ Sensitivity: Can it identify those who do not have the condi-
tion?
ᮀ Positive and negative predictive; and
■ Effectiveness as related to likelihood of positive health out-
comes if intervention is provided.
Screening parameters need to be tailored to the population
and to the nutrition care services to be provided. For example,
the screening parameters identified for a large tertiary acute
care institution specializing in oncology would be vastly differ-
ent than the screening parameters defined for an ambulatory
obstetrics clinic. Depending on the setting and institutional
policies, the dietetics professional may or may not be directly
involved in the screening process. Regardless of whether die-
tetics professionals are actively involved in conducting the
screening process, they are accountable for providing input
into the development of appropriate screening parameters to
ensure that the screening process asks the right questions.
They should also evaluate how effective the screening process
is in terms of correctly identifying clients who require nutrition
care.
In addition to correctly identifying clients who would benefit
from nutrition care, a referral process may be necessary to
ensure that the client has an identifiable method of being linked
to dietetics professionals who will ultimately provide the nutri-
tion care or medical nutrition therapy. While the nutrition
screening and referral is not part of the Nutrition Care Process,
it is a critical antecedent step in the overall system (35).
Outcomes Management System
An outcomes management system evaluates the effectiveness
and efficiency of the entire process (assessment, diagnosis,
interventions, cost, and others), whereas the fourth step of the
process “nutrition monitoring and evaluations” refers to the
evaluation of the patient/client/group’s progress in achieving
outcomes.
Because outcomes management is a system’s commitment to
effective and efficient care, it is depicted outside of the NCP.
Outcomes management links care processes and resource uti-
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Journal of THE AMERICAN DIETETIC ASSOCIATION / 1069
Edition: 2006 9
lization with outcomes. Through outcomes management, rele-
vant data are collected and analyzed in a timely manner so that
performance can be adjusted and improved. Findings are com-
pared with such things as past levels of performance; organiza-
tional, regional, or national norms; and standards or bench-
marks of optimal performance. Generally, this information is
reported to providers, administrators, and payors/funders and
may be part of administrative databases or required reporting
systems.
It requires an infrastructure in which outcomes for the pop-
ulation served are routinely assessed, summarized, and re-
ported. Health care organizations use complex information
management systems to manage resources and track perfor-
mance. Selected information documented throughout the nu-
trition care process is entered into these central information
management systems and structured databases. Examples of
centralized data systems in which nutrition care data should be
included are the following:
■ basic encounter documentation for billing and cost account-
ing;
■ tracking of standard indicators for quality assurance and ac-
creditation;
■ pooling data from a large series of patients/clients/groups to
determine outcomes; and
■ specially designed studies that link process and outcomes to
determine effectiveness and cost effectiveness of diagnostic
and intervention approaches.
The major goal of outcomes management is to utilize col-
lected data to improve the quality of care rendered in the fu-
ture. Monitoring and evaluation data from individuals are
pooled/aggregated for the purposes of professional account-
ability, outcomes management, and systems/processes im-
provement. Results from a large series of patients/clients can
be used to determine the effectiveness of intervention strate-
gies and the impact of nutrition care in improving the overall
health of individuals and groups. The effects of well-monitored
quality improvement initiatives should be reflected in measur-
able improvements in outcomes.
Outcomes management comprehensively evaluates the two
parts of IOM’s definition of quality: outcomes and process. Mea-
suring the relationship between the process and the outcome is
essential for quality improvement. To ensure that the quality of
patient care is not compromised, the focus of quality improve-
ment efforts should always be directed at the outcome of care
(36-43).
FUTURE IMPLICATIONS
Impact on Coverage for Services
Quality-related issues are gaining in importance worldwide.
Even though our knowledge base is increasing, the scientific
evidence for most clinical practices in all of medicine is modest.
So much of what is done in health care does not maximize
quality or minimize cost (44). A standardized Nutrition Care
Process is a necessary foundation tool for gathering valid and
reliable data on howquality nutrition care provided by qualified
dietetics professionals improves the overall quality of health
care provided. Implementing ADA’s Nutrition Care Process
provides a framework for demonstrating that nutrition care
improves outcomes by the following: (a) enhancing the health
of individuals, groups, institutions, or health systems; (b) po-
tentially reducing health care costs by decreasing the need for
medications, clinic and hospital visits, and preventing or delay-
ing nursing home admissions; and (c) serving as the basis for
research, documenting the impact of nutrition care provided
by dietetics professionals (45-47).
Developing Scopes and Practice Standards
The work group reviewed the questions raised by delegates
regarding the role of the RD and DTR in the Nutrition Care
Process. As a result of careful consideration of this important
issue, it was concluded that describing the various types of
tasks and responsibilities appropriate to each of these creden-
tialed dietetics professionals was yet another professional issue
beyond the intent and purpose of developing a standardized
Nutrition Care Process.
A scope of practice of a profession is the range of services
that the profession is authorized to provide. Scopes of practice,
depending on the particular setting in which they are used, can
have different applications. They can serve as a legal document
for state certification/licensure laws or they might be incorpo-
rated into institutional policy and procedure guidelines or job
descriptions. Professional scopes of practice should be based
on the education, training, skills, and competencies of each
profession (48).
As previously noted, a dietetics professional is a person who,
by virtue of academic and clinical training and appropriate cer-
tification and/or licensure, is uniquely qualified to provide a
comprehensive array of professional services relating to pre-
vention and treatment of nutrition-related conditions. A Scope
of Practice articulates the roles of the RD, DTR, and advanced-
practice RD. Issues to be addressed for the future include the
following: (a) the need for a common scope with specialized
guidelines and (b) recognition of the rich diversity of practice
vs exclusive domains of practice regulation.
Professional standards are “authoritative statements that
describe performance common to the profession.” As such,
standards should encompass the following:
■ articulate the expectations the public can have of a dietetics
professional in any practice setting, domain, and/or role;
■ expect and achieve levels of practice against which actual
performance can be measured; and
■ serve as a legal reference to describe “reasonable and pru-
dent” dietetics practice.
The Nutrition Care Process effectively reflects the dietetics
professional as the unique provider of nutrition care when it is
consistently used as a systematic method to think critically and
make decisions to provide safe and effective care. ADA’s Nutri-
tion Care Process will serve as a guide to develop scopes of
practice and standards of practice (49,50). Therefore, the work
group recommended that further work be done to use the Nu-
trition Care Process to describe roles and functions that can be
included in scopes of practice. In May 2003, the Board of Di-
rectors of ADA established a Practice Definitions Task Force
that will identify and differentiate the terms within the profes-
sion that need clarification for members, affiliates, and DPGs
related to licensure, certification, practice acts, and advanced
practice. This task force is also charged to clarify the scope of
practice services, clinical privileges, and accountabilities pro-
vided by RDs/DTRs based on education, training, and experi-
ence.
Education of Dietetics Students
It will be important to review the current CADE Educational
Standards to ensure that the language and level of expected
competencies are consistent with the entry-level practice of
OF PROFESSIONAL INTEREST
1070 / August 2003 Volume 103 Number 8
Edition: 2006 10
the Nutrition Care Process. Further work by the Commission
on Dietetic Registration (CDR) may need to be done to make
revisions on the RD and DTR exams to evaluate entry-level
competencies needed to practice nutrition care in this way.
Revision of texts and other educational materials will also need
to incorporate the key principles and steps of this new process
(51).
Education and Credentialing of Members
Even though dietetics professionals currently provide nutrition
care, this standardized Nutrition Care Process includes some
new principles, concepts, and guidelines in each of its steps.
This is especially true of steps 2 and 4 (Nutrition Diagnosis and
Nutrition Monitoring and Evaluation). Therefore, the implica-
tions for education of dietetics professionals and their practice
are great. Because a large number of dietetics professionals still
are employed in health care systems, a comprehensive educa-
tional plan will be essential. A model to be considered when
planning education is the one used to educate dietetics profes-
sionals on the Professional Development Portfolio (PDP) Pro-
cess (52). Materials that could be used to provide members
with the necessary knowledge and skills in this process could
include but not be limited to the following:
■ articles in the Journal of the American Dietetic Associa-
tion;
■ continuing professional education lectures and presentations
at affiliate and national meetings;
■ self-study materials; case studies, CD-ROM workbooks, and
others;
■ hands-on workshops and training programs;
■ Web-based materials; and
■ inclusion in the learning needs assessment and codes of the
Professional Development Portfolio.
Through the development of this educational strategic plan,
the benefits to dietetics professionals and other stakeholders
will need to be a central theme to promote the change in prac-
tice that comes with using this process to provide nutrition
care.
Evidence-Based Practice
The pressure to do more with less is dramatically affecting all of
health care, including dietetics professionals. This pressure is
forcing the health care industry to restructure to be more effi-
cient and cost-effective in delivering care. It will require the use
of evidenced-based practice to determine what practices are
critical to support outcomes (53,54). The Nutrition Care Pro-
cess will be invaluable as research is completed to evaluate the
services provided by dietetics professionals (55). The Nutrition
Care Process will provide the structure for developing the
methodology and data collection in individual settings, and the
practice-based research networks ADA is in the process of ini-
tiating.
Standardized Language
As noted in Step 2 (Nutrition Diagnosis), having a standard
taxonomy for nutrition diagnosis would be beneficial. Work in
the area of articulating the types of interventions used by die-
tetics professionals has already begun by the Definitions Work
Group under the direction of ADA’s Research Committee. Fur-
ther work to define terms that are part of the Nutrition Care
Process will need to continue. Even though the work group
provided a list of terms relating to the definition and key con-
cepts of the process, there are opportunities to articulate fur-
ther terms that are consistently used in this process. The Board
of Directors of ADA in May 2003 approved continuation and
expansion of a task force to address a comprehensive system
that includes a process for developing and validating standard-
ized language for nutrition diagnosis, intervention, and out-
comes.
SUMMARY
Just as maps are reissued when new roads are built and rivers
change course, this Nutrition Care Process and Model reflects
recent changes in the nutrition and health care environment. It
provides dietetics professionals with the updated “road map” to
follow the best path for high-quality patient/client/group-cen-
tered nutrition care.
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The Quality Management Committee Work Group devel-
oped the Nutrition Care Process and Model with input
from the House of Delegates dialog (October 2002 HOD
meeting, in Philadelphia, PA). The work group members
are the following: Karen Lacey, MS, RD, Chair; Elvira
Johnson, MS, RD; Kessey Kieselhorst, MPA, RD; Mary Jane
Oakland, PhD, RD, FADA; Carlene Russell, RD, FADA; Pa-
tricia Splett, PhD, RD, FADA; Suzanne Bertocchi, DTR,
and Tamara Otterstein, DTR; Ellen Pritchett, RD; Esther
Myers, PhD, RD, FADA; Harold Holler, RD, and Karri
Looby, MS, RD. The work group would like to extend a
special thank you to Marion Hammond, MS, and Naoimi
Trossler, PhD, RD, for their assistance in development of
the Nutrition Care Process and Model.
OF PROFESSIONAL INTEREST
1072 / August 2003 Volume 103 Number 8
Edition: 2006 12
American Dietetic Association’s Standardized Nutrition Language:
Current Status
Introduction
Evidence-based dietetic practice relies on
concise, consistent, and standardized terminology to
create and retrieve digital sources of evidence.
1
This
is essential for documenting nutrition diagnoses,
interventions and outcomes in electronic health
records. A task force of the American Dietetic
Association (ADA) has begun to refine and
disseminate standardized nutrition language. The
language is built on the Nutrition Care Process and
Model that maps quality nutrition care and outcomes,
and recognizes several existing terminologies used by
other health professions. This paper will describe the
logic model for the development of the standardized
nutrition language, the Nutrition Care Process it is
built upon, and its current status.
The project goal is to support nutrition practice,
education, research, and policy with data. It is
assumed that practicing dietitians, educators, and
researchers will use the standardized nutrition
language to document care, aggregate data, and study
the evidence. Standardized terminology will provide
the foundation for developing a national dietitian
care database.
The Nutrition Care Process
The ADA Nutrition Care Model workgroup
published the Nutrition Care Process (NCP) and
Model in August 2003.
2
It provides a definition of
the NCP and describes its steps and framework. The
NCP is “a systematic problem-solving method that
dietetics professionals use to critically think and
make decisions to address nutrition related problems
and provide safe and effective quality nutrition
care.”
2, p1063
The four steps of the NCP, similar to
those of other clinical professions, are: (a) Nutrition
Assessment, (b) Nutrition Diagnosis, (c) Nutrition
Intervention, and (d) Nutrition Monitoring and
Evaluation. Allowing for the reality of an iterative
and comprehensive clinical process, the NCP is not
linear and it includes, but is not limited to, Medical
Nutrition Therapy. Medical Nutrition Therapy is
“nutritional diagnostic, therapy, and counseling
services for the purpose of disease management,
which are furnished by a registered dietitian or
nutrition professional.”
3
The context of the NCP and
surrounding influences are captured in the Model
framework.
Standardized terms are being developed for each
step of the NCP. Nutrition Assessment is “a
systematic process of obtaining, verifying, and
interpreting data in order to make decisions about the
nature and cause of nutrition-related problems.”
2
The
Nutrition Assessment includes signs and symptoms.
Nutrition Diagnosis is “the identification and labeling
that describes an actual occurrence, risk of, or
potential for developing a nutritional problem that
dietetics professionals are responsible for treating
independently.”
2
Nutrition Interventions are “purposely planned
actions designed with the intent of changing a
nutrition-related behavior, risk factor, environmental
condition, or aspect of health status for an individual,
target group, or the community at large.”
2,
Interventions are directed to influence the etiology or
effects of a diagnosis. Nutrition Monitoring is “the
review and measurement of the patient/client/group’s
status at a scheduled (preplanned) follow-up point
with regard to the nutrition diagnosis, intervention
plans/goals, and outcomes.” Evaluation is “the
systematic comparison of current findings with
previous status, intervention goals, or a reference
standard.”
2
Evaluation may measure changes in signs
and symptoms. The NCP steps guide the delivery of
nutrition health services, education, and research and
define categories for documentation of nutrition care.
Development: Comparison with Nursing
In comparison with the development of various
nursing terminologies, the ADA nutrition language
development has been much more rapid and
centralized, due perhaps to comparatively smaller
numbers of nutrition professionals and growing
sophistication in information technology. Nursing
terminology work began in the 1970s, including the
North American Nursing Diagnosis Association
(NANDA)
4
terminology, the Clinical Care
Classification (CCC),
5
and others. NANDA is
specific to nursing diagnoses, while the CCC
addresses diagnoses, interventions, and outcomes.
The Nursing Minimum Data Set,
6
which includes
patient information, nursing diagnoses, nursing
interventions, nursing outcomes, intensity level of
nursing care, and a unique provider number, is an
overarching framework for the various discrete
nursing terminologies, similar to the NCP.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
13
Why Does Dietetics Practice Need a Standardized
Language?
There is currently no agreed upon mechanism by
which dietetics professionals can communicate with
each other or other health care professionals. Because
of this lack of agreement, there is no easy way to
classify, measure, and report on the outcomes of
nutrition interventions in various patient populations.
The Nutrition Care Process includes nutrition
diagnosis and nutrition intervention as unique steps
that provide registered dietitians a mechanism to
consistently document and communicate the work of
dietetics. There is currently no agreed upon
terminology used in dietetics practice which makes it
impossible to gather and aggregate data needed for
research, education, and reimbursement justification
via outcomes analysis.
Logic Model
A Logic Model is a simplified picture that
describes the logical relationships among the
resources invested, the activities that take place, and
the benefits to be realized from the project and the
environment in which the system/project occurs.
With the help of an informatics consultant, the
Standardized Language Task Force adopted a Project
Logic Model that identifies the expected outcomes
and impact of the Standardized Language of
Dietetics. The goal of the dietetics terminology was
seen to be "To provide data to foster nutrition
practice, education, research, and policy.”
Three time frames for evaluating the impact of
the standardized language were agreed upon. The
most immediate impacts were thought to include
recommendations for coordination with existing
terminologies, review of the structure of the dietetics
terminology, to "cross-walk" the new terminology
with existing terminologies to see if overlap exists, to
review existing intervention terms, and to identify
relevant policy issues regarding standardized
nutrition language. Intermediate impacts were
thought to include selection of a structure for the
nutrition diagnostic labels, cross-walk of the
intervention terms, to plan for generation of nutrition
outcomes measures, create strategies for ongoing
maintenance and updates of the language, to design
and implement pilot testing of the standardized
language, and to draft legislative and policy agendas.
The ultimate impact was agreed to include delivery
of quality, cost-effective nutrition care, national
growth of nutrition care, inclusion of the standardized
language in dietetics education and research,
development of a national data warehouse for
nutrition research, and support of policies designed to
foster nutrition practice, education, and research.
Several assumptions were necessary in
development of this logic model. The Task Force was
in agreement that nutrition is an essential component
of high quality health care. There was heightened
awareness of the need for data to document the
processes and outcomes of nutrition care in a variety
of settings. It was also assumed that educators,
practicing dietitians, and researchers would accept
and implement the standardized language and would
be willing to share data using the terminology for
targeted studies and ultimately a national database.
Nutrition Diagnostic Labels
To date, over 60 Nutrition Diagnostic Labels
have been defined by ADA work with focus groups,
domain experts, and membership committees.
Standardized Language Task Force members judged
the match between nutrition diagnoses terms and
similar terms listed in the National Library of
Medicine’s Unified Medical Language System
(UMLS);
7
many terms have synonyms. One of the
robust terminologies in the UMLS is SNOMED-CT.
8
Staff from SNOMED-CT were contacted to discuss
the process of submitting nutrition terms.
The Nutrition Diagnostic Labels include 3
domains: Clinical, Behavioral-Environmental, and
Intake. The domains, sub-classes, and specific
diagnoses are defined in the most recent version, a
summary of which follows.
DOMAIN: INTAKE
Defined as “actual problems related to intake of
energy, nutrients, fluids, bioactive substances through
oral diet or nutrition support (enteral or parenteral
nutrition)”
Class: Caloric Energy Balance
Defined as “actual or estimated changes in energy
(kcal)”
Class: Oral or Nutrition Support Intake
Defined as “actual or estimated food and beverage
intake from oral diet or nutrition support compared
with patient goal”
Class: Fluid Intake Balance
Defined as “actual or estimated fluid intake compared
with patient goal”
Class: Bioactive Substances Balance
Defined as “actual or observed intake of bioactive
substances, including single or multiple functional
food components, ingredients, dietary supplements,
alcohol”
Class: Nutrient Balance
Defined as “actual or estimated intake of specific
nutrient groups or single nutrients as compared with
desired levels”
Sub-Class: Fat and Cholesterol Balance
Sub-Class: Protein Balance
Edition: 2006
Portions of this document have been submitted for publication elsewhere
14
Sub-Class: Carbohydrate and Fiber Balance
Sub-Class: Vitamin Balance
Sub-Class: Mineral Balance
DOMAIN: CLINICAL
Defined as “nutritional findings/problems identified
that relate to medical or physical conditions”
Class: Functional Balance
Defined as “change in physical or mechanical
functioning that interferes with or prevents desired
nutritional consequences”
Class: Biochemical Balance
Defined as “change in capacity to metabolize
nutrients as a result of medications, surgery, or as
indicated by altered lab values”
Class: Weight Balance
Defined as “chronic weight or changed weight status
when compared with usual or desired body weight”
DOMAIN: BEHAVIORAL-
ENVIRONMENTAL
Defined as “nutritional findings/problems identified
that relate to knowledge, attitudes/beliefs, physical
environment, or access to food and food safety”
Class: Knowledge and Beliefs
Defined as “actual knowledge and beliefs as reported,
observed, or documented”
Class: Physical Activity Balance and Function
Defined as “actual physical activity, self-care, and
quality of life problems as reported, observed or
documented”
Class: Food Safety and Access
Defined as “actual problems with food access or food
safety”
© ADA
Problem-Etiology-Signs/Symptoms Statements
A Nutrition Diagnosis is best written as a PES
statement pertaining to one patient/client or group,
specific to one problem (P) and one etiology (E), and
based on assessment of signs and symptoms (S).
2
Implementation of PES statements in clinical practice
is being tested in two pilot studies by ADA members.
Examples of PES statements are
(a) “Overweight/obesity (problem) related to
continued intake of high fat foods (etiology) resulting
in ~300 extra kcal/day as evidenced by a BMI of 30
(sign/symptom), and (b) Impaired ability to prepare
foods/meals (problem) related to fatigue (etiology) as
evidenced by patient/client only consuming one meal
per day.” Interventions are often guided by the
etiology of each problem. Signs and symptoms may
provide measures to evaluate outcomes and the
effectiveness of care. It is possible that the
standardized terms for assessments will be
considered relevant outcome measures.
Nutrition Interventions
Following principles for standardized
terminologies,
9
the ADA has begun to identify and
define Nutrition Intervention terms. A Task Force
meeting in February 2005 identified categories of
interventions including: Treatments/Procedures,
Education, Counseling, and Referral/Coordination.
These categories are similar to those in nursing
terminologies but differing by not including
monitoring/assessment as an intervention, which is a
separate step in the Nutrition Care Process.
Synonyms to the intervention terms will be searched
in the UMLS and domain experts will judge the
extent of the matches. The Nutrition Intervention
Labels will be submitted SNOMED-CT or other
existing coding system that will be included in the
UMLS.
Future Work
Definition of Nutrition Assessment terms and
their relationship with Outcome terms is planned. In
addition, activities to communicate the standardized
language to educators, administrators, clinicians, and
researchers are planned. The ADA believes that
consistent standardized terminology will improve
patient care by enhancing the education, practice, and
research of nutrition professionals. The use of
standardized nutrition language by nutrition
professionals in the United States is in synch with
similar international efforts.
References
1. Bakken S. An informatics infrastructure is
essential for evidence-based practice. J Am Med
Inform Assoc. 2001;8:199-201.
2. Lacey K, Pritchett E. Nutrition care process and
model: ADA adopts road map to quality care and
outcomes management. J Am Diet Assoc.
2003;103:1061-72.
3. Final Medical Nutrition Therapy regulations.
CMS-1169-FC. Federal Register, Nov.1, 2001.
DHHS 42 CFR Parts: 405, 410, 411, 414, and 415.
Available
at:http://cms.hhs.gov/physicians/pfs/cms1169fc.asp?
Accessed: March 7, 2005.
4. North American Nursing Diagnosis Association.
Available at: http://www.nanda.org. Accessed Mar.
7, 2005.
5. Saba V. Clinical Care Classification System.
Available at http://www.sabacare.com. Accessed
March 7, 2005.
6. Werley H, Lang NM. Identification of the Nursing
Minimum Data Set. New York:NY: Springer; 1988.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
15
7. National Library of Medicine. Unified Medical
Language System. 2005. Available at: http://
www.nlm.nih.gov/research/umls/umlsmain.html.
Accessed March 7, 2005.
8. College of American Pathologists. SNOMED
International Clinical Terms. Available at
http://www.snomed.org/. Accessed March 7, 2005.
9. Cimino JJ. Desiderata for controlled medical
vocabularies in the twenty-first century. Meth Inform
Med; 1998;37:394-403.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
16
Introduction to Nutrition Diagnoses/Problems:
The New Component of the Nutrition Care Process
Introduction
The ADA has embarked on an extensive project to identify and define nutrition
diagnoses/problems for the profession of dietetics. This standardized language of nutrition
diagnoses/problems is an integral component in the Nutrition Care Process, a process designed to
improve the consistency and quality of individualized patient/client care and the predictability of
the patient/client outcomes. In fact, several other allied professional, including nursing, physical
therapy, and occupational therapy, utilize defined care processes (1).
Not only will creating this standard language help dietetic professionals better document their
nutrition care, it will serve to help achieve Association strategic goals of promoting demand for
dietetic professionals and help them be more competitive in the market place. It will also provide
a minimum data set and common data elements for future research that includes services of
dietetic professionals.
ADA’s Standardized Language Task Force developed a conceptual framework for the
standardized nutrition language and identified the nutrition diagnoses/problems. The framework
outlines the domains within which the diagnoses/problems would fall and the flow of the
nutrition care process in relation to the continuum of health, disease and disability. Sixty-two
diagnoses/problems have been identified. A worksheet has been developed for each
diagnosis/problem and expert has been incorporated.
The methodology for developing sets of terms such as these includes systematically collecting
data from multiple sources simultaneously. We collected data from a selected group of dietitians
prior to starting the project (from recognized ADA leaders and award winners), from the 12
member task force during the development, from several small group discussions (community,
ambulatory, acute care, and long term care), and from expert researcher reviewers.
The methodology for continued development and refinement of these terms has been identified.
As with the ongoing updating of the American Medical Association Current Procedural
Terminology (CPT) codes, these will also be published on an annual basis. The process to
submit your suggested changes is included in this packet. In addition, the terms have been
included in one ongoing research project in an ambulatory setting. A second descriptive research
study identifying the use of the terms will be planned and conducted through the Dietetics
Practice Based Research Network in 2005-2006. As each of the research studies is completed,
their findings will be incorporated into future versions of these terms. Future iterations and
changes to the diagnoses/problems and the worksheets are expected as this standard language
evolves. Once the initial research is completed we will formally submit these terms to become
part of nationally recognized health care databases. We have already begun the dialogue with
these groups to let them know the direction that we are headed and to keep them appraised of our
progress.
Edition: 2006 17
Nutrition Care Process and Nutrition Diagnosis
ADA’s new nutrition care process for the profession has four steps—nutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (1).
Textbooks often describe nutrition assessment in detail and then move directly into intervention
or therapy. Nutrition diagnosis is a critical step between assessment and intervention. The
nutrition diagnosis is the identification and labeling of the specific nutrition problem that
dietetics professionals are responsible for treating independently.
Naming the nutrition diagnosis provides a way to document the link between nutrition
assessment and nutrition intervention and set realistic and measurable expected outcomes for
each patient/client. Identifying the diagnosis also assists practitioners in establishing priorities
when planning an individual patient/client’s nutrition care.
Nutrition diagnosis differs from medical diagnosis. Medical diagnosis is a disease or pathology
of specific organs or body systems (e.g., diabetes) and does not change as long as the condition
exists. A nutrition diagnosis may be temporary, altering as the patient/client’s response changes
(e.g., excessive carbohydrate intake).
Categorization of the Nutrition Diagnoses
The sixty-two nutrition diagnoses/problems have been given labels that are clustered into three
domains: intake, clinical, and behavioral-environmental. Each domain represents unique
characteristics that contribute to nutritional health. Within each domain are classes and, in some
cases, sub-classes of diagnoses. A definition of each follows:
The Intake domain lists actual problems related to intake of energy, nutrients, fluids,
bioactive substances through oral diet, or nutrition support (enteral or parenteral nutrition.)
Class: Caloric Energy Balance (1)—Actual or estimated changes in energy (kcal).
Class: Oral or Nutrition Support Intake (2)—Actual or estimated food and beverage intake from oral diet
or nutrition support compared with patient/client’s goal.
Class: Fluid Intake Balance (3)—Actual or estimated fluid intake compared with patient/client’s goal.
Class: Bioactive Substances Balance (4)—Actual or observed intake of bioactive substances, including
single or multiple functional food components, ingredients, dietary supplements, and alcohol.
Class: Nutrient Balance (5)—Actual or estimated intake of specific nutrient groups or single nutrients as
compared with desired levels.
Sub-Class: Fat and Cholesterol Balance (51)
Sub-Class: Protein Balance (52)
Sub-Class: Carbohydrate and Fiber Balance (53)
Sub-Class: Vitamin Balance (54)
Sub-Class: Mineral Balance (55)
The Clinical domain is nutritional findings/problems identified that relate to medical or
physical conditions.
Class: Functional Balance (1)—Change in physical or mechanical function that interferes with or prevents
desired nutritional consequences.
Edition: 2006 18
Class: Biochemical Balance (2)—Change in the capacity to metabolize nutrients as a result of medications,
surgery, or as indicated by altered lab values.
Class: Weight Balance (3)—Chronic weight or changed weight status when compared with usual or desired
body weight.
The Behavioral-Environmental domain includes nutritional findings/problems identified
that relate to knowledge, attitudes/beliefs, physical environment, access to food, and food
safety.
Class: Knowledge and Beliefs (1)—Actual knowledge and beliefs as reported, observed, or documented.
Class: Physical Activity Balance and Function (2)—Actual physical activity, self-care, and quality of life
problems as reported, observed, or documented.
Class: Food Safety and Access (3)—Actual problems with food access or food safety.
Examples of nutrition diagnoses and their definitions include:
INTAKE DOMAIN ƒ Caloric Energy Balance
Inadequate energy intake NI-1.4 Energy intake that is less than energy expenditure or recommended
levels. Exception: when the goal is for the client to lose weight or
during end of life care.
CLINICAL DOMAIN ƒ Functional Balance
Swallowing difficulty NC-1.1 Impaired movement of food and liquid from the mouth to the stomach.
BEHAVIORAL-ENVIRONMENTAL DOMAIN ƒ Knowledge and Beliefs
Not ready for diet/lifestyle change NB-
1.3
Lack of perceived value of nutrition-related care benefits compared to
consequences or effort required to making the change; inconsistencies
with other value structure/purpose; antecedent to behavior change.
Nutrition Diagnosis Statements (or PES)
Whenever possible, a nutrition diagnosis statement is written in the PES format that states the
problem (P), the etiology (E), and the signs/symptoms (S).
Examples
ƒ Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing
following drinking of thin liquids (sign/symptoms).
ƒ Inadequate energy intake (problem) related to lack of financial resources to purchase sufficient
food (etiology) as evidenced by weight loss of 6 pounds in the last 2 months (signs/symptoms).
Nutrition Diagnosis Worksheet
A worksheet has been developed for each diagnosis. It contains four distinct components:
nutrition diagnosis label, definition of nutrition diagnosis label, etiology, and signs/symptoms.
These worksheets will assist practitioners with consistently and correctly utilizing the nutrition
diagnoses. Below is a description of the four components of the worksheet.
The Problem or Nutrition Diagnosis Label describes alterations in the patient/client’s nutrition status that
dietetics professionals are responsible for treating independently. Nutrition diagnosis differs from medical
diagnosis in that a nutrition diagnosis changes as the patient/client response changes. The medical diagnosis
Edition: 2006 19
does not change as long as the disease or condition exists. A nutrition diagnosis allows the dietetics professional
to identify realistic and measurable outcomes, formulate interventions, and monitor and evaluate change.
The Definition of Nutrition Diagnosis Label briefly describes the Nutrition Diagnosis Label to differentiate a
discrete problem area.
The Etiology (Cause/Contributing Risk Factors) are those factors contributing to the existence of, or
maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental
problems. It is linked to the diagnosis label by the words “related to.”
The Signs/Symptoms (Defining Characteristics) consist of subjective and/or objective data used to determine
whether the patient/client has the nutrition diagnosis specified. These are the signs and symptoms gathered
through nutrition assessment. It is linked to the etiology by the words “as evidenced by.”
Organization of Data in Signs/Symptoms (Defining Characteristics)
Dietetics professionals use clinical judgment to determine the nutrition diagnosis based on data
collected from the first step of the nutrition care process: nutrition assessment. Therefore, the
items listed in the signs/symptoms (defining characteristics) are organized according to nutrition
assessment category.
Nutrition assessment is the systematic process for obtaining, verifying, and interpreting data
needed to make decisions about the nature and cause of the nutrition-related problem. The
process of nutrition assessment consists of collecting biochemical data, anthropometric
measurements, physical examination findings, food/nutrition history, and client history. On the
nutrition diagnosis worksheet, the signs/symptoms are classified by nutrition assessment
categories.
Biochemical Data include laboratory data, for example, electrolytes, glucose, hemoglobin A1C, thyroid, and lipid
panel.
Anthropometric Measurements include, for instance, height, weight, body mass index (BMI), growth rate, and
rate of weight change.
Nutrition-Focused Physical Examination includes oral health, general physical appearance, muscle and
subcutaneous fat wasting, and affect.
Food and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and
management, physical activity and exercise, and food availability.
Food consumption may include factors such as, food and nutrient intake, meal and snack patterns,
environmental cues to eating, and current diets and/or food modifications.
Nutrition and health awareness and management includes, for example, knowledge and beliefs about
nutrition recommendations, self-monitoring/management practices, and past nutrition counseling and
education.
Physical activity and exercise consists of activity patterns, amount of sedentary time (e.g., TV, phone,
computer), and exercise intensity, frequency, and duration.
Food availability encompasses factors such as, food planning, purchasing, preparation abilities and
limitations, food safety practices, food/nutrition program utilization, and food insecurity.
Edition: 2006 20
Client History consists of four areas: Medication and supplement history, social history, medical/health history,
and personal history.
Medication and supplement history includes, for instance, prescription and over the counter drugs,
herbal and dietary supplements, and illegal drugs.
Social history may include such items as socioeconomic status, social and medical support, cultural and
religious beliefs, housing situation, and social isolation/connection.
Medical/health history includes chief nutrition complaint, present/past illness, disease or complication
risk, family medical history, mental/emotional health, and cognitive abilities.
Personal history consists of factors including age, occupation, role in family, and education level.
Summary
Nutrition diagnosis is the critical link in the nutrition care process between assessment and
intervention. Interventions can then be clearly targeted to address either the etiology or signs and
symptoms of the specific nutrition diagnosis/problem identified. Using a standardized
terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical
thinking that dietetics professionals do visible to other professionals as well as provide a clear
method of communicating among dietetics professionals. Implementation of a standard language
throughout the profession, with tools to assist practitioners, will make this bold initiative a
success. Ongoing input is critical as the standardized language is created to ensure a proper
foundation for its future implementation.
Reference
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;103:1061-1072.
Edition: 2006 21
Edition: 2006 22
INTAKE NI
Defined as “ act ual problems relat ed t o int ake of
energy, nut rient s, fluids, bioact ive subst ances
t hrough oral diet or nut rit ion support ”
Caloric Energy Balance (1)
Defined as “ act ual or est imat ed changes in energy
( kcal) ”
‰Hypermetabolism NI-1.1
( I ncreased energy needs)
‰Increased energy expenditure NI-1.2
‰Hypometabolism NI-1.3
( Decreased energy needs)
‰Inadequate energy intake NI-1.4
‰Excessive energy intake NI-1.5
Oral or Nutrition Support Intake (2)
Defined as “ act ual or est imat ed food and beverage
int ake from oral diet or nut rit ion support compared
wit h pat ient goal”
‰Inadequate oral food/ NI-2.1
beverage intake
‰Excessive oral food/ NI-2.2
beverage intake
‰Inadequate intake from NI-2.3
enteral/parenteral nutrition
infusion
‰Excessive intake from NI-2.4
enteral/parenteral nutrition
‰Inappropriate infusion of NI-2.5
enteral/parenteral nutrition
(use with caution)
Fluid Intake (3)
Defined as “ act ual or est imat ed fluid int ake
compared wit h pat ient goal”
‰Inadequate fluid intake NI-3.1
‰Excessive fluid intake NI-3.2
Bioactive Substance Intake (4)
Defined as “ act ual or observed int ake of bioact ive
subst ances, including single or mult iple funct ional
food component s, ingredient s, diet ary
supplement s, alcohol”
‰Inadequate bioactive NI-4.1
substance intake
‰Excessive bioactive NI-4.2
substance intake
‰Excessive alcohol intake NI-4.3
Nutrient Intake (5)
Defined as “ act ual or est imat ed int ake of specific
nut rient groups or single nut rient s as compared
wit h desired levels”
‰Increased nutrient needs NI-5.1
( specify) ____________________________
‰Evident protein-energy NI-5.2
malnutrition
‰Inadequate protein- NI-5.3
energy intake
‰Decreased nutrient needs NI-5.4
( specify) ____________________________
‰Imbalance of nutrients NI-5.5
Fat and Cholesterol (51)
‰Inadequate fat intake NI-51.1
‰Excessive fat intake NI-51.2
‰Inappropriate intake NI-51.3
of food fats
( specify) ______________________
Protein (52)
‰Inadequate protein intake NI-52.1
‰Excessive protein intake NI-52.2
‰Inappropriate intake NI-52.3
of amino acids
( specify) _______________________
Carbohydrate and Fiber (53)
‰Inadequate carbohydrate NI-53.1
intake
‰Excessive carbohydrate NI-53.2
intake
‰Inappropriate intake of NI-53.3
types of carbohydrate
( specify) _______________________
‰Inconsistent NI-53.4
carbohydrate intake
‰Inadequate fiber intake NI-53.5
‰Excessive fiber intake NI-53.6
Vitamin (54)
‰Inadequate vitamin NI-54.1
intake ( specify)
‰Excessive vitamin NI-54.2
intake ( specify)
‰A ‰C
‰Thiamin ‰D
‰Riboflavin ‰E
‰Niacin ‰K
‰Folate ‰Other _______
Mineral (55)
‰Inadequate mineral intake NI-55.1
( specify)
‰Calcium ‰Iron
‰Potassium ‰Zinc
‰Other _______________
‰Excessive mineral intake NI-55.2
( specify)
‰Calcium ‰Iron
‰Potassium ‰Zinc
‰ Other _______________
CLINICAL NC
Defined as “ nut rit ional findings/ problems ident ified
as relat ed t o medical or physical condit ions”
Functional (1)
Defined as “ change in physical or mechanical
funct ioning t hat int erferes wit h or prevent s desired
nut rit ional consequences”
‰Swallowing difficulty NC-1.1
‰Chewing ( mast icat ory) difficulty NC-1.2
‰Breastfeeding difficulty NC-1.3
‰Altered GI function NC-1.4
Biochemical (2)
Defined as “ change in capacit y t o met abolize
nut rient s as a result of medicat ions, surgery, or as
indicat ed by alt ered lab values”
‰Impaired nutrient utilization NC-2.1
‰Altered nutrition-related NC-2.2
laboratory values ( specify) _____________
‰Food-medication interaction NC-2.3
Weight (3)
Defined as “ chronic weight or changed weight
st at us when compar ed wit h usual or desired body
weight ”
‰Underweight NC-3.1
‰Involuntary weight loss NC-3.2
‰Overweight/obesity NC-3.3
‰Involuntary weight gain NC-3.4
BEHAVIORAL-
ENVIRONMENTAL NB
Defined as “ nut rit ional findings/ problems ident ified
as relat ed t o knowledge, at t it udes/ beliefs, physical
environment , or food supply and safet y”
Knowledge and Beliefs (1)
Defined as “ act ual knowledge and beliefs as
report ed or document ed”
‰Food, nutrition, and NB-1.1
nutrition-related knowledge deficit
‰Harmful beliefs/attitudes NB-1.2
about food or nutrition-
related topics (use with caution)
‰Not ready for diet/ NB-1.3
lifestyle change
‰Self-monitoring deficit NB-1.4
‰Disordered eating pattern NB-1.5
‰Limited adherence to nutrition- NB-1.6
related recommendations
‰Undesirable food choices NB-1.7
Physical Activity
and Function (2)
Defined as “ act ual physical act ivit y, self- care, and
qualit y of life problems as report ed, observed, or
document ed”
‰Physical inactivity NB-2.1
‰Excessive exercise NB-2.2
‰ Inability or lack of desire NB-2.3
to manage self-care
‰Impaired ability to NB-2.4
prepare foods/meals
‰Poor nutrition quality of life NB-2.5
‰Self-feeding difficulty NB-2.6
Food Safety and Access (3)
Defined as “ act ual problems wit h food access or
food safet y”
‰Intake of unsafe food NB-3.1
‰Limited access to food NB-3.2
NUTRITION DIAGNOSTIC TERMINOLOGY
#1 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms _____________________________________________________________________________________________________
#2 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms _____________________________________________________________________________________________________
#3 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms ___________________________________________________________________________________________
Date Identified Date Resolved
N
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