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Nutrition Care Process (NCP)

Prepared by Sandy
Sarcona, MS, RD

Steps of NCP
A Nutrition Assessment
D Nutrition Diagnosis

Problem, Etiology, Signs and


Symptoms

I Nutrition Intervention
M Nutrition Monitoring
E Evaluation

Through nutrition reassessment, dietetics


practitioners perform nutrition monitoring
and evaluation to determine if the nutrition
intervention strategy is working to resolve
the nutrition diagnosis, its etiology, and/or
signs and symptoms

Step 1: Nutrition Assessment


Screening and referral are typical entrance

points into the NCP


Assessment leads to determination that a
nutrition diagnosis/problem exists; it is
possible that a nutrition problem does not
exist
Example: LTC resident on tube feeding;

weight wnl and stable, Albumin wnl, labs wnl,


good skin integrity and hydration status,
feeding continues at recommended rate.

Nutrition Assessment Domains


Food/Nutrition-Related History: FH (diet hx,

energy intake, food and beverage intake,


enteral and parenteral intake, bioactive
substance intake, macronutrient/micronutrient
intake, medication/supplement use,
knowledge/beliefs/attitudes/behavior, etc)
Anthropometric Measurements: AD
Biochemical Data, Medical Tests and
Procedures: BD
Nutrition Focused Physical Findings: PD
(appetite, edema, taste alterations, swallowing
difficulty, etc)
Client History: CH (personal hx, PMH, social
hx)

Nutrition Assessment,
Monitoring and Evaluation
Comparative Standards
Estimated Energy Needs (formula)

Estimated Fat, Protein, and CHO needs


Estimated Fiber Needs (AI)
Estimated Fluid Needs (AI)
Estimated Vitamin and Mineral Needs

(RDA)
Recommended Body Weight /BMI/Growth
(peds)

Example: Food Intake


Indications: amount of food, types of food/meals;
meal/snack patterns, diet quality, food variety
Measurement methods: food intake records, 24hour recall, food frequency, MyPyramid Tracker
Typically used to monitor and evaluate change in
the following nutrition dx: excessive or inadequate
oral food/bev intake, underweight,
overweight/obesity, limited access to food
Evaluation comparison to goal or reference
standard
1) Goal: Pt currently eats ~10% of kcal from
saturated fat Goal to <7% of daily kcal
2) Reference standard: Pts current intake of fat not
meeting AHA criteria to consume <7% of kcal from
sat. fat

Step 2: Nutrition Diagnosis


1. Problem (Diagnostic Label) such as,

Excessive oral food/beverage intake (NI2.2)


2. Etiology (Cause/Contributing Factor)
such as, related to lack of food planning,
purchasing, and preparation skills
3. Signs/Symptoms defining
characteristics) such as, as evidenced by
BMI of 32, intake of high caloric-density
foods/beverages at meals and snacks.

Nutrition Diagnosis - Domains


Intake (NI) actual problems related to

intake of energy, nutrients, fluids, bioactive


substances through oral diet or nutrition
support
Clinical (NC) Nutritional finding/problems
identified that relate to medical or physical
conditions
Behavioral Environmental (NB)
Nutritional findings/problems identified that
related to knowledge, attitudes/beliefs,
physical environment, access to food, or
food safety

Nutrition Dx: Problem, Etiology,


Signs and Symptoms
Involuntary weight

Inadequate energy

intake (NI-2.1) related


to decreased ability to
consume sufficient
energy due to ESRD
and dialysis as
evidenced by
significant weight loss
of 5% in past month,
and lack of interest in
food

gain (NC-3.4) related


to antipsychotic
medication as
evidenced by increase
weight of 11% in 6
months.
Self-feeding difficulty
(NB-2.6) related to
impaired cognitive
ability as evidenced
by weight loss of 6%
in last month and
dropping cups and
food from utensil.

Step 3: Nutrition Intervention


Involves planning and implementation
Planning
Prioritizing the nutrition diagnoses, setting goals
and defining the intervention strategy and
Detailing the nutrition prescription (states
pt/clients recommended dietary intake of
energy, nutrients, etc)
Using the ADAs evidence-based practice
guidelines
Setting goals that are measurable, achievable
and time-defined
Implementation carrying out and

communicating the plan of care

Nutrition Intervention 4
categories
Food and/or Nutrient
Delivery
Individualized approach

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

Nutrition Education

Instruct a pt/client in a

skill or to impart
knowledge to help them
manage or modify food
choices and eating
behavior to maintain or
improve health

Nutrition Counseling

Collaborative counselor-

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

Coordination of
Referral to Care
or
Nutrition

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

Nutrition Intervention
Direct the nutrition intervention at the etiology

of the problem or at the signs and symptoms if


the etiology cannot be changed by the dietetics
practitioner.
AssessmentDiagnosis Intervention
Monitoring & Eval

Problem
Etiology
Signs &

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

Step 4: Monitoring and


Evaluation
Determine the amount of progress made

and whether goals/expected outcomes are


being met
Follow-up monitoring of the signs and
symptoms is used to determine the impact
of the nutrition intervention on the
etiology /signs and symptoms of the
problem.

Monitoring and Evaluation


Food/Nutrition
Related Hx Outcomes
Food and nutrient

intake, supplement
intake, physical
activity, food
availability, etc.
Nutrition-Focused
Physical Finding
Outcomes
Physical appearance,
swallow function,
appetite

Biochemical Data, Medical


Tests & Procedure Outcomes

Lab data and tests

Anthropometric
Measurement
Outcomes

Height, weight,

BMI, growth
pattern, weight hx

Sample:
PES: Self-monitoring knowledge deficit related to

knowledge deficit on how to record food and


beverage intake as evidenced by incomplete food
records at last two clinic visits and lab of HbA1c
= 8.5mg/dL
Assessment Data:(sources of info): blood glucose selfmonitoring records, food diary worksheets and meal
records, blood glucose levels (Fasting, 2-hour
postprandial and/or HbA1c levels)
Intervention: Teaching patient and family members
about use of simple blood glucose self-monitoring
records and meal records
Monitoring and Evaluation:HbA1c levels (goal
<6.5mg/dL); other glucose labs, food diary and records,
discussion about complications of using the records.

Sample:
Dialysis Patient
PES: Excessive mineral intake of Phosphorus

(NI-5.10.6) related to overconsumption of high


Phosphorus foods and not taking Phosphate
Binders as evidenced by hyperphosphatemia
Assessment Data:(sources of info): diet recall,
monthly serum phosphorus level.
Intervention: Teaching patient about use of taking
phosphate binders with meals and instruction on
high phosphorus foods to limit to <1200mg/day
Monitoring and Evaluation: Phosphorus levels (goal
5.5mg/dL); keeping records of P intake from food
and binders

Sample:
Gastroesophagel reflux disease (GERD)
PES: Undesirable food choices (NB-1.7)

related to lack of prior exposure to accurate


nutrition-related information as evidenced by
alcohol intake of ~10 drinks/week and high
fat diet and complaints of heart burn.
Assessment: Diet recall
Intervention: Educate and counsel patient on
dietary management of GERD and the role of
alcohol and fat in promoting heart burn.
Monitoring and Evaluation: Report of decreased
alcohol and fat consumption and less heart burn
and discomfort.

Sample:
Dialysis
PES: Excessive fluid intake (NI 3.2)

related to kidney disease as evidenced by


weight gain of 5kg between treatments
Assessment:
Intervention:
Monitoring/Evaluation:

Sample Case 1
58 year old female with Type 2 DM, ESRD 2

diabetic nephropathy; third month on dialysis


Labs: K+ 5.8mEq/L; BUN 74mg/dL; Creat
5.51mg/dL; Albumin 3.6g/dL; FBS 289mg/dL;
HbgA1c 9.4%; Phosphorus 5.3mEq/L
Rx: 2 PhosLo/meal, 2000IU cholecalciferol,
Metformin, Lipitor
Adhering to phosphate binders. Diet hx 60 gm
protein (10%), 350gm CHO (65%), 61gm fat (25%)
2200 kcal, about 3gm K, 1000ml fluid: pt states she
is okay with fluid restriction, but is overwhelmed
with dialysis and new diet modifications; not sure
what she is allowed to eat anymore; familiar with
diet for diabetes but not renal; good appetite.
Ht. 56, Wt. 160, BMI 25

PES for Case 1


Excessive Carbohydrate Intake NI

5.8.2 related to lack of


willingness/failure to modify
carbohydrate intake as evidenced by
hyperglycemia, FBS 289 ; Hemoglobin
A1c 9.4%, diabetes
Excessive Mineral Intake
(Potassium) NI 5.10.2 related to food
and nutrition-related knowledge deficit
as evidenced by serum K+ of 5.8

Sample Case 2
82 year old male, S/P CVA with right sided weakness 1

mos ago, HTN, ESRD on dialysis 2x/week


Lives alone on 2nd floor of two family house; cannot
drive; use to walk to store prior to stroke but cant
anymore; depends on son to bring him food. Pt claims
that his son does not visit regularly
Alb 2.9
Ht 510, UBW 165lbs prior to stroke; Present wt 154lbs
Diet order: 80gm protein, 2gm Na, 2gm K, 1000ml fluid
Diet hx: B toast w/ butter and coffee, L soup,
crackers and coffee, D-soup, sandwich (peanut butter
and jelly) and tea; S whole milk and 4 cookies

PES Case 2
Limited access to food NB-3.2

related to physical limitation to shop as


evidenced by report of limited supply of
food and variety of food in home;
significant weight loss of 6% in one
month.