Nutrition Care Process (NCP)

Prepared by Sandy Sarcona, MS, RD

Steps of NCP

  A – Nutrition Assessment D – Nutrition Diagnosis  Problem, Etiology, Signs and Symptoms    I – Nutrition Intervention M – Nutrition Monitoring E – Evaluation Through nutrition reassessment, dietetics practitioners perform nutrition monitoring and evaluation to determine if the nutrition intervention strategy is working to resolve the nutrition diagnosis, its etiology, and/or signs and symptoms

Step 1: Nutrition Assessment

  Screening and referral are typical entrance points into the NCP Assessment leads to determination that a nutrition diagnosis/problem exists; it is possible that a nutrition problem does not exist  Example: LTC resident on tube feeding; weight wnl and stable, Albumin wnl, labs wnl, good skin integrity and hydration status, feeding continues at recommended rate.

Nutrition Assessment Domains

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

Nutrition Assessment, Monitoring and Evaluation Comparative Standards

      Estimated Energy Needs (formula) Estimated Fat, Protein, and CHO needs Estimated Fiber Needs (AI) Estimated Fluid Needs (AI) Estimated Vitamin and Mineral Needs (RDA…) Recommended Body Weight /BMI/Growth (peds)

Example: Food Intake

    Indications: amount of food, types of food/meals; meal/snack patterns, diet quality, food variety Measurement methods: food intake records, 24-hour recall, food frequency, MyPyramid Tracker

Typically used to monitor and evaluate change in the following nutrition dx: excessive or inadequate oral food/bev intake, underweight, overweight/obesity, limited access to food

Evaluation – comparison to goal or reference standard 1) Goal: Pt currently eats ~10% of kcal from saturated fat Goal  <7% of daily kcal 2) Reference standard: Pt’s current intake of fat not meeting AHA criteria to consume <7% of kcal from sat. fat to

Step 2: Nutrition Diagnosis

1.

2.

3.

Problem (Diagnostic Label) such as, Excessive oral food/beverage intake (NI-2.2) Etiology (Cause/Contributing Factor) such as, related to

lack of food planning, purchasing, and preparation skills

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

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Nutrition Dx: Problem, Etiology, Signs and Symptoms

Inadequate energy intake (NI 2.1) related to decreased ability to consume sufficient energy due to ESRD and dialysis as evidenced by significant weight loss of 5% in past month, and lack of interest in food   Involuntary weight gain (NC-3.4) related to antipsychotic medication as evidenced by increase weight of 11% in 6 months.

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

Step 3: Nutrition Intervention

 Involves planning and implementation  Planning  Prioritizing the nutrition diagnoses, setting goals and defining the intervention strategy and  Detailing the nutrition prescription (states pt/client’s recommended dietary intake of energy, nutrients, etc)  Using the ADA’s evidence-based practice guidelines  Setting goals that are measurable, achievable and time defined  Implementation – carrying out and communicating the plan of care

Nutrition Intervention – 4 categories

Food and/or Nutrient Delivery  Individualized approach for food/nutrient provision such as meals, snacks, supplements Nutrition Education  Instruct a pt/client in a skill or to impart knowledge to help them manage or modify food choices and eating behavior to maintain or improve health Nutrition Counseling  Collaborative counselor patient relationship, to set priorities, establish goals and create action plans for self care to treat an existing condition and promote health Coordination of Nutrition Care  Referral to or coordination of nutrition care with other health care providers, agencies etc. to assist in managing nutrition related problems

Nutrition Intervention

 Direct the nutrition intervention at the etiology of the problem or at the signs and symptoms if the etiology cannot be changed by the dietetics practitioner.

Assessment Problem Diagnosis Intervention  Etiology Monitoring & Eval  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 Biochemical Data, Medical Tests & Procedure Outcomes  Food and nutrient intake, supplement intake, physical activity, food availability, etc.

Nutrition-Focused Physical Finding Outcomes  Lab data and tests Anthropometric Measurement Outcomes  Physical appearance, swallow function, appetite  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 self-monitoring records, food diary worksheets and meal records, blood glucose levels (Fasting, 2-hour postprandial and/or HbA1c levels) Intervention: Teaching patient and family members about use of simple blood glucose self-monitoring records and meal records Monitoring and Evaluation:HbA1c levels (goal <6.5mg/dL); other glucose labs, food diary and records, discussion about complications of using the records.

Sample:

 Dialysis Patient  PES: Excessive mineral intake of Phosphorus (NI-5.10.6) related to overconsumption of high Phosphorus foods and not taking Phosphate Binders as evidenced by

hyperphosphatemia

 Assessment Data:(sources of info): diet recall, monthly serum phosphorus level.

 Intervention: Teaching patient about use of taking phosphate binders with meals and instruction on high phosphorus foods to limit to <1200mg/day  Monitoring and Evaluation: Phosphorus levels (goal ≤ 5.5mg/dL); keeping records of P intake from food and binders

Sample:

 Gastroesophagel reflux disease (GERD)  PES: Undesirable food choices (NB-1.7) related to lack of

prior exposure to accurate nutrition-related

information as evidenced by alcohol intake of ~10

drinks/week and high fat diet and complaints of heart burn.

 Assessment: Diet recall  Intervention: Educate and counsel patient on dietary management of GERD and the role of alcohol and fat in promoting heart burn.

 Monitoring and Evaluation: Report of decreased alcohol and fat consumption and less heart burn and discomfort.

Sample:

 Dialysis  PES: Excessive fluid intake (NI 3.2) related to kidney disease as evidenced by weight gain of 5kg between

treatments

 Assessment:  Intervention:  Monitoring/Evaluation:

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Sample Case 1

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

Ht. 5’6”, Wt. 160, BMI 25

PES for Case 1

 Excessive Carbohydrate Intake – NI 5.8.2 related to lack of willingness/failure to modify carbohydrate intake as evidenced by hyperglycemia, FBS 289 ; Hemoglobin A1c 9.4%, diabetes  Excessive Mineral Intake (Potassium) – NI 5.10.2 related to food and nutrition-related knowledge deficit as evidenced by serum K+ of 5.8

Sample Case 2

      82 year old male, S/P CVA with right sided weakness 1 mos ago, HTN, ESRD on dialysis 2x/week Lives alone on 2 nd floor of two family house; cannot drive; use to walk to store prior to stroke but can’t anymore; depends on son to bring him food. Pt claims that his son does not visit regularly Alb 2.9

Ht 5’10’, UBW 165lbs prior to stroke; Present wt 154lbs Diet order: 80gm protein, 2gm Na, 2gm K, 1000ml fluid Diet hx: B – toast w/ butter and coffee, L – soup, crackers and coffee, D-soup, sandwich (peanut butter and jelly) and tea; S – whole milk and 4 cookies

PES Case 2

 Limited access to food – NB-3.2 related to physical limitation to shop as evidenced by report of limited supply of food and variety of food in home; significant weight loss of 6% in one month.