Nutrition Care Process _NCP_

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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
 Assessment leads to determination that a nutrition
  diagnosis/problem exists; it is possible that a nutrition
  problem does not exist
   Example: LTC resident on tube feeding; weight wnl and stable,
    Albumin wnl, labs wnl, good skin integrity and hydration status,
    feeding continues at recommended rate.
    Nutrition Assessment Domains
 Food/Nutrition-Related History: FH (diet hx, energy intake,
    food and beverage intake, enteral and parenteral intake, bioactive
    substance intake, macronutrient/micronutrient intake,
    medication/supplement use,
    knowledge/beliefs/attitudes/behavior, etc)
   Anthropometric Measurements: AD
   Biochemical Data, Medical Tests and Procedures: BD
   Nutrition Focused Physical Findings: PD (appetite, edema,
    taste alterations, swallowing difficulty, etc)
   Client History: CH (personal hx, PMH, social hx)
Nutrition Assessment, Monitoring and
Evaluation Comparative Standards

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

    Indications: amount of food, types of food/meals; meal/snack
    patterns, diet quality, food variety
    Measurement methods: food intake records, 24-hour recall, food
    frequency, MyPyramid Tracker
   Typically used to monitor and evaluate change in the following nutrition dx:
    excessive or inadequate oral food/bev intake, underweight, overweight/obesity,
    limited access to food
   Evaluation – comparison to goal or reference standard
   1) Goal: Pt currently eats ~10% of kcal from saturated fat Goal  to
    <7% of daily kcal
   2) Reference standard: Pt’s current intake of fat not meeting AHA
    criteria to consume <7% of kcal from sat. fat
Step 2: Nutrition Diagnosis
1. Problem (Diagnostic Label) such as, Excessive oral
   food/beverage intake (NI-2.2)
2. Etiology (Cause/Contributing Factor) such as, related to
   lack of food planning, purchasing, and preparation skills
3. Signs/Symptoms defining characteristics) such as, as
   evidenced by BMI of 32, intake of high caloric-density
   foods/beverages at meals and snacks.
Nutrition Diagnosis - Domains
 Intake (NI) – actual problems related to intake of energy,
  nutrients, fluids, bioactive substances through oral diet or
  nutrition support
 Clinical (NC) – Nutritional finding/problems identified
  that relate to medical or physical conditions
 Behavioral – Environmental (NB) – Nutritional
  findings/problems identified that related to knowledge,
  attitudes/beliefs, physical environment, access to food, or
  food safety
  Nutrition Dx: Problem, Etiology, Signs
  and Symptoms
                                       Involuntary weight gain
 Inadequate energy intake (NI-
                                        (NC-3.4) related to
  2.1) related to decreased ability     antipsychotic medication as
  to consume sufficient energy          evidenced by increase weight
  due to ESRD and dialysis as           of 11% in 6 months.
  evidenced by significant weight      Self-feeding difficulty (NB-
  loss of 5% in past month, and         2.6) related to impaired
  lack of interest in food              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
      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-
   Implementation – carrying out and communicating the
     plan of care
Nutrition Intervention – 4 categories

Food and/or Nutrient                Nutrition Counseling
Delivery                             Collaborative counselor-
 Individualized approach for         patient relationship, to set
  food/nutrient provision such        priorities, establish goals and
  as meals, snacks, supplements       create action plans for self-
                                      care to treat an existing
Nutrition Education                   condition and promote health
 Instruct a pt/client in a skill
  or to impart knowledge to         Coordination of Nutrition Care
  help them manage or modify         Referral to or coordination of
  food choices and eating             nutrition care with other
  behavior to maintain or             health care providers,
  improve health                      agencies etc. to assist in
                                      managing nutrition related
 Nutrition Intervention
 Direct the nutrition intervention at the etiology of the problem
  or at the signs and symptoms if the etiology cannot be changed
  by the dietetics practitioner.
Assessment      Diagnosis      Intervention    Monitoring & Eval
                                              
        Problem                Etiology        Signs & Symptoms
 Nutrition interventions are intended to eliminate or diminish
  the nutrition diagnosis, or to reduce signs and symptoms of the
  nutrition diagnosis.
Step 4: Monitoring and Evaluation

 Determine the amount of progress made and whether
  goals/expected outcomes are being met

  Follow-up monitoring of the signs and symptoms is used to
   determine the impact of the nutrition intervention on the
        etiology /signs and symptoms of the problem.
Monitoring and Evaluation
Food/Nutrition –Related Hx       Biochemical Data, Medical
Outcomes                         Tests & Procedure Outcomes
 Food and nutrient intake,
                                  Lab data and tests
  supplement intake, physical
  activity, food availability,
Nutrition-Focused Physical       Anthropometric
Finding Outcomes                 Measurement Outcomes
 Physical appearance,            Height, weight, BMI,
  swallow function, appetite       growth pattern, weight hx
 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.
 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
   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
 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
   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.
 Dialysis
   PES: Excessive fluid intake (NI 3.2) related to kidney
    disease as evidenced by weight gain of 5kg between
   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
   Rx: 2 PhosLo/meal, 2000IU cholecalciferol, Metformin, Lipitor
   Adhering to phosphate binders. Diet hx – 60 gm protein (10%),
    350gm CHO (65%), 61gm fat (25%) 2200 kcal, about 3gm K,
    1000ml fluid: pt states she is okay with fluid restriction, but is
    overwhelmed with dialysis and new diet modifications; not sure
    what she is allowed to eat anymore; familiar with diet for diabetes
    but not renal; good appetite.
   Ht. 5’6”, Wt. 160, BMI 25
PES for Case 1
 Excessive Carbohydrate Intake – NI 5.8.2 related
  to lack of willingness/failure to modify carbohydrate
  intake as evidenced by hyperglycemia, FBS 289 ;
  Hemoglobin A1c 9.4%, diabetes
 Excessive Mineral Intake (Potassium) – NI 5.10.2
  related to food and nutrition-related knowledge deficit
  as evidenced by serum K+ of 5.8
Sample Case 2
 82 year old male, S/P CVA with right sided weakness 1 mos ago,
    HTN, ESRD on dialysis 2x/week
   Lives alone on 2nd floor of two family house; cannot drive; use to
    walk to store prior to stroke but can’t anymore; depends on son to
    bring him food. Pt claims that his son does not visit regularly
   Alb 2.9
   Ht 5’10’, UBW 165lbs prior to stroke; Present wt 154lbs
   Diet order: 80gm protein, 2gm Na, 2gm K, 1000ml fluid
   Diet hx: B – toast w/ butter and coffee, L – soup, crackers and
    coffee, D-soup, sandwich (peanut butter and jelly) and tea; S –
    whole milk and 4 cookies
PES Case 2
 Limited access to food – NB-3.2 related to physical
 limitation to shop as evidenced by report of limited
 supply of food and variety of food in home; significant
 weight loss of 6% in one month.