Nutrition Care Process (NCP)
Prepared by Sandy Sarcona, MS, RD
Steps of NCP
 A – Nutrition Assessment
 D – Nutrition Diagnosis
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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,
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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
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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
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.
1.
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-
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
(NC-3.4) related to
antipsychotic medication as
evidenced by increase weight
of 11% in 6 months.
 Self-feeding difficulty (NB2.6) 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 timedefined
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 selfcare to treat an existing
condition and promote health
Coordination of Nutrition Care
 Referral to or coordination of
nutrition care with other
health care providers,
agencies etc. to assist in
managing nutrition related
problems
Nutrition Intervention
 Direct the nutrition intervention at the etiology of the problem
or at the signs and symptoms if the etiology cannot be changed
by the dietetics practitioner.
Assessment
Diagnosis
Problem
Intervention
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Etiology
Monitoring & Eval
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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.
Biochemical Data, Medical
Tests & Procedure Outcomes
 Lab data and tests
Nutrition-Focused Physical
Finding Outcomes
Anthropometric
Measurement Outcomes
 Physical appearance,
 Height, weight, BMI,
swallow function, appetite
growth pattern, weight hx
Sample:
 PES: Self-monitoring knowledge deficit related to
knowledge deficit on how to record food and beverage
intake as evidenced by incomplete food records at last two
clinic visits and lab of HbA1c = 8.5mg/dL
 Assessment Data:(sources of info): blood glucose self-monitoring
records, food diary worksheets and meal records, blood glucose
levels (Fasting, 2-hour postprandial and/or HbA1c levels)
 Intervention: Teaching patient and family members about use of
simple blood glucose self-monitoring records and meal records
 Monitoring and Evaluation:HbA1c levels (goal <6.5mg/dL);
other glucose labs, food diary and records, discussion about
complications of using the records.
Sample:
 Dialysis Patient
 PES: Excessive mineral intake of Phosphorus (NI-5.10.6)
related to overconsumption of high Phosphorus foods and
not taking Phosphate Binders as evidenced by
hyperphosphatemia
 Assessment Data:(sources of info): diet recall, monthly serum
phosphorus level.
 Intervention: Teaching patient about use of taking phosphate
binders with meals and instruction on high phosphorus foods to
limit to <1200mg/day
 Monitoring and Evaluation: Phosphorus levels (goal ≤
5.5mg/dL); keeping records of P intake from food and binders
Sample:
 Gastroesophagel reflux disease (GERD)
 PES: Undesirable food choices (NB-1.7) related to lack of
prior exposure to accurate nutrition-related
information as evidenced by alcohol intake of ~10
drinks/week and high fat diet and complaints of heart
burn.
 Assessment: Diet recall
 Intervention: Educate and counsel patient on dietary
management of GERD and the role of alcohol and fat in
promoting heart burn.
 Monitoring and Evaluation: Report of decreased alcohol and fat
consumption and less heart burn and discomfort.
Sample:
 Dialysis
 PES: Excessive fluid intake (NI 3.2) related to kidney
disease as evidenced by weight gain of 5kg between
treatments
 Assessment:
 Intervention:
 Monitoring/Evaluation:
Sample Case 1
 58 year old female with Type 2 DM, ESRD 2 diabetic
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nephropathy; third month on dialysis
Labs: K+ 5.8mEq/L; BUN 74mg/dL; Creat 5.51mg/dL;
Albumin 3.6g/dL; FBS 289mg/dL; HbgA1c 9.4%; Phosphorus
5.3mEq/L
Rx: 2 PhosLo/meal, 2000IU cholecalciferol, Metformin, Lipitor
Adhering to phosphate binders. Diet hx – 60 gm protein (10%),
350gm CHO (65%), 61gm fat (25%) 2200 kcal, about 3gm K,
1000ml fluid: pt states she is okay with fluid restriction, but is
overwhelmed with dialysis and new diet modifications; not sure
what she is allowed to eat anymore; familiar with diet for diabetes
but not renal; good appetite.
Ht. 5’6”, Wt. 160, BMI 25
PES for Case 1
 Excessive Carbohydrate Intake – NI 5.8.2 related
to lack of willingness/failure to modify carbohydrate
intake as evidenced by hyperglycemia, FBS 289 ;
Hemoglobin A1c 9.4%, diabetes
 Excessive Mineral Intake (Potassium) – NI 5.10.2
related to food and nutrition-related knowledge deficit
as evidenced by serum K+ of 5.8
Sample Case 2
 82 year old male, S/P CVA with right sided weakness 1 mos ago,
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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.