What is the Nutrition Care Process?
The Nutrition Care Process (NCP) is a standardized approach to providing nutrition care. It was adopted by the Academy of Nutrition and Dietetics (AND) in 2003 with the purpose of providing dietitians a framework for providing nutritional services.
The Four Steps of the Nutrition Care Process
There are four steps of the NCP, which include:
- Nutrition assessment
- Diagnosis
- Intervention
- Monitoring/evaluation
Nutrition Assessment
The first step of the NCP is the nutrition assessment. This is where the Registered Dietitian (RD) collects and synthesizes information from a variety of sources including the medical record, referral, patient interview, etc. All of this information is the foundation for the rest of the NCP steps.
Some components of the nutrition assessment may include:
- Anthropometric data, including weight history
- Medical tests and procedures
- Lab values
- Medications and supplements
- Medical history, which can include family history
- Nutrition focused physical exam (NFPE)
- Personal and social history
- Food and nutrient intake by doing a 24 hour recall, usual intake and/or food frequency
- Physical activity
- Patient’s knowledge, attitudes and beliefs
Nutrition Diagnosis
Creating a nutrition diagnosis is the second step of the Nutrition Care Process. Using the information collected in the nutrition assessment, the dietitian identifies a nutrition problem or problems that can be resolved or improved through a nutrition intervention.
The nutrition diagnosis is documented using a PES statement, sometimes known as a nutrition diagnosis statement.
PES statements are written in the following format:
[Problem/nutrition diagnosis] related to [Etiology], as evidenced by [Signs/symptoms].
Problem/Nutrition Diagnosis
PES statements start with the nutrition problem/diagnosis. One or more nutrition diagnoses is selected from a list obtained from the Electronic Nutrition Care Process Terminology (eNCPT). This nutrition diagnostic terminology uses standardized language to keep the Nutrition Care Process concise and consistent.
Some examples of nutrition diagnoses include:
- Excessive energy intake
- Inadequate enteral nutrition infusion
- Obesity Class II
- Growth rate below expected
- Severe acute disease or injury related malnutrition
- Food and nutrition related knowledge deficit
Etiology
The etiology is the “root cause” or contributing risk factor(s) for the nutrition problem. Some examples of etiologies include:
- Poor food planning, purchasing and preparation practices
- Altered body image
- Limited value for behavior change
- Limited physical ability due to injury
- Loss of appetite awareness
- Change in living situation
Signs/Symptoms
The last step of writing the PES statement is the signs/symptoms. These are the defining characteristics collected in the assessment step used to determine the nutrition diagnosis.
The signs and symptoms could be from a variety of sources, such as the medical record, your interview of the patient or from a Nutrition Focused Physical Exam.
You may list several signs and symptoms. They should be specific enough to monitor in the last step of the Nutrition Care Process, which is monitoring/evaluation.
PES Statement Example
Excessive sodium intake related to reliance on convenience and fast foods as evidenced by an average intake of 4343 mg sodium daily, ankle edema and elevated blood pressure readings.
Nutrition Intervention
After the PES statement is written, it is time to provide the intervention. This is where the RD plans and implements actions with the purpose of resolving or improving the nutrition problem. This is done by changing or eliminating the etiology, therefore relieving the signs and symptoms.
Nutrition Intervention Planning and Implementation
The nutrition intervention actually contains two separate parts: planning and then implementing.
Planning the intervention includes prioritizing the interventions, collaborating with the patient, writing a nutrition prescription, selecting strategies and deciding on frequency of care.
Then the plan can be implemented. This may include things like:
- Nutrition education
- Nutrition counseling
- Coordination of nutrition care
- Collaborating with other member(s) of the healthcare team regarding enteral or parenteral nutrition
- Referral to another healthcare provider
- Referral to a community program such as WIC or Meals on Wheels
Nutrition Intervention Example
Let’s use the same PES statement as an example:
Excessive sodium intake related to reliance on convenience and fast foods as evidenced by an average intake of 4343 mg sodium daily, ankle edema and elevated blood pressure readings.
The nutrition problem that we are trying to resolve is excessive sodium intake. The etiology is reliance on convenience and fast foods.
The RD could provide a nutrition prescription of a 1500 mg sodium restricted diet and then refer the patient to Meals on Wheels and get them set up with a low sodium diet through this program.
This specific intervention would ideally resolve the excess sodium intake because the reliance on convenience and fast foods has been eliminated. Therefore, the signs and symptoms of high average intake of sodium, ankle edema and elevated blood pressure should be relieved.
Nutrition Monitoring and Evaluation
The final step of the NCP is monitoring and evaluation. This is where the RD looks at the progress being made and if the expected outcome is being met. Per AND, there are three sub-steps to this process, which include:
- Monitor
- Measure
- Evaluate
Monitor
The monitoring step is where information related to progress of the intervention is reviewed. It should be determined if the intervention is being implemented as prescribed and the patient’s understanding and adherence should be evaluated.
To continue with the previous example, at this time, the dietitian would see if the patient is set up with Meals on Wheels, they are being provided the correct diet, and the patient is actually consuming the meals.
Measure
The dietitian then looks at indicators to measure progress related to the nutrition diagnosis, etiology and signs and symptoms. These indicators may include:
- Patient report
- Self-monitoring data
- Anthropometric data
- Labs
- Medical tests
- Medical procedures
- Nutrition focused physical exam
- Client questionnaires
For this patient, the RD would be looking at things like the patient’s estimated sodium intake and frequency of convenience and fast food intake, as well as other pieces of data including edema status, blood pressure readings and possibly weight and any other recent labs or medical tests.
Evaluate
The final part of the monitoring and evaluation step is evaluation of the new data. The new indicators are compared to both the starting point as well as reference standards.
For example, the patient’s current blood pressure should be compared to previous readings before the nutrition intervention was implemented, as well as standards from the American Heart Association or other reference standards.
The status of goals should be documented at this time. Things such as barriers to progress, positive and negative outcomes, and future plans for nutrition care should also be documented.
Using the NCP in Practice
Overwhelmed? Thinking about every step of the NCP, while simultaneously actually providing the care, can feel like a lot!
While the NCP sounds quite complicated, it is somewhat of a natural way of going about things. You collect data, determine what the problem is, formulate a plan, and then check on the progress. Don’t overthink it!
While dietetic students must learn the NCP and having a framework can be helpful, most dietitian jobs do not require following the NCP to a T. The Academy strongly recommends using the NCP, including PES statements, but it is not required.
Many dietitians chart using a format called ADIME, which follows the NCP. This sets the dietitian up to follow the process without really thinking about it at all.
Nutrition Care Process Steps Summary
The NCP provides dietitians a framework for providing nutritional services. There are four main steps being the assessment, diagnosis, intervention and monitoring and evaluation. While this is a standardized approach, the nutrition care provided to the patient is still individualized.
Note that the 2023 edition of the Nutrition Care Process Terminology (eNCP) is used, which is the most current version at the time of this article being published.