Nutrition Care Process Example 1 – Celiac Disease New Diagnosis

This first example will show how to go through the steps of the NCP with a client who has a new
diagnosis of celiac disease.

Nutrition Care Process Step #1 – Nutrition Assessment

ADIME

The nutritional assessment for a client newly diagnosed with celiac disease might include obtaining data
related to:

 Food/Nutrition-Related History

 Normal food intake (could be determined with a 3-day food record or

24-hour recall)

 Knowledge, beliefs, attitudes related to celiac disease and their

diagnosis

 Relevant eating behaviors (how many meals and snacks they normally
eat, what their eating schedule looks like, where and how they obtain
food, etc.)

 Overall lifestyle and physical activity details

 Stress level

 Any relevant family or social history

 Any history of dieting or elimination diets

 Any supplements or medications they might be taking that could impact

their nutritional status

 Food access and ability to purchase gluten-free foods


 Anthropometric Measurements

 Height, weight, and weight history if weight change is a concern for the
client

 Biochemical Data, Medical Tests, and Procedures

 Celiac diagnosis (serology screen, biopsy performed)

 Concurrent conditions

 Lab Values (CBC, Iron, Folate, Vitamin B12, Calcium, Albumin,

Phosphate, ALP, Vitamin D, Vitamin B6, Copper, Zinc)

 Any other confirmed allergies, intolerances (ie. lactose)

 Any other relevant or concurrent medical conditions (Type-1 Diabetes,

Inflammatory Bowel Diseases, Arthritis, etc.)

 Nutrition Focused Physical Findings

 Digestive symptoms and bowel habits(frequency, severity, persistence), for

example:

 Loose stool

 Constipation

 Nausea

 Abdominal pain

 Bloating

Once this data is obtained, you could assess for:



 Sources of gluten in the diet

 Sources of gluten cross-contact

 Client readiness and motivation for change

 Overall dietary quality and nutrient intake (ex: adequate Fiber, Calcium, Vitamin D, Iron,
Vitamin B12, Folate)

Nutrition Care Process Step #2 – Nutrition Diagnosis

ADIME

The diagnosis would be individualized to the unique client and whether there is something that comes
up in your assessment as a problem that needs to be addressed first.

If the main issue is that the client is completely new to the concept of celiac disease and a gluten-free
diet, a nutrition diagnosis with a “limited food and nutrition knowledge” problem might make the most
sense here such as in the example below:

Limited food and nutrition-related knowledge related to newly diagnosed celiac disease as evidenced
by 3-day food record showing consumption of foods containing gluten and client report of lack of
celiac-disease related knowledge.

For help with building your PES statement, check out our FREE PES Statement Cheat Sheet.

Nutrition Care Process Step #3 – Nutrition Intervention

ADIME

If the main problem is a knowledge deficit, nutrition education would be the main nutrition intervention.
In this case, education may be around:

 The identification of gluten-containing foods

 Label reading


 Gluten cross-contamination

 Gluten-free food choices

Depending on the client’s dietary intake, education on maintaining an overall nutritionally adequate diet
with fiber and micronutrients and correcting any nutrient deficiencies may also be necessary.

For a client who does not have a knowledge deficit but is having difficulty maintaining a gluten-free diet,
nutrition counseling, such as motivational interviewing, may be ideal as an intervention.

Nutrition Care Process Step #4 – Nutrition Monitoring and Evaluation

ADIME

A monitoring plan for a client newly diagnosed with celiac disease may include food tracking, which
could be used to assess compliance to a gluten-free diet, nutritional adequacy, and diet quality at future
appointments.

Other considerations for monitoring may include changes in digestive symptoms, changes in lab values
including nutrient deficiencies, changes in motivation level, or personal factors that may impact diet
compliance.

Nutrition Care Process Example 2 – Polycystic Ovary Syndrome (PCOS)

This example will show how to go through the steps of the NCP with a client who has PCOS.

Nutrition Care Process Step #1 – Nutrition Assessment

ADIME

The nutritional assessment for a client with PCOS might include obtaining data related to:

 Food/Nutrition-Related History

 Weight concerns, cravings, fatigue, stress, subfertility

 Intake (3-day food record / 24-hour recall)

 Client concerns

 Knowledge/beliefs/attitudes related to food



 Eating behaviors

 Readiness/motivation to change

 Access to food

 Lifestyle / physical activity

 Medications or supplements

 Anthropometric Measurements

 Height, weight, weight history

 Biochemical Data, Medical Tests, and Procedures

 Commonly elevated: Total Testosterone, Free Testosterone, DHEA-S, Fasting

Glucose

 Commonly deficient: Zinc, Vitamin D, Magnesium, Vitamin B12

 Relevant medical history or history of concurrent conditions (ex.

diabetes)

 Lab values:

 Nutrition Focused Physical Findings




 Client concerns of acne, hirsutism, digestive issues, etc.

 Client History

 Relevant family history of PCOS

 Fertility concerns

Once this data is obtained, you could assess for:

 Overall dietary quality:

 Glycemic index of the majority of carbohydrates eaten

 Overall fiber intake

 Zinc, Vitamin D, Magnesium, Vitamin B12 (if deficient or suspected

deficiency)

 Omega-3

 Anti-inflammatory vs. pro-inflammatory foods

 Fluid intake (sugar-sweetened beverages, alcohol)

 Meal and snack frequency



 Macronutrient distribution

Nutrition Care Process Step #2 – Nutrition Diagnosis

ADIME

Your nutrition diagnosis would be individualized to the unique client and any pertinent concerns the
client may have.

In an outpatient setting, it can sometimes be tricky to choose a main problem to focus on. Considering
the client’s needs and desires and practical interventions may be helpful in choosing a problem to focus
on first.

For example, if the client you are seeing could benefit from eating more fiber and this is a goal your
client is eager to achieve, it may make sense to start here.

PES statement example:

Inadequate fiber intake related to low intake of whole grains, fruits, vegetables, and legumes as
evidenced by 3-day food record, postprandial hyperglycemia trends on CGM, and client concerns of
feeling hungry shortly after meals.

For help with building your PES statement, check out our FREE PES Statement Cheat Sheet.

Nutrition Care Process Step #3 – Nutrition Intervention

ADIME

Depending on the unique needs of the client, the intervention may focus on education related to:

 Choosing higher fiber or lower glycemic index foods

 Meal and snack timing and frequency

 Mindful eating

 Anti-inflammatory foods

 Macronutrient distribution


 Blood glucose management

Or, focusing on nutrient supplementation, including:

 Inositol

 NAC

 Omega-3

 Addressing any nutrient deficiencies determined from lab value or intake assessment

Intervention may also be counseling related, with a focus on goal setting or motivational interviewing.

Nutrition Care Process Step #4 – Nutrition Monitoring and Evaluation

ADIME

A monitoring plan for a client with PCOS may focus on the client’s self-tracking of their food intake, a
food and mood diary, changes in lab values or blood glucose management, and/or physical findings (ex.
weight changes) if that was a focus of the intervention.

Evaluation will depend significantly on the client’s goals. In the case of the diagnosis of inadequate fiber
intake, and a planned intervention to address that, the evaluation may be related to assessing the
client’s food records for changes to the estimated intake of fiber.

Nutrition Care Process Example 3 – Nutrition Support (Enteral Nutrition)

This final example will show how to go through the steps of the NCP with a client who has been referred
to the dietitian for an enteral nutrition plan.

Nutrition Care Process Step #1 – Nutrition Assessment

ADIME

The nutritional assessment for a client referred for enteral nutrition might include obtaining data related
to:

 Food/Nutrition-Related History




 Nutrition and intake history (per OS intake or days NPO)

 Anthropometric Measurements

 Height

 Current body weight

 Usual body weight

 Biochemical Data, Medical Tests, and Procedures

 Biochemical data related to enteral feeding

 Clinical or medical data related to enteral feeding

 Any nutrient deficiencies on labs

 Current medications

 Any past or planned surgeries or procedures

 Nutrition Focused Physical Findings

 Physical appearance


 Skin fold thickness and mid-arm circumference

 Swallowing ability

 Digestive capabilities (ex. bowel sounds)

 Any nausea, vomiting, diarrhea concerns

 Client History

 Any relevant family, social, or personal history

 Financial means to afford enteral formula

 Assessment Tools

 Results from a malnutrition screening tool

Your assessment will also include the client’s energy, protein, and fluid needs.

Nutrition Care Process Step #2 – Nutrition Diagnosis

ADIME

In a clinical setting, where enteral nutrition is recommended or considered, the nutrition diagnosis is
often related to intake. For a diagnosis related to intake, the intervention of enteral nutrition will address
this problem. Diagnosis related to inadequate or inappropriate enteral or parenteral nutrition may also
be considered if the client is already prescribed nutrition support and is in need of a change of formula
or delivery method.

Clinical status, including involuntary weight loss, may also be considered the main problem.

Example PES statement:

Inadequate oral intake related to swallowing difficulties as evidenced by abnormal swallow study,
unintentional weight loss of 6% in 1 month, low mid-arm circumference, and low hemoglobin levels.

For help with building your PES statement, check out our FREE PES Statement Cheat Sheet.

Nutrition Care Process Step #3 – Nutrition Intervention

ADIME

Compared to the previous examples, where education and counseling were the most logical
interventions, in this situation “Food and/or Nutrient Delivery” will be the category of intervention to
address.

Your intervention may be related to some or all of the following:

 Determining feeding access

 Determining the feeding schedule

 Calculating energy, protein and fluid requirements

 Determining the formula and total amount required to meet needs

 Determining the feeding rate to meet goal

 Determining the risk of refeeding

 Calculating water flushes

From this, the final enteral prescription will be the main intervention, along with any goals for weight
gain and education required. Referral to community supports may also be a part of the intervention.

Nutrition Care Process Step #4 – Nutrition Monitoring and Evaluation

ADIME

Monitoring enteral tolerance will include looking at:




 Energy, protein, and fluid intake

 Gastrointestinal symptoms and changes

 Blood work changes

 Weight changes

 Tube placement

 Medication changes

 “Ins and Outs” (nutritional intake and bladder and bowel outputs)

Evaluation of any changes in nutrition indicators may require future interventions related to transitioning
to bolus feeds prior to discharge to improve normalcy, ensuring enteral formula is covered for home use,
trialing oral intake if possible, weaning off of enteral nutrition, and collaborating with community
supports.

Key Takeaways for Dietitians

 The Nutrition Care Process (NCP) involves 4 steps: assessment, diagnosis, intervention, and
monitoring and evaluation.

 Dietitians can use the NCP as a consistent methodology to guide nutritional care.

 ADIME charting incorporates the steps of the NCP into a documentation style.

 Nutrition Care Process Terminology (NCPT) can be used as part of the NCP to communicate the
assessment, diagnosis, intervention, monitoring & evaluation.