Nutrition Diagnosis From and (ADA)

Nutrition Diagnosis:
A Critical Step in the Nutrition Care Process

Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
ISBN: 0-88091-358-4
Copyright 2006, American Dietetic Association. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means without the prior written consent of the publisher. Printed in the United
States of America.
The views expressed in this publication are those of the authors and do not necessarily
reflect policies and/or official positions of the American Dietetic Association. Mention of
product names in this publication does not constitute endorsement by the authors or the
American Dietetic Association. The American Dietetic Association disclaims
responsibility for the application of the information contained herein.
10 9 8 7 6 5 4 3 2 1
Nutrition Diagnosis: A Critical Step in the Nutrition Care Process
Table of Contents
Section I: The Nutrition Care Process
Nutrition Care Process and Model Article....................................................................1
Section II: Development of Standardized Language
American Dietetic Associations Standardized Language Model: Current Status.....13
Section III: Introduction to Nutrition Diagnosis
Introduction to Nutrition Diagnoses/Problems ...........................................................17
Section IV: Nutrition Diagnosis Reference Sheets
Single Page List of Nutrition Diagnostic Terminology................................................22
Section V: Nutrition Diagnosis Terms and Definitions
Nutrition Terms and Definitions ..................................................................................23
Section VI: Appendix
Procedure for NutritionControlled Vocabulary/Terminology Maintenance/Review154
Acknowledgements
Task Force Members..................................................................................................160
Consultants ................................................................................................................161
Research Reviewers ...................................................................................................162
Additional Reference on Implementation of Nutrition Care Process ....................................165
Feedback Form......................................................................................................................171
Camera Ready Pocket Guide.................................................................................................173
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iii
Nutrition Care Process and Model: ADA adopts road
map to quality care and outcomes management
KAREN LACEY, MS, RD; ELLEN PRITCHETT, RD
T
he establishment and implementation of a standardized
Nutrition Care Process (NCP) and Model were identied as
priority actions for the profession for meeting goals of the
ADA Strategic Plan to Increase demand and utilization of ser-
vices provided by members and Empower members to com-
pete successfully in a rapidly changing environment (1). Pro-
viding high-quality nutrition care means doing the right thing at
the right time, in the right way, for the right person, and achiev-
ing the best possible results. Quality improvement literature
shows that, when a standardized process is implemented, less
variation and more predictability in terms of outcomes occur
(2). When providers of care, no matter their location, use a
process consistently, comparable outcomes data can be gener-
ated to demonstrate value. A standardized Nutrition Care Pro-
cess effectively promotes the dietetics professional as the
unique provider of nutrition care when it is consistently used as
a systematic method to think critically and make decisions to
provide safe and effective nutrition care (3).
This article describes the four steps of ADAs Nutrition Care
Process and the overarching framework of the Nutrition Care
Model that illustrates the context within which the Nutrition
Care Process occurs. In addition, this article provides the ratio-
nale for a standardized process by which nutrition care is pro-
vided, distinguishes between the Nutrition Care Process and
Medical Nutrition Therapy (MNT), and discusses future impli-
cations for the profession.
BACKGROUND
Prior to the adoption of this standardized Nutrition Care Pro-
cess, a variety of nutrition care processes were utilized by prac-
titioners and taught by dietetics educators. Other allied health
professionals, including nursing, physical therapy, and occupa-
tional therapy, utilize dened care processes specic to their
profession (4-6). When asked whether ADA should develop a
standardized Nutrition Care Process, dietetics professionals
were overwhelmingly in favor and strongly supportive of having
a standardized Nutrition Care Process for use by registered
dietitians (RD) and dietetics technicians, registered (DTR).
The Quality Management Committee of the House of Dele-
gates (HOD) appointed a Nutrition Care Model Workgroup in
May 2002 to develop a nutrition care process and model. The
rst draft was presented to the HOD for member input and
review in September 2002. Further discussion occurred during
the October 2002 HOD meeting, in Philadelphia. Revisions
were made accordingly, and the HODunanimously adopted the
nal version of the Nutrition Care Process and Model on March
31, 2003 for implementation and dissemination to the dietetics
profession and the Association for the enhancement of the
practice of dietetics.
SETTING THE STAGE
Denition of Quality/Rationale for a Standardized
Process
The National Academy of Sciences (NAS) Institute of Medi-
cine (IOM) has dened quality as The degree to which health
services for individuals and populations increase the likelihood
of desired health outcomes and are consistent with current
professional knowledge (7,8). The quality performance of pro-
viders can be assessed by measuring the following: (a) their
patients outcomes (end-results) or (b) the degree to which
providers adhere to an accepted care process (7,8). The Com-
mittee on Quality of Health Care in America further states that
it is not acceptable to have a wide quality chasm, or a gap,
between actual and best possible performance (9). In an effort
to ensure that dietetics professionals can meet both require-
ments for quality performance noted above, the American Di-
etetic Association (ADA) supports a standardized Nutrition
Care Process for the profession.
Standardized Process versus Standardized Care
ADAs Nutrition Care Process is a standardized process for
dietetics professionals and not a means to provide standardized
care. A standardized process refers to a consistent structure
and framework used to provide nutrition care, whereas stan-
K. Lacey is lecturer and Director of Dietetic Programs
at the University of Wisconsin-Green Bay, Green Bay. She
is also the Chair of the Quality Management Committee.
E. Pritchett is Director, Quality and Outcomes at ADA
headquarters in Chicago, IL.
If you have questions regarding the Nutrition Care Pro-
cess and Model, please contact Ellen Pritchett, RD, CPHQ,
Director of Quality and Outcomes at ADA,
epritchett@eatright.org
Copyright 2003 by the American Dietetic Association.
0002-8223/03/10308-0014$35.00/0
doi: 10.1053/jada.2003.50564
OF PROFESSIONAL INTEREST
Journal of THE AMERICAN DIETETIC ASSOCIATION / 1061
Edition: 2006 1
dardized care infers that all patients/clients receive the same
care. This process supports and promotes individualized care,
not standardized care. As represented in the model (Figure 1),
the relationship between the patient/client/group and dietetics
professional is at the core of the nutrition care process. There-
fore, nutrition care provided by qualied dietetics profession-
als should always reect both the state of the science and the
state of the art of dietetics practice to meet the individualized
needs of each patient/client/group (10).
Using the NCP
Even though ADAs Nutrition Care Process will primarily be
used to provide nutrition care to individuals in health care set-
tings (inpatient, ambulatory, and extended care), the process
also has applicability in a wide variety of community settings. It
will be used by dietetics professionals to provide nutrition care
to both individuals and groups in community-based agencies
and programs for the purpose of health promotion and disease
prevention (11,12).
Key Terms
To lay the groundwork and facilitate a clear denition of ADAs
Nutrition Care Process, key terms were developed. These def-
initions provide a frame of reference for the specic compo-
nents and their functions.
(a) Process is a series of connected steps or actions to
achieve an outcome and/or any activity or set of activities that
transforms inputs to outputs.
(b) Process Approach is the systematic identication and
management of activities and the interactions between activi-
ties. A process approach emphasizes the importance of the
following:
I understanding and meeting requirements;
I determining if the process adds value;
I determining process performance and effectiveness; and
I using objective measurement for continual improvement of
the process (13).
(c) Critical Thinking integrates facts, informed opinions, ac-
tive listening and observations. It is also a reasoning process in
which ideas are produced and evaluated. The Commission on
Accreditation of Dietetics Education (CADE) denes critical
thinking as transcending the boundaries of formal education
to explore a problem and form a hypothesis and a defensible
conclusion (14). The use of critical thinking provides a unique
strength that dietetics professionals bring to the Nutrition Care
Process. Further characteristics of critical thinking include the
ability to do the following:
I conceptualize;
I think rationally;
I think creatively;
I be inquiring; and
I think autonomously.
FIG 1. ADA Nutrition Care Process and Model.
1062 / August 2003 Volume 103 Number 8
Edition: 2006 2
(d) Decision Making is a critical process for choosing the best
action to meet a desired goal.
(e) Problem Solving is the process of the following:
I problem identication;
I solution formation;
I implementation; and
I evaluation of the results.
(f) Collaboration is a process by which several individuals or
groups with shared concerns are united to address an identied
problem or need, leading to the accomplishment of what each
could not do separately (15).
DEFINITION OF ADAS NCP
Using the terms and concepts described above, ADAs Nutri-
tion Care Process is dened as a systematic problem-solving
method that dietetics professionals use to critically think and
make decisions to address nutrition related problems and pro-
vide safe and effective quality nutrition care.
The Nutrition Care Process consists of four distinct, but in-
terrelated and connected steps: (a) Nutrition Assessment, (b)
Nutrition Diagnosis, (c) Nutrition Intervention, and d) Nutri-
tion Monitoring and Evaluation. These four steps were nalized
based on extensive review and evaluation of previous works
describing nutrition care (16-24). Even though each step
builds on the previous one, the process is not linear. Critical
thinking and problem solving will frequently require that die-
tetics professionals revisit previous steps to reassess, add, or
revise nutrition diagnoses; modify intervention strategies;
and/or evaluate additional outcomes. Figure 2 describes each
of these four steps in a similar format consisting of the follow-
ing:
I denition and purpose;
I key components or substeps with examples as appropriate;
I critical thinking characteristics;
I documentation elements; and
I considerations for continuation, discontinuation, or dis-
charge of care.
Providing nutrition care using ADAs Nutrition Care Process
begins when a patient/client/group has been identied at nutri-
tion risk and needs further assistance to achieve or maintain
nutrition and health goals. It is also important to recognize that
patients/clients who enter the health care system are more
likely to have nutrition problems and therefore benet from
receiving nutrition care in this manner. The Nutrition Care
Process cycles through the steps of assessment, diagnosis, in-
tervention, and monitoring and evaluation. Nutrition care can
involve one or more cycles and ends, ideally, when nutrition
goals have been achieved. However, the patient/client/group
may choose to end care earlier based on personal or external
factors. Using professional judgment, the dietetics professional
may discharge the patient/client/group when it is determined
that no further progress is likely.
PURPOSE OF NCP
ADAs Nutrition Care Process, as described in Figure 2, gives
dietetics professionals a consistent and systematic structure
and method by which to think critically and make decisions. It
also assists dietetics professionals to scientically and holisti-
cally manage nutrition care, thus helping patients better meet
their health and nutrition goals. As dietetics professionals con-
sistently use the Nutrition Care Process, one should expect a
higher probability of producing good outcomes. The Nutrition
Care Process then begins to establish a link between quality
and professional autonomy. Professional autonomy results
from being recognized for what we do well, not just for who we
are. When quality can be demonstrated, as dened previously
by the IOM (7,8), then dietetics professionals will stand out as
the preferred providers of nutrition services. The Nutrition
Care Process, when used consistently, also challenges dietetics
professionals to move beyond experience-based practice to
reach a higher level of evidence-based practice (9,10).
The Nutrition Care Process does not restrict practice but
acknowledges the common dimensions of practice by the fol-
lowing:
I dening a common language that allows nutrition practice to
be more measurable;
I creating a format that enables the process to generate quan-
titative and qualitative data that can then be analyzed and in-
terpreted; and
I serving as the structure to validate nutrition care and show-
ing how the nutrition care that was provided does what it in-
tends to do.
DISTINCTION BETWEEN MNT AND THE NCP
Medical Nutrition Therapy (MNT) was rst dened by ADA in
the mid-1990s to promote the benets of managing or treating
a disease with nutrition. Its components included an assess-
ment of nutritional status of patients and the provision of either
diet modication, counseling, or specialized nutrition thera-
pies. MNT soon became a widely used term to describe a wide
variety of nutrition care services provided by dietetics profes-
sionals. Since MNT was rst introduced, dietetics professionals
have gained much credibility among legislators and other
health care providers. More recently, MNT has been redened
as part of the 2001 Medicare MNT benet legislation to be
nutritional diagnostic, therapy, and counseling services for the
purpose of disease management, which are furnished by a reg-
istered dietitian or nutrition professional (25).
The intent of the NCP is to describe accurately the spectrum
of nutrition care that can be provided by dietetics profession-
als. Dietetics professionals are uniquely qualied by virtue of
academic and supervised practice training and appropriate
certication and/or licensure to provide a comprehensive array
of professional services relating to the prevention or treatment
of nutrition-related illness (14,26). MNT is but one specic
type of nutrition care. The NCP articulates the consistent and
specic steps a dietetics professional would use when deliver-
ing MNT, but it will also be used to guide nutrition education
and other preventative nutrition care services. One of the key
distinguishing characteristics between MNT and the other nu-
trition services using the NCP is that MNT always involves an
in-depth, comprehensive assessment and individualized care.
For example, one individual could receive MNT for diabetes
and also nutrition education services or participate in a com-
munity-based weight loss program (27). Each service would
use the Nutrition Care Process, but the process would be im-
plemented differently; the components of each step of the pro-
cess would be tailored to the type of service.
By articulating the steps of the Nutrition Care Process, the
commonalities (the consistent, standardized, four-step pro-
cess) of nutrition care are emphasized even though the process
is implemented differently for different nutrition services. With
a standardized Nutrition Care Process in place, MNTshould not
be used to describe all of the nutrition services that dietetics
professionals provide. As noted above, MNT is the only appli-
cation of the Nutrition Care Process (28-31). This change in
Edition: 2006 3
STEP 1. NUTRITION ASSESSMENT
Basic Denition &
Purpose
Nutrition Assessment is the rst step of the Nutrition Care Process. Its purpose is to obtain
adequate information in order to identify nutrition-related problems. It is initiated by referral and/or
screening of individuals or groups for nutritional risk factors. Nutrition assessment is a systematic
process of obtaining, verifying, and interpreting data in order to make decisions about the nature and
cause of nutrition-related problems. The specic types of data gathered in the assessment will vary
depending on a) practice settings, b) individual/groups present health status, c) how data are related
to outcomes to be measured, d) recommended practices such as ADAs Evidence Based Guides for
Practice and e) whether it is an initial assessment or a reassessment. Nutrition assessment requires
making comparisons between the information obtained and reliable standards (ideal goals). Nutrition
assessment is an on-going, dynamic process that involves not only initial data collection, but also
continual reassessment and analysis of patient/client/group needs. Assessment provides the
foundation for the nutrition diagnosis at the next step of the Nutrition Care Process.
Data Sources/Tools for
Assessment
Referral information and/or interdisciplinary records
Patient/client interview (across the lifespan)
Community-based surveys and focus groups
Statistical reports; administrative data
Epidemiological studies
Types of Data Collected Nutritional Adequacy (dietary history/detailed nutrient intake)
Health Status (anthropometric and biochemical measurements, physical & clinical conditions,
physiological and disease status)
Functional and Behavioral Status (social and cognitive function, psychological and emotional
factors, quality-of-life measures, change readiness)
Nutrition Assessment
Components
Review dietary intake for factors that affect health conditions and nutrition risk
Evaluate health and disease condition for nutrition-related consequences
Evaluate psychosocial, functional, and behavioral factors related to food access, selection,
preparation, physical activity, and understanding of health condition
Evaluate patient/client/groups knowledge, readiness to learn, and potential for changing behaviors
Identify standards by which data will be compared
Identify possible problem areas for making nutrition diagnoses
Critical Thinking The following types of critical thinking skills are especially needed in the assessment step:
Observing for nonverbal and verbal cues that can guide and prompt effective interviewing
methods;
Determining appropriate data to collect;
Selecting assessment tools and procedures (matching the assessment method to the situation);
Applying assessment tools in valid and reliable ways;
Distinguishing relevant from irrelevant data;
Distinguishing important from unimportant data;
Validating the data;
Organizing & categorizing the data in a meaningful framework that relates to nutrition problems;
and
Determining when a problem requires consultation with or referral to another provider.
Documentation of
Assessment
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.
Quality documentation of the assessment step should be relevant, accurate, and timely. Inclusion of
the following information would further describe quality assessment documentation:
Date and time of assessment;
Pertinent data collected and comparison with standards;
Patient/client/groups perceptions, values, and motivation related to presenting problems;
Changes in patient/client/groups level of understanding, food-related behaviors, and other clinical
outcomes for appropriate follow-up; and
Reason for discharge/discontinuation if appropriate.
Determination for
Continuation of Care
If upon the completion of an initial or reassessment it is determined that the problem cannot be
modied by further nutrition care, discharge or discontinuation from this episode of nutrition care
may be appropriate.
FIG 2. ADA Nutrition Care Process.
Edition: 2006 4
STEP 2. NUTRITION DIAGNOSIS
Basic Denition &
Purpose
Nutrition Diagnosis is the second step of the Nutrition Care Process, and is the identication and
labeling that describes an actual occurrence, risk of, or potential for developing a nutritional problem
that dietetics professionals are responsible for treating independently. At the end of the assessment
step, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnostic category
from which to formulate a specic nutrition diagnostic statement. Nutrition diagnosis should not be
confused with medical diagnosis, which can be dened as a disease or pathology of specic organs
or body systems that can be treated or prevented. A nutrition diagnosis changes as the
patient/client/groups response changes. A medical diagnosis does not change as long as the
disease or condition exists. A patient/client/group may have the medical diagnosis of Type 2
diabetes mellitus; however, after performing a nutrition assessment, dietetics professionals may
diagnose, for example, undesirable overweight status or excessive carbohydrate intake.
Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realistic
and measurable expected outcomes, selecting appropriate interventions, and tracking progress in
attaining those expected outcomes.
Diagnosis
Organized and clustered assessment data
List(s) of nutrition diagnostic categories and nutrition diagnostic labels
Currently the profession does not have a standardized list of nutrition diagnoses. However ADA
has appointed a Standardized Language Work Group to begin development of standardized
language for nutrition diagnoses and intervention. (June 2003)
Nutrition Diagnosis
Components (3
distinct parts)
1. Problem (Diagnostic Label)
The nutrition diagnostic statement describes alterations in the patient/client/groups nutritional status.
A diagnostic label (qualier) is an adjective that describes/qualies the human response such as:
Altered, impaired, ineffective, increased/decreased, risk of, acute or chronic.
2. Etiology (Cause/Contributing Risk Factors)
The related factors (etiologies) are those factors contributing to the existence of, or maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental
problems.
Linked to the problem diagnostic label by words related to (RT)
It is important not only to state the problem, but to also identify the cause of the problem.
This helps determine whether or not nutritional intervention will improve the condition or correct
the problem.
It will also identify who is responsible for addressing the problem. Nutrition problems are either
caused directly by inadequate intake (primary) or as a result of other medical, genetic, or
environmental factors (secondary).
It is also possible that a nutrition problem can be the cause of another problem. For example,
excessive caloric intake may result in unintended weight gain. Understanding the cascade of
events helps to determine how to prioritize the interventions.
It is desirable to target interventions at correcting the cause of the problem whenever possible;
however, in some cases treating the signs and symptoms (consequences) of the problem may also
be justied.
The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in order
of their importance and urgency for the patient/client/group.
3. Signs/Symptoms (Dening Characteristics)
The dening characteristics are a cluster of subjective and objective signs and symptoms
established for each nutrition diagnostic category. The dening characteristics, gathered during
the assessment phase, provide evidence that a nutrition related problem exists and that the
problem identied belongs in the selected diagnostic category. They also quantify the problem
and describe its severity:
Linked to etiology by words as evidenced by (AEB);
The symptoms (subjective data) are changes that the patient/client/group feels and expresses
verbally to dietetics professionals; and
The signs (objective data) are observable changes in the patient/client/groups health status.
Nutrition Diagnostic
Statement (PES)
Whenever possible, a nutrition diagnostic statement is written in a PES format that states the
Problem (P), the Etiology (E), and the Signs & Symptoms (S). However, if the problem is either a risk
(potential) or wellness problem, the nutrition diagnostic statement may have only two elements,
Problem (P), and the Etiology (E), since Signs & Symptoms (S) will not yet be exhibited in the patient.
A well-written Nutrition Diagnostic Statement should be:
1. Clear and concise
2. Specic: patient/client/group-centered
3. Related to one client problem
4. Accurate: relate to one etiology
5. Based on reliable and accurate assessment data
Examples of Nutrition Diagnosis Statements (PES or PE)
Excessive caloric intake (problem) related to frequent consumption of large portions of high fat
meals (etiology) as evidenced by average daily intake of calories exceeding recommended
amount by 500 kcal and 12-pound weight gain during the past 18 months (signs)
FIG 2 contd.
Edition: 2006 5
Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice in a
bottle
Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-pound
weight loss over past month
Risk of weight gain RT a recent decrease in daily physical activity following sports injury
Critical Thinking The following types of critical thinking skills are especially needed in the diagnosis step:
Finding patterns and relationships among the data and possible causes;
Making inferences (if this continues to occur, then this is likely to happen);
Stating the problem clearly and singularly;
Suspending judgment (be objective and factual);
Making interdisciplinary connections;
Ruling in/ruling out specic diagnoses; and
Prioritizing the relative importance of problems for patient/client/group safety.
Documentation of
Diagnosis
Quality documentation of the diagnosis step should be relevant, accurate, and timely. A nutrition
diagnosis is the impression of dietetics professionals at a given point in time. Therefore, as more
assessment data become available, the documentation of the diagnosis may need to be revised and
updated.
Inclusion of the following information would further describe quality documentation of this step:
Date and time; and
Written statement of nutrition diagnosis.
Determination for
Since the diagnosis step primarily involves naming and describing the problem, the determination for
continuation of care seldom occurs at this step. Determination of the continuation of care is more
appropriately made at an earlier or later point in the Nutrition Care Process.
STEP 3. NUTRITION INTERVENTION
Basic Denition &
Purpose
Nutrition Intervention is the third step of the Nutrition Care Process. An intervention is a specic
set of activities and associated materials used to address the problem. Nutrition interventions are
purposefully planned actions designed with the intent of changing a nutrition-related behavior, risk
factor, environmental condition, or aspect of health status for an individual, target group, or the
community at large. This step involves a) selecting, b) planning, and c) implementing appropriate
actions to meet patient/client/groups nutrition needs. The selection of nutrition interventions is driven
by the nutrition diagnosis and provides the basis upon which outcomes are measured and evaluated.
Dietetics professionals may actually do the interventions, or may include delegating or coordinating
the nutrition care that others provide. All interventions must be based on scientic principles and
rationale and, when available, grounded in a high level of quality research (evidence-based
interventions).
Dietetics professionals work collaboratively with the patient/client/group, family, or caregiver to
create a realistic plan that has a good probability of positively inuencing the diagnosis/problem. This
client-driven process is a key element in the success of this step, distinguishing it from previous
planning steps that may or may not have involved the patient/client/group to this degree of
participation.
Interventions
Evidence-based nutrition guides for practice and protocols
Current research literature
Current consensus guidelines and recommendations from other professional organizations
Results of outcome management studies or Continuous Quality Index projects.
Current patient education materials at appropriate reading level and language
Behavior change theories (self-management training, motivational interviewing, behavior
modication, modeling)
Nutrition Intervention
Components
This step includes two distinct interrelated processes:
1. Plan the nutrition intervention (formulate & determine a plan of action)
Prioritize the nutrition diagnoses based on severity of problem; safety; patient/client/groups need;
likelihood that nutrition intervention will impact problem and patient/client/groups perception of
importance.
Consult ADAs MNT Evidence-Based Guides for Practice and other practice guides. These
resources can assist dietetics professionals in identifying science-based ideal goals and selecting
appropriate interventions for MNT. They list appropriate value(s) for control or improvement of the
disease or conditions as dened and supported in the literature.
Determine patient-focused expected outcomes for each nutrition diagnosis. The expected
outcomes are the desired change(s) to be achieved over time as a result of nutrition intervention.
They are based on nutrition diagnosis; for example, increasing or decreasing laboratory values,
decreasing blood pressure, decreasing weight, increasing use of stanols/sterols, or increasing
ber. Expected outcomes should be written in observable and measurable terms that are clear
and concise. They should be patient/client/group-centered and need to be tailored to what is
reasonable to the patients circumstances and appropriate expectations for treatments and
outcomes.
FIG 2 contd.
Edition: 2006 6
Confer with patient/client/group, other caregivers or policies and program standards throughout
planning step.
Dene intervention plan (for example write a nutrition prescription, provide an education plan or
community program, create policies that inuence nutrition programs and standards).
Select specic intervention strategies that are focused on the etiology of the problem and that are
known to be effective based on best current knowledge and evidence.
Dene time and frequency of care including intensity, duration, and follow-up.
Identify resources and/or referrals needed.
2. Implement the nutrition intervention (care is delivered and actions are carried out)
Implementation is the action phase of the nutrition care process. During implementation, dietetics
professionals:
Communicate the plan of nutrition care;
Carry out the plan of nutrition care; and
Continue data collection and modify the plan of care as needed.
Other characteristics that dene quality implementation include:
Individualize the interventions to the setting and client;
Collaborate with other colleagues and health care professionals;
Follow up and verify that implementation is occurring and needs are being met; and
Revise strategies as changes in condition/response occurs.
Critical Thinking Critical thinking is required to determine which intervention strategies are implemented based on
analysis of the assessment data and nutrition diagnosis. The following types of critical thinking skills
are especially needed in the intervention step:
Setting goals and prioritizing;
Transferring knowledge from one situation to another;
Dening the nutrition prescription or basic plan;
Making interdisciplinary connections;
Initiating behavioral and other interventions;
Matching intervention strategies with client needs, diagnoses, and values;
Choosing from among alternatives to determine a course of action; and
Specifying the time and frequency of care.
Documentation of
Nutrition Interventions
Quality documentation of nutrition interventions should be relevant, accurate, and timely. It should
also support further intervention or discharge from care. Changes in patient/client/groups level of
understanding and food-related behaviors must be documented along with changes in clinical or
functional outcomes to assure appropriate care/case management in the future. Inclusion of the
following information would further describe quality documentation of this step:
Date and time;
Specic treatment goals and expected outcomes;
Recommended interventions, individualized for patient;
Any adjustments of plan and justications;
Patient receptivity;
Referrals made and resources used;
Any other information relevant to providing care and monitoring progress over time;
Plans for follow-up and frequency of care; and
Rationale for discharge if appropriate.
Determination for
If the patient/client/group has met intervention goals or is not at this time able/ready to make needed
changes, the dietetics professional may include discharging the client from this episode of care as
part of the planned intervention.
STEP 4. NUTRITION MONITORING AND EVALUATION
Basic Denition &
Purpose
Nutrition Monitoring and Evaluation is the fourth step of the Nutrition Care Process. Monitoring
specically refers to the review and measurement of the patient/client/groups status at a scheduled
(preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans/goals, and
outcomes, whereas Evaluation is the systematic comparison of current ndings with previous status,
intervention goals, or a reference standard. Monitoring and evaluation use selected outcome
indicators (markers) that are relevant to the patient/client/groups dened needs, nutrition diagnosis,
nutrition goals, and disease state. Recommended times for follow-up, along with relevant outcomes
to be monitored, can be found in ADAs Evidence Based Guides for Practice and other evidence-
based sources.
The purpose of monitoring and evaluation is to determine the degree to which progress is being
made and goals or desired outcomes of nutrition care are being met. It is more than just watching
what is happening, it requires an active commitment to measuring and recording the appropriate
outcome indicators (markers) relevant to the nutrition diagnosis and intervention strategies. Data from
this step are used to create an outcomes management system. Refer to Outcomes Management
System in text.
FIG 2 contd.
Edition: 2006 7
Progress should be monitored, measured, and evaluated on a planned schedule until discharge.
Short inpatient stays and lack of return for ambulatory visits do not preclude monitoring, measuring,
and evaluation. Innovative methods can be used to contact patients/clients to monitor progress and
outcomes. Patient condential self-report via mailings and telephone follow-up are some possibilities.
Patients being followed in disease management programs can also be monitored for changes in
nutritional status. Alterations in outcome indicators such as hemoglobin A1C or weight are examples
that trigger reactivation of the nutrition care process.
Monitoring and
Evaluation
Patient/client/group records
Anthropometric measurements, laboratory tests, questionnaires, surveys
Patient/client/group (or guardian) interviews/surveys, pretests, and posttests
Mail or telephone follow-up
ADAs Evidence Based Guides for Practice and other evidence-based sources
Data collection forms, spreadsheets, and computer programs
Types of Outcomes
Collected
The outcome(s) to be measured should be directly related to the nutrition diagnosis and the goals
established in the intervention plan. Examples include, but are not limited to:
Direct nutrition outcomes (knowledge gained, behavior change, food or nutrient intake changes,
improved nutritional status);
Clinical and health status outcomes (laboratory values, weight, blood pressure, risk factor prole
changes, signs and symptoms, clinical status, infections, complications);
Patient/client-centered outcomes (quality of life, satisfaction, self-efcacy, self-management,
functional ability); and
Health care utilization and cost outcomes (medication changes, special procedures,
planned/unplanned clinic visits, preventable hospitalizations, length of hospitalization, prevent or
delay nursing home admission).
Nutrition Monitoring
and Evaluation
Components
This step includes three distinct and interrelated processes:
1. Monitor progress
Check patient/client/group understanding and compliance with plan;
Determine if the intervention is being implemented as prescribed;
Provide evidence that the plan/intervention strategy is or is not changing patient/client/group
behavior or status;
Identify other positive or negative outcomes;
Gather information indicating reasons for lack of progress; and
Support conclusions with evidence.
2. Measure outcomes
Select outcome indicators that are relevant to the nutrition diagnosis or signs or symptoms,
nutrition goals, medical diagnosis, and outcomes and quality management goals.
Use standardized indicators to:
Increase the validity and reliability of measurements of change; and
Facilitate electronic charting, coding, and outcomes measurement.
3. Evaluate outcomes
Compare current ndings with previous status, intervention goals, and/or reference standards.
Critical Thinking The following types of critical thinking skills are especially needed in the monitoring and evaluation step:
Selecting appropriate indicators/measures;
Using appropriate reference standard for comparison;
Dening where patient/client/group is now in terms of expected outcomes;
Explaining variance from expected outcomes;
Determining factors that help or hinder progress; and
Deciding between discharge or continuation of nutrition care.
Documentation of
Monitoring and
Evaluation
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process
and is an integral part of monitoring and evaluation activities. Quality documentation of the
monitoring and evaluation step should be relevant, accurate, and timely. It includes a statement of
where the patient is now in terms of expected outcomes. Standardized documentation enables
pooling of data for outcomes measurement and quality improvement purposes. Quality
documentation should also include:
Date and time;
Specic indicators measured and results;
Progress toward goals (incremental small change can be signicant therefore use of a Likert type
scale may be more descriptive than a met or not met goal evaluation tool);
Factors facilitating or hampering progress;
Other positive or negative outcomes; and
Future plans for nutrition care, monitoring, and follow up or discharge.
Determination for
Based on the ndings, the dietetics professional makes a decision to actively continue care or
discharge the patient/client/group from nutrition care (when necessary and appropriate nutrition care is
completed or no further change is expected at this time). If nutrition care is to be continued, the nutrition
care process cycles back as necessary to assessment, diagnosis, and/or intervention for additional
assessment, renement of the diagnosis and adjustment and/or reinforcement of the plan. If care does not
continue, the patient may still be monitored for a change in status and reentry to nutrition care at a later date.
FIG 2 contd.
Edition: 2006 8
describing what dietetics professionals do is truly a paradigm
shift. This new paradigm is more complete, takes in more pos-
sibilities, and explains observations better. Finally, it allows
dietetics professionals to act in ways that are more likely to
achieve the results that are desired and expected.
NUTRITION CARE MODEL
The Nutrition Care Model is a visual representation that re-
ects key concepts of each step of the Nutrition Care Process
and illustrates the greater context within which the Nutrition
Care Process is conducted. The model also identies other fac-
tors that inuence and impact on the quality of nutrition care
provided. Refer to Figure 1 for an illustration of the model as
described below:
I Central Core: Relationship between patient/client/group and
dietetics professional;
I Nutrition Care Process: Four steps of the nutrition care pro-
cess (Figure 2);
I Outer rings:
I Middle ring: Strengths and abilities that dietetics profession-
als bring to the process (dietetics knowledge, skills, and com-
petencies; critical thinking, collaboration, and communication;
evidence-based practice, and Code of Ethics) (32);
I Outer ring: Environmental factors that inuence the process
(practice settings, health care systems, social systems, and
economics);
I Supporting Systems:
I Screening and Referral System as access to Nutrition Care;
and
I Outcomes Management Systemas a means to provide contin-
uous quality improvement to the process.
The model is intended to depict the relationship with which
all of these components overlap, interact, and move in a dy-
namic manner to provide the best quality nutrition care possi-
ble.
Central to providing nutrition care is the relationship be-
tween the patient/client/group and the dietetics professional.
The patient/client/groups previous educational experiences
and readiness to change inuence this relationship. The edu-
cation and training that dietetics professionals receive have
very strong components devoted to interpersonal knowledge
and skill building such as listening, empathy, coaching, and
positive reinforcing.
The middle ring identies abilities of dietetics professionals
that are especially applicable to the Nutrition Care Process.
These include the unique dietetics knowledge, skill, and com-
petencies that dietetics professionals bring to the process, in
addition to a well-developed capability for critical thinking, col-
laboration, and communication. Also in this ring is evidence-
based practice that emphasizes that nutrition care must incor-
porate currently available scientic evidence, linking what is
done (content) and how it is done (process of care). The Code
of Ethics denes the ethical principles by which dietetics pro-
fessionals should practice (33). Dietetics knowledge and evi-
dence-based practice establish the Nutrition Care Process as
unique to dietetics professionals; no other health care profes-
sional is qualied to provide nutrition care in this manner. How-
ever, the Nutrition Care Process is highly dependent on collab-
oration and integration within the health care team. As stated
above, communication and participation within the health care
teamare critical for identication of individuals who are appro-
priate for nutrition care.
The outer ring identies some of the environmental factors
such as practice settings, health care systems, social systems,
and economics. These factors impact the ability of the patient/
client/group to receive and benet from the interventions of
nutrition care. It is essential that dietetics professionals assess
these factors and be able to evaluate the degree to which they
may be either a positive or negative inuence on the outcomes
of care.
Screening and Referral System
Because screening may or may not be accomplished by dietet-
ics professionals, nutrition screening is a supportive system
and not a step within the Nutrition Care Process. Screening is
extremely important; it is an identication step that is outside
the actual care and provides access to the Nutrition Care
Process.
The Nutrition Care Process depends on an effective screen-
ing and/or referral process that identies clients who would
benet fromnutrition care or MNT. Screening is dened by the
US Preventive Services Task Force as those preventive ser-
vices in which a test or standardized examination procedure is
used to identify patients requiring special intervention (34).
The major requirements for a screening test to be considered
effective are the following:
I Accuracy as dened by the following three components:
Specicity: Can it identify patients with a condition?
Sensitivity: Can it identify those who do not have the condi-
tion?
Positive and negative predictive; and
I Effectiveness as related to likelihood of positive health out-
comes if intervention is provided.
Screening parameters need to be tailored to the population
and to the nutrition care services to be provided. For example,
the screening parameters identied for a large tertiary acute
care institution specializing in oncology would be vastly differ-
ent than the screening parameters dened for an ambulatory
obstetrics clinic. Depending on the setting and institutional
policies, the dietetics professional may or may not be directly
involved in the screening process. Regardless of whether die-
tetics professionals are actively involved in conducting the
screening process, they are accountable for providing input
into the development of appropriate screening parameters to
ensure that the screening process asks the right questions.
They should also evaluate how effective the screening process
is in terms of correctly identifying clients who require nutrition
care.
In addition to correctly identifying clients who would benet
from nutrition care, a referral process may be necessary to
ensure that the client has an identiable method of being linked
to dietetics professionals who will ultimately provide the nutri-
tion care or medical nutrition therapy. While the nutrition
screening and referral is not part of the Nutrition Care Process,
it is a critical antecedent step in the overall system (35).
Outcomes Management System
An outcomes management system evaluates the effectiveness
and efciency of the entire process (assessment, diagnosis,
interventions, cost, and others), whereas the fourth step of the
process nutrition monitoring and evaluations refers to the
evaluation of the patient/client/groups progress in achieving
outcomes.
Because outcomes management is a systems commitment to
effective and efcient care, it is depicted outside of the NCP.
Outcomes management links care processes and resource uti-
Edition: 2006 9
lization with outcomes. Through outcomes management, rele-
vant data are collected and analyzed in a timely manner so that
performance can be adjusted and improved. Findings are com-
pared with such things as past levels of performance; organiza-
tional, regional, or national norms; and standards or bench-
marks of optimal performance. Generally, this information is
reported to providers, administrators, and payors/funders and
may be part of administrative databases or required reporting
systems.
It requires an infrastructure in which outcomes for the pop-
ulation served are routinely assessed, summarized, and re-
ported. Health care organizations use complex information
management systems to manage resources and track perfor-
mance. Selected information documented throughout the nu-
trition care process is entered into these central information
management systems and structured databases. Examples of
centralized data systems in which nutrition care data should be
included are the following:
I basic encounter documentation for billing and cost account-
ing;
I tracking of standard indicators for quality assurance and ac-
creditation;
I pooling data from a large series of patients/clients/groups to
determine outcomes; and
I specially designed studies that link process and outcomes to
determine effectiveness and cost effectiveness of diagnostic
and intervention approaches.
The major goal of outcomes management is to utilize col-
lected data to improve the quality of care rendered in the fu-
ture. Monitoring and evaluation data from individuals are
pooled/aggregated for the purposes of professional account-
ability, outcomes management, and systems/processes im-
provement. Results from a large series of patients/clients can
be used to determine the effectiveness of intervention strate-
gies and the impact of nutrition care in improving the overall
health of individuals and groups. The effects of well-monitored
quality improvement initiatives should be reected in measur-
able improvements in outcomes.
Outcomes management comprehensively evaluates the two
parts of IOMs denition of quality: outcomes and process. Mea-
suring the relationship between the process and the outcome is
essential for quality improvement. To ensure that the quality of
patient care is not compromised, the focus of quality improve-
ment efforts should always be directed at the outcome of care
(36-43).
FUTURE IMPLICATIONS
Impact on Coverage for Services
Quality-related issues are gaining in importance worldwide.
Even though our knowledge base is increasing, the scientic
evidence for most clinical practices in all of medicine is modest.
So much of what is done in health care does not maximize
quality or minimize cost (44). A standardized Nutrition Care
Process is a necessary foundation tool for gathering valid and
reliable data on howquality nutrition care provided by qualied
dietetics professionals improves the overall quality of health
care provided. Implementing ADAs Nutrition Care Process
provides a framework for demonstrating that nutrition care
improves outcomes by the following: (a) enhancing the health
of individuals, groups, institutions, or health systems; (b) po-
tentially reducing health care costs by decreasing the need for
medications, clinic and hospital visits, and preventing or delay-
ing nursing home admissions; and (c) serving as the basis for
research, documenting the impact of nutrition care provided
by dietetics professionals (45-47).
Developing Scopes and Practice Standards
The work group reviewed the questions raised by delegates
regarding the role of the RD and DTR in the Nutrition Care
Process. As a result of careful consideration of this important
issue, it was concluded that describing the various types of
tasks and responsibilities appropriate to each of these creden-
tialed dietetics professionals was yet another professional issue
beyond the intent and purpose of developing a standardized
Nutrition Care Process.
A scope of practice of a profession is the range of services
that the profession is authorized to provide. Scopes of practice,
depending on the particular setting in which they are used, can
have different applications. They can serve as a legal document
for state certication/licensure laws or they might be incorpo-
rated into institutional policy and procedure guidelines or job
descriptions. Professional scopes of practice should be based
on the education, training, skills, and competencies of each
profession (48).
As previously noted, a dietetics professional is a person who,
by virtue of academic and clinical training and appropriate cer-
tication and/or licensure, is uniquely qualied to provide a
comprehensive array of professional services relating to pre-
vention and treatment of nutrition-related conditions. A Scope
of Practice articulates the roles of the RD, DTR, and advanced-
practice RD. Issues to be addressed for the future include the
following: (a) the need for a common scope with specialized
guidelines and (b) recognition of the rich diversity of practice
vs exclusive domains of practice regulation.
Professional standards are authoritative statements that
describe performance common to the profession. As such,
standards should encompass the following:
I articulate the expectations the public can have of a dietetics
professional in any practice setting, domain, and/or role;
I expect and achieve levels of practice against which actual
performance can be measured; and
I serve as a legal reference to describe reasonable and pru-
dent dietetics practice.
The Nutrition Care Process effectively reects the dietetics
professional as the unique provider of nutrition care when it is
consistently used as a systematic method to think critically and
make decisions to provide safe and effective care. ADAs Nutri-
tion Care Process will serve as a guide to develop scopes of
practice and standards of practice (49,50). Therefore, the work
group recommended that further work be done to use the Nu-
trition Care Process to describe roles and functions that can be
included in scopes of practice. In May 2003, the Board of Di-
rectors of ADA established a Practice Denitions Task Force
that will identify and differentiate the terms within the profes-
sion that need clarication for members, afliates, and DPGs
related to licensure, certication, practice acts, and advanced
practice. This task force is also charged to clarify the scope of
practice services, clinical privileges, and accountabilities pro-
vided by RDs/DTRs based on education, training, and experi-
ence.
Education of Dietetics Students
It will be important to review the current CADE Educational
Standards to ensure that the language and level of expected
competencies are consistent with the entry-level practice of
Edition: 2006 10
the Nutrition Care Process. Further work by the Commission
on Dietetic Registration (CDR) may need to be done to make
revisions on the RD and DTR exams to evaluate entry-level
competencies needed to practice nutrition care in this way.
Revision of texts and other educational materials will also need
to incorporate the key principles and steps of this new process
(51).
Education and Credentialing of Members
Even though dietetics professionals currently provide nutrition
care, this standardized Nutrition Care Process includes some
new principles, concepts, and guidelines in each of its steps.
This is especially true of steps 2 and 4 (Nutrition Diagnosis and
Nutrition Monitoring and Evaluation). Therefore, the implica-
tions for education of dietetics professionals and their practice
are great. Because a large number of dietetics professionals still
are employed in health care systems, a comprehensive educa-
tional plan will be essential. A model to be considered when
planning education is the one used to educate dietetics profes-
sionals on the Professional Development Portfolio (PDP) Pro-
cess (52). Materials that could be used to provide members
with the necessary knowledge and skills in this process could
include but not be limited to the following:
I articles in the Journal of the American Dietetic Associa-
tion;
I continuing professional education lectures and presentations
at afliate and national meetings;
I self-study materials; case studies, CD-ROM workbooks, and
others;
I hands-on workshops and training programs;
I Web-based materials; and
I inclusion in the learning needs assessment and codes of the
Professional Development Portfolio.
Through the development of this educational strategic plan,
the benets to dietetics professionals and other stakeholders
will need to be a central theme to promote the change in prac-
tice that comes with using this process to provide nutrition
care.
Evidence-Based Practice
The pressure to do more with less is dramatically affecting all of
health care, including dietetics professionals. This pressure is
forcing the health care industry to restructure to be more ef-
cient and cost-effective in delivering care. It will require the use
of evidenced-based practice to determine what practices are
critical to support outcomes (53,54). The Nutrition Care Pro-
cess will be invaluable as research is completed to evaluate the
services provided by dietetics professionals (55). The Nutrition
Care Process will provide the structure for developing the
methodology and data collection in individual settings, and the
practice-based research networks ADA is in the process of ini-
tiating.
Standardized Language
As noted in Step 2 (Nutrition Diagnosis), having a standard
taxonomy for nutrition diagnosis would be benecial. Work in
the area of articulating the types of interventions used by die-
tetics professionals has already begun by the Denitions Work
Group under the direction of ADAs Research Committee. Fur-
ther work to dene terms that are part of the Nutrition Care
Process will need to continue. Even though the work group
provided a list of terms relating to the denition and key con-
cepts of the process, there are opportunities to articulate fur-
ther terms that are consistently used in this process. The Board
of Directors of ADA in May 2003 approved continuation and
expansion of a task force to address a comprehensive system
that includes a process for developing and validating standard-
ized language for nutrition diagnosis, intervention, and out-
comes.
SUMMARY
Just as maps are reissued when new roads are built and rivers
change course, this Nutrition Care Process and Model reects
recent changes in the nutrition and health care environment. It
provides dietetics professionals with the updated road map to
follow the best path for high-quality patient/client/group-cen-
tered nutrition care.
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The Quality Management Committee Work Group devel-
oped the Nutrition Care Process and Model with input
from the House of Delegates dialog (October 2002 HOD
meeting, in Philadelphia, PA). The work group members
are the following: Karen Lacey, MS, RD, Chair; Elvira
Johnson, MS, RD; Kessey Kieselhorst, MPA, RD; Mary Jane
Oakland, PhD, RD, FADA; Carlene Russell, RD, FADA; Pa-
tricia Splett, PhD, RD, FADA; Suzanne Bertocchi, DTR,
and Tamara Otterstein, DTR; Ellen Pritchett, RD; Esther
Myers, PhD, RD, FADA; Harold Holler, RD, and Karri
Looby, MS, RD. The work group would like to extend a
special thank you to Marion Hammond, MS, and Naoimi
Trossler, PhD, RD, for their assistance in development of
the Nutrition Care Process and Model.
Edition: 2006 12
American Dietetic Associations Standardized Nutrition Language:
Current Status
Introduction
Evidence-based dietetic practice relies on
concise, consistent, and standardized terminology to
create and retrieve digital sources of evidence.
1
This
is essential for documenting nutrition diagnoses,
interventions and outcomes in electronic health
records. A task force of the American Dietetic
Association (ADA) has begun to refine and
disseminate standardized nutrition language. The
language is built on the Nutrition Care Process and
Model that maps quality nutrition care and outcomes,
and recognizes several existing terminologies used by
other health professions. This paper will describe the
logic model for the development of the standardized
nutrition language, the Nutrition Care Process it is
built upon, and its current status.
The project goal is to support nutrition practice,
education, research, and policy with data. It is
assumed that practicing dietitians, educators, and
researchers will use the standardized nutrition
language to document care, aggregate data, and study
the evidence. Standardized terminology will provide
the foundation for developing a national dietitian
care database.
The Nutrition Care Process
The ADA Nutrition Care Model workgroup
published the Nutrition Care Process (NCP) and
Model in August 2003.
2
It provides a definition of
the NCP and describes its steps and framework. The
NCP is a systematic problem-solving method that
dietetics professionals use to critically think and
make decisions to address nutrition related problems
and provide safe and effective quality nutrition
care.
2, p1063
The four steps of the NCP, similar to
those of other clinical professions, are: (a) Nutrition
Assessment, (b) Nutrition Diagnosis, (c) Nutrition
Intervention, and (d) Nutrition Monitoring and
Evaluation. Allowing for the reality of an iterative
and comprehensive clinical process, the NCP is not
linear and it includes, but is not limited to, Medical
Nutrition Therapy. Medical Nutrition Therapy is
nutritional diagnostic, therapy, and counseling
services for the purpose of disease management,
which are furnished by a registered dietitian or
nutrition professional.
3
The context of the NCP and
surrounding influences are captured in the Model
framework.
Standardized terms are being developed for each
step of the NCP. Nutrition Assessment is a
systematic process of obtaining, verifying, and
interpreting data in order to make decisions about the
nature and cause of nutrition-related problems.
2
The
Nutrition Assessment includes signs and symptoms.
Nutrition Diagnosis is the identification and labeling
that describes an actual occurrence, risk of, or
potential for developing a nutritional problem that
dietetics professionals are responsible for treating
independently.
2
Nutrition Interventions are purposely planned
actions designed with the intent of changing a
nutrition-related behavior, risk factor, environmental
condition, or aspect of health status for an individual,
target group, or the community at large.
2,
Interventions are directed to influence the etiology or
effects of a diagnosis. Nutrition Monitoring is the
review and measurement of the patient/client/groups
status at a scheduled (preplanned) follow-up point
with regard to the nutrition diagnosis, intervention
plans/goals, and outcomes. Evaluation is the
systematic comparison of current findings with
previous status, intervention goals, or a reference
standard.
2
Evaluation may measure changes in signs
and symptoms. The NCP steps guide the delivery of
nutrition health services, education, and research and
define categories for documentation of nutrition care.
Development: Comparison with Nursing
In comparison with the development of various
nursing terminologies, the ADA nutrition language
development has been much more rapid and
centralized, due perhaps to comparatively smaller
numbers of nutrition professionals and growing
sophistication in information technology. Nursing
terminology work began in the 1970s, including the
North American Nursing Diagnosis Association
(NANDA)
4
terminology, the Clinical Care
Classification (CCC),
5
and others. NANDA is
specific to nursing diagnoses, while the CCC
addresses diagnoses, interventions, and outcomes.
The Nursing Minimum Data Set,
6
which includes
patient information, nursing diagnoses, nursing
interventions, nursing outcomes, intensity level of
nursing care, and a unique provider number, is an
overarching framework for the various discrete
nursing terminologies, similar to the NCP.
Edition: 2006
Portions of this document have been submitted for publication elsewhere
13
Why Does Dietetics Practice Need a Standardized
Language?
There is currently no agreed upon mechanism by
which dietetics professionals can communicate with
each other or other health care professionals. Because
of this lack of agreement, there is no easy way to
classify, measure, and report on the outcomes of
nutrition interventions in various patient populations.
The Nutrition Care Process includes nutrition
diagnosis and nutrition intervention as unique steps
that provide registered dietitians a mechanism to
consistently document and communicate the work of
dietetics. There is currently no agreed upon
terminology used in dietetics practice which makes it
impossible to gather and aggregate data needed for
research, education, and reimbursement justification
via outcomes analysis.
Logic Model
A Logic Model is a simplified picture that
describes the logical relationships among the
resources invested, the activities that take place, and
the benefits to be realized from the project and the
environment in which the system/project occurs.
With the help of an informatics consultant, the
Standardized Language Task Force adopted a Project
Logic Model that identifies the expected outcomes
and impact of the Standardized Language of
Dietetics. The goal of the dietetics terminology was
seen to be "To provide data to foster nutrition
practice, education, research, and policy.
Three time frames for evaluating the impact of
the standardized language were agreed upon. The
most immediate impacts were thought to include
recommendations for coordination with existing
terminologies, review of the structure of the dietetics
terminology, to "cross-walk" the new terminology
with existing terminologies to see if overlap exists, to
review existing intervention terms, and to identify
relevant policy issues regarding standardized
nutrition language. Intermediate impacts were
thought to include selection of a structure for the
nutrition diagnostic labels, cross-walk of the
intervention terms, to plan for generation of nutrition
outcomes measures, create strategies for ongoing
maintenance and updates of the language, to design
and implement pilot testing of the standardized
language, and to draft legislative and policy agendas.
The ultimate impact was agreed to include delivery
of quality, cost-effective nutrition care, national
growth of nutrition care, inclusion of the standardized
language in dietetics education and research,
development of a national data warehouse for
nutrition research, and support of policies designed to
foster nutrition practice, education, and research.
Several assumptions were necessary in
development of this logic model. The Task Force was
in agreement that nutrition is an essential component
of high quality health care. There was heightened
awareness of the need for data to document the
processes and outcomes of nutrition care in a variety
of settings. It was also assumed that educators,
practicing dietitians, and researchers would accept
and implement the standardized language and would
be willing to share data using the terminology for
targeted studies and ultimately a national database.
Nutrition Diagnostic Labels
To date, over 60 Nutrition Diagnostic Labels
have been defined by ADA work with focus groups,
domain experts, and membership committees.
Standardized Language Task Force members judged
the match between nutrition diagnoses terms and
similar terms listed in the National Library of
Medicines Unified Medical Language System
(UMLS);
7
many terms have synonyms. One of the
robust terminologies in the UMLS is SNOMED-CT.
8
Staff from SNOMED-CT were contacted to discuss
the process of submitting nutrition terms.
The Nutrition Diagnostic Labels include 3
domains: Clinical, Behavioral-Environmental, and
Intake. The domains, sub-classes, and specific
diagnoses are defined in the most recent version, a
summary of which follows.
DOMAIN: INTAKE
Defined as actual problems related to intake of
energy, nutrients, fluids, bioactive substances through
oral diet or nutrition support (enteral or parenteral
nutrition)
Class: Caloric Energy Balance
Defined as actual or estimated changes in energy
(kcal)
Class: Oral or Nutrition Support Intake
Defined as actual or estimated food and beverage
intake from oral diet or nutrition support compared
with patient goal
Class: Fluid Intake Balance
Defined as actual or estimated fluid intake compared
with patient goal
Class: Bioactive Substances Balance
Defined as actual or observed intake of bioactive
substances, including single or multiple functional
food components, ingredients, dietary supplements,
alcohol
Class: Nutrient Balance
Defined as actual or estimated intake of specific
nutrient groups or single nutrients as compared with
desired levels
Sub-Class: Fat and Cholesterol Balance
Sub-Class: Protein Balance
Edition: 2006
14
Sub-Class: Carbohydrate and Fiber Balance
Sub-Class: Vitamin Balance
Sub-Class: Mineral Balance
DOMAIN: CLINICAL
Defined as nutritional findings/problems identified
that relate to medical or physical conditions
Class: Functional Balance
Defined as change in physical or mechanical
functioning that interferes with or prevents desired
nutritional consequences
Class: Biochemical Balance
Defined as change in capacity to metabolize
nutrients as a result of medications, surgery, or as
indicated by altered lab values
Class: Weight Balance
Defined as chronic weight or changed weight status
when compared with usual or desired body weight
DOMAIN: BEHAVIORAL-
ENVIRONMENTAL
that relate to knowledge, attitudes/beliefs, physical
environment, or access to food and food safety
Class: Knowledge and Beliefs
Defined as actual knowledge and beliefs as reported,
observed, or documented
Class: Physical Activity Balance and Function
Defined as actual physical activity, self-care, and
quality of life problems as reported, observed or
documented
Class: Food Safety and Access
Defined as actual problems with food access or food
safety
ADA
Problem-Etiology-Signs/Symptoms Statements
A Nutrition Diagnosis is best written as a PES
statement pertaining to one patient/client or group,
specific to one problem (P) and one etiology (E), and
based on assessment of signs and symptoms (S).
2
Implementation of PES statements in clinical practice
is being tested in two pilot studies by ADA members.
Examples of PES statements are
(a) Overweight/obesity (problem) related to
continued intake of high fat foods (etiology) resulting
in ~300 extra kcal/day as evidenced by a BMI of 30
(sign/symptom), and (b) Impaired ability to prepare
foods/meals (problem) related to fatigue (etiology) as
evidenced by patient/client only consuming one meal
per day. Interventions are often guided by the
etiology of each problem. Signs and symptoms may
provide measures to evaluate outcomes and the
effectiveness of care. It is possible that the
standardized terms for assessments will be
considered relevant outcome measures.
Nutrition Interventions
Following principles for standardized
terminologies,
9
the ADA has begun to identify and
define Nutrition Intervention terms. A Task Force
meeting in February 2005 identified categories of
interventions including: Treatments/Procedures,
Education, Counseling, and Referral/Coordination.
These categories are similar to those in nursing
terminologies but differing by not including
monitoring/assessment as an intervention, which is a
separate step in the Nutrition Care Process.
Synonyms to the intervention terms will be searched
in the UMLS and domain experts will judge the
extent of the matches. The Nutrition Intervention
Labels will be submitted SNOMED-CT or other
existing coding system that will be included in the
UMLS.
Future Work
Definition of Nutrition Assessment terms and
their relationship with Outcome terms is planned. In
addition, activities to communicate the standardized
language to educators, administrators, clinicians, and
researchers are planned. The ADA believes that
consistent standardized terminology will improve
patient care by enhancing the education, practice, and
research of nutrition professionals. The use of
standardized nutrition language by nutrition
professionals in the United States is in synch with
similar international efforts.
References
1. Bakken S. An informatics infrastructure is
essential for evidence-based practice. J Am Med
Inform Assoc. 2001;8:199-201.
2. Lacey K, Pritchett E. Nutrition care process and
model: ADA adopts road map to quality care and
outcomes management. J Am Diet Assoc.
2003;103:1061-72.
3. Final Medical Nutrition Therapy regulations.
CMS-1169-FC. Federal Register, Nov.1, 2001.
DHHS 42 CFR Parts: 405, 410, 411, 414, and 415.
Available
at:http://cms.hhs.gov/physicians/pfs/cms1169fc.asp?
Accessed: March 7, 2005.
4. North American Nursing Diagnosis Association.
Available at: http://www.nanda.org. Accessed Mar.
7, 2005.
5. Saba V. Clinical Care Classification System.
Available at http://www.sabacare.com. Accessed
March 7, 2005.
6. Werley H, Lang NM. Identification of the Nursing
Minimum Data Set. New York:NY: Springer; 1988.
Edition: 2006
15
7. National Library of Medicine. Unified Medical
Language System. 2005. Available at: http://
www.nlm.nih.gov/research/umls/umlsmain.html.
Accessed March 7, 2005.
8. College of American Pathologists. SNOMED
International Clinical Terms. Available at
http://www.snomed.org/. Accessed March 7, 2005.
9. Cimino JJ. Desiderata for controlled medical
vocabularies in the twenty-first century. Meth Inform
Med; 1998;37:394-403.
Edition: 2006
16
Introduction to Nutrition Diagnoses/Problems:
The New Component of the Nutrition Care Process
Introduction
The ADA has embarked on an extensive project to identify and define nutrition
diagnoses/problems for the profession of dietetics. This standardized language of nutrition
diagnoses/problems is an integral component in the Nutrition Care Process, a process designed to
improve the consistency and quality of individualized patient/client care and the predictability of
the patient/client outcomes. In fact, several other allied professional, including nursing, physical
therapy, and occupational therapy, utilize defined care processes (1).
Not only will creating this standard language help dietetic professionals better document their
nutrition care, it will serve to help achieve Association strategic goals of promoting demand for
dietetic professionals and help them be more competitive in the market place. It will also provide
a minimum data set and common data elements for future research that includes services of
dietetic professionals.
ADAs Standardized Language Task Force developed a conceptual framework for the
standardized nutrition language and identified the nutrition diagnoses/problems. The framework
outlines the domains within which the diagnoses/problems would fall and the flow of the
nutrition care process in relation to the continuum of health, disease and disability. Sixty-two
diagnoses/problems have been identified. A worksheet has been developed for each
diagnosis/problem and expert has been incorporated.
The methodology for developing sets of terms such as these includes systematically collecting
data from multiple sources simultaneously. We collected data from a selected group of dietitians
prior to starting the project (from recognized ADA leaders and award winners), from the 12
member task force during the development, from several small group discussions (community,
ambulatory, acute care, and long term care), and from expert researcher reviewers.
The methodology for continued development and refinement of these terms has been identified.
As with the ongoing updating of the American Medical Association Current Procedural
Terminology (CPT) codes, these will also be published on an annual basis. The process to
submit your suggested changes is included in this packet. In addition, the terms have been
included in one ongoing research project in an ambulatory setting. A second descriptive research
study identifying the use of the terms will be planned and conducted through the Dietetics
Practice Based Research Network in 2005-2006. As each of the research studies is completed,
their findings will be incorporated into future versions of these terms. Future iterations and
changes to the diagnoses/problems and the worksheets are expected as this standard language
evolves. Once the initial research is completed we will formally submit these terms to become
part of nationally recognized health care databases. We have already begun the dialogue with
these groups to let them know the direction that we are headed and to keep them appraised of our
progress.
Edition: 2006 17
Nutrition Care Process and Nutrition Diagnosis
ADAs new nutrition care process for the profession has four stepsnutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (1).
Textbooks often describe nutrition assessment in detail and then move directly into intervention
or therapy. Nutrition diagnosis is a critical step between assessment and intervention. The
nutrition diagnosis is the identification and labeling of the specific nutrition problem that
dietetics professionals are responsible for treating independently.
Naming the nutrition diagnosis provides a way to document the link between nutrition
assessment and nutrition intervention and set realistic and measurable expected outcomes for
each patient/client. Identifying the diagnosis also assists practitioners in establishing priorities
when planning an individual patient/clients nutrition care.
Nutrition diagnosis differs from medical diagnosis. Medical diagnosis is a disease or pathology
of specific organs or body systems (e.g., diabetes) and does not change as long as the condition
exists. A nutrition diagnosis may be temporary, altering as the patient/clients response changes
(e.g., excessive carbohydrate intake).
Categorization of the Nutrition Diagnoses
The sixty-two nutrition diagnoses/problems have been given labels that are clustered into three
domains: intake, clinical, and behavioral-environmental. Each domain represents unique
characteristics that contribute to nutritional health. Within each domain are classes and, in some
cases, sub-classes of diagnoses. A definition of each follows:
The Intake domain lists actual problems related to intake of energy, nutrients, fluids,
bioactive substances through oral diet, or nutrition support (enteral or parenteral nutrition.)
Class: Caloric Energy Balance (1)Actual or estimated changes in energy (kcal).
Class: Oral or Nutrition Support Intake (2)Actual or estimated food and beverage intake from oral diet
or nutrition support compared with patient/clients goal.
Class: Fluid Intake Balance (3)Actual or estimated fluid intake compared with patient/clients goal.
Class: Bioactive Substances Balance (4)Actual or observed intake of bioactive substances, including
single or multiple functional food components, ingredients, dietary supplements, and alcohol.
Class: Nutrient Balance (5)Actual or estimated intake of specific nutrient groups or single nutrients as
compared with desired levels.
Sub-Class: Fat and Cholesterol Balance (51)
Sub-Class: Protein Balance (52)
Sub-Class: Carbohydrate and Fiber Balance (53)
Sub-Class: Vitamin Balance (54)
Sub-Class: Mineral Balance (55)
The Clinical domain is nutritional findings/problems identified that relate to medical or
physical conditions.
Class: Functional Balance (1)Change in physical or mechanical function that interferes with or prevents
desired nutritional consequences.
Edition: 2006 18
Class: Biochemical Balance (2)Change in the capacity to metabolize nutrients as a result of medications,
surgery, or as indicated by altered lab values.
Class: Weight Balance (3)Chronic weight or changed weight status when compared with usual or desired
body weight.
The Behavioral-Environmental domain includes nutritional findings/problems identified
that relate to knowledge, attitudes/beliefs, physical environment, access to food, and food
safety.
Class: Knowledge and Beliefs (1)Actual knowledge and beliefs as reported, observed, or documented.
Class: Physical Activity Balance and Function (2)Actual physical activity, self-care, and quality of life
problems as reported, observed, or documented.
Class: Food Safety and Access (3)Actual problems with food access or food safety.
Examples of nutrition diagnoses and their definitions include:
INTAKE DOMAIN Caloric Energy Balance
Inadequate energy intake NI-1.4 Energy intake that is less than energy expenditure or recommended
levels. Exception: when the goal is for the client to lose weight or
during end of life care.
CLINICAL DOMAIN Functional Balance
Swallowing difficulty NC-1.1 Impaired movement of food and liquid from the mouth to the stomach.
BEHAVIORAL-ENVIRONMENTAL DOMAIN Knowledge and Beliefs
Not ready for diet/lifestyle change NB-
1.3
Lack of perceived value of nutrition-related care benefits compared to
consequences or effort required to making the change; inconsistencies
with other value structure/purpose; antecedent to behavior change.
Nutrition Diagnosis Statements (or PES)
Whenever possible, a nutrition diagnosis statement is written in the PES format that states the
problem (P), the etiology (E), and the signs/symptoms (S).
Examples
Swallowing difficulty (problem) related to stroke (etiology) as evidenced by coughing
following drinking of thin liquids (sign/symptoms).
Inadequate energy intake (problem) related to lack of financial resources to purchase sufficient
food (etiology) as evidenced by weight loss of 6 pounds in the last 2 months (signs/symptoms).
Nutrition Diagnosis Worksheet
A worksheet has been developed for each diagnosis. It contains four distinct components:
nutrition diagnosis label, definition of nutrition diagnosis label, etiology, and signs/symptoms.
These worksheets will assist practitioners with consistently and correctly utilizing the nutrition
diagnoses. Below is a description of the four components of the worksheet.
The Problem or Nutrition Diagnosis Label describes alterations in the patient/clients nutrition status that
dietetics professionals are responsible for treating independently. Nutrition diagnosis differs from medical
diagnosis in that a nutrition diagnosis changes as the patient/client response changes. The medical diagnosis
Edition: 2006 19
does not change as long as the disease or condition exists. A nutrition diagnosis allows the dietetics professional
to identify realistic and measurable outcomes, formulate interventions, and monitor and evaluate change.
The Definition of Nutrition Diagnosis Label briefly describes the Nutrition Diagnosis Label to differentiate a
discrete problem area.
The Etiology (Cause/Contributing Risk Factors) are those factors contributing to the existence of, or
maintenance of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental
problems. It is linked to the diagnosis label by the words related to.
The Signs/Symptoms (Defining Characteristics) consist of subjective and/or objective data used to determine
whether the patient/client has the nutrition diagnosis specified. These are the signs and symptoms gathered
through nutrition assessment. It is linked to the etiology by the words as evidenced by.
Organization of Data in Signs/Symptoms (Defining Characteristics)
Dietetics professionals use clinical judgment to determine the nutrition diagnosis based on data
collected from the first step of the nutrition care process: nutrition assessment. Therefore, the
items listed in the signs/symptoms (defining characteristics) are organized according to nutrition
assessment category.
Nutrition assessment is the systematic process for obtaining, verifying, and interpreting data
needed to make decisions about the nature and cause of the nutrition-related problem. The
process of nutrition assessment consists of collecting biochemical data, anthropometric
measurements, physical examination findings, food/nutrition history, and client history. On the
nutrition diagnosis worksheet, the signs/symptoms are classified by nutrition assessment
categories.
Biochemical Data include laboratory data, for example, electrolytes, glucose, hemoglobin A1C, thyroid, and lipid
panel.
Anthropometric Measurements include, for instance, height, weight, body mass index (BMI), growth rate, and
rate of weight change.
Nutrition-Focused Physical Examination includes oral health, general physical appearance, muscle and
subcutaneous fat wasting, and affect.
Food and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and
management, physical activity and exercise, and food availability.
Food consumption may include factors such as, food and nutrient intake, meal and snack patterns,
environmental cues to eating, and current diets and/or food modifications.
Nutrition and health awareness and management includes, for example, knowledge and beliefs about
nutrition recommendations, self-monitoring/management practices, and past nutrition counseling and
education.
Physical activity and exercise consists of activity patterns, amount of sedentary time (e.g., TV, phone,
computer), and exercise intensity, frequency, and duration.
Food availability encompasses factors such as, food planning, purchasing, preparation abilities and
limitations, food safety practices, food/nutrition program utilization, and food insecurity.
Edition: 2006 20
Client History consists of four areas: Medication and supplement history, social history, medical/health history,
and personal history.
Medication and supplement history includes, for instance, prescription and over the counter drugs,
herbal and dietary supplements, and illegal drugs.
Social history may include such items as socioeconomic status, social and medical support, cultural and
religious beliefs, housing situation, and social isolation/connection.
Medical/health history includes chief nutrition complaint, present/past illness, disease or complication
risk, family medical history, mental/emotional health, and cognitive abilities.
Personal history consists of factors including age, occupation, role in family, and education level.
Summary
Nutrition diagnosis is the critical link in the nutrition care process between assessment and
intervention. Interventions can then be clearly targeted to address either the etiology or signs and
symptoms of the specific nutrition diagnosis/problem identified. Using a standardized
terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical
thinking that dietetics professionals do visible to other professionals as well as provide a clear
method of communicating among dietetics professionals. Implementation of a standard language
throughout the profession, with tools to assist practitioners, will make this bold initiative a
success. Ongoing input is critical as the standardized language is created to ensure a proper
foundation for its future implementation.
Reference
1. Lacey K, Pritchett E. Nutrition care process and model: ADA adopts road map to quality care
and outcomes management. J Am Diet Assoc. 2003;103:1061-1072.
Edition: 2006 21
Edition: 2006 22
INTAKE NI
Defined as actual problems related to intake of
energy, nutrients, fluids, bioactive substances
through oral diet or nutrition support
Caloric Energy Balance (1)
Defined as actual or estimated changes in energy
(kcal)
Hypermetabolism NI-1.1
(Increased energy needs)
Increased energy expenditure NI-1.2
Hypometabolism NI-1.3
(Decreased energy needs)
Inadequate energy intake NI-1.4
Excessive energy intake NI-1.5
Oral or Nutrition Support Intake (2)
Defined as actual or estimated food and beverage
intake from oral diet or nutrition support compared
with patient goal
Inadequate oral food/ NI-2.1
beverage intake
Excessive oral food/ NI-2.2
beverage intake
Inadequate intake from NI-2.3
enteral/parenteral nutrition
infusion
Excessive intake from NI-2.4
Inappropriate infusion of NI-2.5
(use with caution)
Fluid Intake (3)
Defined as actual or estimated fluid intake
compared with patient goal
Inadequate fluid intake NI-3.1
Excessive fluid intake NI-3.2
Bioactive Substance Intake (4)
Defined as actual or observed intake of bioactive
substances, including single or multiple functional
food components, ingredients, dietary
supplements, alcohol
Inadequate bioactive NI-4.1
substance intake
Excessive bioactive NI-4.2
substance intake
Excessive alcohol intake NI-4.3
Nutrient Intake (5)
Defined as actual or estimated intake of specific
nutrient groups or single nutrients as compared
with desired levels
Increased nutrient needs NI-5.1
(specify) ____________________________
Evident protein-energy NI-5.2
malnutrition
Inadequate protein- NI-5.3
energy intake
Decreased nutrient needs NI-5.4
(specify) ____________________________
Imbalance of nutrients NI-5.5
Fat and Cholesterol (51)
Inadequate fat intake NI-51.1
Excessive fat intake NI-51.2
Inappropriate intake NI-51.3
of food fats
(specify) ______________________
Protein (52)
Inadequate protein intake NI-52.1
Excessive protein intake NI-52.2
Inappropriate intake NI-52.3
of amino acids
(specify)_______________________
Carbohydrate and Fiber (53)
Inadequate carbohydrate NI-53.1
intake
Excessive carbohydrate NI-53.2
intake
Inappropriate intake of NI-53.3
types of carbohydrate
(specify)_______________________
Inconsistent NI-53.4
carbohydrate intake
Inadequate fiber intake NI-53.5
Excessive fiber intake NI-53.6
Vitamin (54)
Inadequate vitamin NI-54.1
intake (specify)
Excessive vitamin NI-54.2
intake (specify)
A C
Thiamin D
Riboflavin E
Niacin K
Folate Other _______
Mineral (55)
Inadequate mineral intake NI-55.1
(specify)
Calcium Iron
Potassium Zinc
Other _______________
Excessive mineral intake NI-55.2
(specify)
Calcium Iron
Potassium Zinc
Other _______________
CLINICAL NC
as related to medical or physical conditions
Functional (1)
Defined as change in physical or mechanical
functioning that interferes with or prevents desired
nutritional consequences
Swallowing difficulty NC-1.1
Chewing (masticatory) difficulty NC-1.2
Breastfeeding difficulty NC-1.3
Altered GI function NC-1.4
Biochemical (2)
Defined as change in capacity to metabolize
nutrients as a result of medications, surgery, or as
indicated by altered lab values
Impaired nutrient utilization NC-2.1
Altered nutrition-related NC-2.2
laboratory values (specify) _____________
Food-medication interaction NC-2.3
Weight (3)
Defined as chronic weight or changed weight
status when compared with usual or desired body
weight
Underweight NC-3.1
Involuntary weight loss NC-3.2
Overweight/obesity NC-3.3
Involuntary weight gain NC-3.4
BEHAVIORAL-
ENVIRONMENTAL NB
as related to knowledge, attitudes/beliefs, physical
environment, or food supply and safety
Knowledge and Beliefs (1)
Defined as actual knowledge and beliefs as
reported or documented
Food, nutrition, and NB-1.1
nutrition-related knowledge deficit
Harmful beliefs/attitudes NB-1.2
about food or nutrition-
related topics (use with caution)
Not ready for diet/ NB-1.3
lifestyle change
Self-monitoring deficit NB-1.4
Disordered eating pattern NB-1.5
Limited adherence to nutrition- NB-1.6
related recommendations
Undesirable food choices NB-1.7
Physical Activity
and Function (2)
Defined as actual physical activity, self-care, and
quality of life problems as reported, observed, or
documented
Physical inactivity NB-2.1
Excessive exercise NB-2.2
Inability or lack of desire NB-2.3
to manage self-care
Impaired ability to NB-2.4
prepare foods/meals
Poor nutrition quality of life NB-2.5
Self-feeding difficulty NB-2.6
Food Safety and Access (3)
Defined as actual problems with food access or
food safety
Intake of unsafe food NB-3.1
Limited access to food NB-3.2
NUTRITION DIAGNOSTIC TERMINOLOGY
#1 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms _____________________________________________________________________________________________________
#2 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms _____________________________________________________________________________________________________
#3 Problem ____________________________________________________________________________________________________________
Etiology ____________________________________________________________________________________________________________
Signs/Symptoms ___________________________________________________________________________________________
Date Identified Date Resolved
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SUBJECT: NUTRITION CONTROLLED VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
SUBJECT: NUTRITION CONTROLLED
VOCABULARY/TERMINOLOGY
MAINTENANCE/REVIEW
AMERICAN DIETETIC
ASSOCIATION
120 South Riverside Plaza Suite 2000
CHICAGO, ILLINOIS 60606-6995
Effective Date: April 2005
Revision Date: June 2006
Review Date:
PURPOSE:
This policy establishes the has established the process followed by the Nutrition Care
Process/Standardized Language (NCP/SL) Committee to maintain a current Nutrition Care
Process and list of nutrition controlled vocabulary terminology that document the Nutrition Care
Process.
STRUCTURE:
The NCP/SL Committee is a joint House of Delegates and Board of Directors Committee and
provides semi-annual reports to both bodies.
PROCEDURES:
The NCP/SL Committee accepts proposals for modification or additions to the Nutrition
Diagnostic Terminology as follows:
1. Any individual ADA member or Dietetic Practice Group can submit proposals for
modification or additions by completing the attached two documents:
a. Proposed Nutrition Diagnostic Terminology Modification/Addition letter
b. Reference worksheet for proposed modification/addition
2. The NCP/SL will review the submissions at their routine face-to-face meetings or
teleconferences to establish the following:
a. Is the term already represented by an existing term?
i. If so the new term can be added as a synonym for the existing term or
replace the existing term.
ii. If not, then the term can be considered for addition to the list of terms as
long as it meets the need for describing elements of dietetic practice in the
context of the nutrition care process.
b. Does the term overlap with an existing term, but add new elements?
i. If yes, then the existing term can be modified to include the new elements
or the proposed term can be clarified to be distinctly different from the
existing term through a dialogue with the proposal submitter.
ii. If no, then consider adding new term.
c. Is the term distinct and separate from all existing terms?
i. If yes, then ensure that the term is in the context of dietetic practice within
the Nutrition Care Process and consider adding to list of terms.
ii. If no, then work with proposal submitter to discuss how to integrate into
existing terms or create a separate term.
3. The NCP/SL Committee will prepare a summary of comments and one representative of
the NCP/SL will confer with the proposal submitter after the initial discussion to answer
Edition: 2006 154
MAINTENANCE/REVIEW
questions and discuss the initial input from the NCP/SL Committee. If the proposal
submitter is not satisfied with the direction proposed by the NCP/SL Committee, then
they will be invited to submit additional documentation and have time on the next
teleconference/meeting agenda to personally present their concerns.
4. Changes or modifications accepted by the NCP/SL Committeewill be integrated into the
list that is re-published on an annual basis.
STAFFING:
Governance and Scientific Affairs and Research provide staff support to NCP/SL Committee and
for Research Committee functions.
Attachments
1. Letter template for proposing a New Term for Nutrition Diagnostic Terminology
2. Letter template for proposing Modifications to Nutrition Diagnostic Terminology
3. Template for Reference Sheet to support additions/modifications to Nutrition
Diagnostic Terminology
4. Completed Reference Sheet Example (Case with PES statement not included)
Edition: 2006 155
MAINTENANCE/REVIEW
Attachment 1: Letter Template for Proposing a New Term for Nutrition Diagnostic
Terminology
Date: _____________
To: NCP/SL Committee
Scientific Affairs and Research
American Dietetic Association
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
emyers@eatright.org; cchanner@eatright.org
Subject: Proposed Addition to Nutrition Diagnostic Terminology
(I/We) would like to propose a new term, _____________________(Proposed term to add to
the Nutrition Diagnostic Terminology list). The reason I/we believe that this term should be
added is as follows (insert concise rationale for change and may include brief example of
when the situation arose that the current term was inadequately defined):
1. (Insert first statement of rationale.)
2. (Insert second statement of rationale, if applicable.)
3. (Insert example of situation where this modification was needed.)
Other terms that are similar and explanations of why they do not exactly match our new
proposed term are as follows:
1. (Insert number and name.) (Insert 2-3 sentences to illustrate why the existing term
does not meet your need.)
2. (Insert number and name.) (Insert 2-3 sentences to illustrate why the existing term
does not meet your need.)
3. (Add as many as applicable.)
Attached is the a reference sheet that includes the label, description, proposed domain and
category, examples of etiologies and signs and symptoms and a case that illustrates when this
term would be used and the corresponding PES statement that would be used in medical
record documentation.
The point of contact for this proposal is ___________________________________ (insert
name), who can be reached at ______(best contact telephone number) and _______(e-mail
address).
Thank you for considering our request.
Signature block
(Organizational unit if applicable)
Attachments: (1) Completed Reference Sheet Template (Case and PES statement example not
included)
Edition: 2006 156
MAINTENANCE/REVIEW
Attachment 2: Letter Template for Proposing Modifications to Nutrition Diagnostic
Terminology
Date: ____________________
To: NCP/SL Committee
American Dietetic Association
emyers@eatright.org; cchanner@eatright.org
Subject: Proposed Modification to Existing Nutrition Diagnostic Terminology
(I/We) would like to propose a modification or the term, _____________________(insert
Number and Name from current Nutrition Diagnostic Terminology list). The reason I/we
believe that this term should be modified is as follows (insert concise rationale for change
and may include brief example of when the situation arose that the current term was
inadequately defined):
1. (Insert first statement of rationale.)
2. (Insert second statement of rationale, if applicable.)
3. (Insert example of situation where this modification was needed.)
Attached is the revised reference sheet which shows the changes highlighted or bolded for
your consideration.
The point of contact for this proposal is ___________________________________ (insert
name), who can be reached at ______(best contact telephone number) and _______(e-mail
address).
Thank you for considering our request.
Signature block
(Organizational unit if applicable)
Attachments: (1) Completed Reference Sheet Template
Edition: 2006 157
MAINTENANCE/REVIEW
Attachment 3: Template for Reference Sheet for New Term or Proposing Modifications
Select DOMAIN: CLINICAL/FUNCTIONAL or BEHAVIORAL/ENVIRONMENTAL
Select Category, e.g., Functional Balance
Nutrition Diagnostic Label (Leave number blank, if new term.)
Insert a 1-4 word label.
Definition of Nutrition Diagnostic Label
Insert 1 sentence or bullet that describes the intent of the new or modified label.
Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:
Insert common etiologies for Nutrition Diagnostic Label
Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms
gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem
and describe its severity.
Category
Potential Indicators of this Nutrition Diagnosis (one or more
must be present)
Biochemical Data (Insert as appropriate.)
Anthropometric Measurements (Insert as appropriate.)
Physical Exam Findings (Insert as appropriate.)
Food/Nutrition History (Insert as appropriate.)
Client History (Insert as appropriate.)
Edition: 2006 158
MAINTENANCE/REVIEW
Attachment 4: Template for Completed Reference Sheet
DOMAIN: CLINICAL/FUNCTIONAL
Category: Functional Balance
Nutrition Diagnostic Label (NC-1.1.)
Swallowing difficulty.
Definition of Nutrition Diagnostic Label
Impaired movement of food and liquid from the mouth to the stomach.
Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the existence of or the maintenance of
pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:
Mechanical causes such as inflammation; surgery; stricture; or oral, pharyngeal and esophageal
tumors
Motor causes, e.g., neurological or muscular disorders such as cerebral palsy, stroke, multiple
sclerosis, scleroderma, or prematurity
Signs/Symptoms (Defining Characteristics) A typical cluster of subjective and objective signs and symptoms
gathered during the nutrition assessment process that provide evidence that a problem exists; quantify the problem
and describe its severity.
Category
Potential Indicators of this Nutrition Diagnosis (one or more
must be present)
Biochemical Data
Anthropometric Measurements
Physical Exam Findings Evidence of dehydration, e.g., dry mucous membranes, poor skin
turgor
Food/Nutrition History Observations or reports of:
Coughing, choking, prolonged chewing, pouching of food,
regurgitation, facial expression changes during eating, prolonged
feeding time, drooling, noisy wet upper airway sounds, feeling of
food getting stuck, pain while swallowing
Decreased food intake
Avoidance of foods
Mealtime resistance
Client History Conditions associated with a diagnosis or treatment of dysphagia,
achalasia
Radiological findings, e.g., abnormal swallowing studies
Repeated upper respiratory infections and/or pneumonia
Edition: 2006 159
2003-2005 Standardized Language Task Force and Terminology Expert Reviewers
Edition: 2006 160
Standardized Language Task Force
Chair
Sylvia Escott-Stump, MA, RD, LDN
Dietetic Programs Director
East Carolina University
155 Rivers Building, Dept. NUHM
Greenville, NC 27858
Task Force Member 2003-2005
Peter Beyer, MS, RD, LD
Associate Professor
University of Kansas Medical Center
7315 Rosewood Drive
Prairie Village, KS 66208-2458
Christina Biesemeier MS, RD, LDN, FADA
313 Logans Circle
Franklin TN 37067-1363
Pam Charney, MS, RD, CNSD
2460 64
th
Ave SE
Mercer Island, WA 98040
Marion Franz, MS, RD, CDE
6635 Limerick Dr.
Minneapolis, MN 55439-1260
Karen Lacey, MS, RD, CD
500 Saint Marys Blvd
Green Bay, WI 54301-2610
Kathleen Niedert, MBA, RD, LD, FADA
PO Box 843
110 Ardis Street
Hudson, IA 50643-0843
Mary Jane Oakland, PhD, RD, LD, FADA
1612 Truman Drive
Ames, IA 50010-4344
Patricia Splett, PhD, MPH, RD
Splett & Associates
3219 Midland Avenue
St. Paul, MN 55110
Frances Tyus, MS, RD, LD
19412 Mayfair Ln
Cleveland, OH 44128-2727
Naomi Trostler, PhD, RD
Institute of Biochemistry, Food Science, and
Nutrition
Faculty of Agriculture, Food and Environmental
Quality Sciences
The Hebrew University of Jerusalem
PO Box 12
Rehovot 76100, Israel
Robin Leonhardt, RD
1905 North 24
th
Street
Sheboygan, WI 53081-2124
Attended Face to Face Meeting in Summer
2003
Staff Liaisons
Esther Myers, PhD, RD, FADA
Director of Scientific Affairs and Research
ADA Headquarters
Work (312) 899-4860
Fax (312) 899-4757
E-mail: emyers@eatright.org
Ellen Pritchett, RD, CPHQ
Director, Quality and Outcomes
ADA Headquarters
Work (312) 899-4823
Fax (312) 899-4757
E-mail: epritchett@eatright.org
Staff Liaison 2003-2005
Lt Col Vivian Hutson, MA, MHA, RD, LD,
Fellow,
American College of Healthcare Executives
Staff Liaison 2003-2004
Consultants
Donna G. Pertel, MEd, RD
5 Bonny Lane
Clinton, CT 06413
Splett & Associates
3219 Midland Avenue
St. Paul, MN 55110
Melinda L. Jenkins, Ph.D., FNP
Assistant Professor of Clinical Nursing
Columbia University School of Nursing
630 W. 168 St., mail code 6
New York, NY 10032
Annalynn Skipper, MS, RD, FADA
P.O. Box 45
Oak Park, IL 60303
Edition: 2006 161
(Cornell)
Increased energy expenditure (when
part of hypermetabolism)
NI-1.2 Jonathan Waitman, MD for Louis Arrone, MD
(Cornell)
Hypometabolism NI-1.3 Edith Lerner, PhD (Case Western Reserve University)
Inadequate energy intake NI-1.4 Joel Mason, MD (Tufts)
Excessive energy intake NI-1.5 Jim Hill, MD (University of Colorado)
INTAKE DOMAIN Oral or Nutrition Support Intake
Inadequate oral food/beverage intake NI-2.1 Anne Voss, PhD, RD (Ross Labs)
Excessive oral food/beverage intake NI-2.2 Jessica Krenkel, MS, RD (University of Nevada)
Inadequate intake from
NI-2.3 Kenneth Kudsk, MD (University of Wisconsin)
Excessive intake from
NI-2.4 Annalynn Skipper, MS, RD (University of Nebraska
Lincoln)
Inappropriate infusion of
NI-2.5 Annalynn Skipper, MS, RD (University of Nebraska-
Lincoln)
INTAKE DOMAIN Fluid Intake Balance
Inadequate fluid intake NI-3.1 Ann Grandjean, EdD, RD (International Center for
Sports Nutrition)
Excessive fluid intake NI-3.2 Joel Kopple, MD (UCLA)
INTAKE DOMAIN Bioactive Substances Intake Balance
Inadequate bioactive substance intake NI-4.1 Johanna Lappe, PhD, RN (Creighton)
Excess bioactive substance NI-4.2 Elizabeth Jeffery, PhD (Univ. of IL, Champaign)
Excessive alcohol intake NI-4.3 Janice Harris, PhD, RD (University of Kansas)
INTAKE DOMAIN Nutrient Intake Balance
Increased nutrient needs (specify) NI-5.1 Carol Braunschweig, PhD, RD (University of Illinois,
Chicago)
Evident protein-energy malnutrition NI-5.2 Charlette R. Gallagher Allred, PhD, RD (Retired-Ross
Labs)
Inadequate protein energy intake NI-5.3 Trisha Fuhrman, MS, RD, FADA, CNSD (Coram, Inc.)
Decreased nutrient needs (specify) NI-5.4 Jeannmarie Beiseigel, PhD, RD (USDA)
Imbalance of nutrients NI-5.5 Molly Kretsch, PhD, RD (USDA)
INTAKE DOMAIN Nutrient Balance Fat and Cholesterol Balance
Inadequate fat intake NI-51.1 Alice Lichtenstein, DSc (Tufts)
Excessive fat intake NI-51.2 Wendy Mueller Cunnigham, PhD, RD (Cal State)
Inappropriate intake of food fats NI-51.3 Nancy Lewis, PhD, RD (University of Nebraska-
Lincoln)
INTAKE DOMAIN Nutrient Balance Protein Balance
Inadequate protein intake NI-52.1 Don Layman, PhD (University of Illinois-Champaign)
Excessive or unbalanced protein intake NI-52.2 Linda A. Vaughan, PhD, RD (Arizona State)
Inappropriate intake of amino acids NI-52.3 Allison Yates, PhD, RD (Industry, formerly Director of
the IOM Food and Nutrition Board)
INTAKE DOMAIN Nutrient Balance Carbohydrate Balance
Inadequate carbohydrate intake NI-53.1 Robert Wolfe, PhD (University of Texas Medical
Branch)
Excessive carbohydrate intake NI-53.2 Anne Daly, MS, RD
Inappropriate intake of types of
carbohydrate
NI-53.3 Lyn Wheeler, MS, RD, CD, FADA, CDE (Indiana
University School of Medicine)
Inconsistent intake of carbohydrate NI-53.4 Maggie Powers, MS, RD, CDE (International Diabetes
Center)
Inadequate fiber intake NI-53.5 Joanne Slavin, PhD, RD (University of Minnesota)
Excess fiber intake NI-53.6 Judith Marlett, PhD, RD (University of Wisconsin)
INTAKE DOMAIN Nutrient Balance Vitamin Balance
Inadequate vitamin intake (specify) NI-54.1 Laurie A. Kruzich, MS, RD (Iowa State)
Kristina Penniston, PhD, RD (University of Wisconsin)
Edition: 2006 163
Expert Reviewers
Nutrition Diagnosis Labels
Nutrition Diagnostic Label Dx Label # Reviewers
CLINICAL DOMAIN Functional Balance
Swallowing difficulty NC-1.1 Moshe Shike, MD (Memorial Sloan Kettering)
Chewing (masticatory) difficulty NC-1.2 Helen Smiciklas-Wright, PhD, RD (Penn State)
Riva Touger-Decker, PhD, RD (UMDNJ)
Breastfeeding difficulty NC-1.3 Maureen A. Murtaugh, PhD, RD (University of Utah)
Altered GI function NC-1.4 Larry Cheskin, MD (Johns Hopkins)
CLINICAL DOMAIN Biochemical Balance
Impaired nutrient utilization NC-2.1 Laura Matarese, MS, RD, CNSD (Cleveland Clinic)
Altered nutrition-related laboratory
values
NC-2.2 Denise Baird Schwartz, MS, RD, CNSD (Clinical
practice)
Food-medication interaction NC-2.3 Andrea Hutchins, PhD, RD (Arizona State University
East, Mesa, AZ)
CLINICAL DOMAIN Weight Balance
Underweight NC-3.1 Bonnie Spear, PhD, RD (University of Alabama,
Birmingham)
Involuntary weight loss NC-3.2 Jody Vogelzang, MS, RD, LD, CD, FADA (Texas
Womens University)
Overweight/obesity NC-3.3 Rebecca Mullis, PhD, RD (Georgia)
Involuntary weight gain NC-3.4 Celia Hayes, MS, RD (HRSA)
BEHAVIORAL-ENVIRONMENTAL DOMAIN Knowledge and Beliefs
Food- and nutrition-related knowledge
deficit
NB-1.1 Penny Kris-Etherton, PhD, RD (Penn State)
Harmful beliefs/attitudes about food,
nutrition, and nutrition-related topics
NB-1.2 Keith-Thomas Ayoob, PhD, RD (Albert Einstein)
Not ready for diet/lifestyle change NB-1.3 Geoffrey Greene, PhD, RD (University of Rhode
Island)
Self-monitoring deficit NB-1.4 Linda Delahanty, MS, RD (Harvard)
Disordered eating pattern NB-1.5 Eileen Stellefson Myers, PhD, RD (Private practice)
Leah Graves, MS, RD (Saint Francis Hospital, Tulsa,
OK)
Limited adherence to nutrition-related
recommendations
NB-1.6 Ellen Parham, PhD, RD (Northern IL)
Undesirable food choices NB-1.7 Kathy Cobb, MS, RD (Centers for Disease Control)
BEHAVIORAL-ENVIRONMENTAL DOMAIN Physical Activity Balance and Function
Physical inactivity NB-2.1 Melinda Manore, PhD, RD (Oregon State)
Excessive exercise NB-2.2 Katherine Beals, PhD, RD (Industry, formerly Ball
State)
Inability to manage self-care NB-2.3 Emily Gier, MS, RD (Cornell)
Impaired ability to prepare foods/meals NB-2.4 Marla Reicks, PhD, RD (U of MN)
Poor nutrition quality of life NB-2.5 Elvira Johnson, MS, RD (Private practice)
Self-feeding difficulty NB-2.6 Mary Cluskey, PhD, RD (Oregon State)
BEHAVIORAL-ENVIRONMENTAL DOMAIN Food Safety and Access
Intake of unsafe food NB-3.1 Johanna Dwyer, DSc, RD (Tufts)
Limited access to food NB-3.2 Sondra King, PhD, RD (Northern Illinois University)
INTAKE DOMAIN Caloric Energy Balance
Hypermetabolism NI-1.1 Jonathan Waitman, MD for Louis Arrone, MD
Edition: 2006 162
Excess vitamin intake (specify) NI-54.2 Kristina Penniston, PhD, RD (University of Wisconsin)
INTAKE DOMAIN Nutrient Balance Mineral Balance
Inadequate mineral intake (specify) NI-55.1 Bob Heaney, MD (Creighton)
Excessive mineral intake (specify) NI-55.2 Joan Fischer, PhD, RD (University of Georgia)
Edition: 2006 164
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from the association
Implementing Nutrition Diagnosis, Step Two in the
Nutrition Care Process and Model: Challenges and
Lessons Learned in Two Health Care Facilities
Jennifer Mathieu; Mandy Foust, RD; Patricia Ouellette, RD
I
n adherence to the American Die-
tetic Associations (ADA) Strategic
Plan goal of establishing and im-
plementing a standardized Nutrition
Care Process (NCP) in the hopes of
increasing demand and utilization of
services provided by members (1), di-
etetics professionals in two health
care facilities established an NCP pi-
lot program in 2005, in collaboration
with ADA. The pilot sites were the
Virginia Hospital Center in Arlington
and the Veterans Affairs Medical
Center in San Diego, CA.
This article gives a background on
the NCP and model, the standardized
language used in the nutrition diag-
nosis step, medical record documen-
tation, and an explanation of how the
two sites came to participate in the
pilot program. It also provides a time-
line for each sites implementation of
the NCP, including challenges faced
and lessons learned. Similarities and
differences in approaches will also be
discussed. Managers from both facili-
ties will offer advice to facilities who
are contemplating implementation of
the NCP and nutrition diagnoses in
the future.
BACKGROUND
ADA developed a four-step NCP and
Model that appeared in the August
2003 issue of the Journal. The NCP
consists of four distinct but interre-
lated and connected stepsNutri-
tion Assessment, Nutrition Diagno-
sis, Nutrition Intervention, and
Nutrition Monitoring and Evaluation
(2). The NCP and Model were devel-
oped by the Quality Management
Committee Work Group with input
from the House of Delegates.
This new model calls for dietetics
professionals to incorporate a new
stepmaking a nutrition diagnosis
which involves working with dened
terminology. It also asks dietetics
professionals to chart their diagnosis
in the form of a statement that estab-
lishes the patients problem (diagnos-
tic label), etiology (cause/contributing
risk factors), and signs and symptoms
(dening characteristics). This is
known as a PESS statement, and
makes up the heart of the NCPs sec-
ond stepnutrition diagnosis.
The second step is the culture
shift, says Susan Ramsey, MS, RD,
CDE, LDN, senior manager of medi-
cal nutrition services for Sodexho who
also serves on ADAs Research Com-
mittee. The second step forces us to
make a one-line statement. It brings
the whole assessment into one clear
vision.
According to the article by Lacey
and Pritchett, using the new model
provides many benets. The model
denes a common language that al-
lows nutrition practice to be more
measurable, creates a format that en-
ables the process to generate quanti-
tative and qualitative data that can
then be analyzed and interpreted,
serves as the structure to validate nu-
trition care, and shows how the care
that was provided does what it in-
tends to do (2). It also gives the pro-
fession a greater sense of autonomy,
says Ramsey. Its given us responsi-
bility for our work instead of looking
for permission from others.
The nutrition diagnostic labels and
reference sheets were developed by
the Standardized Language Task
Force, chaired by Sylvia Escott-
Stump, MA, RD, LDN. It is from this
list that dietetics professionals utiliz-
ing the NCP list the P (problem) part
of their PESS statement. According to
Escott-Stump, this Standardized
Language will help bring dietetics
professionals a new focus and the
ability to target their interventions
into more effective results that will
match the patient nutrition diagnosis
(problem).
It is Escott-Stumps belief that doc-
umenting nutrition diagnoses, inter-
ventions, and outcomes will allow for
dietetics professionals to better track
diagnoses over several clients, allow-
ing the profession to be more likely to
track the types of nutrition diagnoses
that clients have, and be able to state
that the profession affects certain
types of acute and chronic diseases
more than others.
For example, now we believe that
our impact on cardiovascular, endo-
crine, and renal diseases is strong,
but we may nd that our profession-
als impact gastrointestinal disorders
the most, says Escott-Stump. By
having standardized language, we
will be able to validate or correct our
suspicions.
This pilot implementation of the
nutrition care model also tested a new
method of charting that differs from
the traditional Subjective Objective
Assessment Plan format (SOAP). The
new ADI template stands for Assess-
ment, Diagnosis, and Intervention
(including Monitoring and Evalua-
tion).
According to Dr Esther Myers,
J. Mathieu is xxx, Houston, TX.
M. Foust is xxx. P. Ouellette is
xxx.
Address correspondence to: Jen-
nifer Mathieu, 5639 Berry Creek
Dr, Houston, TX 77017. E-mail:
jenmathieu27@yahoo.com
0002-8223/05/xx0x-0000$30.00/0
doi: 10.1016/j.jada.2005.07.015
2005 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 1
Edition: 2006 165
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PhD, RD, FADA, ADAs Research and
Scientic Affairs director, ADA plans
to expand these two pilot tests
through the Peer Network for Nutri-
tion Diagnosis in the next 2 years.
This group of dietetics professionals
will receive additional training and
networking opportunities to assist
them as they implement this new
model within their facility and then
share their knowledge with other di-
etetics professionals in their geo-
graphical region.
Their experience will be used to de-
termine what additional implementa-
tion tools are needed. In addition, a
formal research project will be con-
ducted through the Dietetics Practice
Based Research Network in early
2006.
IMPLEMENTATION OF THE PROGRAM
Virginia Hospital Center
Mandy Foust, RD and Clinical Nutri-
tion Manager of the Virginia Hospital
Center, is contracted through So-
dexho to oversee patient services at
the 400-bed facility. In December
2004, Foust, who had learned about
PESS statements while in school, de-
cided to have her college dietetic in-
tern Anne Avery research current
changes and updates in charting for
dietetics professionals.
Avery spoke with Dr Myers and dis-
cussed the possibility of the Virginia
Hospital Center serving as a pilot site
for the new model. Foust was excited
about the idea for several reasons. To
me, the nutrition care model is a clin-
ically based, concise way of charting
that sets goals and is more standard-
ized with other disciplines, she says.
Until the implementation of the pilot
project, the RDs on staff at the Vir-
ginia Hospital Center used the SOAP
format of charting.
A conference call took place be-
tween Foust, Dr Myers, Avery, and
Averys internship director at Vir-
ginia Tech. Foust selected one of her
ve inpatient registered dietitians
(RDs) to serve as the rst RD to use
the new method. It was decided Avery
would present an in-service on the
nutrition care model to the dietetics
professionals on staff. This in-service
provided the RDs with introductory
information, the four steps of the
NCP, PESS statements, diagnostic
labeling, and why the changes would
be benecial.
Foust says there were concerns
from her staff about the new method.
These included that the new ADI
charting format would not allow them
to be thorough enough and that it
seemed too cookie cutter. Staff also
expressed concern that it would be
difcult to sum up two or more seri-
ous problems in one PESS statement.
They also worried that physicians
would be wary of the term nutrition
diagnosis.
Over several days in mid-Decem-
ber, Foust arranged meetings with
several hospital administrators, in-
cluding the vice president of the hos-
pital, the chief nursing ofcer, the
medical staff president, and the chief
of the nutrition committee to get their
feedback on the pilot project. She also
kept her supervisor at Sodexho
abreast of the situation. Because I
am a contractor, I want to make sure
Im covering my bases, says Foust.
She says the Virginia Hospital Center
is very interdisciplinary and that
she wanted there to be an awareness
of the upcoming changes.
Administrators initially had ques-
tions about how the new method
would benet patients, but Foust says
after she met with them and pre-
sented them with information on the
nutrition care model, they were recep-
tive to the changes. The physician
who served as chief of the hospitals
nutrition committee had concerns
about the idea of a nutrition diagno-
sis. Foust says she reassured him
that the new method did not ask RDs
to make a medical diagnosis or inter-
fere with a physicians orders.
After the nutrition committee ap-
proved the project in early January
2005, Foust was asked to inform sev-
eral other hospital staff members
about the new format, including the
chief of surgery and the chief of sur-
gical education. Because the rst RD
to participate in the pilot project
worked in the intensive care unit
(ICU), Foust was also asked to notify
the medical director of the ICU, two
ICU nurse educators, and the ICU
patient care director via formal let-
ters. Responses to these letters en-
couraged Foust to seek approval for
the project from the hospitals pa-
tient-monitoring committee.
During the end of January while
waiting for a response from the pa-
tient-monitoring committee, Foust
met for about an hour each week with
the RD who would be the rst to use
the new method. The RD used actual
patients from her daily census to be-
gin practicing PESS statements and
ADI charting. Foust shared the re-
sults with Dr Myers and the Stan-
dardized Language Task Force often.
Through early to mid-February the
RD submitted her notes in both the
SOAP format and the new format as a
way of practicing the new method.
At the end of January, the patient-
monitoring committee gave the
project its approval. Before imple-
mentation ofcially occurred, Foust
requested permission and modied
the Hakel-Smith Coding Instrument
as an auditing tool to evaluate the
charts. She also developed a question-
naire for allied health professionals to
give feedback on the new system of
charting.
On February 16, 2005, the ICU RD,
Korinne Umbaugh, ofcially began
submitting all of her notes using the
ADI template. Foust audited two to
three charts each day. In late Febru-
ary, a second RD began using the new
method of charting. On March 28, a
third RD began the process. By the
middle of April, all ve RDs were us-
ing the ADI template, with the fth
RD beginning the process on the sec-
ond week of the month.
Throughout the entire transition
Foust met formally and informally
with staff RDs both individually and
in groups. Foust says at least 20 min-
utes of each weekly hour-long staff
meeting continues to be spent dis-
cussing the new method of charting
and reviewing PESS statements. At
this time Foust is editing about 10%
of the charts.
Unfortunately, Foust did not re-
ceive as many completed question-
naires as she hoped for from allied
health professionals. However, her
initial chart audits showed that by
the end of April the staff had become
much more comfortable with the pro-
cess. Audits revealed notes that
steadily became more direct and con-
cise, as well as more outcome-ori-
ented. Extraneous information was
not included as often.
Veterans Affairs Medical Center, San
Diego
Patricia Ouellette, RD, is the deputy
director of nutrition and food services
for the Veterans Affairs Medical Cen-
2 Month 2005 Volume xx Number x
Edition: 2006 166
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ter in San Diego, CA. The Medical
Center is a 238-bed facility. There are
three RDs who focus on the inpatient
areas of the facility.
In January 2004, the facilitys di-
rector of nutrition and food service,
Ginger Hughes, MS, RD, distributed
the August 2003 article by Karen
Lacey, MS, RD and Ellen Pritchett,
RD, about the NCP that appeared in
the Journal. The staff was advised to
read the article and become familiar
with it. In the fall of 2004, internship
program director Tere Bush-Zurn and
outpatient dietitian Teresa Hilleary
received a scholarship to attend the
Nutrition Diagnosis Roundtable for
Educators workshop at the ADAs
2004 Food and Nutrition Conference
and Exhibition. Bush-Zurn and Hill-
eary relayed what they learned with
the rest of their staff when they re-
turned to California.
In November 2004, a staff meeting
is held to discuss questions and con-
cerns surrounding the NCP and
PESS statements. The staff agreed to
start using the PESS statements as
soon as possible. After a December
2004 workshop presented by a visit-
ing Lacey, the staff agreed that they
wanted to work toward transitioning
to the nutrition care model and would
serve as a pilot site.
It evolved after a year of looking at
the process and after a lot of discus-
sions with the staff, says Ouellette.
We are a teaching institution and we
wanted to challenge ourselves in
terms of our practice. We also have a
dietetic internship program and feel
responsible for providing the interns
with the most progressive concepts in
our eld of practice.
As with the Virginia Hospital Cen-
ter RDs, the RDs at the VA had been
using the SOAP format for many
years and they had similar concerns
over whether the new method would
be deemed thorough enough. They
were also concerned that one PESS
statement would not be enough if the
patient had several complicated prob-
lems.
Based on staff consensus, in Febru-
ary 2005 the staff started devoting
time at the weekly staff meeting to
discussing issues related to the new
method. The staff practiced writing
PESS statements and shared the re-
sults with each other during this
time. They also discussed questions
and concerns related to the new
method.
At the same time, several staff
members, including the staffs perfor-
mance improvement/information tech-
nology dietitian, worked separately to
develop a point-and-click computer
version of the inpatient initial nutri-
tion assessment ADI template that
could be used by the inpatient RDs on
staff when writing their notes.
During the last week in March, the
inpatient RDs spent 1 week writing
their notes using both the old SOAP
method and the new template. On
April 4, the staff ofcially imple-
mented the new version of charting
for the inpatient initial nutrition as-
sessments and stopped using the
SOAP method completely. For the
rst month after the ofcial imple-
mentation, Ouellette checked every
inpatient initial nutrition assessment
chart note and provided weekly feed-
back to the staff.
In May, the auditing components
were incorporated into the NFS Peri-
odic Performance Review plan imple-
mented as part of the Joint Commis-
sion on Accreditation of Healthcare
Organizations continuous readiness
philosophy. Although not required,
they believed this was a good way to
continue to audit and document the
process.
Ouellette continued to meet with
RDs individually as problems and
questions developed about the
change. Her initial audits revealed
that the majority of the staff uses the
same ve to six diagnostic labels. She
also assessed that after 2 weeks of
using the new ADI template exclu-
sively, PESS statements markedly
improved and chart notes became
more focused and concise. After 3
weeks the amount of time spent on
the notes shortened, suggesting that
the staff was becoming more comfort-
able with the process.
In regard to diagnostic labels, Ouel-
lettes staff began the practice of uti-
lizing two diagnostic labels and com-
bining them into one PESS statement
if the two conditions were closely re-
lated (eg, difculty swallowing and
chewing difculty).
The monitoring component of the
process still needs to be observed
carefully, as many of Ouellettes staff
members are not yet in the habit of
stating which specic laboratory tests
need to be performed.
SIMILARITIES AND DIFFERENCES
The biggest difference between the
two sites was the time spent seeking
approval for the project before pro-
ceeding. As a contractor, Foust be-
lieved she needed to secure approval
from several different administrators
before beginning implementation.
Ouellettes approval process occurred
much more informally. Ouellette says
this is because the VA allows exibil-
ity in how Nutrition and Food Ser-
vices processes are carried out.
Another difference centered on the
way staff RDs began participating in
the implementation. Ouellettes staff
discussed the process for about a year
before they all began the new method
of charting at the same time. Ouel-
lette and her staff wanted to work
with only one inpatient charting tem-
plate at a time, and this allowed them
to do so. Also, Ouellette believed that
if the SOAP method template was
available, RDs might be tempted to go
back to the old format that they felt
most comfortable using.
After the staff in-service, Foust
started one of her RDs on the new
method and others followed over a pe-
riod of months. As the implementa-
tion was occurring, the staff had sev-
eral meetings to discuss the new
changes. Foust believed this gradual
method of implementation allowed
time for RDs who were having trouble
with the new method to learn from
RDs who were actively working with
it.
The similarities between both sites
included the increased amount of ad-
ministrative time spent on the change
(especially at the manager level) as
well as the decision to focus the
change to inpatient areas only. Foust
and Ouellette both said this decision
was made because inpatient cases
tend to be more complex, and if these
cases could be dealt with successfully
it would be even easier to make the
transition with outpatient cases. The
sites shared another similarity in
that the types of concerns held by the
staffs were nearly identical, as were
the challenges they faced and the les-
sons they learned.
CHALLENGES AND LESSONS LEARNED
According to Foust and Ouellette, the
biggest challenge for both sites was
assisting their RDs in completely
changing the way they think about
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their chart notes. Its a brand new
language, says Foust. My RDs are
already seeing 14, 16 patients a day,
and its a long process when youre
starting something new.
Both managers say their RDs had a
hard time excluding extraneous lan-
guage. In the SOAP format, for exam-
ple, RDs were used to including infor-
mation about everything from
decades-old surgeries, the patients
general mood, and other aspects of
the patients condition that are not
relevant to a nutrition diagnosis.
With the nutrition care model, the
charting must be much more exact.
This new method requires us to focus
on establishing a nutrition label and
forces us to restrict our charting to
what is relevant to that nutritional
diagnosis, says Ouellette.
Also challenging for the RDs was
the creation of the PESS statements.
They initially roadblock with the
PESS, says Foust. It is a completely
different way of formatting your
thoughts. Its moving from a very con-
versational way of charting to a more
clinical-sounding, concise note. This
results in a struggle when rst chart-
ing.
Staff members at both sites had
concerns over what to do when there
seemed to be two separate but equally
important problems. After discus-
sions with Dr Myers, it was decided
that, on occasion, two PESS state-
ments can be used.
Ouellette adds that another chal-
lenge comes from the fact that the
nutrition care model means a differ-
ent way of approaching formatting
the chart note. The chart note really
has to be decided after determining
the PESS statement, says Ouellette.
The statement can only be deter-
mined after a thorough nutritional
assessment. The chart review and pa-
tient consultation method are the
same, but the structuring of the chart
note is quite different. We no longer
do this in a linear fashion. We start
from the middle with the PESS state-
ment and complete both endsas-
sessment and goalsfrom there.
RDs also struggled with how to
write PESS statements for patients
that simply had no nutrition risk.
Foust says she urged her staff to rec-
ognize that if they were experts in
making a nutrition diagnosis, they
could say that at certain times there
is no nutrition diagnosis. Ouellette
adds that it might be a good idea to
create a category of potential diag-
nostic labels that could be used for
patients who are basically stable with
tube feedings or dialysis, but who still
need to be monitored.
While the PESS statement proved
to be the most difcult hurdle, RDs
also had to learn to be more specic
when it came time to express how
they would monitor and evaluate
their patients. It wasnt enough to
write monitor labs, says Foust. You
need to give specic labs and then
follow with an explanation and ex-
pected outcomes.
For managers, keeping morale of
staff up was a challenge. This was
especially true for RDs who spoke of
feeling stied by the new method and
who constantly feared they were
making a mistake. Managers learned
they needed to spend extra time en-
couraging their RDs and reminding
them that they were working on a
cutting-edge project.
All of my RDs are competent and
brilliant, says Foust. Changing the
way they chart and implementing
new techniques can cause doubt. This
can potentially alter their clinical self
condence, and you want to maintain
a positive outlook to avoid this.
Both Foust and Ouellette say it was
benecial to work in groups on PESS
statements and learn from each
other, being sure to highlight well-
written charts as well as the ones that
that needed attention. Foust and
Ouellette also learned that not every
RD would learn at the same pace.
While RDs who had been in the pro-
fession for a shorter amount of time
were often able to grasp the concept
faster, Ouellette adds that, in gen-
eral, the RDs who had the easiest
time were the ones with personality
types that adjusted well to change,
regardless of experience level.
ADVICE TO SITES READY FOR
IMPLEMENTATION
Both Foust and Ouellette offer simi-
lar advice to sites seeking to imple-
ment the NCP and model. Both sug-
gest an in-service for the staff and the
distribution of materials well ahead
of implementation. Ouellette also
suggests providing training from a
knowledgeable source, as was the
case with Karen Lacey speaking to
her staff using ADA slides describing
the NCP.
Both managers suggest setting
aside a generous portion of the weekly
staff meeting time to discuss the
model, review PESS statements, an-
swer questions, and motivate the
staff with positive feedback.
While Foust and Ouellette had dif-
ferent experiences in terms of seeking
approval from the administration to
implement the program, both suggest
allowing time to meet with the neces-
sary people in the facility, as the ap-
proval needed will differ from facility
to facility.
Most of all, Ouellette and Foust
suggest that future managers and
staffs remind themselves that transi-
tioning to the nutrition care model is
a benecial but time-consuming pro-
cess that requires patience. Both say
they have seen marked improve-
ments among their staff over time,
and many of the initial challenges
have been overcome with patience
and practice.
Youre changing the way youre
thinking, youre changing the way
youre charting, its a huge change,
says Ouellette. There are no short-
cuts you can take. But my staff is
excited about being on the forefront.
Its certainly a worthwhile thing.
Adds Foust, This continues to be
an excellent groundbreaking experi-
ence.
The authors would like to acknowl-
edge the contributions of the follow-
ing people in the preparation of this
article: Susan Ramsey, MS, RD, CDE,
LDN, senior manager of medical nu-
trition services for Sodexho who also
serves on ADAs Research Commit-
tee; Sylvia Escott-Stump MA, RD,
LDN, Standardized Language Task
Force Chair; and Esther Myers, PhD,
RD, FADA, ADAs Research and Sci-
entic Affairs director.
References
1. American Dietetic Association
Strategic Plan. Available at:
http://www.eatright.org (mem-
ber-only section). Accessed April
17, 2005.
2. Lacey K, Pritchett E. Nutrition
Care Process and Model: ADA
adopts road map to quality care
and outcomes management. J Am
Diet Assoc. 2003;103:1061-1072.
Edition: 2006 168
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TIMELINES OF IMPLEMENTATION
Virginia Hospital Center
December 2004
Idea of participating in pilot project presented to facil-
ity.
Staff in-service held to educate staff about the NCP,
ADI charting, and PESS statements.
Meetings between clinical nutrition manager and hos-
pital administrators to discuss the NCP and seek ap-
proval for participation in the pilot project.
January 2005
Hospital nutrition committee approves the pilot
project.
Other hospital administrators, including those on the
unit where the rst RD to participate in the project
works, are informed of the pilot project.
The hospitals patient-monitoring committee approves
the pilot project.
Throughout the month of January, the rst RD to take
part in the project meets regularly with clinical nutri-
tion manager to practice ADI charting and PESS state-
ments.
Clinical nutrition manager obtains permission and
modies the Hakel-Smith Coding Instrument as a way
of auditing charts.
February 2005
Fromearly to mid-February, the rst RDto participate
in the project charts using both the ADI and SOAP
formats before formally transitioning to the ADI
method alone on February 16.
In late February, a second RD begins to exclusively use
the ADI method of charting.
March 2005
By the end of March, a third RDhas transitioned to the
ADI method of charting.
Throughout the entire process, the clinical nutrition
manager meets formally and informally with RDs both
individually and in groups to discuss concerns and
monitor progress.
Throughout the process, at least 20 minutes of each
weekly staff meeting are devoted to reviewing the ADI
method of charting, PESS statements, questions, and
concerns.
April 2005
By the start of April, a fourth RD is exclusively using
the ADI method of charting, with the fth and nal RD
making the transition by mid-April.
The clinical nutrition manager audits 10% of charts.
Veterans Affairs Medical Center, San Diego
January 2004
Director of nutrition and food services distributes jour-
nal articles about the NCP to staff.
October 2004
Two staff members attend the Nutrition Diagnosis
Roundtable for Educators workshop at ADAs Food
and Nutrition Conference and Exhibition and share
what they learn with the rest of the staff upon their
return.
November 2004
A staff meeting is held to discuss questions and con-
cerns surrounding the NCP and PESS statements.
December 2004
ADAs Karen Lacey, Chair of ADAs Quality Manage-
ment Working Group on the NCP, provides the staff
with a workshop on the NCP.
February 2005
The staff begins to devote time during each weekly
staff meeting to practice using the new method and to
share PESS statements.
Several staff members, including the staffs perfor-
mance improvement/information technology dietitian,
develop a point-and-click computer version of the ADI
template for the staff to use.
March 2005
Toward the end of March, the staff spends 1 week
using both the SOAP format and the new ADI tem-
plate to chart notes.
April 2005
On April 4, the staff ofcially implements the new
method of charting exclusively.
The deputy director of nutrition and food service
checks each inpatient initial nutrition assessment
chart note and provides feedback to individuals.
May 2005
Ongoing auditing was accomplished by incorporating
the auditing elements into the periodic performance
review plan implemented to ensure continuous readi-
ness for the Joint Commission on Accreditation of
Healthcare Organizations review.
Month 2005 Journal of the AMERICAN DIETETIC ASSOCIATION 5
Edition: 2006 169
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NUTRITION CARE PROCESS AND MODEL WORK GROUP
Karen Lacey, MS, RD, Chair
Elvira Johnson, MS, RD
Kessey Kieselhorst, MPA, RD
Mary Jane Oakland, PhD, RD, FADA
Carlene Russell, RD, FADA
Patricia Splett, PhD, RD, FADA
Staff Liaisons:
Harold Holler, RD
Esther Myers, PhD, RD, FADA
Ellen Pritchett, RD
Karri Looby, MS, RD
The work group would like to extend a special thank
you to Marion Hammond, MS, and Naomi Trostler, PhD,
RD, for their assistance in development of the NCP and
Model.
STANDARDIZED LANGUAGE TASK FORCE
Sylvia Escott-Stump, MA, RD, LDN, Chair
Peter Beyer, MS, RD, LD
Christina Biesemeier MS, RD, LDN, FADA
Pam Charney, MS, RD, CNSD
Marion Franz, MS, RD, CDE
Karen Lacey, MS, RD, CD
Carrie LePeyre, RD, LDN
Kathleen Niedert, MBA, RD, LD, FADA
Mary Jane Oakland, PhD, RD, LD, FADA
Frances Tyus, MS, RD, LD
The task force would like to extend a special thank you
to Naomi Trostler, PhD, RD, FADA.
Edition: 2006 170
FEEDBACK FORM
We welcome feedback on revisions to this reference for Nutrition Diagnosing. After
evaluating each section, please indicate whether you would recommend that the section should
be included in the next edition. Following this, please identify other questions that you would
like answered in the next version. Finally, any additional materials you would find helpful is
appreciated. Thank you for your time.
Should the following items should be included in the nex
version:
Please
Check ()
YES NO
The Nutrition Care Process: Nutrition Care Process and Model Article
Development of Standardized Language: American Dietetic
Associations Standardized Language Model/Current Status
Introduction to Nutrition Diagnoses/Problems
Nutrition Diagnosis Reference Sheets: Single page list of Nutrition
Diagnostic Terminology
Nutrition Diagnosis Terms and Definitions: Table of Contents for next
document
Nutrition Diagnosis Reference Sheets (128 pages)
Procedure for Nutrition Controlled Vocabulary/Terminology
Maintenance/Review
Camera Ready Pocket Guide
What questions would you like answered in the 2007 version?
What additional materials would be helpful in the 2007 version?
Please remove this form from packet and mail to:
Nutrition Care Process /Standardized Language Committee
American dietetic Association
You can also email this information to: cchanner@eatright.org
Edition: 2006 171
Edition: 2006 172
INTAKE NI
Defned as actual problems related to intake of energy, nutrients, uids, bioactive
substances through oral diet or nutrition support'
Caloric Energy Balance (1)
Defned as actual or estimated changes in energy (kcal)'
Hypermetabolism (Increased energy needs) NI-1.1
Increased energy expenditure NI-1.2
Hypometabolism (Decreased energy needs) NI-1.3
Inadequate energy intake NI-1.4
Excessive energy intake NI-1.5
Oral or Nutrition Support Intake (2)
Defned as actual or estimated food and beverage intake from oral diet or nutrition
support' compared with patient goal'
Inadequate oral food/beverage intake NI-2.1
Excessive oral food/beverage intake NI-2.2
Inadequate intake from NI-2.3
enteral/parenteral nutrition infusion
Excessive intake from NI-2.4
Inappropriate infusion of NI-2.5
enteral/parenteral nutrition (use with caution)
Fluid Intake (3)
Defned as actual or estimated uid intake compared with patient goal'
Inadequate fuid intake NI-3.1
Excessive fuid intake NI-3.2
Bioactive Substances Intake (4)
Defned as actual or observed intake of bioactive substances, including single or
multiple functional food components, ingredients, dietary supplements, alcohol'
Inadequate bioactive substance intake NI-4.1
Excessive bioactive substance intake NI-4.2
Excessive alcohol intake NI-4.3
Nutrient Intake (5)
Defned as actual or estimated intake of specifc nutrient groups or single nutrients
as compared with desired levels'
Increased nutrient needs NI-5.1
(specify) _______________________________________
Evident protein-energy malnutrition NI-5.2
Inadequate protein-energy intake NI-5.3
Decreased nutrient needs NI-5.4
(specify) _______________________________________
Imbalance of nutrients NI-5.5
Fat and Cholesterol (51)
Inadequate fat intake NI-51.1
Excessive fat intake NI-51.2
Inappropriate intake of food fats NI-51.3
(specify) _______________________________________
Protein (52)
Inadequate protein intake NI-52.1
Excessive protein intake NI-52.2
Inappropriate intake of amino acids NI-52.3
(specify) _______________________________________
Carbohydrate and Fiber (53)
Inadequate carbohydrate intake NI-53.1
Excessive carbohydrate intake NI-53.2
Inappropriate intake of types of carbohydrate NI-53.3
(specify) _______________________________________
Inconsistent carbohydrate intake NI-53.4
Inadequate fber intake NI-53.5
Excessive fber intake NI-53.6
V i t a m i n ( 5 4 )
I n a d e q u a t e v i t a m i n i n t a k e ( s p e c i f y ) N I - 5 4 . 1
E x c e s s i v e v i t a m i n i n t a k e ( s p e c i f y ) N I - 5 4 . 2
A C
T h i a m i n D
R i b o f a v i n E
N i a c i n K
F o l a t e O t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M i n e r a l ( 5 5 )
I n a d e q u a t e m i n e r a l i n t a k e ( s p e c i f y ) N I - 5 5 . 1
C a l c i u m I r o n
P o t a s s i u m Z i n c
O t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E x c e s s i v e m i n e r a l i n t a k e ( s p e c i f y ) N I - 5 5 . 2
C a l c i u m I r o n
P o t a s s i u m Z i n c
O t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C L I N I C A L N C
D e f n e d a s n u t r i t i o n a l f n d i n g s / p r o b l e m s i d e n t i f e d a s r e l a t e d t o m e d i c a l o r p h y s i c a l
c o n d i t i o n s '
F u n c t i o n a l ( 1 )
D e f n e d a s c h a n g e i n p h y s i c a l o r m e c h a n i c a l f u n c t i o n i n g t h a t i n t e r f e r e s w i t h o r
p r e v e n t s d e s i r e d n u t r i t i o n a l c o n s e q u e n c e s '
S w a l l o w i n g d i f f c u l t y N C - 1 . 1
C h e w i n g ( m a s t i c a t o r y ) d i f f c u l t y N C - 1 . 2
B r e a s t f e e d i n g d i f f c u l t y N C - 1 . 3
A l t e r e d G I f u n c t i o n N C - 1 . 4
B i o c h e m i c a l ( 2 )
D e f n e d a s c h a n g e i n c a p a c i t y t o m e t a b o l i z e n u t r i e n t s a s a r e s u l t o f m e d i c a t i o n s ,
s u r g e r y , o r a s i n d i c a t e d b y a l t e r e d l a b v a l u e s '
I m p a i r e d n u t r i e n t u t i l i z a t i o n N C - 2 . 1
A l t e r e d n u t r i t i o n - r e l a t e d l a b o r a t o r y v a l u e s N C - 2 . 2
( s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
F o o d - m e d i c a t i o n i n t e r a c t i o n N C - 2 . 3
W e i g h t ( 3 )
D e f n e d a s c h r o n i c w e i g h t o r c h a n g e d w e i g h t s t a t u s w h e n c o m p a r e d w i t h u s u a l o r
d e s i r e d b o d y w e i g h t '
U n d e r w e i g h t N C - 3 . 1
I n v o l u n t a r y w e i g h t l o s s N C - 3 . 2
O v e r w e i g h t / o b e s i t y N C - 3 . 3
I n v o l u n t a r y w e i g h t g a i n N C - 3 . 4
B E H A V I O R A L - E N V I R O N M E N T A L N B
D e f n e d a s n u t r i t i o n a l f n d i n g s / p r o b l e m s i d e n t i f e d a s r e l a t e d t o k n o w l e d g e , a t t i t u d e s /
b e l i e f s , p h y s i c a l e n v i r o n m e n t , o r f o o d s u p p l y a n d s a f e t y '
K n o w l e d g e a n d B e l i e f s ( 1 )
D e f n e d a s a c t u a l k n o w l e d g e a n d b e l i e f s a s r e p o r t e d , o b s e r v e d , o r d o c u m e n t e d '
F o o d , n u t r i t i t i o n , a n d n u t r i t i o n - r e l a t e d N B - 1 . 1
k n o w l e d g e d e f c i t
H a r m f u l b e l i e f s / a t t i t u d e s a b o u t f o o d o r N B - 1 . 2
n u t r i t i o n - r e l a t e d t o p i c s ( u s e w i t h c a u t i o n )
N o t r e a d y f o r d i e t / l i f e s t y l e c h a n g e N B - 1 . 3
S e l f - m o n i t o r i n g d e f c i t N B - 1 . 4
D i s o r d e r e d e a t i n g p a t t e r n N B - 1 . 5
L i m i t e d a d h e r e n c e t o n u t r i t i o n - N B - 1 . 6
r e l a t e d r e c o m m e n d a t i o n s
U n d e s i r a b l e f o o d c h o i c e s N B - 1 . 7
P h y s i c a l A c t i v i t y a n d F u n c t i o n ( 2 )
D e f n e d a s a c t u a l p h y s i c a l a c t i v i t y , s e l f - c a r e , a n d q u a l i t y o f l i f e p r o b l e m s a s r e p o r t e d ,
o b s e r v e d , o r d o c u m e n t e d '
P h y s i c a l i n a c t i v i t y N B - 2 . 1
E x c e s s i v e e x e r c i s e N B - 2 . 2
I n a b i l i t y o r l a c k o f d e s i r e t o m a n a g e s e l f - c a r e N B - 2 . 3
I m p a i r e d a b i l i t y t o p r e p a r e f o o d s / m e a l s N B - 2 . 4
P o o r n u t r i t i o n q u a l i t y o f l i f e N B - 2 . 5
S e l f - f e e d i n g d i f f c u l t y N B - 2 . 6
F o o d S a f e t y a n d A c c e s s ( 3 )
D e f n e d a s a c t u a l p r o b l e m s w i t h f o o d a c c e s s o r f o o d s a f e t y '
I n t a k e o f u n s a f e f o o d N B - 3 . 1
L i m i t e d a c c e s s t o f o o d N B - 3 . 2
Edition: 2006
NUTRITION DIAGNOSTIC TERMINOLOGY NUTRITION DIAGNOSTIC TERMINOLOGY
N U T R I T I O N D I A G N O S T I C T E R M I N O L O G Y N U T R I T I O N D I A G N O S T I C T E R M I N O L O G Y
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