Nutrition Care Process

(NCP)
Step 2:Nutrition
Diagnosis
Nutrition Counseling
FNU 425
 Outline
 Overview of nutrition diagnosis

 Apply nutrition diagnoses terms

 Create PES statements to 5 cases

 Step 2: Nutrition Diagnosis
Nutrition
Diagnosis

 “ The identification and labeling of the specific

nutrition problem that dietetics practitioners are
responsible for treating independently”

 Not a medical diagnosis!

 Type 2 diabetes = medical diagnosis

 Excessive carbohydrate intake resulting in elevated blood
glucose levels = nutrition diagnosis
Step 2: Nutrition Diagnosis
 The critical link in the NCP between nutrition
assessment and intervention.

 Nutrition diagnosis is written in PES statement

Categories of Nutrition Diagnoses
1. Intake (NI)
 Excessive or Inadequate food/nutrient intake
compared to actual or estimated needs

2. Clinical (NC)
 Nutrition problems that relate to medical or physical
conditions
3. Behavioral/environmental (NB)
 Knowledge, attitudes, beliefs, physical environment,
access to food, food safety
What is PES statement?...
PES statement
 Problem: (Diagnostic Label)

 Etiology: (Cause/contributing risk factors)

 Signs/Symptoms: (Defining characteristics)

 Signs = objective data = observable, measurable changes

 Symptoms = subjective data = changes pt feels and expresses

PES statement
 Problem…

related to …Etiology…
as evidenced by …Signs/symptoms

Note: The etiology explains why the problem exists.

The signs & symptoms are evidence of the problem.

PES Statement
 Excessive calorie intake P Excessive Calorie
related to regular intake
consumption of large
portions of high-fat meals E regular consumption of
as evidenced by diet history large portions of high-
and weight status fat meals
S diet history and wt
status
 Nutrition
Nutrition Nutrition Nutrition
Monitoring &
Assessment Diagnosis Intervention
Evaluation

Problem Etiology Signs & Symptoms

 Evaluating Your PES Statement
 There are no right or wrong PES statements

But…

some are better than others!

 Evaluating PES Statements
Step by Step
When reviewing a PES Statement, ask the following questions:
Problem:
 Can the RD resolve or improve the nutrition diagnosis?
Etiology:
 Is the etiology the most specific root cause?

 Will intervention resolve the problem by addressing the etiology? If not, can intervention
at least improve the signs and symptoms?

Signs/Symptoms:
 Will measuring the signs and symptoms tell you if the problem is resolved or improved?

 Are the signs and symptoms specific enough that you can measure/evaluate changes at the
next visit to document resolution or improvement of the problem (diagnosis)?

PES Overall:

 Does your nutrition assessment data support the identified problem, etiology and signs
and symptoms?
 Step 3:Nutrition Intervention
 “to resolve or improve the identified nutrition problem
by planning & implementing appropriate interventions”
Nutrition
Intervention

 4 categories:
- Food and/or Nutrient Delivery (ND)
- Nutrition Education (E)
- Nutrition Counseling (C)
- Coordination of Nutrition Care (RC)
Nutrition Nutrition Nutrition
Assessment Diagnosis Intervention

Problem Etiology Sign/Symptoms

 Step 4: Nutrition Monitoring &
Evaluation
 Determine the amount of progress made to reach the specified
goal(s)& whether goals/expected outcomes are being met
Nutrition
Monitoring
&
Evaluation

 4 categories

- Food/Nutrition-Related History (FH)

- Anthropometric Data (AD)
- Biochemical Data (BD)
- Nutrition-Focused Physical Data (PD)
 Nutrition Monitoring & Evaluation
 Nutrition monitoring & evaluation determine if the nutrition
intervention strategy is working to resolve the nutrition
diagnosis

Nutrition
Nutrition Nutrition Nutrition Monitoring
Assessment Diagnosis Intervention &
Evaluation

Problem Etiology Sign/Symptoms

Practice Time!..
 Case study:1
 67 year old white male, lives alone in apartment, on
disability, 5’6”, 135#.

 Heart failure diagnosed 2 months ago, wt loss of 20#

from dyspnea, shortness of breath and inability to
consume large meals.

 Unable to shop or cook, uses many processed food

with high sodium intake.

 Pt’s 24 hr recall shows 1000-1200 Kcal intake.

‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 18
 Nutrition Assessment Data
Food/nutrition- Anthropometric Nutrition focused physical Client
Biochemical data
related history measurements examination findings history

Food intake Personal data:

Ht: 5’6” None None
Mineral: Na 67 y/o white
Wt: 135#
Type of food/meal: male
Wt change:
convenience frozen meals Social history:
20# in 2 mon
Amount of food: unable live alone in
BMI:
to consume large meals apartment, on
Energy intake: ~1000- disability
1200 Kcal/day Nutrition-
Behavior: oriented
Social network: doesn’t medical/health
like to eat alone history:
Nutrition-related Cardiovascular:
activities of daily living: heart failure in
Physical ability to last 2 mon, SOB
complete tasks for meal
preparation: unable to
shop or cook
‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 19
 Case study:1 con’t
 Inadequate energy intake (NI-1.4) RT dyspnea, SOB
AEB 20 lb wt loss (why?)

 Inadequate oral food/beverage intake (NI-2.1) RT

inability to shop & cook AEB caloric intake of 500
Kcal less than estimated requirements and 20 lb wt
loss in XX weeks.
 Case study: 2
 8 y/o white male child with food allergies. Referral from
pediatric clinic
 Allergy to peanuts & eggs. Usually eats 4-5 foods
 Intake b/t 1200-1500 Kcal/day
 Underweight (30th % for age now; ~ 44th a year ago)
Poor appetite; recently more irritable & fatigued than
usual. Medical Dx of iron deficiency anemia.
 Attend school (3rd grade). Parents separated recently;
lives with mother. Needs to take lunches to school.
Mother asks for guidance on what to pack & how to help
her child gain wt.
‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 21
 Nutrition Assessment
Data

Food/nutrition-related Anthropometric Biochemical Nutrition focused physical Client

history measurements data examination findings history
Food intake
Type of food/meal: take Ht: 4’1” (1 yr Digestive Personal data:
lunch to school ago= 4’0”) None system: poor 8 y/o white male
Food variety: limited to 4-5 Wt: 15.5 Ibs (1 yr appetite child
foods ago= 50 Ibs) Nerves & Social history:
Energy intake: ~1200-1500 BMI for age cognitions: more Hx of recent
Kcal/day percentile: ~ 30th irritable & crisis: parents
Behavior: % (1 yr ago= 44th fatigued than getting divorced
Mealtime behavior: limited %) usuall Nutrition-
numbers of accepted foods oriented
Food & nutrition medical/health
knowledge: history:
Area & level of knowledge: Medical
mom’s asking for help in diagnosis: iron
menu planning to gain wt deficiency
Beliefs & attitude: afraid to anemia
try new foods due to possible
allergic reactions ‫ا‬. ‫نهى سليماني استشارات غذائيه‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 22
 Case study:2 con’t
 Inadequate energy and iron intake (NI-1.4 & NI-5.10.1) RT fear
of allergic reactions AEB underweight at 30th percentile wt for
Ht and age and diagnosed iron deficiency anemia

 Food and nutrition-related knowledge deficit (NB-1.1) RT fear of

allergens in food AEB poor appetite and intake of only 4-5 foods
in 24-hr recall and stated concern about food allergies.
 What happen to your thinking if…

-- Mom states that she has had 4-5 previous sessions w/ the dietitian
regarding his diet?

-- Diet Hx reveals that Mom is giving the child a multivitamin w/

iron?
 Case study: 3
 34 y/o male with Hx of DMII, HTN,
hyperlipidemia.

 Ht: 5' 10"; wt:250 lbs; BMI= 36 (Obesity II).

 Works night shift, eats 2 meals/day in

restaurants- fried foods, burgers, ice cream,
beers. Does not add salt to foods.

 Plays golf 1x month.

‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣

28/2/2012 24
 Case study: 3 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Eats 2 meals/day in Ht: 5' 10"; wt:250 lbs; 34 y/o male;

restaurant; fried BMI=36 DM II; HTN
foods, burger, ice (obesity II) Hyperlipidemia;
cream, beers. Night shift work
Doesn’t add salt
to foods.
Plays golf 1x month.
Write your PES statement…

‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣

28/2/2012 25
 Case study: 3 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Eats 2 meals/day in 34 y/o male;

ht: 5' 10"; wt:250 lb; DM II; HTN
restaurant; fried
foods, burger, ice BMI=36 Hyperlipidemia;
cream, beers. (obesity II) Night shift work
Doesn’t add salt
to foods.
Plays golf 1x month.

Excessive energy intake (NI-1.5) R/T frequent use

of restaurant foods AEB high intake of caloric foods & BMI=36
 Case study: 4
 50 y/o white female, Dx of multiple allergies, including milk
allergy. wt=114 lbs, Ht= 5'6".

 She has come to see you in the outpatient clinic. No available

lab work.

 Tends to fatigue easily & to have a lot of GI distress. Recently,

she has had chronic mild diarrhea after meals.

 From her intake records & patterns, you identify that she is
consuming hidden milk products ( in cheese sauces, cream
sauces, & salad dressings) & doesn't ask about food
ingredients at restaurants or read labels.

‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣

28/2/2012 27
 Case study: 4 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Consumes hidden milk products 50 y/o female;

wt=114 lbs; Ht= 5'6" Fatigue; GI
(cheese & cream sauces, salad Milk allergy;
BMI=18 distress
dressings); Chronic mild
doesn’t read labels & ask about Diarrhea after
food Ingredients at restaurant meals

Write your PES statement…

‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 28
 Case study: 4 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Consumes hidden milk products 50 y/o female;

(cheese & cream sauces, salad wt=120 lb; ht= 5'6" Fatigue; GI Milk allergy;
dressings); BMI=18 distress Chronic mild
doesn’t read labels & ask about Diarrhea after meals
food Ingredients at restaurant

Inappropriate intake of type of CHO (lactose) (NI-5.8.3) RT food-&

nutrition-related knowledge deficit AEB BMI=18, fatigue, GI distress,
chronic mild diarrhea, &consumption of
hidden milk products
 Case study: 5
 62 y/o, a large man, wt =200 lbs, BMI= 29

 Has been gaining weight over the last 5 years in his group home. His
doctor said he needs to exercise more or he’ll become obese; he
doesn't want to be told he needs to exercise for his health.

 When he first came to the group home he was much more active than
currently. He would go for walks in a park by himself when the
weather was good. He bowled every week with the other men in the
group home and was very good at it. A year later he climbed a Mt.
with 1of the staff. The staff person left his job at the group home
about 3 mon later and no one else was interested in taking him
hiking. He worked out at the YMCA for a period of time but he didn't
find other people to workout with him & he quit.

 He started eating more food within the next year as he started to gain
wt.
‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 30
 Case study: 5 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Eat more food after wt=200#; BMI=29;

his friend left the 62 y/o male; Lives in
gain wt over the
group home; doesn't a group home
last 5 yrs;
want to be told he needs
to exercise for his health;
was more active than now;
enjoyed hiking with his friend
didn't find other people to
workout with him & he quit. Write your PES statement…
‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 31
 Case study: 5 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Eat more food after his friend left wt=200#; BMI=29;

the group home; was more active gain wt over the 62 y/o male; Lives in
than now; enjoyed hiking with his last 5 yrs; a group home
friend; doesn't want to be told he
Needs to exercise for his health.

Lack of desire to manage self-care (NB-2.3) RT lack

of social support for implementing changes AEB
anger regarding need to exercise, unwillingness to workout &
wt gain over last 5 yrs
 Case study: 6
 15 y/o white teen, pregnant. Hx of disordered eating
& was hospitalized for this problem approximately
2yrs ago.
 wt before the pregnancy was 95 lbs & Ht:5' 1". She is
now 24 weeks pregnant & weighs 102 lb.

 Serum Alb= 3.4 g/dl; blood Glu= 110 mg/100 ml; &
HbA1c= 5%.
 avoids food & calorie-containing beverages;
excessive physical activity.
‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 33
 Case study: 6 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Alb=3.4 g/dl,
Avoids food & Before pregnancy: 15 yrs, female,
HgA1c=5%
calorie-containing Wt=43 kg; Ht=155;BMI=17.9; pregnant teen;
Glu=110mg/100ml
beverages; Hx of disordered
excessive During 24 weeks of Pregnancy: eating; hospitalized
physical activity Wt= 45 kg; BMI= 18.7 for this problem 2yrs
ago

Write your PES statement…

‫ا‬. ‫استشارات غذائيه‬ ‫نهى سليماني‬-١٤٣٢ ‫الفصل الدراسي الثاني‬-‫هـ‬١٤٣٣
28/2/2012 34
 Case study: 6 con’t
Nutrition
Assessment

Food/Nutrition Biochemical Anthropometric Physical Data Client History

History (FH) Data (BD) Measures (AD) (PD) (CH)

Alb=3.4g/dl, Before pregnancy: 15 yrs, female, pregnant teen;

Avoids food & HgA1c=5% Hx of disordered
calorie-containing Glu=110mg/100ml Wt=43 kg; ht=155;BMI=17.9;
eating; hospitalized
beverages; excessive for this problem 2yrs
physical activity During 24 weeks of Pregnancy:
Wt= 45 kg; BMI= 18.7 ago

Disordered eating pattern (NB-1.5) R/T pt's desire to

regulate wt AEB failure to gain appropriate wt
during pregnancy, avoidance of food/calorie-containing beverages,
Excessive physical activity & Hx of disordered eating