A Message From the INDI President

We are delighted to be starting the Journey to Nutrition Diagnosis for all our members.

We set up a Nutrition Care Process and Model (NCPM) Steering Group last year to start the process of how we could bring the NCPM to Ireland. Delivery of the NCPM was identified as a key operational action under our Strategic Goal of Improving the Nation’s Health. Our plan to deliver NCPM for our members has been greatly accelerated by this collaboration with Nutricia Medical.

NCPM uses a consistent, systematic structure and method, a common dietetic language and an evidence based approach. The process provides a framework for demonstrating how nutrition care improves outcomes. In the current economic and health climate it is essential that Dietitians develop nationwide outcomes to demonstrate the impact of our nutritional interventions on the health of our patients. With a small fraternity such as the Dietetic community in Ireland, the NCPM provides a huge opportunity to standardise and promote our effectiveness.

As with any new venture, there will be change, but this change brings great opportunity. The INDI - Nutricia Medical partnership will enable us to roll out an education programme on how you can implement NCPM in your setting. This is applicable to all Dietitians whether in community, hospital or in freelance dietetics.

On behalf of council, I would like to thank our NCPM working group members (Dr. Ciara McGowan, Philomena Flood, Dr. Clare Corish, Sarah McEvoy, Yvonne Sayles, Laura Harrington, and Orla Haughey) for their work to date and also in advance of the work ahead to enable roll out of the NCPM. Our thanks must also go to Sue Kellie (BDA) and Pauline Mulholland (NI BDA) for their assistance regarding the NCPM. Finally, I would like to thank Nutricia Medical for partnering with us on this extremely important project.

Today is the launch of this journey with our members and we look forward to the continued roll out of the NCPM education programme over the year ahead.

Richelle Flanagan
President, INDI

A Message From Maurice Hickey, Nutricia Medical

“Nutricia Medical look forward to partnering with the INDI in making the NCPM a reality within Irish Healthcare which I have no doubt will be of significant benefit to the patient, the ultimate goal of both Nutricia Medical and INDI members.”

Use the links below to explore more information about the Journey Towards Nutrition Diagnosis

Video from the Journey Towards Nutrition Diagnosis Meeting 29th January 2014
The Journey Towards Nutrition Diagnosis Meeting Report 29th January 2014
Members of the NCP Working Group within the INDI
References & Recommended Further Reading
Photographs from the NCPM Launch Event

Video from the Journey Towards Nutrition Diagnosis Meeting 29th January 2014

The Journey Towards Nutrition Diagnosis Meeting Report 29th January 2014

Dr. Ciara McGowan, PhD, MINDI

The Nutrition Care Process and Model (NCPM) was recently launched by the Irish Nutrition & Dietetic Institute (INDI), in partnership with Nutricia Medical at the recent Nutricia Medical sponsored education evening on 29th January.

The guest speaker of the evening Constantina (Tina) Papoutsakis, PhD, RD is the Chair Elect of the International Work Group on the Nutrition Care Process and Standardized Language of the Academy of Nutrition and Dietetics in the United States. Tina shared her wealth of knowledge about the NCPM through a lecture style presentation followed by a practical workshop session. This report provides a summary account of the information shared by Tina at the launch of the NCP.

The Nutrition Care Process (NCP) is a structured method describing how dietitians provide nutrition care using four interrelated steps: ‘Nutrition Assessment’, ‘Nutrition Diagnosis’, ‘Nutrition Intervention’ and ‘Nutrition Monitoring and Evaluation’. Using a care process provides a framework to allow dietitians to individualise nutrition care using the best evidence available.

Other health professionals including nurses and occupational therapists already use care processes that are unique to their profession. The NCP was first adopted in 2003 by the former American Dietetic Association (ADA) (now the Academy of Nutrition and Dietetics) to provide dietitians with a structured methodology for critical thinking and decision making.

Figure 1 illustrates the steps of the NCP. The central core of the model is the relationship between the dietitian and the client/patient(s). One of the two outer rings represents all the skills, knowledge and attributes the dietitian brings to the NCP. The second of the two outer rings represents the external or environmental factors that affect the NCP including: healthcare systems and socioeconomic factors. Outside the model there is the ‘referral’ to the dietitian (usually by another professional) and the patient outcomes at the end of the NCP. As previously mentioned the NCP contains four steps.

Step 1: Nutrition Assessment

The purpose of this stage is to obtain and interpret data or information in order to decipher what the nutrition-related problem is. Assessment data includes relevant information obtained from the patient’s medical chart, medications, biochemistry, anthropometric data and diet history.

Step 2: Nutrition Diagnosis

This is the ‘newest’ concept to our practice. The purpose of this step is to identify a nutrition related problem that is based on the data gathered in step one. The nutrition diagnosis is not to be confused with a medical diagnosis which we are more familiar with. There may be cases where no nutritional diagnosis can be made or identified.

There are three parts to forming a nutrition diagnosis: ‘Problem’, ‘Etiology’ and ‘Signs / Symptoms’. This three parts form what’s known as a ‘PES’ statement. The ‘Problem’ is the diagnostic label (e.g. ‘malnutrition’ or ‘inadequate energy intake’). The ‘Etiology’ is the cause of the problem (WHY the problem exists). The ‘Signs / Symptoms’ are the defining characteristics of the diagnosis (PROOF of the problem). The PES statement is written down in a specific manner as shown in the example below:

P – Unintended weight loss
Related to….
E – Inadequate energy
and protein intake
As evidenced by….
S – Five percent (3kg) weight loss
in the past month

The nutrition diagnosis requires the dietitian to think critically about the nutrition related issues affecting the patient / client.

Step 3: Nutrition Intervention

The purpose of this step is to implement a nutrition care plan to address the identified nutrition problem and to set goals and outcomes. It includes a nutrition prescription or plan (where we need to go) and a nutrition implementation (what we need to do to get there).

Step 4: Nutrition Monitoring & Evaluation

This step allows for monitoring progress of the nutrition care plan, to measure outcomes and evaluate outcomes. All outcomes must be measurable using evidenced based guidelines and they must be related to the PES statement (step 2). It is recommended to have at least one goal per nutrition diagnosis.

The following case study outlines the four steps of the NCP put together.

Case Study

80 year old female referred by nursing staff for enteral feeding assessment.

Nutrition Assessment:
Medical History: Asthma, hypertension and respiratory failure
Anthropometry: Weight: 50kg, height: 1.68m, usual body weight: 60kg (1 year ago), BMI: 17.7 kg/m2, ideal body weight: 64.5kg.
Biochemistry: potassium 3.3mmol/l, phosphate 2.5 mmol/l, magnesium 1.7 mmol/l.
Diet History: Family report minimal oral intake in past 3 months with patient meeting less than 50% of nutritional needs.
Estimated nutritional needs: 20 kcal / kg (1000kcal), 50 - 75g protein (1 – 1.5g/kg).

Nutrition Diagnosis:
Malnutrition related to inadequate oral intake as evidenced by BMI 17.7 and 17% weight loss in 1 year.

Nutrition Intervention:
Commence enteral feeding via NG tube providing 1000kcal (20kcal/kg) and 60g protein (1.2g protein/kg). Monitor and supplement electrolytes until within normal range.

Nutrition Monitoring and Evaluation:
Patient to receive gradual increase in enteral nutrition to reach a goal of 25kcal / kg and 1.2 – 1.5g protein/kg - review in 1 day.

Standardised Language

The International Dietetics and Nutrition Terminology (IDNT) also known as the standardised language of dietetics provides dietitians using the NCP with a standard terminology for all four steps of the NCP. They are available in the International Dietetics and Nutrition Terminology Reference Manual from the Academy (see references below).

Using standardised terminology allows dietitians in all settings to use the same words to describe all parts of the NCP and this will result in more structured and effective recording and documentation. Using standardised language is also essential for electronic patient records and will be needed in the future as Ireland prepares to introduce electronic patient record systems.

Looking to the Future

Most dietitians in Ireland working in the clinical / community setting are very familiar with most steps of the NCP and employ them in their current practice. The biggest change is the ‘Nutrition Diagnosis’ step and the critical thinking that is associated with this. The structured method of recording and documenting the NCP may also mean a change in practice for many dietitians.

Fully adopting and implementing the NCP will require a change in thinking and we are all aware that change can be uncomfortable and unsettling. At the same time change can be very refreshing and positive. In 2013 the INDI set up a working group to focus on bringing the NCPM to Ireland. Our main goal is to educate members about the NCP and over the coming year we intend to provide more education to members on this topic.

For those people who attended the education evening on the 29th January you are free to begin using the NCP in your practice but on an official level it is likely that one department will be chosen to officially pilot rolling out the NCP. The NCP working group will be working in partnership with Nutricia Medical in rolling out this project.

Finally, I would like to thank all members of the working group and Nutricia Medical for their work on this project to date.

Dr. Ciara McGowan, PhD, MINDI
Email contact: cmcgowa@gmail.com

Members of the NCP Working Group within the INDI

Dr. Ciara McGowan (St. James’s Hospital), Philomena Flood (Vice President INDI), Dr. Clare Corish (DIT), Orla Haughey (St. James’s Hospital), Yvonne Sayles (Mater Hospital), Laura Harrington (Rotunda Hospital) and Sarah McEvoy (St. Mary’s Hospital).

References & Recommended Further Reading:

Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition care process and model part I: the 2008 update. J Am Diet Assoc 108(7):1113-7.

Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition care process part II: using the International Dietetics and Nutrition Terminology to document the nutrition care process. J Am Diet Assoc 108(8):1287-93.

Gardner-Cardani J, Yonkoski D, Kerestes J (2007). Nutrition care process implementation: a change management perspective. J Am Diet Assoc 107(8):1429-33.

International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago IL: American Dietetic Association, 2007.
Website address: aincp.webauthor.com provides lots of information on the different steps of the NCP provided by the Academy of Nutrition and Dietetics.

Download all the presentations from the NCPM Launch Event here.

Download the hand-outs provided by Prof. Papoutsakis at the NCPM Launch Event below:
Terminology Sheets
Nutrition Assessment Snapshot
Snapshot NCP Step 2 Nutrition Diagnosis
Snapshot NCP Step 3 Nutrition Intervention
Nutrition Monitoring and Evaluation
NCP FAQs
NCP Implementing Change Checklist

Photographs from the Journey Towards Nutrition Diagnosis Meeting

Dr. Ciara McGowan, Chairperson of the INDI NCPM Working Group

INDI NCPM Working Group with Noreen Roche, Nutricia Medical

Jo Wilson, Nutricia Medical, Niamh Fitzpatrick and Niamh Flanagan, Cavan General and Mary Kenny, Nutricia Medical.

Prof Constantina Papoutsakis,The National and Kapodistrian University of Athens

Maurice Hickey, Nutricia Medical, Margaret O’Neill, Community Dietitian Manager and Noreen Roche, Nutricia Medical.

Kara Cullen, Beaumont Hospital, Linda Dooley, St. James’s Hospital, Edel Duffy, Nutricia Medical and Sheila Sugrue, Lecturer, DIT.

Maurice Hickey, Nutricia Medical, Richelle Flanagan, INDI President, Prof Constantina Papoutsakis, The National and Kapodistrian University of Athens and Dr Ciara McGowan, St. James’s Hospital.