After taking the Nutrition Assessment, the dietitian formulates some preliminary Nutrition Diagnoses, and considers which Nutrition Interventions to propose for the patient's consideration. These initial Diagnoses can be modified as the patient supplies more information and the true underlying causes or etiologies of the condition become clear. The dietitian’s final understanding of the nutrition problems will be outlined in the Nutritional Diagnosis Statement, consisting of the Problem/Etiology/Signs and Symptoms (PES) documented in the nutrition progress note or chart entry. The dietitian may have identified several possible Nutrition Diagnoses during the course of the consultation. However, if the patient is unwilling to address a particular Nutrition Diagnosis during counseling, the practitioner may discuss another.
The dietitian may have identified low priority nutrition problems. Examples of criteria dietitians use to prioritise Diagnosis are included in the Introduction chapter. The dietitian can record any low priority issues in the progress notes as items to be addressed in subsequent consultations.
Hint — use the eNCPT Diagnosis Reference Sheets at www.ncpro.org to identify the Signs and Symptoms (Potential Indicators) necessary to document that a Nutrition Diagnosis applies to your patient.
Explanatory additions to the NCP Mind Map are in blue italics. NCP terms and codes are in black font.
Nutrition Diagnosis Status Values
Dietitians are encouraged to use the labels below to communicate the status of each nutrition diagnosis identified. Definitions are provided to explain the meaning of the label on the Nutrition diagnosis status (EV-2) reference sheet.
Additional details can be found at Nutrition Monitoring and Evaluation Actions: Monitor, Measure, and Evaluate page. These concepts are on the Nutrition Assessment/Monitoring and Evaluation terminology list at eNCPT.
| NUTRITION DIAGNOSIS STATUS VALUES | |
| New nutrition diagnosis | Problem identified in nutrition diagnosis was not identified in any nutrition diagnoses made in the previous assessment. |
| Active nutrition diagnosis | The signs and symptoms in the nutrition diagnosis require nutrition intervention and monitoring and evaluation to meet the goal. |
| Resolved nutrition diagnosis | The signs and symptoms identified in the Nutrition Diagnosis have met or exceeded the goal. |
| Discontinued nutrition diagnosis | The nutrition diagnosis no longer exists because the client’s condition or situation has changed. The client’s current assessment data no longer support this nutrition diagnosis. |
| INTAKE NUTRITION DIAGNOSIS (NI) |
| ENERGY BALANCE NUTRITION DIAGNOSES (NI-1) Actual or estimated changes in energy (calorie/kcal/kJ) balance. Increased energy expenditure (NI-1.1) · Compare energy intake to either estimated energy requirements based on basal rates and physical activity levels OR to nutrition prescription Inadequate energy intake (NI-1.2) Predicted inadequate energy intake (NI-1.4) ORAL OR NUTRITION SUPPORT INTAKE NUTRITION DIAGNOSES (NI-2) Actual or estimated food and beverage intake from oral diet or nutrition support compared with patient/client goal. Inadequate oral intake (NI-2.1) Unbalanced diet pattern (NI-2.11) FLUID INTAKE NUTRITION DIAGNOSES (NI-3) Actual or estimated fluid intake compared with patient/client goal. Inadequate fluid intake (NI-3.1) BIOACTIVE CONSTITUENT INTAKE NUTRITION DIAGNOSES (NI-4) Actual or estimated intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol. Excessive alcohol intake (NI-4.3) NUTRIENT INTAKE NUTRITION DIAGNOSES (NI-5) Actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels. Increased nutrient needs (specify) (NI-5.1) · Assessment shows a requirement for supplements, delayed growth, medication affecting absorption, anabolism Inadequate protein-energy intake (NI-5.2) Fat and cholesterol intake nutrition diagnoses (NI-5.5) · Inadequate fat intake (NI-5.5.1) Protein intake nutrition diagnoses (NI-5.6) · Inadequate protein intake (NI-5.6.1) Carbohydrate and fiber intake nutrition diagnoses (NI-5.8) · Inadequate carbohydrate intake (NI-5.8.1) · Excessive carbohydrate intake (NI-5.8.2) · Inadequate fiber intake (NI-5.8.5), even though energy intake may be high, fiber intake may be low Vitamin intake nutrition diagnoses (NI-5.9) · Inadequate vitamin intake (specify) (NI-5.9.1), fat-soluble vitamins · A (NI-5.9.1.1) · D (NI-5.9.1.3) · E (NI-5.9.1.4) · K (NI-5.9.1.5) Mineral intake nutrition diagnoses (NI-5.10) · Inadequate mineral intake (specify) (NI-5.10.1) · Calcium (NI-5.10.1.1) · Chloride (NI-5.10.1.2) · Iron (NI-5.10.1.3) · Sodium (NI-5.10.1.7) |
| CLINICAL NUTRITION DIAGNOSES (NC) |
| FUNCTIONAL NUTRITION DIAGNOSES (NC-1) Change in physical or mechanical functioning that interferes with or prevents desired nutritional consequences. Altered GI function (NC-1.4) · Assessment shows abnormal digestive enzymes, intake of specific foods due to GI symptoms (appetite loss, cramping, distension, nausea, stool changes) BIOCHEMICAL NUTRITION DIAGNOSES (NC-2) Change in capacity to metabolize nutrients as a result of medications, surgery, or as indicated by altered laboratory values. Altered nutrition-related laboratory values (specify) (NC-2.2) Food-medication interaction (specify) (NC-2.3) WEIGHT NUTRITION DIAGNOSES (NC-3) Chronic weight or changed weight status when compared with usual or desired body weight. Underweight (NC-3.1) Unintended weight loss (NC-3.2) Growth rate below expected (NC-3.5) MALNUTRITION DISORDERS DIAGNOSES (NC-4) Health consequences resulting from insufficient or excessive energy and/or nutrient intake compared to physiologic needs and/or utilization. Malnutrition (undernutrition) (NC-4.1) · Chronic disease or condition related malnutrition (NC-4.1.2) · Illness related pediatric malnutrition (NC-4.1.5) |
| BEHAVIORAL-ENVIRONMENTAL NUTRITION DIAGNOSES (NB) |
|
KNOWLEDGE AND BELIEFS NUTRITION DIAGNOSES (NB-1) Food insecurity (NB-3.2) |
EXAMPLE PES STATEMENTS FOR CYSTIC FIBROSIS(1,2)
| DOMAIN | TERMS | PES |
| INTAKE NUTRITION DIAGNOSES (NI) | ENERGY BALANCE NUTRITION DIAGNOSES(NI-1) Inadequate energy intake (NI-1.2) |
Inadequate energy intake (NI-1.2) (P) related to feeding refusal and poor appetite (E) as evidenced by estimated energy intake of 65 kcals/kg/day compared to estimated energy needs of 120 kcal/kg/day and weight crossed 3rd percentile in last 8 months (S) |
| ORAL OR NUTRITION SUPPORT INTAKE NUTRITION DIAGNOSES (NI-2) Inadequate oral intake (NI-2.1) |
Inadequate oral intake (NI-2.1) (P) related to poor appetite during hospital admission with patient unwell following severe respiratory infection (E) as evidenced by nurse's records indicate patient is consuming less than 50% of meals and no mid-meal snacks (S) |
|
| CLINICAL NUTRITION DIAGNOSES (NC) | WEIGHT NUTRITION DIAGNOSES (NC-3) Underweight (NC-3.1) |
Underweight (NC-3.1) (P) related to Inadequate oral intake (NI-2.1) and patient reporting disinterest in food and eating (E) as evidenced by current BMI of 16 kg/m2, weight loss of 4.5 kg in past month and a diet history showing estimated energy intake of 1 200 kcal or 60% of estimated energy requirements (S) |
| BEHAVIORAL-ENVIRONMENTAL NUTRITION DIAGNOSES (NB) | KNOWLEDGE AND BELIEFS NUTRITION DIAGNOSES (NB-1) Food and nutrition related knowledge deficit (NB-1.1) |
Food and nutrition related knowledge deficit (NB-1.1) (P) related to lack of prior nutrition education regarding high-energy/high-protein eating practices (E) as evidenced by inability to apply food- and nutrition-related information to home meal plan (S) |
| KNOWLEDGE AND BELIEFS NUTRITION DIAGNOSES (NB-1) Not ready for nutrition related behavior change (NB-1.3) |
Not ready for nutrition related behavior change (NB-1.3) (P) related to conflict with personal or family values (E) as evidenced by unintended weight loss despite previous nutrition education and counseling and the results of a psycho-social assessment reflecting reluctance to commit to changes (S) |
References
1. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. 2023. Accessed 2 May 2024. Available from: https://www.ncpro.org/.
2. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. NCP Step 2: Nutrition Diagnosis. 2020. Accessed 11 May 2021. Available from: https://www.ncpro.org/pubs/2020-encpt-en/page-036.