Common Nutrition Care Process Terminology Concepts Used in the Nutrition Care Process
The utilization of common nutrition care process terminology (NCPT) concepts is provided for all professionals in the dietetics and nutrition field as a result of the nutrition care process (NCP) being the standard of care in their practice. This ensures proper documentation and reporting in accordance with the NCP guidelines. The concepts chosen are those that are broadly applicable for professionals engaged in quality improvement initiatives and included in nutrition and health interoperability standards for electronic data collection and exchange. Almost all NCP concepts have internationally agreed upon definitions, however, those that do not have a note indicate that a definition has not been developed at this time.
Additional terms and important application guidance are included in the online electronic Nutrition Care Process Terminology (eNCPT) (ncpro.org) for use by any nutrition and dietetics professional and is available for purchase by subscription. Subscription options are available here.
The eNCPT includes:
-Critical thinking advice associated with each nutrition care process step.
-Additional and refined concepts that are applicable to practice (eg, subjective global assessment tool rating, protein intake per kilogram).
-Indicators or signs and symptoms of nutrition diagnoses.
-Typical nutrition diagnoses and components associated with specific nutrition interventions.
NCP Step 1: Nutrition Assessment and Reassessment / NCP Step 4: Monitoring and Evaluation Terminology
|Estimated energy intake||Amount of energy intake from all sources including food, beverages, supplements, and via enteral and parenteral routes.|
|Estimated fluid intake||Amount of fluid intake from all sources including food, beverages, breastmilk, infant formula, supplements, and via enteral and parenteral routes.|
|Estimated protein intake||Protein intake from all sources including food, beverages, supplements, and via enteral and parenteral routes.|
|Breastmilk/infant formula intake||Amount of breastmilk, and/or the amount, type, and concentration on infant formula consumed orally.|
|Diet order||A general or modified diet prescribed and documented in a client medical record by a credentialed provider as part of a medical treatment plan.|
|Enteral nutrition order||No definition has been developed.|
|Parenteral nutrition order||No definition has been developed.|
|Food intake||Amount, type, and pattern of food consumed and quality of diet.|
|Enteral nutrition intake||Amount or type of enteral nutrition intake provided via a tube.|
|Parenteral nutrition intake||Amount or type of parenteral nutrition and/or fluids provided intravenously.|
|Food and nutrition knowledge||Content areas and level of understanding about food, nutrition and health, or nutrition-related information and guidelines relevant to client needs.|
|Safe food availability||Reliable acquisition of safe and acceptable food to meet nutrition needs for an active, healthy life.|
|Height||Defined as measures of a body’s length, typically from head to foot.|
|Weight||Defined as measures of a body’s mass, heaviness or lightness of a body.|
|Weight Change||Defined as measures of the difference in body weight typically over time.|
|Body mass index||Defined as measures of a body’s weight relative to height.|
|Loss of subcutaneous fat||No definition has been developed.|
|Muscle atrophy||No definition has been developed.|
|Nutrition assessment, monitoring and evaluation tools||Tools used for health or disease status or risk assessment, reassessment, and monitoring and evaluation.|
|Intervention goal status||Evaluation of progress toward meeting goals set in the course of nutrition intervention.|
|Nutrition diagnosis status||Evaluation of the status of a nutrition diagnosis.|
|Estimated energy needs||Estimated quantity of total energy needed for nutritional adequacy.|
|Estimated protein needs||Estimated quantity and/or type of protein needed for nutritional adequacy.|
|Estimated fluid needs||Estimated quantity of fluid needed for nutritional adequacy.|
NCP Step 2: Nutrition Diagnosis
Note for intake nutrition diagnoses: Whenever possible, nutrient intake data should be considered in combination with clinical, biochemical, anthropometric information, medical diagnosis, clinical status, and/or other factors to provide a valid assessment of nutritional status based on a totality of the evidence. (Institute of Medicine. Dietary Reference Intakes: Applications in Dietary Assessment. Washington, DC: National Academies Press; 2000.)
|Inadequate energy Intake||Energy intake that is less than energy expenditure, established reference standards, or recommendations based on physiological needs.|
|Excessive energy Intake||Energy intake that exceeds energy expenditure, established reference standards, or recommendations based on physiological needs.|
|Inadequate oral intake||Oral food/beverage intake that is less than established reference standards or recommendations based on physiological needs.|
|Inadequate protein intake||Lower intake of protein compared to established reference standards or recommendations based on physiological needs.|
|Inadequate fluid intake||Lower intake of fluid-containing foods or substances compared to established reference standards or recommendations based on physiological needs.|
|Inadequate enteral nutrition infusion||Enteral infusion that provides fewer calories/kcal/kJ or nutrients compared to established reference standards or recommendations based on physiological needs.|
|Inadequate parenteral nutrition infusion||Parenteral infusion that provides fewer calories/kcal/kJ or nutrients compared to established reference standards or recommendations based on physiological needs.|
|Swallowing difficulty||Impaired or difficult movement of food and liquid within the oral cavity to the stomach.|
|Unintended weight loss||Decrease in body weight that is not planned or desired.|
|Overweight/obesity||Increased adiposity compared to established reference standards or recommendations, ranging from overweight to morbid obesity.|
|Malnutrition (undernutrition)||Inadequate intake of protein and/or energy, over a period of time, sufficient to negatively impact growth/development, and/or to result in loss of fat and or muscle stores.|
|Starvation related malnutrition||Inadequate intake of protein and/or energy over a period of time sufficient to result in loss of fat and/or muscle mass without apparent inflammation and in the context of environmental and/or social circumstances. (Moderate)|
|Chronic disease or condition related malnutrition||Inadequate intake of protein and/or energy over a period of time sufficient to result in loss of fat and/or muscle mass with apparent mild to moderate inflammation and in the context of chronic illness or condition. (Moderate or Severe)|
|Acute disease or injury related malnutrition||Inadequate intake of protein and/or energy resulting in loss of fat and/or muscle mass with apparent marked inflammatory response and in the context of acute illness or injury. (Moderate or Severe)|
|Non illness related pediatric malnutrition (mild, moderate, severe)||Inadequate nutrient intake due to environmental or behavioral factors which may negatively affect growth, development, and/or other outcomes. Indicators for identifying Mild, Moderate, and Severe Non illness related pediatric malnutrition are included here.|
|Illness related pediatric malnutrition (mild, moderate, severe)||Nutrient deficit or imbalance due to disease or injury which may negatively affect growth, development, and/or other outcomes. Indicators for identifying Mild, Moderate, and Severe illness related pediatric malnutrition are included here.|
|Food and nutrition related knowledge deficit||Incomplete or inaccurate knowledge about food, nutrition, or nutrition related information and guidelines.|
Uncertain, limited, or unstable access to food that is adequate in quantity and in nutritional quality; culturally acceptable; safe and acquired in socially acceptable ways.
Note. The definition is an outcome from the collaborative work of the Gravity Project, where the Academy was a terminology lead for the Food Insecurity data set.
NCP Step 3: Nutrition Intervention
|Identify nutrition intervention goal||Description of a desired outcome of a nutrition intervention.|
|Nutrition prescription||The client’s tailored recommended intake of energy and/or selected foods or nutrients based on current reference standards and evidenced based practice nutrition guidelines and related to the client’s health and nutrition diagnosis.|
|Modify composition of meals||No definition has been developed.|
|Enteral nutrition||Nutrition provided through the gastrointestinal tract via tube, catheter, or stoma that delivers nutrients distal to the oral cavity.|
|Parenteral nutrition/intravenous (IV) fluids||Administration of nutrients and fluids intravenously, centrally or peripherally.|
|Nutrition supplement therapy||Commercial or prepared foods or beverages intended to supplement energy, protein, carbohydrate, fiber, and/or fat intake that may also contribute to vitamin and mineral intake.|
|Content related nutrition education||Instruction or training intended to lead to nutrition related content knowledge.|
|Collaboration and referral of nutrition care||Facilitating services or interventions with other professionals, institutions, or agencies on behalf of the client prior to discharge from nutrition care.|
|Discharge and transfer of nutrition care to other providers||Discharge planning and transfer of nutrition care from one level or location of care to another.|
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