The first step in the nutrition care process is the nutrition assessment. This involves collecting information about the patient’s ailment through family and medical history questionnaires, medical charts, oral or written communication with the medical staff, and related research. Health care personnel are responsible for recording and analyzing food and nutrition intake, body composition, and laboratory data as it relates to the patient’s condition. All of these factor into the overall health of a patient because it can affect how their body reacts to a disease. Health care professionals use this process to establish a patient’s needs and to help a patient set goals.
After the assessment has been completed, the next step is nutrition diagnosis. A nutrition diagnostic statement is usually written in a PES format that states the problem (P), the etiology (cause) (E), and the signs and symptoms (S). For example, the nutrition diagnosis for someone with type 2 diabetes could be “Type 2 diabetes (P) related to excessive carbohydrate intake (E) as evidenced by elevated blood glucose levels (S).” The nutrition diagnosis assists medical professionals in deciding which steps to take next.
Once a patient is assessed and diagnosed, a course of action can be determined. Nutrition intervention can include diet modification, implementing specialized nutrition therapies, and counseling. The intervention will be most effective when it is customized for the patient. The intervention plan has to take into consideration factors that are recorded in the assessment process. Among many are the patient’s energy needs, if certain foods will interact negatively or positively with their condition, and drug interactions. Nutrition education and counseling are also important aspects of an intervention plan. Patients and families that understand the necessary changes to food or nutrient...