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ICAN: Infant, Child, & Adolescent Nutrition August 2009
Infants
Specialty Practice
Using the Nutrition Care Process in the
Neonatal Intensive Care Unit
Nancy Nevin-Folino, MEd, RD, CSP, LD, FADA, and Corri K. Hanson, MS, RD, LMNT
Abstract: The Nutrition Care Process mentary publication, International in reference to the adult population.
introduced by the American Dietetic Dietetics & Nutrition Terminology (IDNT) Fortunately, with the 2009 IDNT Reference
3 3
Association in 2003 can be used Reference Manual, in 2009. The NCP is Manual, infant nutrition care has been
within the neonatal intensive care unit specific to what dietitians do for nutri- added and clarified in the Diagnosis ref-
(NICU) for standardization of taxon- tion delivery with patients, clients, or erence sheets (see Table 1 for a review
omy for nutrition care. Using this pro- groups. Therefore, with use, the NCP can of the updates). It is essential to use this
cess in the NICU will help to quantify describe in quantitative detail the activi- approved national dietetic language sys-
the nutrition activities unique to the ties unique to the profession of dietetics. tem in identifying and quantifying the
neonatal nutrition specialist, unify The adoption of this standardized dietetic contribution that RDs make in the provi-
descriptors of nutrition delivery func- taxonomy process can classify, quantify, sion of health care to neonates. Outcome
tions for data collection, and support and support registered dietician (RD) ser- data would be very beneficial in verifying
registered dietician services to other vices to other health professionals. the unique contribution that dietitians
health care professionals. A case study
is presented, with tables explaining
the 4 steps to the process, and a useful “The NCP is specific to what dietitians do for
summary of nutrition diagnosis within
the NICU population provides a needed nutrition delivery with patients, clients, or groups.”
reference to the neonatal nutritionist
and NICU staff.
Keywords: newborn; neonate; early life There are 4 steps to the process, with make for length-of-stay and quality-of-life
span nutrition; premature; nutrition care each step defined by standardized lan- issues as well as supporting neonatal
3
process guage in the IDNT Reference Manual nutrition positions.
(see Figure 1 for the IDNT hierarchy). A specialty nutrition practice toolkit proj-
he Nutrition Care Process (NCP) is The IDNT can be incorporated into elec- ect was conceived at an NCP workshop
a model that has been put forth by tronic health record systems and will pro- held in Ohio in 2007. The hope was to
Tthe American Dietetic Association vide a uniform method of documenting provide guidance and examples to facil-
(ADA) using standardized taxonomy for nutrition services. itate consistent nutrition diagnosis within
nutrition care. The model was first pub- At first, it was challenging to use the neonatal nutrition practice. The Neonatal
1 4
lished in 2003 and has been evolv- NCP in the neonatal intensive care unit Nutrition Toolkit format is based on the
ing with use. An update was published (NICU). The terminology, explanations, sections of the ADA’s companion Pocket
2 and examples were mostly used Guide for International Dietetics & Nutrition
in August 2008 and also the comple-
DOI: 10.1177/1941406409342196. From Dayton Children’s, The Children’s Medical Center of Dayton, Dayton, Ohio (NN-F) and Nebraska Medical Center, Omaha (CKH).
Address correspondence to Nancy Nevin-Folino, MEd, RD, CSP, LD, FADA, Dayton Children’s, One Children’s Plaza, Dayton, OH 45404-1815; e-mail: nevin-folinon@
childrensdayton.org.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2009 The Author(s)
190
vol. 1 • no. 4 ICAN: Infant, Child, & Adolescent Nutrition
Figure 1.
2
International Dietetics and Nutrition Terminology hierarchy. Copyright © 2008, with permission from Elsevier, publisher of the
Journal of the American Dietetic Association.
5
Terminology (IDNT) Reference Manual and The Neonatal Nutrition Toolkit for Nutritionists. This online product is avail-
4
has many helpful sections and case stud- the Nutrition Care Process is a com- able from the ADA. Included are dia-
ies based on the neonatal population. The bined project by the Pediatric Nutrition log and examples of the NCP with the
ADA envisions many specialty practice NCP Practice Group of the American Dietetic neonatal population defined as ill preterm
toolkits in the future. Association and the Ohio Neonatal and term infants who are hospitalized
191
ICAN: Infant, Child, & Adolescent Nutrition August 2009
Table 1.
3
Publication Highlights, Revisions, and Clarifications
• Development of comparative standards reference sheets. A comparative standard reference sheet for growth is provided.
• Nutrition Diagnosis NI 5.2: Evident Protein-Energy Malnutrition. Modifications to the signs/symptoms now include growth
rates for pediatrics.
• Nutrition Diagnosis NI 5.6.1: Inadequate Fat Intake. Etiology now includes alteration in gestational tract structure and/or
function, supporting signs/symptoms already listed in the nutrition diagnosis.
• Nutrition Diagnosis NC 1.1: Swallowing Difficulty. Etiology now includes altered suck, swallow, and breathe patterns.
• Nutrition Diagnosis NC 2.2: Altered Nutrition-Related Laboratory Values. The etiology of prematurity has been added as a
potential cause or contributing factor for this diagnosis.
• Nutrition Diagnosis NC 3.1: Underweight. Additional etiologies of small for gestational age, intrauterine growth restricted, or
lack of progress/appropriate weight gain per day have been added.
• Nutrition Diagnosis NB 1.1: Food and Nutrition-Related Knowledge Deficit. Etiologies now include lack of understanding of
infant/child cues to indicate hunger.
• Nutrition Diagnosis NB 2.2: Excessive Exercise. The diagnosis has been changed to excessive physical activity, and the definition
has been changed to include voluntary or involuntary physical activity or movement that interferes with energy needs or growth.
• The Standardized Language Committee clarification statement that is included on the nutrition assessment and monitoring
and evaluation reference sheets is also included as part of the definitions for the 11 nutrition diagnoses with inadequate in
the label. The committee determined that if an alternate work with the same meaning is helpful or needed, the approved
alternate is the word suboptimal. Thus, dietetics professionals could use either the nutrition diagnosis label suboptimal intake
or inadequate intake.
• Nutrition assessment domain changes. The titles of 2 domains were modified for clarity. “Food/Nutrition History” has been
changed to “Food/Nutrition-Related History,” and “Physical Exam Findings” has been changed to “Nutrition-Focused
Physical Exam Findings.” These clarifications may help pediatric practitioners use nutrition assessment domains in a more
focused fashion.
© 2009 American Dietetic Association. Adapted with permission.
and up to 6 months of age (although this patients is no different with the NCP; it the Neonatal Nutrition Toolkit that out-
could be used in outpatient and commu- is the documentation style that is in a lines many different approaches to doc-
nity settings for infants, if applicable). more orderly and concise format. Other umenting in the medical records. Online
The case studies provided in the tool- health professionals often appreciate the instructional files are available from the
kit and with this article help the practitio- Nutrition Diagnosis and Intervention sec- ADA6 concerning incorporation of the
ner see the NCP from start to finish in a tions because it is easier to pick out treat- NCP into electronic medical records using
patient assessment of infants that is typi- ment and/or recommendations compared the IDNT taxonomy. Checking with other
cal of what a neonatal or pediatric dieti- to a narrative charting style. dietetics professionals in similar clinical
tian sees in a clinical day. Although the For several institutions, starting and areas may help for suggestions and ideas
case studies are not to be considered using the NCP is a gradual incorporation to begin the NCP documentation. The
“best practice” recommendations, they do of steps 1 through 4, with many dietet- end date recommended for full incorpo-
give examples of typical nutrition ther- ics departments beginning with the Nutri- ration of the NCP is 2010.
apy. Each dietitian may address differ- tion Diagnosis and the PES (Problem, The Neonatal Nutrition Toolkit offers a
ent problems or diagnoses in a different Etiology, Signs, and Symptoms) state- section on “Using Case Study Activities
order or priority than the case study, but ments (see Table 2 for examples of appli- for Education and Training.” Often in
it is the process here that is highlighted cable PES statements for intensive care learning and collaborative environments,
and detailed. The nutrition treatment of newborns). There is a detailed section in new information or clinical processes
192
vol. 1 • no. 4 ICAN: Infant, Child, & Adolescent Nutrition
Table 2.
PES: Problem, Etiology, and Signs and Symptom Examples for High-Risk Newborns
Problem Etiology Signs and Symptoms
Problem/diagnosis is the nutrition The cause of the nutrition problem and What the patient is experiencing that can
problem or why the registered can change or be affected by the be changed and then monitored for
dietician (RD) is intervening nutrition intervention improvement
NI 1.2: Increased Energy Accelerated needs secondary to 1. Growth velocity on chart curve
Expenditure 1. Maintenance of body temperature below goal; not maintaining the 10th
or percentile
2. Increased work of breathing or
2. Gaining 85% of recommended weight
gain/d
NI 1.4: Inadequate Energy Intake Administration of unfortified breast milk Gaining 85% of recommended weight
(suboptimal) gain
NI 2.3: Inadequate Intake From Low fat/lipid per kg/d Hypertriglyceridemia (250 mg/dL)
Enteral/Parenteral Nutrition
NC 2.1: Impaired Nutrient Utilization 1. Gastrointestinal (GI) tract resection 1. Malabsorption with fatty loose stools
or or
2. Compromised function of GI organs 2. Cholestasis (direct bilirubin 4.3 mg/dL)
NC 2.2: Altered Nutrition-Related 1. Limited iron reserves 1. Low hematocrit, elevated reticulocytes
Laboratory Values or or
2. Calcium/phosphorus incapability in 2. Alkaline phosphatase >800 U/L,
total parenteral nutrition (TPN) solution phosphorus 2.2 mg/dL
NC 3.2: Underweight 1. Nutrition order not meeting estimated 1. At 75% of weight gain/kg/d needs
requirements or
or 2. Steroid medication use causing
2. Estimated recommended intake not hypermetabolism
giving consistent weight gain/growth
can be more easily understood because and intervention that changed over time nutrition care that have been approved
of educational discussion. What one per- as the patient progressed through the by the ADA). The case study, however,
son has trouble understanding, another hospital course. This case study for- does reflect the types of situations that
group member may have experience or mat is used in the Neonatal Nutrition may occur in practice. The case study
knowledge that makes the process sim- Toolkit.4 The toolkit also contains format is to aid in the education and
plified. There are continuing education “Assessment Only” files for each case practice of the process, not as a recom-
opportunities using case studies avail- study presented (5 total) that lead into mended charting style.
able in the toolkit7 and on the Web site the case study for the NCP.
8
of the ADA. These files contain the nutrition assess- Neonatal Nutrition
The following case study provides ment data allowing the practitioner or Practice Case Study
more than one nutrition diagnosis group to fill in the diagnosis or diagno-
and more than one nutrition interven- ses, intervention(s), and monitoring and Case Example:
tion for an infant who could be still in evaluation steps. Hospitalized Infant
the NICU and/or intermediate unit for Again, the case study presented here is Patient scenario. This patient is an
older babies. This case study presents for discussion and education purposes 8-month-old girl who was born at 35
a patient who would have had multiple and is not meant to be considered “best weeks gestational age with a birth weight
nutrition visits with nutrition diagnosis practice” (or the recommendations for of 1.814 kg. The patient was initially
193
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