Intervention and Nutrition Care Planning
Domain 3's output becomes Domain 4's plan: selecting interventions, setting goals, and delivering nutrition safely.
Intervention domains
The NCP groups interventions as food and/or nutrient delivery, nutrition education, nutrition counselling, and coordination of nutrition care. Each must link to the PES etiology and state who does what.
Goals
Write SMART goals: specific, measurable, achievable, relevant, time-bound. "Patient will consume 90 g protein/day for 4 weeks, tracked by 3-day food records" beats "improve protein intake".
Enteral versus parenteral
Rule: if the gut works, use it. EN maintains gut integrity, costs less, and carries fewer infectious complications. EN is generally started within 24–48 hours in critically ill patients who cannot eat adequately; PN is reserved for contraindications such as mechanical bowel obstruction, prolonged ileus, high-output fistula, or severe malabsorption. Combine routes when oral intake covers part of the need.
Refeeding syndrome
Risk with BMI <16, >15% weight loss, negligible intake >10 days, or low baseline potassium/phosphate/magnesium. Give thiamine before or with feeding, start at 10–20 kcal/kg/day, advance over 4–7 days, and monitor phosphate, potassium, and magnesium daily in the first week; watch for fluid overload.
Diet levels and safety
Texture-modified diets and thickened fluids use IDDSI levels; formula choice considers fibre, protein density, osmolality, and free-water flushes. Allergy, intolerance, culture, religion, and cost shape the plan and adherence.
Worked example
A 45-year-old admitted with severe acute pancreatitis, unable to eat, no ileus. Reasoning: the old "bowel rest" rule is outdated; enteral nutrition - including nasogastric - is preferred over PN because it lowers infectious complications and mortality and preserves gut barrier function, and it does not worsen pain. Plan: NG EN at a low rate, advance as tolerated, reassess intake daily, transition to oral diet when tolerated.
Traps
Choosing PN first because the pancreas is "resting"; giving thiamine only after feeding has begun; goals with no metric or timeframe; writing a medical prescription instead of a nutrition prescription; ignoring the patient's preference and capacity to follow the plan.