Nutrition care plans provide communication for nutrition care between residents and members of the interdisciplinary team (IDT).

They are a crucial component of documentation that help ensure residents maintain acceptable parameters of nutritional status.

Unfortunately, many dietitians or dietary managers working in long-term care may wonder how to write a strong nutrition care plan or what information should be included when writing one.

This article helps guide you through the process of writing individualized person-centered nutrition care plans for long-term care with examples.

What Is the Care Plan?

A care plan is an action plan created between residents and IDT members (1).

Members of the IDT team may include:

  • The attending physician
  • A registered nurse
  • Nurse aide
  • A member of the food and nutrition services staff
  • Social worker
  • Other appropriate staff or health professionals

The care plan includes measurable goals and timeframes to meet a resident’s individual medical, nutrition, nursing, and psychosocial needs and wishes.

Care plans are person-centered meaning they empower the residents with control in making their own choices and having control over their daily lives.

As needs change and goals are met, care plans must be reviewed and revised by the IDT team.

Nutrition Care Plan Basics

The individualized nutrition care plan is based on information gathered by the comprehensive nutrition assessment and additional nutritional assessments.

The nutrition care plan addresses identified causes of impaired nutritional status and reflects the resident’s goals and choices. It also identifies resident-specific interventions and a time frame and parameters for monitoring.

The Care Area Assessment (CAA) will trigger for any nutrition problem that requires further assessing.

If triggered, determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness, or need affects the resident. Document whether each area triggered needs care planning.

There may be times, however, when a resident risk, weakness, or need is identified but may not cause a CAA to trigger. Address these areas and document whether to develop a care plan.

Residents do have the right to refuse certain treatments that the IDT team believes may help the resident reach their highest practicable level of well-being or to keep the resident safe.

In these situations — particularly those that pose a risk to the resident’s health or safety, such as the refusal of thickened liquids — the nutrition care plan should identify the care or service being declined, the risk associated with that choice, and efforts by the IDT to educate the resident and representative, if applicable.

Nutrition Care Planning Styles and Examples

There are three ways or styles of writing nutrition care plans:

  • Resident planned: This style sounds like the resident wrote the care plan, e.g., due to my recent stroke, I have trouble swallowing safely and require a mechanically altered diet.
  • Problem, etiology, and signs or symptoms (PES): This style uses a PES statement, e.g., swallowing difficulty related to cerebrovascular accident (CVA) requiring mechanically altered diet as evidenced by coughing and hoarse voice associated with eating.
  • Resident stated: This style uses the term resident or their name, e.g., resident has dysphagia secondary to CVA and requires a mechanically altered diet for safe and efficient swallowing.

The style you use will likely depend on which electronic health record (EHR) software your facility uses.

In either case, always include the resident in the nutrition care planning process to ensure the care plan reflects the resident’s goals and wishes.

Nutrition Care Plan Examples

Here are some examples of nutrition care plans using the three writing styles:

Resident planned example:

  • Problem: I have had recent and severe weight loss of 6% in 1 month.
  • Goal 1: I will exhibit no significant weight loss through next review as evidenced by maintaining my current weight of 180 lbs within +/- 5 lbs.
  • Intervention 1: I will consume 75-100% of meals
  • Intervention 2: Staff will provide my diet as ordered or recommended by my doctor or dietitian.
  • Intervention 3: I will receive consults from my dietitian as needed.
  • Intervention 4: Staff will inform my doctor and family of any significant weight loss.
  • Intervention 5: Staff will offer me alternatives If I consume less than 50% at meals. I like PB&J sandwiches, burgers and french fries, and milk.

PES example:

  • Problem: Feeding tube necessary for nutritional needs related to dysphagia secondary to CVA as evidenced by inability to safely and efficiently swallow.
  • Goal 1: Nutritional needs will be met by tube feedings 100% of the time.
  • Goal 2: Will be free of dehydration as evidenced by good skin turgor and moist mucus membranes.
  • Goal 3: Will maintain nutritional status as evidenced by maintaining weight in the range of 150-155 lbs.
  • Intervention 1: Feeding as ordered per RD recommendations.
  • Intervention 2: Observe skin turgor and for moist mucus membranes.
  • Intervention 3: Weigh per facility policy with follow-up as indicated.
  • Intervention 4: Observe tube placement before each feeding.
  • Intervention 5: Monitor feeding tube site for redness or signs of infection.
  • Intervention 6: Monitor for tube dislodgement, blockage, or leakage,
  • Intervention 7: Monitor for tube feeding tolerance.
  • Intervention 8: Elevate head 30 degrees during feeding.

Resident stated example:

  • Problem: Resident has liver cirrhosis and needs a 2 gram sodium-restricted diet.
  • Goal: Resident will receive appropriate diet and consume between 75-100% of meals.
  • Intervention 1: Offer diet ordered by MD or RD.
  • Intervention 2: Weigh per facility protocol and document significant changes.
  • Intervention 3: Monitor meal consumption and offer substitutes if resident consumes less than 50%. Resident enjoys soups, turkey sandwiches, and mashed potatoes.

As conditions change, goals are met, interventions are determined to be ineffective, or as specific treatable causes of nutrition-related problems — for example, chewing difficulties and poor appetite — are identified, the nutrition care plan should be updated (2).

The Bottom Line

Nutrition care plans are an important component of documentation in long-term care that ensure residents maintain acceptable parameters of nutrition.

They must include the resident and be updated as conditions change, goals are met, interventions are determined to be ineffective, or as specific treatable causes of nutrition-related problems are identified.