Dietetics EPA2 Establish and implement evidenced based nutrition goals, aims and care plan

This EPA includes: - Identification and prioritisation of nutritional problems and aetiology using information gathered through EPA 1. - The use of clinical reasoning skills and knowledge of the evidence base to create nutrition goals, aims and plan for the patient.

Context: Adult patients in the critical care setting requiring oral or enteral nutrition. It is recommended that EPA 1 is completed before EPA 2.

Limitations: Does not include assessment of patients requiring parenteral nutrition

Print this EPA

You can print this EPA in a completable template by clicking print below.

If you select any prior completed EPAs via the options below the printable form will automatically mark these as "achieved".

EPA overview information
Required knowledge and skills
  1. C3Framework Shared AHP Competencies
  2. C3Framework Dietetics Domains:
    • Assessing Nutritional Risk
    • Biochemistry
    • Effects of Critical Illness on Nutritional Interventions
    • Refeeding Syndrome
    • Gastrointestinal Function
    • Estimating Targets
    • Nutritional Routes
    • Nutritional Products
    • Nutritional Diagnosis
    • Dietetic Care Plan
Assessment to measure progress
  • Anonymised patient records of patient assessments
  • Supervision documentation
  • Reflective reports
Basis for formal entrustment decisions

An entrustment decision should be made by an experienced critical care dietitian after observing this EPA completed on more than one patient.

Use the EPA Completion Template (PDF, 88KB) for this.

Previously completed EPAs:
If you have completed any previous EPAs, select them here
to highlight where competencies have already been met.

Shared AHP competencies

Competency description Self assessment Senior assessment


Infection Prevention and Control:

Able to demonstrate knowledge of general infection control prevention and control including hand hygiene, aprons, masks and aseptic non-touch technique


Patient Emergency Management:

Has completed Basic Life Support Training as per local trust policy


Describes how they would summon help in an emergency and locate crash bells


Describes how to call a medical emergency call via switch


Describes own role and expected contribution in medical emergency eg. Basic Life Support, providing assistance to MDT as able


Patient ID:

Demonstrates positive patient identification and awareness of allergies


Monitoring Vital Signs:

Demonstrates how to monitor vital signs (Temp, HR, SpO2, RR, blood pressure, MAP)


Interprets observations in an ICU setting, considering trends and normal ranges for all (Temp, HR, SpO2, RR, blood pressure)


Able to troubleshoot difficulties with taking vital signs eg. poor trace on pulse oximeter, missing ECG leads, positional sensitivity of arterial line


Awareness of who to escalate concerns to in relation to patient safety with recognition of different levels of urgency and reporting to different staff members dependent on situation



Can describe the bed numbering, storage location of safety equipment, location of offices and other key areas within the critical care unit


Can describe the shift patterns and handover process of other MDT members


Able to identify key MDT members by their role, including critical care nurses, nurse in charge, consultant on call


Demonstrates how to locate the local protocols and guidelines relevant to own role


Has an awareness of key ICU meetings relevant to role e.g. MDT meetings, handovers, safety briefings, teaching sessions.


Can identify standard ICU bedspace equipment and location of equipment necessary for role



Communication with patient:

Describe barriers to communication in ICU including those associated with PPE, illness and ICU interventions.


Awareness of communication aids with patients to overcome communication barriers i.e. PPE + oral intubation


Communication with family + friends:

Describe the support services available to help liaise with family including family support nurses, PALS, psychology services as appropriate.


Describe barriers to communication with family and methods to improve this


Knows importance of confidentiality and consent to share information with friends and family


Communication with colleagues:

Awareness of peer support and psychological support



Local IT Training:

Demonstrates how to access and document in patient records using local IT systems


Demonstrates how to view results and imaging on local IT systems


Moving and Handling

Awareness of Falls prevention and who to escalate to if concerned regarding falls risks


Compliant with Manual Handling training as per local trust policy.


Non-technical skills


Demonstrate working in an MDT by building and maintaining relationships with other professions


Aware of the roles and responsibilities of other members of the MDT


Clarifies, accepts and executes tasks delegated by the team leader


Explains the importance of highlighting safety issues / concerns to a member of your team in a prompt manner


Uses appropriate level of assertiveness for the clinical situation


Demonstrates a logical and systematic handover using local format


Outline how to escalate and to whom if there are patient / safety concerns


Identify and respond to patient / staff safety issues appropriately


Clinical Assessment and Basic Life Support


Demonstrate ways to open up airway using simple manoeuvres (inc. repositioning, head tilt chin lift, jaw thrust)


Demonstrates how to deliver manual ventilation using two person bag-valve-mask (BVM) technique


Recognise and escalate airway compromise in a tracheostomised patient


Mouth care:

Demonstrates how to perform and document oral hygiene



Knows the types of oxygen delivery system and their limitations (including reservoir mask, simple face mask, venturi system and nasal cannulae)


Demonstrates how to deliver oxygen urgently (including reservoir mask, simple face mask, venturi system and nasal cannulae)


Describe how to escalate or de-escalate oxygen therapy in a step wise manner eg. nasal cannulae to face mask.


Lines and attachments:

Recognise different lines and their location relevant to local population (eg arterial lines, central line, vas-cath)



Identify enteral feeding tube in situ, whether it is connected to feed and whether the feed pump is running


Knows to discuss plans with nursing staff prior to moving or reposition a patient with NG feed running


Aware of events which can displace feeding tubes and to escalate accordingly


Describes how to check enteral feeding length and escalates if tube length has changed


Describe how to recognise dysphagia and an escalation plan including referral to SLT


Demonstrates how to assist patients with eating and drinking


Have an awareness of modified diets or thickened fluids in line with SLT recommendations



Demonstrate how to categorise neurological status using the AVPU scoring


Describe factors that may cause or contribute to delirium


Describes how to recognise delirium


Demonstrates how to complete a CAM-ICU score


Demonstrates an understanding of non-pharmacological management of delirium


Demonstrates knowledge of the Mental Capacity Act, when capacity assessment is indicated, how to assess capacity and when specialist communication support is required eg. referral to SLT



Demonstrates how to use pain faces or a similar visual analog scale


Demonstrates an understanding on the impact of pain on patient presentation eg. agitation


Demonstrates an understanding of the impact of pain medication on patient presentation eg. sedative effect



Demonstrates an understanding of RASS (or alternative sedation) scoring system


Able to access and read using ICU drug charts


Demonstrates an awareness of common ICU sedative medications


Demonstrates a basic knowledge of common ICU medications and their role e.g. sedatives, vasopressors, inotropes


Core competencies

Competency description Self assessment Senior assessment

Assessing Nutritional Risk

Identifies and prioritises patients who would be at high nutritional risk


Interprets measured anthropometry and critically analyses accuracy of measurements


Selects most accurate anthropometry for use in establishing nutrition care plan



Implements appropriate nutrition care plan to manage abnormalities (i.e low electrolyte feeds / semi elemental feed)


Advocates for abnormal biochemistry in relation to nutrition care plans within the MDT


Effects of Critical Illness on Nutritional Interventions

Implements appropriate nutrition care plan based on organ failure / organ support requirements. Considerations made but not limited to:

  • ventilation status and mode of ventilation;
  • propofol dose;
  • cardiovascular support;
  • Renal function (Renal replacement therapy, fluid balance goals and urine output);
  • Blood glucose control

Refeeding Syndrome

Identifies patients at risk of refeeding and implements appropriate nutrition care plan in critical care setting


Requests appropriate management of refeeding with the MDT (i.e. prescription of Pabrinex, electrolyte monitoring frequency, electrolyte replacements)


Gastrointestinal (GI) Function

Able to recognise relevant medications and describe how they impact the GI tract

  • Intravenous (IV) fluids;
  • Electrolytes (IV and enteral);
  • Laxatives (including mode of action);
  • Prokinetics;
  • Proton pump inhibitors (PPIs);

Awareness of:

  • Local Gastric Residual Values (GRVs) protocol ;
  • Local bowel protocols;
  • The use of faecal management systems to protect wounds.

Implements appropriate nutrition care plan for patients at risk of absorption and / or motility problems


Implements appropriate nutrition care plan for patients on medication with drug-nutrient interactions


Considers discussion with pharmacy / medical team regarding change to IV medication where indicated (i.e. poor absorption / tolerance, inability to meet nutritional targets in reduced feeding times)


Advocates for suggested management of:

  • High gastric residual values (GRVs / aspirates);
  • Diarrhoea / constipation;
  • High stoma output;
  • Fasting for procedures (if local guidance available).

Estimating Targets

Able to calculate energy, protein and micronutrient requirements for specific patient groups including but not limited to:

  • Ventilated and self-ventilating patients
  • Obese
  • Renal failure (on and off filter regimens)
  • Pressure areas
  • Disease specific requirements (based on local patient population, i.e. Liver, Surgical, Trauma, ARDS, COVID, ECMO)

Considers metabolic phase of critical illness when calculating nutritional requirements


Nutritional Routes

Able to identify and recommend appropriate feeding route(s) (PO / EN / PN)


Able to identify and recommend enteral feeding tube (gastric, post-pyloric)


Able to identify and recommend appropriate use of nasal bridles and mittens


Identifies and communicates with relevant MDT members when long-term feeding tubes are indicated


Identifies and communicates with relevant MDT members when there are concerns over swallow safety


Identifies and communicates with relevant MDT members when parenteral nutrition is required


Nutritional Products

Able to select an appropriate nutritional products and devise appropriate feeding regimen (oral and enteral)


Nutritional Diagnosis

Able to devise appropriate nutritional diagnosis for critically unwell patient


Dietetic Care Plan

Able to demonstrate clinical reasoning skills


Able to formulate aims and goals of nutrition intervention considering all clinical parameters


Able to develop appropriate nutrition care plan based on aims and goals


Communicates dietetic care plan with MDT