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Nutrition Care Process Worksheet

Patient ID Jose
Possible Nutrition Diagnosis

Step 1 - Nutrition Assessment


Food/Nutrition-Related History
1. Food and nutrient intake
2. Food and nutrient administration
3. Medication and
complementary/alternative medicine
use
4. Knowledge/beliefs/attitudes
5. Behavior
6. Factors affecting food access and
food/nutrition-related supplies
7. Physical activity and function
8. Nutrition-related patient/client-centered
measures
Anthropometric Measurements
1. Height/length
2. Weight
3. Frame size
4. Weight change
5. Body mass index
6. Growth pattern indices/percentile ranks
7. Body composition estimates
Biochemical Data, Medical Tests and
Procedures

Nutrition-Focused Physical Findings


1. Overall appearance
2. Body Language
3. Cardiovascular-pulmonary
4. Extremities, muscles and bones
5. Digestive system
6. Head and eyes
7. Nerves and cognition
8. Skin
9. Vital signs
Client History
1. Personal history
2. Patient/client/family medical/health
history

1. Pts mother is concerned about his


weight.
2. Pt consumes his intakes orally.
3. Pt is not on any medications.
4. Pt mother is wanted information on how
to cook healthy and wants her entire family
to eat better.
5. Pt mothers reports she is taking steps to
eat healthier by not buying certain foods
like soda pop.
6. No factors affecting access to food or
food/nutrition related supplies.
7. Pt plays soccer and is active daily.
8. N/A
1. 50
2. 101#
3. Large
4. rapidly gaining weight since age 2
5. 28
6. over the 100th percentile for weight for
height
7. IBW: N/A for age
N/A

1.
2.
3.
9.

Pt here with mother, sister, and brother.


Pt mother interested, kids playing.
-8. Normal
N/A

1. 8 year old male here for weight loss. Pt has


history of being over weight. Pt in second
grade. No major medical history.
2. Grandparent has diabetes.

3. Social history

3. Pt lives at home with 1 brother, 3 sisters,


and parents.

Critical thinking:
1. Determine appropriate data to collect
2. Select valid and reliable tools for data collection
3. Select appropriate norms and standards for comparing data
4. Organizing the data in a meaningful way that relates to the nutrition problem
5. Categorizing the data in a meaningful way that relates to the nutrition
problem

Step 2 Nutrition Diagnosis


Intake (NI)
Class 1 Energy Balance (NI-1.1 to NI 1.5)
Class 2 Oral or Nutrition Support Intake (NI2.1 to
NI-2.11)
Class 3 Fluid Intake (NI-3.1 to NI-3.2)
Class 4 Bioactive Substances Intake (NI-4.1 to
NI 4.3)
Class 5 Nutrient Intake (NI-5.1 to NI-5.4)
Subclass 5.5 Fat and Cholesterol (NI-5.5.1 to
NI-5.5.3)
Subclass 5.6 Protein (NI-5.6.1 to NI-5.6.3)
Subclass 5.7 Amino Acid (NI 5.7.1)
Subclass 5.8 Carbohydrate and Fiber (NI5.8.1 to 5.8.6)
Subclass 5.9 Vitamin (NI-5.9.1 to NI-5.9.2)
Subclass 5.10 Minerals (NI-5.10.1 to NI5.10.2)
Subclass 5.11 Multi-nutrient (NI-5.11.1 to NI5.11.12)
Clinical (NC)
Class 1 Functional (NC-1.1 to NC-1.5)
Class 2 Biochemical (NC-2.1 to NC-2.4)
Class 3 Weight (NC-3.1 to NC-3.6)
Class 4 Malnutrition Disorders (NC-4.1)
Behavioral-environmental (NB)
Class 1 Knowledge and beliefs (NB-1.1 to NB1.7)
Class 2 Physical Activity and Function (NB-2.1 to
NB-2.6)
Class 3 Food Safety and Access (NB-3.1 to NB3.3)
Other
No nutrition diagnosis at this time (NO-1.1)

Class of
Diagnosi
s

Expanded Nutrition Diagnostic


Terminology found in the eNCPT
located at:
https://ncpt.webauthor.com/

(P) Diagnosis or Problem


Obesity, class II
Related to
(E) Etiology
Hx of excessive energy intake and hx of high fat diet
As Evidenced by
(S) Signs/Symptoms
Pt over the 100th percentile on weight for height chart.

Step 3 Nutrition Intervention


Food and/or Nutrient Delivery (ND)
Meal and Snacks (ND-1.1 to ND-1.5)
Enteral and Parenteral Nutrition (ND-2)
Enteral Nutrition (ND-2.1.1 to ND-2.1.9)
Parenteral Nutrition/IV Fluids (ND-2.2.1 to ND-2.2.8)
Nutrition Supplement Therapy (ND-3)
Medical Food Supplement Therapy (ND-3.1.1 to ND-3.1.5)
Vitamin and Mineral Supplement Therapy (ND-3.2.1 to
ND-3.2.4)
Bioactive Substance Management (ND-3.3.1 to ND-3.3.9)
Feeding Assistance (ND-4.1 to D-4.6)
Manage Feeding Environment (ND-5.1 to ND-5.9)
Nutrition-Related Medication Management (ND-6.1 to ND6.3)

Expanded Nutrition
Diagnostic Terminology
found in the eNCPT located
at:
https://ncpt.webauthor.com/

Nutrition Education (E)


Nutrition Education-Content (E-1.1 to E-1.7)
Nutrition Education-Application (E-2.1 to E-2.3)

Nutrition Counseling (C)


Theoretical basis/approach (C-1.1 to C-1.5)
Strategies (C-2.1 to C-2.11)

Coordinated of Nutrition Care by a Nutrition


Professional (RC)
Collaboration and Referral of Nutrition Care (RC-1.1 to RC1.6)
Discharge and Transfer of Nutrition Care to New Setting or
Provider (RC-2.1 to RC-2.3)

Nutrition Prescription
Nutrition Education (E1-2) on a general healthy diet including tips to avoid fast food, avoid
processed meats like hot dogs, bacon, chicken nuggets, and consume lean meats like chicken,
ground turkey, and low fat red meat. Encouraged pt mother to cook with olive or coconut oil
instead of butter. Encouraged pt mother to prepare large amounts of food to have ready instead
of going to a fast food place. Encouraged pt mother to limit pop and sweet juices to the children.
Intervention

Provided education on a general healthy diet and gave My Plate handout to pt

#1
Goal

mother.
Pt mother will be able to state what foods should be avoided and are healthy instead.

#1
Goal

Pt mother will make sure children and pt are active.

#2

Step 4 Nutrition Monitoring and Evaluation


Food/Nutrition-Related History
1. Food and nutrient intake
2. Food and nutrient administration
3. Medication and complementary/alternative medicine
use
4. Knowledge/beliefs/attitudes
5. Behavior
6. Factors affecting food access and food/nutritionrelated supplies
7. Physical activity and function
8. Nutrition-related patient/client-centered measures
Anthropometric Measurements
1. Height/length
2. Weight
3. Frame size
4. Weight change
5. Body mass index
6. Growth pattern indices/percentile ranks
7. Body composition estimates
Biochemical Data, Medical Tests and Procedures
Nutrition-Focused Physical Findings

Diagnostic Terminology
found in the eNCPT located
at:
https://ncpt.webauthor.com
/

Comparative Standards
1.
2.
3.
4.
5.

Energy needs
Macronutrient needs
Fluid needs
Micronutrient needs
Weight and growth recommendations

Targets on nutrition intervention


Food and Nutrition Knowledge/Skill (FH 4.1) will increase regarding a general healthy diet.
Intervention and goal/expected

Increase food nutrition related knowledge and healthy

outcome
cooking tips.
Indicat Conversation with pt mother
Criteri

Pt mother will be able to tell us healthy

or
Indicat

a
Criteri

cooking methods she has used.


Pt will bring food records to go over at

next apt.

or

Recored by pt mother