Nutrition Care Process Worksheet

Patient ID: Weight Control/Obesity

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

Pt does not follow a specific diet at home.

Currently receiving a regular diet. Pt
consume 100% of x2-3 meals/day. Able to
feed self. Pt reports good appetite.
Medications: Sodium chloride @ 80 ml/hr;
Vitamin D3; Folic acid; heparin;
meropenem IV; nystatin; omeprazole;
Vitamin B1; vancomycin;
Pt presented with cellulitis. Has a past
medical history of morbid obesity s/p
gastric bypass surgery in 2013, GERD,
recurrent cellulitis and lymphedema.
Nutrition screen negative for referral
triggers. Pt has large lymphedemas on
both R and L interior thighs, which he
reports make it difficult for him to walk. Pt
reports he typically consumes one big
meal, and consumes x2 smaller meals
later in the day due to being still full from
the first meal. Pt reports he usually drinks
regular soda and juice. Pt states he is
scheduled to meet with an RD after
discharge.
No reported limitations in accessing food.

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

Ht: 1.88 m (6 2.02)

Wt: 284.859 kg (628 lb)
BMI: 80.6 kg/(m2)
102 lb wt gain x1.5 years

Na 134, K 3.5, Cl 104, CO2 23, BUN 11,

Creatinine 0.77; Glucose 134; Ca 8.1

Pleasant obese male who is currently

bedridden due to large lymphedemas

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
3. Social history

located on both interior thighs. Bowel

sounds WNL. Skin is dry and flaky.

Pt has an active problem list of cellulitis

of left lower extremity, morbid obesity,
acute renal failure; anemia; HTN,
lymphedema, sepsis, thrombocytosis;
candidiasis; hypokalemia, bacteremia;
GERD;
Pt is single and lives alone.

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

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

Pt states that after his bariatric surgery

he lost 200 lbs, but when his father
became ill he was focusing more on his
father and not his health. Pt reports
that his father passed away 1 year ago
and he gave up on taking care of
himself. Pt states that he is ready to
start losing weight again.
Estimated energy needs (based on
adjusted body weight of 133.9 kg):
Kcal: 2410-2680
Protein: 107 g 134 g
Fluid: 3000 ml

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

Limited adherence to nutrition related recommendations

Related to
(E) Etiology
Food and nutrition related knowledge deficit concerning how to make nutrition related changes

As Evidenced by
(S) Signs/Symptoms
Pts comments on current food/beverage choices

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
RD to provide education on consuming a balanced diet for the healthy adult man. Diet
education to cover portion sizes, building a balanced meal, healthy drink choices, whole grains,
lean protein sources, and increasing fruit and vegetable consumption.

Intervention

Consuming a balanced diet for an adult man

#1
Goal

Pt to understand portion sizes

#1
Goal

Pt to understand daily serving amounts of grains, proteins, fruits and vegetables

#2
Goal

Pt to understand healthy drink choices

#3

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

RD to follow up with pt, to assess if there has been an improvement in pt nutrition related
knowledge deficit.

Intervention and goal/expected

outcome

Pt will understand and follow recommendations for creating

a balanced diet, and portion control.

Understand and follow portion
Criteri Pt will be able to demonstrate portion
size recommendations.

sizes by showing knowledge of nutrition

label reading and knowing basic portion
sizes by using his hand (ie. Portion of

Indicat

meat should be about the size of your

or
Indicat

Consuming more fruits and

Criteri

palm).
During hospital stay, pt will have been

or

vegetables

attempting to consume fruits and

vegetables closer to the recommend

Pt will be consuming more whole

Criteri

daily amount.
Pt will be able to name adequate sources

grains and lean meats, and

for lean meats and whole grains.

Indicat

avoiding fatty meats and simple

or

carbohydrates.