NUTRITION CARE PROCESS

Age:
Initials:

Male/Female
Date:
A
Admitting diagnosis: ___________________________________________________________________
Relevant Medical/Surgical History: ________________________________________________________
_____________________________________________________________________________________
Pertinent Medications:___________________________________________________________________
_____________________________________________________________________________________
PHYSICAL ASSESSMENT
Age________

Ht________

Chewing/Swallowing issues:

Admt wt__________

BMI_________

Nausea/Vomiting:

UBW________
Elimination:

Weight Change ________

LABORATORY ASSESSMENT
Date

Lab
Na
K
Glu
BUN
Cr

Result

Date

Lab
S. Alb
Prealbumin
Hgb
Hct
T. Chol

Result

Date

Lab

Result

NUTRITION EVALUATION
Present Diet Order:___________________________________ Intake__________________________________
Dietary Supplement: _____________________ Enteral/Parenteral Regimen provides:_______________________
Diet/intake PTA _____________________________________________________________________________
Diet history as appropriate: _____________________________________________________________________
___________________________________________________________________________________________
ESTIMATED NUTRITIONAL NEEDS
Calories: __________________

Protein: _______________________ Fluid needs:

_________________________

Increased requirements for: ______________________________________________________________________

Method and rationale: __________________________________________________________________________

NUTRITION DIAGNOSIS:

INTERVENTION

ME

MONITORING AND EVALUATION