New Era University

College of Nursing

NUTRITION CARE PROCESS

(with integrated Drug Study & Health Education Plan)

Client’s Name: _______________________________ Sex: __________ Age: __________

Marital Status: ____________ Height: __________ Weight: _______ BMI: ____________
Date of Interview: ___________________________ Interviewer: _________________

I. Assessment Phase

A. Medical History

a. Present Illness & Chief Complaint

b. Past Illness & Surgery, allergies, hospitalization, etc.

c. Physical state of health: height & weight, BMI, WHR, appetite, digestion,
elimination problems, nutriture, etc..

B. Socio-economic Background

a. Ancestry or ethnic Background:

b. Type of Family

c. Occupation

d. Educational Attainment

e. Religion:

f. Type of Residence:

g. Income Bracket:

h. Recreation/ Habit/ Exercise:

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C. Dietary History

a. Food likes & dislikes

b. Frequency of Meals & Time eaten

c. Cooking Facilities

d. Food budget per person

e. Other sources of nutrients (pills, supplements)

f. Past dietary restrictions and medical reasons

g. Nutritional knowledge and Its Source

D. Dietary Needs while in the Hospital (optional)

a. Food likes and dislikes

b. Present Dietary Prescriptions & Rationale

d. Appetite: Ability to chew, any vomiting, cramps, abdominal distention.

e. Any Physical handicap

f. Food tolerance

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E. 24-hour Diet Recall

a. What time did you go to bed the other night?

__________________________________________________________________
__________________________________________________________________

Was this the usual time?

__________________________________________________________________
__________________________________________________________________

b. What time did you get up yesterday morning? ____________________________

Was this the usual time? _________________________

c. When was the first time you had anything to eat or drink?
__________________________________________________________________
__________________________________________________________________

What did you have and how much?

__________________________________________________________________
__________________________________________________________________

d. When did you eat again? _________________________________

Where? ___________________________________________

What and how much?

__________________________________________________________________
__________________________________________________________________

e. When did you eat next? ___________________________________________

What did you eat and how much?

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

f. Did you eat or drink anything else? _________________________________

1. Anything between first and second meal? ____________________________
2. Anything between 3rd and 4th meal? _________________________________
3. Anything from 3rd meal to bed time? ________________________________

g. Was this day’s food intake different from usual? If so, why?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

h. Is weekend eating different? If so, why?

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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 Food & Fluid Intake from Time of Awakening until the Next Morning 24-hour Recall

Time Food & Drink Consumed

Number of Servings in the Food Groups
Name & Type Amount Milk Meat Vitamin A Vitamin C Vegetable- Bread & Butter, Fat, Miscellaneous
Group Group Group Group Fruit Cereal & Oil
Group Group

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F. Food Frequency Questionnaire

1. Do you drink milk? If so, how much? _________________________

What kind of milk? ________ Full Cream
________ Whole Milk
________ Low Fat Milk
_________ Others

2. Do you use fat? If so, what kind? ___________________________

How much? ____________________

3. How many times do you eat meat? ____________________

Eggs__________ Cheese _________ Beans __________

4. Do you eat snack foods? If so, which ones?

__________________________________________________________________
__________________________________________________________________
How often? ____________ How much? ________________________

5. What vegetables do you eat? (in each group).

How often? _____________________
a. Broccoli ______ Bell Pepper __________
Cooked greens _________ Carrot __________
Sweet potato ________

b. Tomato _______ Cabbage/ Pechay ________

Cauliflower ___________ Okra _______
Peas ________ Celery ______ Lettuce ________

c. Others ______________________________________________________

6. What fruits do you eat and how often?

a. Apples ___________ Pears ___________
Banana ___________ Berries _________
Grapes ___________ Pineapple __________ Raisins _________

b. Oranges/ Ponkan ________ Calamansi _________

Guava ________ Mango _________

c. Others _________________________________________________

7. Bread & Cereal Products

a. How much bread do you usually eat with each meal ? _______
Between meals? _____________

b. Do you eat cereal? _________ frequency ____________

Cooked ______________ dry _____________

c. How often do you eat foods such as macaroni, spaghetti, noodles, and the
like? _________________________________

8. Do you use salt? ____________

Do you crave for salty foods? _______________________

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9. How many teaspoon of sugar do you use per day? ____________________

10. Do you drink water? __________________

How often during the day? _____________________

How much each time? _______________________

How much would you say you drink each day? ____________________

11. Do you drink alcohol? ___________ How often? _________

How much? ___________

Beer, wine, vodka, others? __________________________________________

G. Dietary History

1. Economics
Amount of money for food each week or month and individual perception of its
adequacy for meeting food needs.
__________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

2. Physical Activity
a. Occupation
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

b. Exercise
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

c. Sleep – hours per day ____________________________________________

3. Ethnic & Cultural Background

a. Influences on eating habits
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

b. Religion
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

c. Education
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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4. Home Life & Meal Patterns
a. Number of Household members: _______________________________
b. Person who does shopping: ____________________________________
c. Person who does cooking and relationship to this person
___________________________________________________________
d. Food storage & cooking facilities
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

e. Type of housing _____________________________________________

f. Ability to shop & prepare food
__________________________________________________________________
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5. Appetite
a. good, poor, any changes
__________________________________________________________________
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__________________________________________________________________
b. Factors that affect appetite
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c. Taste & smell perception
__________________________________________________________________
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6. Allergies, Intolerances, and Food Avoidance

a. Foods avoided and reason
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

b. Length of time of avoidance

7. Dental & Oral Health

a. Problems with eating
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

b. Foods that cannot be eaten

__________________________________________________________________
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__________________________________________________________________

c. Problems with swallowing, salivation, and food sticking

__________________________________________________________________
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 8. Gastrointestinal Concerns
a. Problems with heartburn, bloating, gas, diarrhea, constipation, distention
__________________________________________________________________
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b. Frequency of problems
_______________________________________________________________
_______________________________________________________________
c. Home remedies
_______________________________________________________________
_______________________________________________________________
d. Drugs used
_______________________________________________________________
_______________________________________________________________

9. Chronic diseases
__________________________________________________________________
__________________________________________________________________
a. Treatment
_______________________________________________________________
_______________________________________________________________
b. Length of time of treatment
_______________________________________________________________
_______________________________________________________________
c. Dietary modifications
_______________________________________________________________
_______________________________________________________________

10. Medications
a. Vitamins or minerals supplement
_______________________________________________________________
_______________________________________________________________
b. Other medications
_______________________________________________________________
_______________________________________________________________

H. Food Diary/ Record – record two weekdays and one weekend day.

Time Place Client Meal Amount of Name &

Time Food Served Type of Food

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 I. Observation of Food Intake
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

J. Physical Assessment related to Nutritional Status

Body Area/ Part Findings Analysis/ Interpretation
1. Hair

2. Face

3. Eyes

4. Lips

5. Teeth

6. Gums

7. Glands.

8. Tongue

9. Skin

10. Nails

11. Subcutaneous
Tissue
12. Muscular &
Skeletal System
13. Internal System
a. Gastrointestinal

b. Nervous

c. Cardiac

d. Urinary

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 K. Biochemical Assessment

1. Blood Chemistry/ Enzymes/ Electrolytes

Test Findings Analysis/ Interpretation

BUN
CREA
ALT (SGPT)
SGOT
FBS
HbA1C
Triglycerides
HDL
LDL
VLDL
Total Cholesterol
Sodium
Potassium
Albumin
Others (specify)

2. Urinalysis
3. Others (please indicate results).

L. Anthropometric Measurements

1. Skinfold Thickness
Measurement Findings: __________________
Analysis & Interpretation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Body Circumferences
a. Head/ Chest Circumference Findings: _______________________
Analysis & Interpretation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

b. Mid Upper Arm Circumference (MUAC)

Measurement Findings: __________________
Analysis & Interpretation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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II. Prioritization of Identified Nutritional Problems/ Diagnosis

1. Problem No. 1
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Justification:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Diagnosis (PES format):

________________________________________________________________________
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2. Problem No. 2
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Justification:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Diagnosis (PES format):

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Problem No. 3
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Justification:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Diagnosis (PES format):

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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 C. Planning for Nutritional Care

1. Calculation of Desirable Body Weight & Energy Needs

Ador Dionisio’s Method Tannhauser’s Method

Answer: Answer:

2. Calculation of the daily energy requirement

Nutritional Measurements Answer

1. Basal Metabolic Rate (use raise to ¾
power).

2. Estimation of Daily Energy

Requirement

3. Estimation of Total Energy Need

4. Estimation of Energy Balance

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3. Calculating Diets & Meal Planning

a. Procedures

1. Following the steps in estimating desirable body weight (DBW), calculate

your total energy allowance (TEA).

2. Determine your height = ________ and actual body weight = ________ kgs

3. Calculate your basal needs = _____ x _____ kg (DBW) x 24 = _______ kcal

Male = 1 kcal/kg of DBW/hour

Female = 0.9 kcal/kg of DBW/hour

4. Estimate physical activities = _____________ kcal

Physical needs = approximate percentage increase above basal needs

(use lower factor for women)
Bed rest 10-20%
Sedentary 30%
Light activity 50-60%
Moderately active 60-70%
Severely active 90-110%

5. Add values from 3 and 4 to get TEA = ______ kcal + _____ = kcal

6. Distribute the total energy allowance among carbohydrates, proteins and fats.

7. For a normal diet, allow 65% of the total energy allowance for carbohydrates,
15% proteins and 20% fats. Thus the corresponding energy contributors of the
three nutrients are as follows:

Carbohydrates = _________ kcal x 0.65 = _______ kcal

Proteins = ________ kcal x 0.15 = _______ kcal
Fats = ________ kcal x 0.20= ________ kcal
Total = _________ kcal
8. Calculate the number of grams of carbohydrates, proteins and fats by dividing
the calories for each nutrient by corresponding physiologic fuel values (CHO
and CHON = 4 kcal/g and Fat = 9 kcal/ g).
Carbohydrates = ________ kcal/ 4 = _______ g
Proteins = ________ kcal/4 = _______ g
Fats = ________ kcal/9 = _______ g
9. For simplicity and practicality of the diet prescription (Rx), round off calories
to the nearest 50, and carbohydrates, proteins and fats to the nearest 5 g. Thus,
your diet prescription is:

Diet Rx : _______ kcal/day

______ g Carbohydrates
______ g Proteins
______ g Fats

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 4. Meal Plan for Normal Diet
Food Exchanges No. of Exchanges CHO CHON Fat Energy Meal Distributions
g g g kcal B L D Snacks
1. Vegetables

2. Fruits

3. Milk

4. Rice

5. Meat

6. Sugar

7. Fat

TOTAL

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5. Sample Menu for a Normal Diet

Breakfast Lunch Dinner

(Indicate House Hold Measures) (Indicate House Hold Measures) (Indicate House Hold Measures)

Snacks
(Indicate House Hold Measures)

AM Snack PM Snack Midnight Snack

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 D. Implementation
1. Nursing Care Plan

Assessment Analysis Planning Nursing/ Nutritional Rationale Evaluation

Interventions

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2. Drug Study (follow format given from Pharmacology lecture)

3. Teaching Care Plan (follow given format from Health Education class)

E. Monitoring & Evaluation (encompassing with the Nursing Care Plan)

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