NTDT330

Nutrition Care Plan Final Project

MyPlate Assessment Form (add or delete lines if needed) kcal:

Intake (food and amount) MyPlate Actual Intake Exceeds Standard, Meets
Standard/Equivalent Standard or Under Standard

Grains

English muffin (1 large, 2 oz

white)

Crackers (10 squares, 1.4 oz

saltines)

Tortilla (1 small, flour) 1 oz

Rice (1/2 cup, white) 1 oz

Egg roll (with pork) (1 egg ½ oz

roll)

Popcorn (3 cups) 1 oz

6 oz 6.9 oz Exceeds by .9 oz

Vegetable

Lettuce (1 cup, romaine) ½ cup

Tomato (1 cup) 1 cup

Stir fry (beef and 1 cup

vegetable) (2 cups)

Egg roll (with pork) (1 egg ¼ cup

roll)

2 ½ cups 3 ¼ cup Exceeds by ¾ cup

Fruit

Apple juice (1 cup) 1 cup

2 cups 1 cup Under by 1 cup

Dairy

Cheese (American, 1 slice) 1/3 cup

3 cups 1/3 cup Under by 2.7 cups

Protein

Eggs (1 large) 1 oz
 Bacon (2 slices) 1 oz

Peanut butter (4 tbsp) 4 oz

Turkey (cold cut, 5 slices) 5 oz

Stir fry (beef and 3 oz

vegetable) (2 cups)

Egg roll (with pork) (1 egg ½ oz

roll)

5 ½ ounces 14 ½ oz Exceeds by 9 oz

Oils

Mayo (2 tbsp) X

Egg roll (1 pork egg roll) X

Stir fry (2 cups) X

Peanut butter (4 tbsp) X

Empty Kcals

Creamer (3 tbsp) X

Mayo (2 tbsp) X

American Cheese (1 slice) X

Egg roll (1 pork egg role) X

Stir fry (beef and veggie) (2 X

cups)

Crackers (10 squares) X

Bacon (2 slices) X

Peanut butter X

Exceeds

Assessment:
Food/Nutrition Related History:
Food and Nutrient Intake
Grains: Client consumes a diet high in refined grains, low in whole grains, and exceeds recommended grain intake by .9 oz.
Since client has a family history of HTN, increasing whole grain consumption may help reduce her risk of developing HTN
in the future and may help with goal of improving overall healthfulness of her diet. The dietary fiber that whole grains
provide may also help the client feel fuller longer and assist in weight management.
Vegetables: Client has adequate vegetable consumption, and exceeds recommendation by ¾ cup. Almost half of her
vegetable consumption comes from processed foods. Consuming a larger variety of vegetables from less processed sources,
such as steaming or sauteing her own broccoli, may help to ensure adequate vitamin and nutrient intake. Increasing vegetable
 intake may also help her feel fuller while eating less calories due to the fiber vegetables provide and may assist in weight
management.
Fruits: Client does not meet recommended fruit intake and is under by 1 cup. Client’s only source of fruit comes from apple
juice. Incorporating more fruits into her diet will ensure the client is receiving adequate amounts of vitamins and fiber and
will contribute antioxidants to the diet.
Dairy: Client does not consume adequate dairy and is under by 2.7 cups. Increasing low-fat dairy consumption is important
for the client in order to ensure adequate calcium and vitamin D intake.
Protein: Client has adequate protein intake and exceeds by 9 oz. Much of the client’s protein comes from high-fat sources,
such as peanut butter, bacon, and stir fry. Increasing lean protein consumption will help to improve the overall healthfulness
of the client’s diet and decrease the client’s fat intake, assisting with weight management.
Oils: Client’s diet contains oils that mostly come from high fat sources, which are most likely contributing extra fat to her
diet. Oils that contain healthy fats, like olive oil, may be beneficial to add to the diet to help assist with weight management
and improve the overall healthfulness of her diet.
Empty Calories: The client’s diet is very high in empty calories, which may indicate excessive calorie intake. These foods are
most likely contributing extra fat to the diet. Monitoring empty calorie intake can help to prevent further weight gain and
assist in improving overall healthfulness of the diet.
Overall Intake: Client eats about 3 meals per day and 2 snacks. The client’s diet is high in processed foods, potentially due to
eating out often. Adding whole grains, fruits, lean protein, and low-fat dairy to the client’s diet will help the client with her
goal of increasing the overall healthfulness of her diet without strict dieting and help with goal of weight management.
Fluid Intake: Client states she drinks about 1-2 glasses of water per day. Client also consumes coffee and apple juice.
Increasing water intake will help to ensure hydration and may also help curve hunger and craving and may assist with the
goal of weight management.
Prior Nutrition Education:
No prior nutrition education
Vitamins/Supplements:
Vitamin C
Beliefs:
Believes that changes in diet will help to manage weight and recent weight gain. Client does not wish to diet. Wants to set
food goals for each week. Looks to family and friends for support.
Physical Activity:
Client does not currently participate in regular physical activity. Client spends about 8 hours a day being sedentary.

Anthropometrics:
Height: 5’6
Weight: 150 lbs.
IBW: 130 lbs.
BMI: 24.2, normal weight

Biochemical Data: not available

Medical Tests and Procedures: not available

Nutrition Focused Physical Exam: not available

Client History:
Personal and Family Medical History
 Reports sudden weight change and stress
 Family history of high blood pressure on both maternal and paternal sides
 Does not follow a special dietary plan; has never followed a special diet
Social History
 Junior college student
 Lives with 3 roommates
 Prepares meals in home, roommates do shopping
 Single, unemployed
 Eats out 4-5x per week
Comparative Standards:
Based off MyPlate recommendations:
2 cups of fruit/day
2 ½ cups vegetables/day
6 ounces grains/day
5 ½ ounces protein/day
3 cups dairy/day

Estimated Needs: 2,000 kcal/day (based off MyPlate recommendations)

Client Stage of Change: Preparation Stage

Diagnosis:
1. Excessive energy intake related to consuming a diet high in fat and processed foods and low in whole grains, fruits, dairy,
and lean protein as evidenced by a food record in which the client consumes a diet high in processed foods, reports eating out
often, and reports experience with recent weight gain.
2. Food and nutrition related knowledge deficit related to no previous nutrition education as evidenced by report by client of no
previous nutrition education and client’s desire to receive nutrition education in order to improve overall healthfulness of her
diet and assist in weight management.

Interventions:
Nutrition Prescription (recommended diet/regime):
 General healthful diet – Client will increase the overall healthfulness of her diet by aiming to meet MyPlate standards of
consuming 2 cups of fruit per day, 2 ½ cups of vegetables per day, 6 ounces of grains per day with half of those grains being
from whole grain sources, 5 ½ ounces of protein per day, and 3 cups of dairy per day.
 Nutrition education on nutrition relationship to health – Client will continue to be educated about macronutrient distribution
based on MyPlate standards, the importance of consuming a balanced diet and the diet’s effect on weight management, and
methods to use in order to make the necessary and desired dietary changes.

SMART Goals:
 Client will work to increase whole grain consumption by choosing whole grain wraps, bagels, breads, etc. when eating out or
at home at least once a day for the next 2 weeks.
 Client will work to increase fluid consumption by drinking at least one 8 oz glass of water with each meal every day for the
next 2 weeks.

Monitoring & Evaluation:

 Indicator: Types of foods/meals
o Criteria: Client will work to meet MyPlate standards of 2 cups of fruit/day, 2.5 cup of vegetables/day, 6 oz of
grains/day with half of the grains coming from whole grain sources, 5.5 oz of protein/day, and 3 cups of dairy/day.
 Indicator: Oral fluids
o Criteria: Client will work to meet fluid recommendation of ~75-150 oz of water per day.