Nutrition Care Process Worksheet

Patient ID GI disorders
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. Pt reports she doesnt follow any diet at

home.
2. Pt consumes all her intakes orally.
3. Pt is currently on a multivitamin,
vitamin K supplement, and vancomycin.
4. Pt is not knowledge about why she is
having N/V and diarrhea.
5. Pt takes her medicines daily and has a
positive attitude.
6. NO factors affecting access to food or
food/nutrition related supplies.
7. No physical activity noted.
8. N/A
1.
2.
3.
4.
5.
6.
7.

62
95#
Small
No wt changes noted.
BMI 17.4
N/A
IBW: 110#, %IBW: 86%

BUN 5, CR 0.3, Ca 7.6, K 3.1

1. Pt appears tired but engaged in the

conversation.
2. Pt has a positive body language and
seemed interested.
3. N/A
4. Normal
5. Positive for Cdiff
6. Normal
7. Normal
8. Normal
9. Temp: 96.7 F, BP 118/69
1. Pt is 84 year old Causcian female who is
presented with N/V and diarrhea. Pt hx
includes high cholesterol, heart disease,
and osteoporosis.

3. Social history

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

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

2. Both parents are diseased.

3. Pt lives at a nursing home and does not
drink or smoke.
1. Mifflin-St Joer
161 + 10 (43.2 kg)+ 6.25 (157.5 cm) -5
(84) =1,157.4 kcal/day
2. 0.8-1g pro/kg = 34.6- 43.2 g pro/day
3. 25ml/kg= = 1080ml
4. Multivitamin/ mineral supplement that
meets RDA.
5. N/A

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

(P) Diagnosis or Problem

1. Increased nutrient needs for protein and calories
2. Altered GI function
Related to
(E) Etiology
1. increased biological demand for nutrients
2. poor appetite and diarrhea
As Evidenced by
(S) Signs/Symptoms
1. pt with stage 1 pressure ulcer
2. cdiff diagnosis

Expanded Nutrition Diagnostic

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

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 Supplement Therapy (ND 3) to send Magic Cup supplement QD at PM snack to promote
adequate caloric intake and to aid in wound healing. Send yogurt BID at breakfast and lunch to
promote adequate calorie and prebiotic intake.
Intervention

Monitor intake of supplements and snacks.

#1
Goal

Pt will intake 50% of yogurts.

#1
Goal

Pt will intake 50% of Magic Cup.

#2
Intervention
#2
Goal
#1

Monitor intakes of food trays.

Pt will intake >50% of all trays.

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

Energy Needs (C 1.1.2) are increased due to pressure ulcer and diarrhea with diagnosis of c-diff.

Intervention and goal/expected

Send Magic Cup QD and yogurt BID.

outcome
Indicat Monitor intakes of supplements

Criteri

Pt will eat >50% of supplements and

or

snacks.

and snacks.