Nutrition Care Process Worksheet

Patient ID: GI
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 eats 5-6 small bland meals throughout

the day to help manage abdominal pain
and diarrhea. Pt tries to avoid heavy
meals such as pasta. Pt consumes meals
po.
Medication: Famotidine; methylprednisone;
flagyl; nicotine patch; hydromorphone;
Pt presented with complaints of nausea,
diarrhea, and RLQ pain x4 days, with a
primary problem of an AKI. Pt was dx with
Crohns disease in 1980. Pt has a H/O
noncompliance with medical treatment
presenting hazards to health. Pt reports
poor appetite x4 days PTA. No reports of
vomiting, chewing/swallowing issues, or
constipation. C-diff negative.
No reported issues with limited access to
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
2. Body Language
3. Cardiovascular-pulmonary
4. Extremities, muscles and bones

Ht: 55
Wt: 46.2 kg (101 lb)
BMI: 16.95
Weight Hx:
02/07/15 56.7 kg (125 lb)
02/05/15 61.7 kg (136 lb)
08/25/14 59.8 kg (136 lb)
35lb wt loss x14 months (25% et loss
x14 months, significant)
Na 143; K 4.5; Cl 119; CO2 18; BUN 17;
Creatinine 1.25; Glucose 117; Calcium
8.3; Mg 2.0; Albumin 3.8; Total Bilirubin
0.3; AST 12; ALT 9; ALK PHOS 109;
Lipase 70;

Pt appeared thin. Pt reported frequent

diarrhea, nausea, and abdominal pain
after eating.

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

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

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

Pt was dx with Crohns disease in 1980;

Pt has a PMH of anemia, depression,
anxiety, enterovesical fistula, PID, H/O
noncompliance with medical treatment,
chronic abdominal pain, small bowel
obstruction, and ovarian cysts. Pt does
all of her own cooking and grocery
shopping.
1400-1620 kcal/day
51-65 gm Protein/day
1400-1620 ml H2O/day

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

Class of
Diagnosi
s

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)

Expanded Nutrition Diagnostic

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

(P) Diagnosis or Problem

Possible inadequate oral intake

Related to
(E) Etiology
Decreased ability to consume sufficient energy

As Evidenced by
(S) Signs/Symptoms
Significant weight loss of 35lb x14 months (25% wt loss) and reports of poor appetite PTA

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 comprehensive education on nutritional management of Crohns disease. Diet
instruction to include frequency and size of meals, low-fat food choices, low sugar food choices,
and low fiber foods.

Intervention

Comprehensive nutrition education

#1
Goal

Pt to understand size and frequency of meals for IBD

#1
Goal

Pt to understand low fat and low sugar food options

#2
Goal

Pt to understand low fiber food options

#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 evaluate ability to make appropriate food choices to help control
symptoms of IBD, and the effectiveness of the diet education.

Intervention and goal/expected

outcome

Pt will understand and follow and understand IBD nutrition

therapy diet to help control symptoms of IBD.

Understand and follow eating
Criteri Pt will consume 5-6 small meals per day,
more frequent, small meals

Indicat

throughout the day.

and will be able to provide an example of

a small meal. Pt will also be able to

or
Pt will understand and follow low

Criteri

maintain her weight.

Pt will be able to name example of low

fat and low sugar food options.

fat and low sugar food options, and will

have decreased frequency of IBD

Indicat

symptoms such as diarrhea and

or

abdominal pain.

Indicat
or

Pt will understand and follow a

Criteri

Pt will be able to provide examples of low

low fiber diet.

fiber foods and correctly pick them from

a menu.