Professional Documents
Culture Documents
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
Radiation
Chemotherapy
Left thoracoscopy with biopsy of mediastinal
mass
1. 175.26cm
2. 132.109
3. Large
4. Lost 30lbs in past few months
5. 43.0
6. N/A
147% ideal body wt
1. Fatigue
2. normal
3. Orthopnea/ chest pain/ dyspnea
cough/ pleuritic chest pain/
4. No pedal edema and normal pulse
5. Dysphagia no cough/ normal bowel
sounds
6. Normal S1, Normal S2/ neck supple
7. Normal speech/ no head aches
8. No rashes/ no breakdown/ X3
WBC 15.05
RBC 3.99
Hgb 12.3
Sodium 133
Creatinine 0.57
Glucose 149-156
Albumin 2.9
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
oriented
9. BP 151/85/ pulse 102/ temp. 97.7
resp rate 22
1. COPD, HTN , N/V 1 month,
depression
2. CAD (mother), cancer (brother)
1. 2,400-2,5080 (28-30kcal/kg)
2. 86-103 (1-1.2g/kg)
3. 2,400ml
4. N/A
5. Pt needs to keep a stable wt during
cancer treatment
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
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)
Related to
(E) Etiology
Inability to take adequate po and increases metabolic needs
As Evidenced by
(S) Signs/Symptoms
Pt only drinking liquids at home, 30lb wt loss/few months, lung cancer and large mediastinal
mass
Expanded Nutrition
Diagnostic Terminology
found in the eNCPT located
at:
https://ncpt.webauthor.com/
Nutrition Prescription
High protein and high calories recommended for wt stability and to maintain lean body mass
during chemo tx. Pt
Given some modification for high calorie foods because of severe reflux.
Intervention
#1
Goal
#1
Goal
#2
Goal
#3
Intervention
#2
Goal
#1
Goal
#2
Goal
#3
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
outcome
Indicat Weight
Criteri
or
Indicat
a
Criteri
calories
or
Indicat
a
Criteri
or
outcome
Indicat Pt understand food he can eat
Criteri
or
Indicat
a
Criteri
or
Indicat
a
Criteri
or
appropriate foods
Less N/V and increased intakes