Nutrition Care Process Worksheet

Patient ID Renal Disease

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

Possible Nutrition Diagnosis

Increased nutrient needs
1. Pt tries to follow a renal and diabetic
diet at home.
2. Pt consumes all his intakes orally.
3. Pt is on insulin.
4. Pt was interested in renal and diabetes
diet information.
5. Pt was engaged in conversation.
6. No factors affecting access to food or
food/nutrition related supplies.
7. N/A
8. N/A

1.
2.
3.
4.
5.
6.
7.

65
232#
Large
No wt changes reported.
38.6 BMI
N/A
IBW: 136# %IBW: 170%

GLU 198-483, BUN 52, CR 5.2, K 3.7, Na 126,

Cl 89

1. Pt sitting in bed, looks tired.

2. Pt interested in conversation and asking
questions.
3. Hx of hypertension and high
cholesterol.
4. Pt can not walk on feet, pt wheel chair
bound.
5. Normal
6. Normal
7. Normal
8. Dry and warm.
9. Temp: 97.1 F, BP 164/95
1. 64 year old male here for renal failure
with a hx of end stage renal disease,
cerebral palsy, and diabetes.
2. No family hx.

3. Social history

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

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

3. Pt lives at an extended care facility.

1. Mifflin-St Joer
10 (105.4 kg) + 6.25 (165cm) -5 (64) + 5
= 1770 kcal/day
2. 1-1.5g pro/kg = 105.4- 158.1 g pro/day
3. 30ml/kg= 30 x 105.4 kg= 3162ml
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

Altered nutrition related laboratory values
Altered nutrition related laboratory values
Increased nutrient needs for protein and calories
Related to
(E) Etiology
Diabetes
End stage renal disease
Increased biological demand for wound healing
As Evidenced by
(S) Signs/Symptoms
Blood glucose range 198-483mg/dL
Cr 5.2, BUN 52, Na 126, Cl 89

Expanded Nutrition Diagnostic

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

Pt with stage 3 and stage 2 pressure ulcers and pt on dialysis treatment

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 Education (E 1-2) on a diabetic and renal diet. Encouraged pt to consume 3 meals a day
spaced 4-6 hours apart containing 60 grams carbohydrate. Encouraged pt to consume high
protein diet and avoid high potassium and high sodium foods. Encouraged pt to limit fluid
consumption. Nutrition supplement therapy (ND3) will be started and a high protein supplement
will be sent to pt.
Intervention

Provided education on a diabetes and renal diet using General Diet Guidelines-

#1
Goal

Renal Diet and Counting Carbohydrates for People with Diabetes handouts.
Pt will be able to states what foods are high is potassium and sodium.

#1
Goal

Pt will be able to state what foods have carbohydrates and read a food label.

#2
Intervention
#1
Goal
#1

Provide a high protein supplement for wound healing. Send Juven QD at pm snack

and Gelatin 20 QD at lunch.

Pt will eat 75% of snacks and supplements.

Goal
#2

Pt will get at least 100g protein per day.

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

Food and Nutrition Knowledge/ Skill (FH 4.1) will increased regarding a renal and diabetes diet.
Energy needs for protein will be met through supplements.
Intervention and goal/expected

Increase food nutrition related knowledge regarding a renal

outcome
Indicat Conversation with pt

and diabetes diet.

Criteri Pt will be able to state how many grams of

or
Indicat

Conversation with pt

a
Criteri

CHO he can eat per meal.

Pt will be able to state how much fluid he

Conversation with pt

a
Criteri

can drink per day.

Pt will be able to state what kinds of

grains, fruits, and vegetables he can

or
Indicat
or
Intervention and goal/expected
outcome
Indicat Wound Nurse

consume.
Pts wound will start to heal.
Criteri

Pt wounds will decrease in stages.

or
Indicat
or

Medical Chart

a
Criteri
a

Pt will drink/eat >75% of supplements.