Nutrition Care Process Worksheet

Patient ID: GI patient __________

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

1. Pt on clear liquid diet- limited tolerance

to fluids
2. Pt initially orally taking in clear liquids.
Pt changed to TPN after 5 days of poor
intake and pt not able to advance diet
3. Phenergan, reglan, Norvasc, diovan,
Zofran, catopres, IV fluids Tropal,
dilaudid, xylocaine-mdv, fentanyl,
antibiotics,
4. Knowledge about previous cancerwanted to just do light chemo and
comfort measures
5. Pt looked like she was in pain/pt looked
like she was nauseous
6. N/A
7. Limited physical activity and function
8. Pt unable to tolerate food due to mass
in colon

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

1. 162.56cm or 64inches
2. 79.832 kg or 175lbs
3. Normal
4. 15lbs in past few months
5. 30.2
6. N/A
7. Adjusted body wt 59.22 and ideal
body wt 120lbs

Biochemical Data, Medical Tests and

Procedures
X-ray and CT scan

CA 125 antigen- 655.6

Sodium -132
Chloride 97
BUN 3.0
Magnesium 1.60
Total protein 5.8
Albumin 2.8
Pre-albumin 10

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

1. Distress from GI symptoms

2. Pt in pain
3. S1, S2 normal- no gallops,murmur or
rubs/clear to auscultation
4. No edema
5. Distended, tender to palpate on left
side with firm nature/ bowel sounds
present/ N/V

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

6. Normocephalic with no pallor,

extraocular movements intact/
throat clear/ tympanic membrane
not injected
7. Alert oriented x3. Cranial nerves IIXII intact, no motor, sensory or focal
deficit
8. WNL
9. Temp- 99.3/ pulse- 92/ blood
pressure-155/72

1. Colon cancer, GERD, hyperlipidemia,

HTN, borderline DM
2. CAD, HTN, diabetes, cancer (brothers
and father)
3. Lives at home/ fianc/ good family and
friend support
1,598- 1,776 calories per day (27-30kca/kg)
Protein: 59-71g (1-1.2g/kg)
1,700ml fluid
TPN- B vitamins, sodium chloride, potassium
chloride, magnesium sulfate, chromium,
copper, manganese, Se, zn
Maintain wt

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

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)

Expanded Nutrition Diagnostic

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

(P) Diagnosis or Problem

Inadequate oral intake

Related to
(E) Etiology
Decreased appetite due to pain

As Evidenced by
(S) Signs/Symptoms
N/V, pt reporting poor appetite, TPN and pt receiving clear liquids.

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
TPN- clinamix 5% amino acids, 20% dextrose and 250ml lipids. Pt receiving 66grams protein and
a total of 1,662 calories a day which meets/ exceeds the pt nutrition needs.

Intervention

TPN

#1
Goal

meet nutritional needs due to poor intake

#1
Goal

Rest GI tract and reduce pain

#2
Goal

Adequate protein to preserve lean body mass

#3
Intervention

Advance to Enteral feeding

#2
Goal

If pt is feeling less nauseous and not vomiting wean off TPN and advance to enteral

#1

feeding.

Goal
#2
Goal
#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

Prevent malnutrition and loss in lean body mass. Stable electrolyte levels.

Intervention and goal/expected

Adequate TPN administration

outcome
Indicat Wt

Criteri

Maintain stable weight

or
Indicat

No Muscle wasting

a
Criteri

Pt appears to me well-nourished and does

Labs

a
Criteri

not look cachectic

Pt receiving adequate and not excessive

electrolytes form TPN

or
Indicat
or