Nutrition Care Process Worksheet

Patient ID: Cancer

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 currently receiving TPN due to

dysphagia, throat pain, and thick oral
secretions limiting po intake. Pt on NDD1
diet, thin liquids. Po as tolerated working
up to goal >50% po.
Parenteral Nutrition: Standard Clinimix
5/20 @ 65 ml/hr ~ providing 78gm
protein1060 kcal. Will meet 80% of
nutrition needs.
Medications: TPN w/ fat emulsions;
fentanyl, levofloxacin; lidocaine viscous;
Marys Magic Mouthwash; Tamsuosin;
acetometophen; benzocaine-menthol,
calcium carbonate, dextrose 50% in water
(D50W); heparin; porcine; insulin lispro 100
units/ml; lorazepam; morphine;
ondansetron
Pt transferred from CHVH. Pt has lung CA
with liver and bone mets. Pt completed
radiation to neck area resulting in
dysphagia, throat pain, and thick oral
secretions.

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

Pt has no known limitations to food

accessibility.
Ht: 1.778 m (510)
Wt: 73.7 kg (162 lb 7.7 oz)
BMI: 23.4
Weight loss 15 lb recently (8.5% wt
loss). Eating only water, boost x3 weeks
PTA.
Na 147; K 3.9; Cl 109; CO2 26; BUN 22;
Creatinine 0.88; Glucose 103; Phos 3.8;
Mg 1.9; Prealbumin 7;

Pt appears thin. Pt appears lethargic

and continues to nod off during consult.

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
3. Social history

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

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

Pt arrived from the community rehab

hospital after reports of poor po intake
due to dysphagia, throat pains, and
thick mucus secretions. Pt refuses to
have a g-tube placed, but has a
properly functioning gut.
Kcal: 1840-2220
Protein: >90 g
Fluid: 2000 ml

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

Inadequate oral intake

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

As Evidenced by
(S) Signs/Symptoms
Weight loss and symptoms of dysphagia, throat pain, and thick mucus secretions in throat

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 will provide information on the NDD1 (pureed) diet, and encourage po intake with patient.
RD will also provide education on foods that will help decreased throat pain while eating.

Intervention

Encourage increased po intake

#1
Goal

Educate and inform patient on different kinds of pureed foods

#1
Goal

Educated and inform pt on types of foods that ease throat pain

#2
Goal

Educated and inform pt on importance of caloric intake

#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 see if pt has increased po intake, and is practicing techniques to help
decrease throat pain while eating.

Intervention and goal/expected

Increased po intake

outcome
Indicat Pt will maintain weight

Criteri

Pt will increase po intake to closer meet

Pt will understand education on

a
Criteri

nutrient needs
During hospital stay, pt will have been

Indicat

foods that will help avoid

attempting to consume foods that will

or
Indicat

continued throat pain.

Pt will understand dysphagia diet

Criteri

not irritate throat.

Pt will be able to choose items off the

hospital menu that follow NDD1 diet.

or

or