Nutrition Care Process Worksheet

Patient ID New onset Diabetic __________

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
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

1. Pt consuming 100% of meals/ Pt

receiving 3 meals a day with HS snack
to prevent hypoglycemia/ alcohol use
2. Consumes food orally
3. Zestril, Heparin, K-DUr 20 Meq tab,
protnix, IV fluids, Tylenol , Lantus,
Humalin R
4. Lack prior knowledge of diabetes and
diabetic diet
5. Tobacco use
6. Pt is not currently employed and does
not currently have health insurance.
Case manager helping pt get health
insurance.
7. N/A
1. 182.88cm/ 72inches
2. 117.679kg/ 258.9lbs
3. Large
4. 2.8kg (about 6lbs) wt gain since admission
6 days ago
5. 35.2
6. N/A
7. IBW 178lbs
POC glucose 125-267
Glucose 122-529
Sodium 135
BUN 5.0
Anion Gap 17
HgA1C 12.4%
No acute distress
Normal
Regular rate, normal S1, normal S2, no
murmurs/ a few rales bilaterally,
resonant
No edema, pules present, no blubbing,
no cyanosis
Soft, no tenderness, bowel sounds
present, no hepatospenomegaly
Head atraumatic, PERRLA, mucous
membrane moist
Oriented X 3, alert, no gross motor
sensory deficit
Temp 98.1, Resp. rate 21-26, blood
pressure 145/75

Client History
4. Personal history
5. Patient/client/family medical/health
history
6. Social history

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

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

1. No significant past hx
2. Cerebrovascular accident (grandfather),
CAD, HTN grandma, grandpa), cancer
(grandpa), DM
3. Lives with brother/ has a girlfriend/
unemployed
1. Using adjusted body wt
89.3kg
2. 2,200-2,400 kcals per day
(25-27kcal/kg)
3. 4-5 carb choices per meal
4. 2,600ml fluid (30ml/kg
5. N/A
6. 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

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

Altered nutrition related lab values (Bl Glu/POC/HgA1C)
Food and nutrition related knowledge deficit
Related to
(E) Etiology
Endocrine dysfunction
Lack of prior exposure to information
As Evidenced by
(S) Signs/Symptoms
DKA with new onset DM , HbA1C 12.4% and significantly elevated Bl Glu/POC levels
Newly diagnosed DM

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
Eat three meals a day with consistent cabs at each meal. Eat carbohydrate and protein foods
together when eating.
Choose high fiber foods such as whole grains, fruits and vegetables. Recommend a 2,200 caloire
diabetic during admission and long term.
Intervention

Educate pt on basics of diabetic diet

#1
Goal

Pt eats carb foods with foods containing protein at each meal

#1
Goal

Eats three meals a day and does not skip meals

#2
Goal

Pt understands what foods contain carbohydrates

#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

Pt will be successfully manage diabetes day to day on his own till he receives further education.
Pt will be given referral and contact information for the diabetes center for further more
individualized and detailed education.

Intervention and goal/expected

Pt understands diabetic diet information

outcome
Carb and protein together

Criteri

Quizzed pt examples of carb food and

protein foods and gave example of

Pt eating consistently throughout

Criteri

combinations
Pt ordering three meals and pt eating

day

a
Criteri

Indicat
or
Indicat
or
Indicat
or

evening snack