Nutrition Care Process Worksheet

Patient ID Underweight/ weight gain

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

Malnutrition
1. Pt has a good appetite and consumes at
least three meals a day. Plus
supplement when possible.
2. Consumes food orally
3. Multivitamin, Flonase, Zithromax,
prednisone, Pneumovax, IV fluids,
Advair, Buspar, Bystolic, Daliresp,
Spiriva Handihaler, Duoneb, Xanax,
Narco 5-325, solumedrol, Xopenex
4. Knew that he was underweight and that
he needed to gain weight and add
calories. Positive attitude toward
supplements but cant always afford
them.
5. Difficulty breathing when eating leding
to some fatigue. Pt feels bloated after
eating making him feel more full
6. Pt said that they could not afford to buy
boost/ensure all the time. Got powdered
milk at food pantry when possible.
7. Pt may struggle with ADL due to COPD
8. Unintended weight loss

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, 177.8cm,
2. 49.895kg
3. Small
4. Pts weight fluctuates between 110lbs
and 120lbs/ has always been on the
thin side
5. 15.857lbs
6. N/A
7. IBW 166lbs or 75.45kg / pt needs to
gain 57 lbs to be at ideal body weight

Biochemical Data, Medical Tests and

Procedures

RBC: 4.54
Hgb: 13.8
Hct: 40.1
Lymph # 0.83
Mono # 1.30

Nutrition-Focused Physical Findings

1. Awake, alert and oriented/ thin and

1.
2.
3.
4.
5.
6.
7.
8.
9.

Overall appearance
Body Language
Cardiovascular-pulmonary
Extremities, muscles and bones
Digestive system
Head and eyes
Nerves and cognition
Skin
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

cachectic
2. Weak
3. Normal S1 and S2 without gallops or
murmur/ Auscultation showed poor
air exchange and bilateral rhonchi/
on Bipap
4. No evidenced of clubbing, cyanosis,
edema or calf tenderness
5. No N/V or diarrhea/ Unremarkable
for palpable mass, organomegaly,
abdominal distension, tenderness,
rebound or rigidity
6. Intact Pupils are equal and reactive
with intact extraocular muscles. No
injection. No icterus. No palpable
cervical adenopathy, thyromegaly,
jugular venous distension or carotid
bruits
7. Grossly intact for motor, sensory and
cerebellar function. Cranial nerves
intact and symmetric bilaterally.
8. Cool, jaundiced, skin risk
assessment 20
9. Pulse: 89, Resp rate: 20, temp 99.2 ,
BP 117/62
1. GOLD stage IV, Emphysema,
depression and anxiety
2. CAD, MI, HTN, diabetes and cancer
(mother and father)
3. Married/ lives with wife/ children
1. 2,200 (35kcal +500kcals for
weight gain)
2. N/A
3. 60-74g protein (1.2-1.5g/kg)
4. 1,800ml (30ml/kg)
5. N/A
6. Pt needs to gain at least 57lbs
to be at IBW

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

Expanded Nutrition Diagnostic

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

(P) Diagnosis or Problem

Malnutrition

Related to
(E) Etiology
Increased energy needs from COPD and metabolic needs exceeding caloric intake

As Evidenced by
(S) Signs/Symptoms
A BMI of 15.7 and pt consuming adequate meals while still remaining underweight.

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
Pt changed from heart healthy/cardiac diet to regular diet to increase calorie intake. Ensure
Enlive with each meal to promote weight gain and prevent weight loss.

Intervention

Healthy eating with COPD

#1
Goal

Increase protein intake

#1
Goal

Consume ensure or boost each day

#2
Goal

Consume a well- balanced diet

#3
Intervention
#2
Goal
#1

High calorie recipes handout

Increase calorie intake

Goal

Increase protein intake

#2
Goal
#3
Intervention
#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

Weight gain and weight loss prevention secondary to COPD.

Intervention and goal/expected

Adequate calories and protein

outcome
Indicat Weight

Criteri

No more weight loss/ weight gain 1-2lbs a

or
Indicat

a
Criteri

week

or
Indicat

a
Criteri

or

Intervention and goal/expected

Maximize intake with COPD

outcome
Indicat Small meals throughout the day

Criteri

or

5-6 small meals a day to increase intake

Indicat

Consuming High protein foods

Criteri

1-2 servings at each meal/ check intakes

Supplement to increase protein

a
Criteri

to see if pt is ordering protein foods

Drink 1-2 boost, ensure or homemade

and calories

shake each day / send pt Ensure Enlive

or
Indicat
or

with each meal