Nutrition Care Process Worksheet

Patient ID Heart 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 reports she doesnt follow any diet at
home but tries not to add salt to food.
2. Pt consumes all her intakes orally.
3. Pt is currently on a multivitamin, and
statin.
4. Pt is will to change her diet at home.
5. Pt takes her medicines daily and has a
positive attitude.
6. No factors affecting access to food or
food/nutrition related supplies.
7. No physical activity noted.
8. N/A
1.
2.
3.
4.
5.
6.
7.

62
130#
Small
No wt changes noted.
BMI 23.8.
N/A
IBW: 110#, %IBW: 118%

Labs reviewed.

1. Pt appears tired but engaged in the

conversation.
2. Pt has a positive body language and
seemed interested.
3. Recent open heart surgery.
4. Normal
5. Normal
6. Normal
7. Normal
8. Normal
9. Temp: 96.7 F, BP 145/69
1. Pt is 74 year old Causcian female who is
present with aortic valve replacement
and heart failure.
2. Both parents are diseased.

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 home and does not drink or

smoke.
1. Mifflin-St Joer
161 + 10 (59kg)+ 6.25 (157.5 cm) -5 (74)
=1,479 kcal/day
2. 0.8-1g pro/kg = 47.2-59g pro/day
3. 30ml/kg= 1170ml
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

1. Increased nutrient needs for protein and calories
2. Swallowing difficulty
Related to
(E) Etiology
1. increased biological demand for nutrients
2. right sides weakness secondary to previous CVA
As Evidenced by
(S) Signs/Symptoms
1. pt post op day #1 from open heart surgery
2. pt need for thickened liquids for speech therapy evaluation

Expanded Nutrition Diagnostic

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

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 Supplement Therapy (ND 3) to send Mighty Shake QD at AM snack and Magic Cup at PM
snack to promote adequate caloric intake.
Intervention

Monitor intake of all PO intakes, meals, supplements, and snacks.

#1
Goal

Pt will intake 50% of Mighty Shake and Magic Cup.

#1
Goal

Pt will intake >50% of meals.

#2
Intervention
#2
Goal
#1

Monitor tolerance of diet.

Pt will tolerate diet.

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

Energy Needs (C 1.1.2) are increased due to decreased appetite and post op day #1 surgery.

Intervention and goal/expected

Send Magic Cup QD and Mighty Shake QD.

outcome
Indicat Monitor intakes of all PO intakes,

Criteri

Pt will eat >50% of supplements and

or

meals.

supplements, and snacks.