Nutrition Care Process Worksheet

Patient ID _Oncology _________

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 has been struggling to tolerate

many foods and had had decreased
intake
2. Pt consumes food orally
3. Protonix, ambien, antibiotics,
Percocet, morphine, etoposide,
carboplatin
4. Pt had little knowledge about how to
increase nutrient intake while going
through cancer treatments.
5. Smoker / pt having restrictive
eating. Pt has intolerance to many
foods due t to excessive reflux.
6. N/A
7. No factors affecting physical activity
or function
8. Poor nutrition related quality of life
due GI dysfunction

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
Radiation
Chemotherapy
Left thoracoscopy with biopsy of mediastinal
mass

1. 175.26cm
2. 132.109
3. Large
4. Lost 30lbs in past few months
5. 43.0
6. N/A
147% ideal body wt

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

1. Fatigue
2. normal
3. Orthopnea/ chest pain/ dyspnea
cough/ pleuritic chest pain/
4. No pedal edema and normal pulse
5. Dysphagia no cough/ normal bowel
sounds
6. Normal S1, Normal S2/ neck supple
7. Normal speech/ no head aches
8. No rashes/ no breakdown/ X3

WBC 15.05
RBC 3.99
Hgb 12.3
Sodium 133
Creatinine 0.57
Glucose 149-156
Albumin 2.9

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

oriented
9. BP 151/85/ pulse 102/ temp. 97.7
resp rate 22
1. COPD, HTN , N/V 1 month,
depression
2. CAD (mother), cancer (brother)
1. 2,400-2,5080 (28-30kcal/kg)
2. 86-103 (1-1.2g/kg)
3. 2,400ml
4. N/A
5. Pt needs to keep a stable wt during
cancer treatment

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
Inability to take adequate po and increases metabolic needs

As Evidenced by
(S) Signs/Symptoms
Pt only drinking liquids at home, 30lb wt loss/few months, lung cancer and large mediastinal

mass

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
High protein and high calories recommended for wt stability and to maintain lean body mass
during chemo tx. Pt
Given some modification for high calorie foods because of severe reflux.
Intervention
#1
Goal
#1
Goal
#2
Goal
#3

High calorie and high protein education

Maintain wt and or lean body mass

Intervention

Recommendations for sever reflux

#2
Goal

Choosing softer moist foods

#1
Goal

Low fat foods

#2
Goal

Smaller more frequent meals

#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

Maintain wt and maintain lean body mass. Increasing fruit and vegetable consumption to
increase antioxidants.

Intervention and goal/expected

Getting enough protein and calories

outcome
Indicat Weight

Criteri

Pt consuming adequate protein and

or
Indicat

a
Criteri

calories

or
Indicat

a
Criteri

or

Intervention and goal/expected

Reduced reflux symptoms

outcome
Indicat Pt understand food he can eat

Criteri

Pt ordering smaller meals and ordering

or
Indicat

Reflux more under control

a
Criteri

or
Indicat

a
Criteri

or

appropriate foods
Less N/V and increased intakes