Nutrition Care Process Worksheet

Patient ID: Cardiovascular

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 does not follow a low sodium diet at

home.
Currently receiving a cardiac diet 2 gm Na;
low fat; 1500 ml fluid restriction. Pt is able
to feed self. Pt reports good appetite.
Mecations: Lasix; milrinone; amiodarone;
aspirin; carvediol; digoxin; gabapentin;
latanoprost; potassium choloride;
sildenafil; spironolactone; warfarin;
Primary problem of CHF. Pt presented with
weight gain and increased weakness. H/O
mitral valve disease. Pt has had a 35 lb
weight gain x2.5 weeks. Pt was difficult to
keep on topic during education. Comes
from home.
Sister does most grocery shopping for pt.

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

Ht: 1.93 m (64)

Wt: 130 kg (286 lb 9.6 oz)
BMI: 34.9 (not accurate of actual body
weight due to fluid accumulation)
Edema: +3 BLE; +4 perineal
Weight Hx:
04/05/16 130 kg (286 lb)
02/11/16 104 kg (230 lb)
11/05/15 110 kg (244lb)
Na 137; K+ 3.9; Cl 102; CO2 27; BUN
21; Creatinine 0.83; Glucose 94; Ca 8.5;
Albumin 2.9

Well-nourished male. Bowel sounds

WNL; Per pt, last BM loose;

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

65-year-old male. Lives alone, and his

sister helps with daily chores and
grocery shopping. Pt does not follow a
fluid restriction at home, and does not
take daily weights. Pt kept getting off
topic during education. Unfortunately,
due to pts lacks of participation in
education anticipate fair to poor
compliance upon discharge home.
Based on adjusted body weight
of 101.4 kg
2535-3042 kcal/day
81-101 g pro/day
1500 ml fluid restricition

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)
(P) Diagnosis or Problem
Food and nutrition related knowledge deficit

Related to
(E) Etiology
Lack of recent education on nutrition related needs

As Evidenced by
(S) Signs/Symptoms
Pt reports and questions

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
RD to provide comprehensive education on a low sodium diet and fluid restriction. Diet
instruction to cover topics including added table salt, grocery store shopping tips, salt free
spices, tracking daily fluid intake, daily weights and high sodium food items.

Intervention

Comprehensive nutrition education

#1
Goal

Pt to understand fluid restriction

#1
Goal

Pt to understand and follow low sodium diet

#2
Goal

Pt to understand low sodium food choices

#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 evaluate the pt ability to make appropriate low sodium food choices
and evaluate the effectiveness of the fluid restriction education.

Pt will understand and follow a low sodium diet, understand

Intervention and goal/expected
outcome

low sodium food choices, and understand the fluid

restriction.
Understand and follow low
Criteri

Pt will be able to name appropriate low

sodium diet

sodium food choices, and will be able to

Indicat

select appropriate low sodium items at

or
Indicat
or
Indicat

Pt will understand and follow

Criteri

the grocery store.

Pt will maintain a stable weight within 3

fluid restriction.

lb of usual body weight to avoid fluid

Criteri

overload.
Pt will be able to relay low sodium

Pt will understand low sodium

food choices from grocery store.

or

grocery store food choices to sister who

assists him with grocery shopping.