Nutrition Care Process Worksheet

Patient ID: Renal

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
Client History

Length of Stay: Pt admitted w/ peritonitis

due to infected peritoneal dialysis catheter.
Complained of generalized abdominal pain,
worse in the upper abdomen. Pt reported
painful bowel movements on admit. Pt has
past medical hx of diabetes, hypertension,
and hyperlipidemia. Pt did not report any
recent unexpected weight loss, but is
interested in losing weight. Reports eating
at least on TV dinner per day at home, and
wanting to consume 2 protein bars as meal
replacements for breakfast and lunch.
Husband helps prepare meals, especially
breakfast. Pt will begin HD on Monday
permanently. Pt reported prior ed on HD
renal diet, and declined any nutrition
education and questions today.
Height: 1.676 m (55.98)
Weight: 121.4 kg (267 lb 10.2 oz) [PREDIALYSIS WEIGHT]
IBW: 59.1 kg
Percent IBW: 205%
Adjusted Body Weight: 74.7 kg
BMI: 43.3
Na 137, K 3.8, Cl, 98, CO2 29, BUN 25,
Creatinine 4.46, GLU 150, Calcium 8.6,
PHOS 3.8, MG, 1.8, Albumin 1.2,
HGBA1C 7.3, BG POC 206;

Pt reports having gone through HD prior

to going on peritoneal dialysis. Pt is a
chronically ill, obese female. Skin
condition is pale/flaky. Pt last filed
bowel movement was formed on 2/2.

63 year-old female.

1. Personal history
2. Patient/client/family medical/health
history
3. Social history

Pt has past medical hx of DM, HTN, and

HLD. Pt had 4 gall stones removed
(2/5).
Family Hx: N/A
Social History: Currently lives with
husband; children are adults and do not
live at home;

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

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

Estimated total energy needs:

1870-2240 kcals (kcal/kg [ABW:
74.7 kg]); Protein: 90g-105g
(25g-30g maintenance); Fluid:
1500 ml (fluid restriction per md
order)

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

Possible food and nutrition related knowledge deficit

Related to
(E) Etiology
Complex diet needs

As Evidenced by
(S) Signs/Symptoms
Pt report of food intake after d/c

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
As needed, consult RD on the difference between peritoneal dialysis diet vs. the hemodialysis
diet. Education patient on the importance of a low phosphorus and sodium diet, and shopping
tips and label reading for HD.

Intervention

Meals/Snacks

#1
Goal

Renal/Diabetic diet 3gm K; 3-4 gm Na; Low phosphorus; 150 gm CHO con; 1500 ml

#1
Goal

fluid;
Pt consume >50% x3 meal/day

#2
Goal
#3
Intervention
#2

Nutrition Education

Goal

Provide pt education on shopping tips and label reading for HD

#1
Goal

May consider referral to outpatient RD to address pts concerns for weight loss while

#2
Goal
#3

being on HD 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

PT provided education handout on shopping tips and label reading for HD. Anticipated fair to
poor compliance upon discharge home (2/2) pt comments for plans of eating patterns at home.
RD available for further diet education via consult. May also consider referral to outpatient
dietitian to address pt concerns for weight loss while being on HD renal diet.

Intervention and goal/expected

Weight/Weight Change

outcome
Indicat Maintain weight

Criteri

Pt consumes balanced diet

or
Indicat

a
Criteri

Pt monitors her fluid intake

Maintain weight

or
Indicat

a
Criteri

or

Intervention and goal/expected

Labs/Medical Tests/ Procedures

outcome
Indicat Phosphorus

Criteri

2.5-4.5 mg/dL

or
Indicat

BUN

a
Criteri

10-20 mg/dL

or
Indicat

Creatinine

a
Criteri

0.5-1.1 mg/dL

or

Intervention and goal/expected

Food and Nutrition Knowledge

outcome
Indicat Per pt conversation

Criteri

List 3 sodium substitutes

or
Indicat

Per pt conversation

a
Criteri

Explain how she monitors fluid restriction

Per pt conversation

a
Criteri

List 3 high phosphorus foods

or
Indicat
or