Nutrition Care Process Worksheet

Patient ID: Diabetes

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

Pt does not follow a diabetic a diabetic

diet at home.
Currently receiving a 225 gm CHO
consistent diabetic diet. Pt is able to feed
self. Pt reports good appetite.
Medications: ceftriaxone, cetirizine;
enoxaparin; fluticasone; influenza
vaccine; insulin glargine; benzonatate;
codeine-guaifenesin; D50W; glucagon;
insulin lispro; ondansetron;
Pt is a home health care nurse who works
nights. Pt does all of her own cooking and
grocery shopping. Pt cares for 5 teenage
boys. Pt reports previous DM education,
but states she is always looking for
updated information. Pt seemed
knowledgeable about different CHO
sources.
No known limitations to access to food.
Ht: 1.702 m (57)
Wt: 73.936 kg (163 lb)
BMI: 25.6
IBW: 61.4 kg
%IBW: 120%
No documented weight change per
chart review.
Na 135; K 4.1; Cl 107; CO2 22; BUN
10; Creatinine 0.71; Glucose 129; Ca
8.0; A1C 14.8;
POC Glucose: 547 (on admission to
ED)

Nutrition-Focused Physical Findings

1. Overall appearance
2. Body Language

Pt appears well nourished. Pt in good

spirits. Bowel sounds WNL. Braden
Scale Score 22. No problems with

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
3. Social history

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

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

cognition and no reports of

neuropathy.

Pt is a home health care nurse who

works nights. Pt is a mother of 5
teenage boys. Pt does not cook
regularly due to her unusual schedule.
Pt also reports sleeping very little. Pt
has had type 2 diabetes x11 years. Pt
came to ED when blood glucose
meter read high. Pt does not
consume regular meals and does not
count her CHO. Pt checks insulin once
per day.
Kcal: 1850-2220
Protein: 59-74 g
Fluid: 2000 ml

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)
(P) Diagnosis or Problem
Elevated lab values

Related to
(E) Etiology
Endocrine dysfunction

Class of
Diagnosi
s

Expanded Nutrition Diagnostic

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

As Evidenced by
(S) Signs/Symptoms
Elevated A1C of 14.8%

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 pt with handouts Diabetes Food and You and Carbohydrate
Counting for People with Diabetes. Will discuss with patient the importance of
eating consistent meals throughout the day, different sources of carbohydrates,
and how to build balanced meals.

Intervention

Comprehensive diabetic education

#1
Goal

Pt to understand the components of a balanced meal

#1
Goal

Pt to understand different carbohydrate sources

#2
Goal

Pt to understand the importance of eating consistently

#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 assess if there has been an improvement in nutrition
related knowledge deficit related to recent diabetic education.

Pt will understand and follow recommendations for

Intervention and

a diabetic diet, that will ultimately help reduce the

goal/expected outcome
pts A1C.
Indicat Understand CHO sources
Criteri
or
Indicat
or
Indicat

Pt will be able to choose the CHO

Pt will be consuming meals

a
Criteri

sources from the hospital menu.

Pt will be eating x3 meals/day + a

consistently.

nighttime snack to help control

Criteri

blood glucose levels.

Pt will be able to choose items

Pt will understand how to

build a healthy plate.

from the menu that incorporate

all most food groups and stay

or

within her CHO limit.