NCM 105 LECTURE/ NUTRITION CARE PROCESS
NAME: DAIS, SARAH J. SCORE: _________________
COURSE, YEAR & SECTION: BSN 2-E DATE: SEPTEMBER 18, 2022
THE STEPS IN NUTRITION CARE PROCESS:
INSTRUCTIONS: Provide at least two (2) for Nutrition Assessment, Nutrition Interventions and Nutrition Monitoring and Evaluation for each Nutrition Diagnosis stated in
column 2.
Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and
Evaluation
Food/Nutrition History Reports or observations of: Excessive caloric intake r/t Diagnosis 1: Excessive Calorie Intake Records of daily food
Frequent food preparation with added fat that frequent consumption of large intake, weekly weight
is not of desired type for condition portions of high fat meals AEB Objectives: measurement, and physical
Frequent consumption of fats that are average daily intake of calories Pt will reduce eating high fat meals con- activity are improved
undesirable for condition (i.e., saturated fat, exceeding recommended amount sisting (saturated fat, trans fat, choles-
trans fat, cholesterol, omega-6 fatty acids) by 500 kcal and 12-pound weight terol, & omega-6 fatty acids). Lose weight after following
Inadequate intake of monounsaturated, gain during the past 18 months. Pt will follow the recommended amount prescribed meal plan
polyunsaturated, or omega-3 fatty acids of daily calorie intake.
Client History Implementation:
Diagnosed with hypertension, experiences Pt will try to eat more lean protein foods
epigastric pain and good fats (monounsaturated fats and
Family health history: hypertension and heart polyunsaturated fats)
disease. Pt’s daily intake of calories should not
Client desires to implement a Mediterranean- exceed from 500 kcal as recommended
type diet by his nutritionist.
Biochemical Data Inappropriate infant feeding Diagnosis 2: Improper Breastfeeding
Laboratory evidence of dehydration in infant practice RT lack of knowledge AEB Patterns
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NCM 105 LECTURE/ NUTRITION CARE PROCESS
Anthropometric Measurements infant receiving bedtime juice in a Objectives: Improved nutritional lab
Low body weight of infant bottle. Pt will be enlightened about the reports of infant and
importance of breast milk to infants. mother
Food/Nutrition History Observations or reports of
(infant): Pt will know about the strategies for Observed infant increased
Coughing enhancing breastfeeding. in weight
Crying, latching on and off, pounding on breasts
Decreased feeding frequency/duration Implementation:
Infant lethargy Pt will try to breastfeed the infant even at
Fewer than six wet diapers in 24 hours night time after learning about the
Infant experiences diarrhea importance of breastfeeding.
Observations or reports of (mother): Pt will exhibit the types of breastfeeding
Small amount of milk when pumping holds and patterns when providing breast
Lack of confidence in ability to breastfeed milk to infant.
Concerns regarding mother’s choice to
breastfeed/lack of support
Insufficient knowledge of breastfeeding or
infant hunger/satiety signals
Client History
Conditions associated with a diagnosis or
treatment (infant): premature birth
Conditions associated with a diagnosis or
treatment (mother): history of breast surgery
Anthropometric Measurements Unintended weight loss r/t Diagnosis 3: Involuntary Weight Loss Improved weight
Weight loss of 6% within 1 month inadequate provision of energy by measurements and nutrient
enteral products AEB 6-pound Objectives: intake as analyzed
Physical Examination Findings weight loss over past month. Pt will avoid skipping meals and eat on
Increased heart rate right time.
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NCM 105 LECTURE/ NUTRITION CARE PROCESS
Increased respiratory rate Pt will modify his diet to include Observed weight gain after
Loss of subcutaneous fat and muscle stores adequate calories and protein through a month
the use of nutrient-dense foods.
Food/Nutrition History Reports or observations of:
Poor intake, change in eating habits, skipped Implementation:
meals Pt will try to eat three to five healthy
Clothes become looser in fit meals per day.
Client History Pt will include nutrient-dense foods in his
Medications associated with weight loss: diet, especially when his appetite is
certain antidepressants limited.
Diagnosis 4: Involuntary Weight Gain
Anthropometric Measurements Risk of weight gain r/t a recent Reviewed dietary intake
BMI is above normative standard for age and decrease in daily physical activity Objectives: records and physical
gender following sports injury. activity.
Waist circumference is above normative Pt will engage to light physical activity on
standard for age and gender the injured site gradually increasing activ- Observed recovery in injury
Increased skinfold thickness ity. leading back to proper
Weight for height above normative standard for Pt will try to control daily food intake lim- sports training and diet
ited to suggested TER
age and gender
Pt will practice healthy eating to improve
Physical Exam Findings the diet.
Increased body adiposity
Food/Nutrition History Reports or observations of: Implementation:
Overconsumption of high-fat and calorically-
dense food & beverage Pt will maintain light regular exercise for
Consumption of large portions of food (portion at least 60 min/day.
size greater than twice than recommended)
Excessive energy intake
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NCM 105 LECTURE/ NUTRITION CARE PROCESS
Infrequent, low-duration and low-intensity Pt will decrease the amount of energy-
physical activity dense foods eaten and limit the food in-
Large amounts of sedentary activities, take based on TER
Inability to maintain weight
Food/Nutrition History Reports or observations of: Pt will eat more health foods by including
Infrequent, low-duration and low-intensity fruits, vegetables, and whole grains in the
physical activity diet.
Large amounts of sedentary activities
Barriers to physical activity: availability of a safe
environment for exercise
Client History
Low cardio-respiratory fitness and low muscle
strength
Conditions associated with a diagnosis or
treatment : eating disorder not otherwise
specified
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