Chapter 5 Nutrition Care Process Figure 5.3

Figure 5.3 Nutrition Care Process Documentation Template: Initial Assessment NCP Documentation Template: Initial Assessment

Name: ________________________________________ Adm. Date: ______________ Room: _____________

Nutrition Assessment Food and Nutrition-Related History: (food/nutrient intake, food/nutrient administration, medication/herbal supple ment use, knowledge/beliefs, food and supplies availability, physical activity, nutrition quality of life)

Current Nutrition Prescription: ________________________________________________________________ Dietary Intake/Appetite: ❒ <25% kcal/kJ needs

❒ 25–50% kcal/kJ needs Fluid Intake:

❒ 75–100% kcal needs ❒ <1000 mL/day

Supplements: Vitamin/mineral/herbal supplements: Eating environment:

❒ room

Physical Activity: Medications:

Anthropometric Measurements (height, weight, body mass index, and weight history) Ht.

Wt. Wt. loss/gain:

❍ >5% in 1 month ❒ intentional

Biomedical Data, Medical Tests & Procedures (lab data) Glucose

HbA1c

Creatinine Other

Albumin NA+ Hemoglobin Usual Body Wt.

❍ >10% in 6 months ❒ unintentional

❒ <1500 mL/day ❒ 50–75% kcal /kJ needs ❒ 1500–2000 mL/day ❒ >2000 mL/day

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❒ dining room

❒ independent diner ❒ dependent diner ❒ total care with all ADL’s

❒ restorative dining

❒ rehab dining ❒ independent diner with assistance

BMI ❒ no significant change Lab date: K+ Hematocrit BUN Calcium

Nutrition-Focused Physical Findings (evaluation of body systems, muscle and subcutaneous fat wasting, oral health, suck/ swallow/breathe ability, appetite, and affect) ❒ chewing problems

❒ swallowing problems ❒ temporal wasting ❒ dentures ❒ other physical signs of fat wasting; if yes, explain

Comments: Skin condition: ❒ intact ❒ stasis ulcer ❒ pressure ulcer ❒ Yes

Edema: ❒ No Age: ❒ nausea Stage ❒ vomiting

Client History (personal history, medical history, and social history) DOB:

Medical diagnoses:

❒ alert and verbal ❒ alert and nonverbal ❒ alert with confusion ❒ nonalert and nonverbal ❒ ambulatory

❒ nonambulatory ❒ walks with walker ❒ wanderer ❒ moves about in wheelchair

Client comments: _______________________________________________________________________________________ ______________________________________________________________________________________________________

Comparative Standards (Academy references from Evidence Analysis Library) Estimated needs for energy: RMR = _______ X ________ (AF) X ________ (IF) = _____ kcal/kJ Estimated needs for protein: Estimated needs for fluid:

__________ g/kg = __________ g/day __________ mL/kg = _________ mL/day

Source: Reprinted with permission from Academy of Nutrition and Dietetics. Long-Term Care Nutrition Care Process Toolkit. Chi- cago, IL: Academy of Nutrition and Dietetics; 2011:58.

❒ diarrhea Location ❒ constipation ❒ edentulous ❒ permanent teeth