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Part I Introduction to Nutrition Care in Older Adults

Figure 5.4 Nutrition Care Process Documentation Template: Reassessment NCP Documentation Template: Reassessment

Figure 5.4 Name: ______________________________________ Adm. Date: _______________

Nutrition Diagnosis Problem (P): related to

Etiology (E): as evidenced by

Signs/Symptoms (S/S):

Problem (P): related to

Etiology (E): as evidenced by Signs/Symptoms (S/S):

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/Intake of supplement: 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: ❒ intentional

Glucose BMI

❍ >3% in 7 days ❍ >5% in 30 days ❍ >7.5% in 90 days ❒ unintentional

❒ no significant change

Biomedical Data, Medical Tests & Procedures (lab data) HbA1c

NA+ Creatinine Albumin Other _____________________________

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

Comments ❒ temporal wasting Edema:

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

❒ No

❒ changes in feeding/dining ability Comments ❒ nausea ❒ vomiting ❒ diarrhea ❒ constipation Comments

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

Age: Client comments:

❒ other physical signs of fat wasting; if yes, explain Stage

Location Hemoglobin K+ Hematocrit Comments: Lab date: BUN Calcium ❍ >10% in 180 days ❒ <1500 mL/day ❒ dining room ❒ 50–75% kcal /kJ needs ❒ 1500–2000 mL/day ❒ >2000 mL/day ❒ restorative dining ❒ rehab dining Room: ___________________ Type of assessment: ❒ Quarterly ❒ Annual ❒ Significant Change ❒ Consult ❒ Other _________________

Source: Reprinted with permission from Academy of Nutrition and Dietetics. Long-Term Care Nutrition Care Process Toolkit. Chicago, IL: Academy of Nutrition and Dietetics; 2011:60.