NUTRITION

CARE PLAN
PREPARED BY: CARIAGA, CATALUÑA, CHAN, CLAR, CONCEPCION, CORONEL, CRUZ, CRUZ, DE
JESUS, DELOS REYES
 Client's Profile

Nutrition Assessment

NUTRITION Nutrition Diagnosis

CARE
PLAN
Planning/Goals

Nutrition Intervention

Nutrition Monitoring and Evaluation

CLIENT'S
PROFILE
 PERSONAL DATA

Name: A.K.A Soleil Race: Asian

Age: 20 Religion: Roman Catholic
Sex: Female Ethnic Origin: Tagalog
Pronouns: She/Her
Education: College undergraduate
Marital Status: Single
 NUTRITION
ASSESSMENT
 SUBJECTIVE DATA/CUES
RECENT CHANGES IN WEIGHT
ANTHROPOMETRIC MEASUREMENT Pre-pandemic: 57 kg.
Usual Weight: 132 lbs. | 60 kg. Current situation: 72 kg.

AFTER 2 WEEKS OF WORKOUT AND A CALORIE DEFICIT DIET: 71 kg.

GOAL WEIGHT: Go back to 57 kg., minimum of 55 kg.

 DIETARY INTAKE DATA
“I am on a caloric deficit and I am not guided by a nutritionist. The following are my
caloric intake in a day; a minimum of 1000 kcal and a maximum of 1500 kcal” as
verbalized by the patient.
“I have one snack, one dinner, and then magkasama na yung lunch and breakfast ko
every day. For brunch, I had 100 g of Rice, 100 g of Sauteed sayote, and 1 serving of
chicken breasts. For dinner, I had 100 g of Rice, 2 sticks of Barbeque,1 serving of Beef
Mami, and 1 serving of Asado siopao. For my snacks, I had 100 g of Biko Rice Cake ''
as verbalized by the patient.
"I usually drink 2 L of water a day"

MEAL TIME/USUAL MEAL TIME

BREAKFAST & LUNCH (BRUNCH): 11:00 AM

MEAL PLACE
SNACK: 3:00 PM
DINNER: 7:00 PM Home
 HABITS
“There are no food restrictions for me, any food is acceptable. I am not picky
when it comes to food, and I eat whatever is available. However, vegetables
and foods high in protein are my food preferences.”

“The usual preparation for our meats are either boiled, fried, grilled, or sauteed.
While the vegetables are usually sauteed, fried, or boiled."

“I do exercises six times a week for two hours each time. Weight loss, cardio,
and strength are the kinds of exercise I do” as verbalized by the patient.
 RISK FACTORS
Ventilation is good “Kulob kasi, bale walang bintana and exhaust fan. Minsan
mainit dalawa lang din kasi ang opening na parang door type yung isa gate
na mismo”
General sanitary condition is good. “We clean every day and we also do
general cleaning. Nevertheless, since our drainage is open the insects and
vermin are uncontrollable”
Drainage Facility is open
Open garbage container
 OBJECTIVE DATA
VITAL SIGNS: Temperature – 36.5 C
Blood pressure – 110/70 mmHg
Pulse rate – 68 bpm
Respiratory rate – 17 bpm

OBJECTIVE DATA
ANTHROPOMETRIC MEASUREMENT
HEIGHT: 161 cm. | 5 ft. and 3 inch. TRICEPS SKIN FOLD: 21.1 mm
WEIGHT: 157.63 lbs. | 71.5 kg.

BODY MASS INDEX: 27.58

INTERPRETATION: OVERWEIGHT
 OBJECTIVE DATA
REQUIRED BASAL METABOLIC RATE AS CALCULATED BY THE STUDENT
NURSE:
BASAL METABOLIC RATE
(157.63 lbs.)(14) = 2206.82
= 2206.82 - 400
BMR = 1806.82

OBJECTIVE DATA
REQUIRED PROTEIN INTAKE AS CALCULATED BY THE STUDENT NURSE:

PROTEIN
(157.63 lbs.) (1.4 g)= 220.682 g
= 220.682 g x 4
CHON = 882.728 kcal
 OBJECTIVE DATA
REQUIRED FAT INTAKE AS CALCULATED BY THE STUDENT NURSE:

FAT
(157.63 lbs.) (.5) = 78.815 g
= 78.815 g x 9
FAT = 709.335 kcal

OBJECTIVE DATA
REQUIRED CARBOHYDRATE INTAKE AS CALCULATED BY THE STUDENT
NURSE:
CARBOHYDRATE
882.728 kcal + 709.335 kcal = 1592.063
= 1592.063 - 1806.82
CHO = 214.757 kcal
 BIOCHEMICAL DATA CLINICAL DATA
LABORATORY: TEETH:
URIC ACID - 0.46 DENTURES: N/A
SGOT - 13.0 but the client is wearing
CALCIUM - 2.11 braces
GLOBULIN - 38.1
STAB - 0.01
 DIETARY INTAKE DATA
Kcal count for CARBOHYDRATES:
=(154.14 g) (4 kcal) = 616.56 kcal
Kcal count for PROTEIN:
= (83.74 g) (4 kcal)= 334.96 kcal
Kcal count for FATS:
= (36.25 g) (9 kcal)= 326.25 kcal

TOTAL KCAL COUNT

616.56 kcal + 334.96 kcal + 326.25 kcal

= 1,277.77 kcal
NUTRITION
DIAGNOSIS
 NUTRITION DX

INEFFECTIVE HEALTH MAINTENANCE related to inadequate health teaching as

evidenced by the client's body mass index is >25.0 & <29.9, excess Carbohydrates
intake, measurement of food intake, time and duration of intervals of food intake.
PLANNING/
GOALS
 SPECIFIC ACHIEVABLE
The client will be The client must be
able to change her mindful regarding the
behavior and nutrients present in the
foods that she is
attitude in relevance
consuming, through
to diet in order to
targeting nutrient-
lower her caloric MEASURABLE
dense foods which are
intake. The client should be high in nutrients but low
able to lose in calories.
approximately 1 kg of
body weight every
week.
 REALISTIC

The client should be

able to increase her
self-efficiency in
TIME-BOUND
terms of improving
her lifestyle to achieve In a span of 2 - 3 weeks, the client will
her desired weight be able to slowly incorporate the
suggested modifications in her food
choices, food intake, diet, and
exercise and progressively achieve
proper and balanced nutrition
towards her planned change of
weight
 NUTRITION
INTERVENTION
The client agrees with the
The client should choose
following interventions: The client should know that
appropriate and healthy
an increase in the intake of
food choices with
fluids particularly water,
relevance to the type of
The client will ideally 11.5 cups (2.7 liters)
diet (Caloric Deficit Diet).
demonstrate behavior per day is an integral part of
modification techniques: being healthy.
self-monitoring
The client will modify her
The client will follow the
diet by reducing the
proportioning of food groups
The client can formulate consumption of food rich
in carbohydrates (pies,
in MyPlate to have an
a current eating plan to
rice cakes, siopao). Lean appropriate amount of
reach enough calorie
more into protein-rich nutrients; e.g., 2 cups of fruits,
intake by installing the
foods (beef, chicken, fish, 2 ½ cups of vegetables, 6
MyFitnessPal application
to monitor daily food yoghurt) through nutrient- ounces of grains, 3 cups of
intake ensuring its proper dense foods. dairy products, and 5 ½
amount. ounces of meat daily to
balance consumption.
The client agrees with the
following interventions:
The client will control food
portion sizes through
meal replacements.
The client will reassess
calorie requirements
every 2-4 week.(changes
in metabolism occur)
The client should assess
weight and blood pressure
once or twice each week.
The client should take
TThe client will attend routine
vitamins and mineral
consultations with a dietitian
supplements as prescribed
to improve her diet plan and
by the doctor
caloric intake.
The client should be able to
demonstrate how to read The client verbalized a plan
food labels and calories on to continue her exercise
food products, as well as to regimen for cardio, strength,
choose foods that are low in and weight loss for 2 hours a
Carbohydrates and added day and 6 times a week. This
sugars.
shall be designed along with
their primary healthcare
provider.
The client will utilize proper
measuring devices to attain
adequate serving sizes for her
diet.
 NUTRITION
MONITORING AND
EVALUATION
 AFTER 2 AND 3 WEEKS OF NUTRITION INTERVENTION:

The client demonstrated behavior modification techniques:

self-monitoring

The client was able to monitor her meal plan calories for each day
via MyFitnessPal

The usual meals of the patient such as barbeque, beef mami and
asado siopao were successfully shifted in accordance with her
Caloric Deficit Diet.

From the client’s usual consumption of carbohydrates which is 616.

56 kcal to 1592.063 kcal. The patient relies on foods that are rich in
protein such as beef, chicken, fish and yoghurt.

Given that the patient has a 0.10 rate in uric acid, the patient
consumed 2L of water a day.
 AFTER 2 AND 3 WEEKS OF NUTRITION INTERVENTION:

The patient applies in her meal the right proportion of food groups
based in MyPlate with the following groups:
Dairy = 2-3 servings
Protein = 2-3 servings
Vegetable = 3-5 servings
Fruit = 2-4 servings
Grains = 6-11 servings

The client followed a strict proportion of food by meal replacements.

Every 2-4 weeks the patient repeatedly assesses her calorie

requirements of:
Protein = 882.78 kcal
Fats = 709. 335 kcal
Carbohydrates = 1592. 063 kcal
 AFTER 2 AND 3 WEEKS OF NUTRITION INTERVENTION:

Each week the patient assessed her weight and blood pressure once
or twice.

The client takes note on how to read food labels and calories on food
products, also considers foods that are low in Carbohydrates and
added sugars.

The patient returned from her work-out routine for cardio, strength
and weight loss, every 2 hours a day and 6 times a week.

The client took her vitamins and minerals supplements after meals
as recommended by her doctor.

The client utilized measuring devices like measuring spoons and cups
for her daily meal.


AFTER 6-12 MONTHS OF NUTRITION INTERVENTION:

The client attended four follow-up visits with a dietician

and improved her diet plan and caloric intake.


REFERENCES:

Protein. (n.d.). Better Health Channel. Retrieved November

24, 2021, from
https://www.betterhealth.vic.gov.au/health/healthyliving/
protein

Sampson, W. (2019, May 29). How to lower uric acid levels

naturally. Medical News Today.
https://www.medicalnewstoday.com/articles/325317

Wayne, G. (2021, September 1). Imbalanced Nutrition: More

Than Body Requirements Nursing Care Plans. Nurselabs.
https://nurseslabs.com/imbalanced-nutrition-more-
body-requirements/