MODULE 4

Steps in the Nutritional Care Process

NAME OF STUDENT:MA. CORAZON TRIZZIA S. ALBA WEEK NUMBER 4TH and 5th
COURSE CODE ND111 NAME OF FACULTY ANNELYN DY-CAMATO
COURSE TITLE NUTRITION CARE PROCESS

III.ACTIVITIES
Write the Nutrition Assessment of the sample case under the Assessment activity.
ANSWER:

NUTRITIONAL ASSESSMENT
Client History:
65 year old female admitted with Congestive Heart Failure; heart failure team consulted; had
been admitted with same diagnosis in the last 3 months; Betabloc; output > input by 2.5 liters
Food/Nutrition Related History:
Food allergies/intolerances/religious or cultural food practices and other considerations: Has
been told to weigh self daily but has no bathroom scale at home; does not add salt to foods
at the table; ate instant noodle soup for lunch and 3 slices of lean meat for dinner a day
before admission; no physical activity for 2 years; does not restrict fluids; has never received
nutrition counseling.
Current Diet/TF Regimen: Current diet order 2 gram sodium.

Anthropometric Measurements:
Weight: 160 lbs
Weight Change: Has lost 4 pounds in 30 hours since admission

Biochemical Data, Medical Tests and Procedures:

Relevant Laboratory Values: Above normal range of BUN and creatinine with no physical
activity for 2 years.

Nutrition-Focused Physical Findings:

Swollen face and extremities

IV.ASSESSMENT:
Apply the Nutritional Assessment domains in applying the clinical application of a case scenario
of:

Medical History:
65 year old female admitted with Congestive heart failure; heart failure team consulted; had
been admitted with same diagnosis in the last 3 months,
Medicine:
Betabloc; current diet order 2 gram sodium. Has lost 4 pounds in 30 hours since admission;
outpurt > input by 2.5 liters, 60 lbs, had above normal range of BUN, creatinine with no physical
activity for 2 years.
Nutrition History:
Has been told to weigh self daily but has no bathroom scale at home. Does not add salt to foods
at the table. Noticed swollen face and extremities on day prior to admission. Day before
admission ate instant noodle soup for lunch and 3 slices of lean meat for dinner; does not
restrict fluids; has never received nutrition counseling.
ANSWER:

DOMAINS DESCRIPTION

Food/Nutrition related Has been told to weigh self daily but has no bathroom scale at home;
history does not add salt to foods at the table; ate instant noodle soup for lunch
and 3 slices of lean meat for dinner a day before admission; no physical
activity for 2 years; does not restrict fluids; has never received nutrition
counseling, Current diet order 2 gram sodium.
Anthropometric Weight: 60 lbs
Measurements (AD) Weight Change: Has lost 4 pounds in 30 hours since admission
Biochemical Data. Medical Above normal range of BUN and creatinine with no physical activity for 2
Tests and Procedures(BD) years.

Nutrition Focused Physical Swollen face and extremities

Findings (PD)
Client History (CH) 65 year old female admitted with Congestive Heart Failure; heart failure
team consulted; had been admitted with same diagnosis in the last 3
months; Betabloc; output > input by 2.5 liters

Comparative Standards Estimated Nutrition Needs (kcal): -30 kcal

(CS) Carbohydrate (grams per kg): 2-3 g/kg
Protein (grams per kg): 1.5 g/kg
Fats (grams per kg): 0.6-0.8 g/kg
Fluid Needs (L): 1.5-2