Nutrition Care Process worksheet

Patient profile
Name …………………………………………………………………………………….. Age ……………………… Sex ………………………
Wt/Ht …………………………………………. BMI ………………………………. Waist circumference = ………………………..
CC: ………………………………………………………………………………………… HPI: …………………………………………………………………………….
PMH: ………………………………………………………………………………………………………………………………………………………………………………
U/D: ……………………………………………………………………………………………………………………………………………………………………………….
SH: ………………………………………………………………………………………………………………………………………………………………………………….
Assessment
Problem ………………………………………………………………..........……………………………………………………………….....................................
Etiology ………………………………………………………………..........………………………………………………………………......................................
Sign & symptom ………………………………………………………………..........………………………………………………………………......................
Plan
Nutritional type/route ………………………………………………………………..........………………………………………………………………............
Fluid requirement ……………………………………………..ml Energy requirement …………………………………………………………kcal
Protein requirement ………………………………………………………g
Protein Carbohydrate Lipid
………………% ………………% ………………%
………………kcal ………………kcal ………………kcal
………………g ………………g ………………g
เตรียมจาก stock solution
o 15% amino acid …………………………………………………………………………………ml
o 50% dextrose ………………………………………………………………………..……………ml
o 20% fat emulsion ………………………………………………….…………………………..ml
o Fluid osmolarity …………………………………………………………….………….mOsm/L via ………………………………..vein
o Drip rate …………………………………………………………………………..……………..ml/h