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Medical Nutrition Therapy Care Plan

January 11, 2017   /
Author: 
Nutrition411 Staff
Sandra Moretz, RD, LD

Assessment

Reason for assessment: _____________________________________________________________________________

Diagnosis: ______________________________________________________________________________

Diet order: ______________________________________________________________________________

Medications: ______________________________________________________________________________

Labs
Date: _________
Glu: __________
BUN: _________
Creat: _________
K+: ___________
HGB: _________
HCT: _________

Other labs:____________________________________________________ 
Skin: _________________________________________________________

Ht:___________ Wt:_____________ IBW:_____________ %IBW:_____________ BMI:_____________

Usual wt:______ % weight change:_______________ 

Weight history: ______________________________________________________________________________

GI Problems: N V D C BM:______________________

I/O: __________________ 
Appetite/intake: ______________________________________________________________________________

Problems: ___Chewing ___Swallowing
Food allergies/preferences: _______________________________________________________________________

Comments:_____________________________________________________________________

Estimated Nutrition Needs (based on actual body weight) 

Energy:______________kcal/kg =____________________kcal/day Formula used:________________

Protein:______________g/kg =______________________g/day Formula used:___________________

Fluid:_______________mL/kg =_____________________mL/day Formula used:_________________

Nutrition Diagnosis:    ___No nutritional problems identified

Problem I__________________________________________

related to (etiology) ___________________________
as evidenced by signs/symptoms)_________________________________________________________________

Problem II_________________________________________

related to______________________________
as evidenced by _______________________________________________________________________________

Intervention and Goals
___Maintain wt
___Promote wt gain/gradual loss 
___Maintain/replete visceral proteins 
___Maintain PO intake 
___Improve PO > 75% 
___Maintain skin integrity 
___Promote skin healing 
___Provide adequate nutrition via TF/TPN: _________________________________________________________

Monitor and Evaluate
___ Monitor nutritional status    
___ PO intake, diet tolerance
___ Diet progression
___ Labs: _____________________________
___ Weight
___ Wound healing/skin integrity
___ Tube feeding/TPN
___ Need for diet education
___ Other:_____________________________
__________________________________

Recommendation/Care Plan

___ Continue current nutrition POC
___ Change diet to: _____________________
___ Add snacks: _______________________
___ Add supplements: ___________________
___ Honor cultural/religious/personal food preferences to extent possible
___ Initiate alternate nutrition route
___ Change TPN/TF to: __________________
__________________________________

Signature: _________________________________________ 

Date/Time: _________________________