Score: __________________
Name: Linda Lei M. Estrella Date: September 11, 2024
Lab. Section: Z1-2L Instructor: Ma’am Rose Dichosa
Exercise 2. Writing a Nutrition Care Plan
Case Study Analysis
Nutrition Care Plan
Develop your nutritional care plan using the suggested terminologies by AND
as reflected in the eNCPT Tutorials using the ADIME progress notes.
NUTRITION CARE PLAN (NCP) FORM
Name/Date/Time: Mrs. Diaz/ September 10/ 1 PM
Reason for Referral/Presenting Diet Consultation
Complaint/Diagnosis:
NUTRITION ASSESSMENT
Age: 64 years old Height: 5 ft 6 inches
Weight: 70 kg BMI: 24.91 kg/m2 (Normal)
Estimated Energy 2050 kcal Estimated 65 g
Needs: Protein Needs:
Other (specify): N/A Other N/A
(specify):
● Food/Nutrition- Related History
● Total energy estimated intake in 24 hours [FH-1.1.1.1.1]: 3232 kcal for the weekday
● Estimated fluid intake [FH-1.2.1.1]: No water intake recorded, consumption of 3-5 glasses
of wine every Saturday and Sunday
● Sugar sweetened beverage estimated oral intake in 24 hours [FH-1.2.1.1.1.3]: 1 can
● Caffeinated beverage estimated oral intake in 24 hours [FH-1.2.1.1.1.7]: 2 glasses
● Types of food [FH-1.2.2.2.7]: Self prepared food intake
● Meal/Snack Pattern [FH-1.2.2.3]: Usually skips AM snack
● Food Variety [FH-1.2.2.5]: Minimal fruit and vegetable intake
● Alcohol intake in one week [FH-1.4.1.1]: 3-5 glasses every Saturday and Sunday
● Total fat estimated intake in 24 hours [FH-1.5.1.1.1]: 151.9 g
● Total protein estimated intake in 24 hours [FH-1.5.3.1.1]: 101.6 g
● Total carbohydrate estimated intake in 24 hours [FH-1.5.5.1.1]: 365. 1 g
● Vitamin A estimated intake in 24 hours [FH-1.6.1.1.1]: 291 mg
● Vitamin C estimated intake in 24 hours [FH-1.6.1.1.2]: 95 mg
● Thiamin estimated intake in 24 hours [FH-1.6.1.1.6]: 1.3 mg
● Riboflavin estimated intake in 24 hours [FH-1.6.1.1.7]: 1.2 mg
● Niacin estimated intake in 24 hours [FH-1.6.1.1.8]: 65.9 mg
● Calcium estimated intake in 24 hours [FH-1.6.2.1.1]: 906 mg
● Iron estimated intake in 24 hours [FH-1.6.2.1.3]: 13.7 mg
● Phosphorus estimated intake in 24 hours [FH-1.6.2.1.6]: 1341 mg
● Diet history[FH-2.1]: A reduced diet was prescribed by a previous nutritionist-dietitian
but she was unable to follow it.
● Belief and attitude determination [FH-4.3]: She had problems adhering to the
recommendations due to her belief that she needs high amounts of energy to sustain her
daily work activities and she is still not ready for any diet or lifestyle change
● Physical activity history [FH-7.3.1]: Cooking and taking her dog for a walk
Anthropometric Measures Biochemical Data, Medical Tests and
Procedures
● Body height [AD-1.1.1]: 5 ft 6 in ● Total Cholesterol [BD-1.7.5]: 290 mg/dL
● Body weight [AD-1.1.2]: 70.0 kg ● Blood Pressure,systolic [PD-1.1.21.1]: 80
● Body mass index (BMI) [AD-1.1.5.1]: mmHg
24.91 kg/m^2 ● Blood Pressure, diastolic {PD-1.1.21.2]:
● Waist circumference [AD-1.1.7.14]: 35 129 mmHg
inches
● Hip circumference [AD-1.1.7.17]: 37
inches
Nutrition Assessment, Monitoring and Comparative Standards
Evaluation Tools
N/A ● Total energy estimated needs in 24
hours [CS-1.1.1]: 1610 kcal
● Total fat estimated needs in 24 hours
[CS-2.1.1]: 45g
● Total protein estimated needs in 24
hours [CS-2.2.1]: 62g
● Total carbohydrate estimated needs in
24 hours [CS-2.3.1]: 240g
● Total fluid estimated needs in 24 hours
[CS-3.1.1]: 8-10 glasses
NUTRITION DIAGNOSIS
PES Statement 1 Excessive energy intake [NI-1.3] related to high
Problem, Etiology, Signs consumption of carbohydrates, protein and fat
and Symptoms as evidenced by food recall and estimated
intake that exceeds estimated energy needs.
PES Statement 2 Inadequate Vitamin A intake [NI-5.8.5] related
Problem, Etiology, Signs to limited consumption of fruits, vegetables,
and Symptoms and whole grains as evidenced by food recall
and choices of food.
PES Statement 3 Risk for development of chronic disease such as
Problem, Etiology, Signs diabetes and stroke [NC-4.1.2] related to family
and Symptoms history, elevated total cholesterol levels and
prehypertension as evidenced by biochemical
data, medical tests and family and the client’s
history.
NUTRITION INTERVENTION
Nutrition Prescription Reduce intake of carbohydrates, saturated fats,
and alcohol while increasing fruits, vegetables,
and whole grains.
Aims/Goals (SMART) ● RND to decrease energy intake
[ND-1.1.12.2] to meet energy
requirement.
● RND to prescribe the client nutrition
prescription for oral nutrition [NP-1.1]
that is 2,050 kcal/day, 65 g of protein,
310 g of carbohydrates and 60 g of fat.
● RND to encourage an increase fluid
intake [ND-1.1.18.1] and decrease in
caffeine and alcohol consumption.
● RND to recommend [ND-1.1.22]
increase in vegetable and fruit intake to
meet Vitamin A requirement.
● RND to conduct content nutrition
education [E-1.1] for fluid intake, fruit,
and vegetable intake.
● RND to encourage consistency in
physical activity [E-1.3].
Detail of Intervention/Plan Nutrition Education [E] and Counseling [C]
through Content related nutrition education
[E-1.1], Education on nutrition’s influence on
health [E-1.2], and Nutrition counseling based
on goal setting strategy [C-2.2].
Short Term:
1. Reduce intake of refined carbohydrates,
and saturated fat to lower total
cholesterol levels within the normal
range.
2. Increase daily intake of fruits and
vegetables to at least 3-4 servings per
day.
3. Limit alcohol consumption to no more
than 1-2 glasses of wine per weekend.
Long Term:
1. Increase fluid intake to meet the
requirement, increase water intake and
decrease caffeine and alcohol intake.
2. Follow consumption of only one serving
caffeinated beverage or drink
non-caffeinated beverages as
replacement.
3. Adopt a balanced, nutrient rich diet
with 5 servings of fruits and vegetables
daily and 2-3 servings of whole grains
4. Maintain regular physical activity
NUTRITION MONITORING AND EVALUATION
Tick all that apply
Food/Nutrient/Energy Nutrition Assessment,
Monitoring, and
Anthropometrics Evaluation Tools
Behavior or Labs (specify)
Knowledge/Beliefs/Attitudes
Specific Indicators Criteria for Success Time Frame
Indicators,
Criteria and Total energy estimated 75 to 100% Within a week
Time intake in 24 hours recommendation
frame [FH-1.1.1.1.1]
What will you
assess Total fluid estimated At least 1610 mL per Within a week
during follow-up intake in 24 hours day; at most one
consultations? [FH-1.2.1.1.1] caffeinated beverage per
day
Meal/snack pattern Follow: 3 meals and 2 Within a week
[FH-1.2.2.3] snacks
Nutrition knowledge of Understands the By the end of the
individual client [FH-4.1.3] principle of MoVaBa, session
and have new
perspective about
healthy diets
Body mass index (BMI) Maintain within the Every consultation
[AD-1.1.5.1] range (18.5 to 24.9
kg/m2)
Attachment 1: Dietary Assessment (Evaluation of Food Intake)
Attachment 2:
Diet Rx Calculations:
Translation of CPF into Food Exchanges
Food List No. of CHO (g) PRO (g) Fats (g) Energy
Exchang (kcal)
es
Vegetable 3 9 3 - 48
Fruit 2 20 - - 80
Whole Milk 1 12 8 10 170
Low Fat Milk 1 12 8 5 125
Rice A 4 92 - - 368
Rice B 4 92 8 - 400
Rice C 2 46 8 - 216
Low Fat Meat 2 - 16 2 82
Medium Fat Meat 2 - 16 12 172
Sugar 4 20 - - 80
Fat 7 - - 35 315
TOTAL - 317 67 64 2056
Distribution of exchanges to meals
Food List Breakfa AM Lunch PM Dinner MN Total
st Snack Snack Snack Ex
Vegetable 1½ 1½ 3
Fruit 1 1 2
Whole Milk 1 1
Low Fat Milk 1 1
Rice A 2 2 4
Rice B 2 2 4
Rice C 2 2
Low Fat Meat 2 2
Medium Fat 2 2
Meat
Sugar 1 1 1 1 4
Fat 5 1/2 1/2 1 7
One-Day Sample Meal Plan
MEAL/TIME FOOD NO. OF SAMPLE MENU HH WT (g)
LIST EXCHANGES MEASURE
Breakfast Whole 1 Milk powder, full 5 Tbsp 35 g
Milk cream
Rice A 2 Cassava mashed, 2 pcs 110 g
with sugar and
margarine
Sugar 1 Honey 1 tsp 5g
AM Snack Fruit 1 Blueberries ½ cup 80 g
Rice A 2 Banana, saba, 1 pc 65 g
boiled
Lunch Vegetable 1½ Kare Kare
pechay, eggplant, 1 ½ cup 135 g
string beans
Medium 2 Beef chuck meat 2 slices, 70 g
Fat Meat mbs
Fat 5 Peanut Butter 2 ½ tbsp 50 g
½ Candy, Milk 3 pcs 10 g
Sugar 1 Chocolate
Rice B 2 White Rice 1 cup 160 g
PM Snack Fruit 1 Strawberry 1 ¼ cups 165
Low Fat 1 Yogurt 1 cup 250 g
Milk
Rice C 1 Pan de coco 1 pc 45 g
Sugar 1
Fat ½
Dinner Beef Broccoli
Vegetable 1½ Broccoli 1 ½ cup 135 g
Low Fat 2 Beef Lean Meat 2 slices, 70 g
Meat mbs
Fat 1 Coconut Oil 1 tsp 5g
Rice B 2 White rice 1 cup 160 g
Sugar 1 Polvoron 1 pc 10 g
