Nutrition Interventions in Place, No New Nutrition Problems, Pes As Above

Problem / Related To / As evidenced by
Inadequate calorie / protein intake
Inadequate oral intake / Dysphasia, swallowing difficulty
Chewing difficulty
Decreased appetite
Difficulty feeding self
Altered taste perception from chemo/radiation, chronic disease, multiple meds
Stroke, MS, Parkinson’s / Coughing, Pocketing, spitting out food
Spilling of majority of meal
Weight loss of X3 in time frame
Resident reports ill fitting or unavailable dentures
SLP reports . . .
PO < 50%
Resident states trouble eating
Inadequate oral intake / Impaired oral intake
Unable to consume po safely / NPO, Sedation, Vent
Resident wishes no artificial nutrition
Inadequate fluid intake / Dementia
Decreased desire to urinate
Decreased thirst perception
Dislike of thickened liquids / Physical findings of dry mucous membranes, poor skin turgor, dark urine, cloudy urine
Dx UTI,
Inadequate output per nursing
Oral intake of < XXX cc fluid per daily average
Impaired nutrient utilization / Compromised function of the GI tract due to radiation therapy
Vomiting, Emesis
S/P GI surgery / Diarrhea
Nausea, Vomiting x frequency
Weight loss of X# in timeframe
Excessive CHO intake / Unrestricted diet order
Non compliant to diet / Weight gain of XX # in timeframe
Blood sugars elevated (list lab / accuchecks and values)
Excessive energy intake
Excessive mineral intake / Excessive snacking from vending machine
Limited adherence to nutrition related recommendations / Increased Na or K lab values
Snacking from vending machine, consuming outside foods
Ordering out or requesting additional food
Overweight
Obese / Decrease energy expenditure associated with sedentary lifestyle, limited physical activity / BMI > 30
Weight gain of XX # in timeframe
Underweight / Increased energy needs
Inadequate intake / Recent ___ diagnosis and treatment (ie cancer)
Weight loss X in timeframe
Weight < IBW, BMI < 20
Problem / Related To / As evidenced by
Increased calorie / protein needs / Increased involuntary physical activity (Parkinson’s disease)
Wound, Surgery, Infection, Septic
Cancer, MS / Recent weight loss of x# in timeframe
Inadequate protein stores (list alb or prealb value)
Wound (stage and location)
Altered GI function / Non compliance with gluten free diet
Excessive consumption of sugar free candy
Non compliance with GERD prevention advice
Impaction, Illeus
No bowel sounds / Diarrhea
Constipation
GI complaints per resident
NPO status
Need for TPN for nutrition support
Altered nutrient related lab value / Impaired utilization from renal disease
Excessive CHO intake
Excessive fat intake
Inadequate fluid intake / State lab and value
Nutrition related knowledge deficit / Dietary management of (name specific disease process ie DM, CHF, Renal, Diverticular, HTN, edema, constipation) / Resident reports lack of knowledge regarding (be specific)
Inadequate intake from Tube feeding, enteral formula / Low rate of infusion
Resident pulled out tube
TF not at goal
Diet order as written does not meet needs or goal / Current order less than goal rate of __ cc/hr
TF meeting <100% needs
Excessive Intake from TF or TPN
Inadequate Intake from TF or TPN / TF or TPN order > or < estimated needs / Inappropriate lab value (list)
Blood sugars elevated (list)
Weight loss or gain of X# in timeframe
Inability or lack of desire to manage self care
Impaired ability to prepare foods / meals / Physical inactivity
Diagnosis (stroke, wound, dementia, etc)
Limited mobility
Limited knowledge / Admission in LTC / rehab care.

If no new problems exist, weight stable, all labs WNL, no new wounds, etc then state,

“Nutrition interventions in place, no new nutrition problems, pes as above.”

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