INITIAL NUTRITION ASSESSMENT 39

INITIAL NUTRITION ASSESSMENT

DEMOGRAPHICS:

Name:

DOB:

MRN: I”’ Dialysis:

4!e: - Sex: Status: Marital

1” Outpt TX:

Significant Other:

Date:

TREATMENT:

ESRD Dx: Modality: Physician: Primary Nurse:

HL: Schedule - MWF, TTS, lS, 2S, 3S Dialyzer - F80, F60, F50 ?- PD: Exchanges:

Access - Permcath, AVF, AVG QB - 250.300,350,400 )- Kcal:

Dialysate - K+ 0, 1, 2, 3 QD - 500,600, ~ Kcal Absorbed:

Time - 3:30, 4:00 ,-

MEDICAL:

Meds: Binders

DM

Rocaltrol

Chol

Caicijex

GI

Iron

Abnormal Labs:

- -

Recommendations: Adequacy: uRR___ Delivered KT/V Urea Clearance CRCL PCR WR-

Comments: Access: QB: QD: Time: Dialyzer: Plan:

NUTRITION ASSESSMENT:

Ht: -wt:- ~ EDW: UBW: ABW: IBW: % IBW: BMI:

wt Hx: % wt Loss: Frame Size:

IDWG: Urine Output: Vision: Hearing: Cognitive: Education Level

Appetite: Excellent, Good Fair, Poor Taste Change: sweet Salty Sour Bitter

GI: N V D Mouth Pain: __ __ __ __ C Dry Mouth: Dysphagia:

Dentition: own Dentures: Upper Lower Partial Fit/Condition

Ambulation: Activity Level: Exercise:

40 CRISTIN E. FEEHRER

SOCIAL:

Psychosocial Considerations: occupation: Home Services:

Household Members: Meal Preparation: Shopping:

Kitchen Facilities: Stove Microwave Refrigerator Freezer Small Appliances

DIET HISTORY:

Previous Diet Restrictions: Date: Instruction: DiEiculty :

PO Supplement Hx: Current Supplement Rx:

Current Diet Rx: Kcal -m PRCI -mg Na --.---mg K+ -mgm - cc Fluid

Eating Habits: DialysisDays: -B -L -D -S

Nondialysis Days: __ B -L __ D __ S

Weekend: .-mB-L--D-S

Meals Eaten Out: Breakfast, Lunch, Dinner

Frequency:

Where:

TYPICAL MEAL PATTERN:

Breakfast Lunch Dinner Snacks

Meal Pattern Analysis: Kcal gmTP -w I-lEw -----em a-10 -s---mew FAT

CHO % % PRO % FAT cc Fluid Mona ___ mg K+ ___ mgm

Adequacy of Intake: Inadequate, Adequate, Excessive % of Nutritional Needs: Calories Protein

INITIAL NUTRITION ASSESSMENT 41

FOOD FREQUENCY:

Milk

Cheese

Ice Cream

yogurt

Eis Fish/Shellfish

Poultry

Red Meat

Processed Meat

Cured Meat

Dried Beans

Nuts/Seeds

Peanut Butter

Vegetables (end frs, frz)

Tomatoes/Products

Potatoes

Pasta

Rice

Bread

RECOMMENDED DIET Rx:

Calories

- gm Protein -gm=v

cc Fluid

NUTRITION EDUCATION:

Protein

Phosphorus

Potassium

SOdilIItI

Fluid

Adequacy

Casseroles

Soups (cd dry, hmd) Convenience Foods

Citrus Fruit (end, frs)

Other Fruit (end frs)

Fruit Juice

Salty Snacks

Dessert

Chocolate Artificial Sweetener

Salt

Salt Substitute

Low sodium seasoning

coffee

Tea

Soda

Water

Ice Alcohol

( kcal/kg )

(------- gm/kg)

( Based on __ kg)

Diet & Dialysis

IronQogen

Vitamins

Cookbook

mg Sodium

mg Potassium

mg Phosphorus

Meat Portion Guide

Seasonings

Salt Substitate

Na-K-PO4 Counter

Renal Diet Components

Dietitian’s Card

Disaster Diet

Other

Level of Understanding:

Further Education Needs:

Anticipated Compliance:

42 CRISTIN E. FEEHRER

NUTRITION SUMMARY:

Risk of Malnutrition: High, Moderate, Low

Current Problems:

Assessment:

Goals/plan:

Dietitian Signature: Date: