Nutrition Care Plan Example: Unintentional Weight Loss

Do you want a simple and straight forward nutrition care plan example from someone who spent YEARS building them?

Then you’re in the right place!

Building a nutrition care plan can be difficult to make sure you write it perfectly.  Sometimes Dietitians waste so much time trying to make sure they include everything, and still fail an audit.  That’s why we’re going to be building nutrition care plans for you!

You can check back here to see new nutrition care plan examples to help guide you no matter what the nutrition diagnosis! We’ll be adding them as a new section to the website!

Building a Nutrition Care Plan 

A nutrition care plan is going to be individualised for all your patients, but there are some basic ones that you can build off of.

You don’t need to reinvent the wheel for nutrition care plans.  If you have a list of basic nutrition goals, we can use those as a foundation every time.  

Building a nutrition care plan will always include:

  1. Nutrition Problem/Diagnosis
  2. Nutrition Goals
  3. Nutrition Interventions

Does that look familiar?  

It’s because it’s basically just the Nutrition Care Process.  

If you have performed the Nutrition Care Process for your patient, then you will just restructure it for your nutrition care plan.

Nutrition Care Plan Example:
Unintentional Weight Loss

The start of all our nutrition care plans is figuring out, what is the nutrition problem? 

Try to narrow down based on your nutrition assessment what the focus of your nutrition care plan is going to be about.  

You can have multiple nutrition problems/nutrition diagnosis, each will have it’s own nutrition goals and interventions.  

For this example, let’s look at nutrition diagnosis: unintentional weight loss.

nutrition care plan example: unintentional weight loss
Keep reading for full nutrition care plan examples!

Nutrition Diagnosis

Unintentional weight loss is a really common nutrition diagnosis.  Especially in elderly individuals.  

You can use this as a nutrition diagnosis whether it is designated as a clinically significant amount or not.  Though it helps with your PES statement if it is clinically significant.

When you build your nutrition care plan for unintentional weight loss your entire goal is essentially to prevent further weight loss.  You can also phrase it as weight maintenance.

If you have an elderly patient it can be difficult to promote weight gain.  

This doesn’t mean we don’t try to promote weight gain, but we want to set realistic goals.

How to Phrase a Nutrition Problem/Nutrition Diagnosis:

Nutrition Problem:

Mrs. Smith has had unintentional weight loss of 7.5% in 1/12.

You can keep these short and sweet.  Some will teach you to write it in first person, PES statement style, sentences.  But that’s not my style and I’ve always passed audits.

I prefer to be straight to the point, I include the patient’s name, the nutrition diagnosis, and if I can I include some objective data.

Like I said earlier, you can have multiple nutrition problems/nutrition diagnoses, but we are just focusing on one in this article.

Nutrition Goals

This is where you can really expand on your nutrition goals for your NCP.  

I typically recommend having more than one nutrition goal, but some would argue you only need one.  Find what works best for you.

You need to include enough information in your nutrition goal that an auditor will see that you have been specific.  I don’t think you can do this in one nutrition goal.  

How To Phrase Nutrition Goals:

  1. Mrs. Smith will experience no further weight loss by her weight recording of December 2022.
  2. Mrs. Smith will maintain body weight within normal weight range based on BMI 23.0-29.9 (63.0 kg – 80.0 kg).
  3. Mrs. Smith will maintain a BMI of 24.4.
  4. Mrs. Smith will maintain current body weight through the time of her next monthly weight in December 2022.
  5. Mrs. Smith will maintain adequate oral food and fluid intake through >75% intake at all meals provided.
  6. Mrs. Smith will maintain normal nutrition status as assessed by an SGA assessment.

If you notice each of our nutrition goals has:

  1. Personalised – name included.
  2. A nutrition goal focused on weight promotion.
  3. A measurable aspect to it – can be a date, a weight number, a percentage.  All are designated to Mrs. Smith.

You want your nutrition goals to have a central focus based on the nutrition diagnosis.

Her nutrition diagnosis was unintentional weight loss, so you want your goals to all either promote weight maintenance, or intake.

Don’t go on a tangent and include something related to her chewing and swallowing.  If you have a chewing/swallowing goal, that is unlikely to relate to weight.  

If you have chewing and swallowing as a goal, you should have some type of chewing/swallowing impairment in your diagnosis/problem list.

If you want to read more about a Dysphagia care plan, click here to read the article.  

Nutrition Interventions

The nutrition interventions are all going to be focused on preventing further weight loss!

You are transcribing what your nutrition interventions are into the nutrition care plan.  It’s as simple as that.

You do not need to overthink this, just write exactly what you prescribed.

How to Phrase Nutrition Interventions:

  1.  Mrs. Smith will receive the fortified recipes for oatmeal at breakfast and fortified potatoes daily at supper.
  2. Mrs. Smith will receive an egg salad sandwich for evening snack daily as requested.
  3. Mrs. Smith will receive whole milk daily with her lunch.
  4. Mrs. Smith will receive a standard long term care, regular texture, regular fluid, diet daily for all meals.
  5. Mrs. Smith will receive a minimum of 2000 mL of fluids daily.
  6. Mrs. Smith will be weighed on her bath day in the first week of each month.
  7. Mrs. Smith will eat in the main dining room for all meals.
  8. Mrs. Smith will have her tray set up for her at all meals.
  9. A health care aide will record Mrs. Smith’s approximate meal intake daily in the recording book.

Do you notice that every nutrition intervention listed here has been tailored to be specific to Mrs. Smith?

If an auditor came through and read through Mrs. Smith’s nutrition care plan, they would know exactly:

  1. How to serve Mrs. Smith meals
  2. What her diet type is
  3. Where she eats her meals
  4. Her weigh schedule
  5. Where her meal intake is recorded and how frequently
  6. How much food and fluids she receives daily
  7. Her snack and snack schedule
  8. Specific diet instructions

All of these nutrition interventions acknowledge and address that Mrs. Smith has been losing weight and what the facility is doing to prevent it.

If you want to learn how to find the root cause of weight loss in elderly, read this article for some great tips!

Closing Thoughts on the Nutrition Care Plan Example

Building a nutrition care plan is a fairly simple process once you have the steps in place.  

On this website you will find many nutrition care plans going forward AND a basic nutrition care plan builder coming!

Is there a nutrition care plan example you’re looking for instructions for?  Just send a message to longtermcarerd@gmail.com

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Michelle Saari is a Registered Dietitian based in Canada. She has a Master's Degree in Human Nutritional Sciences and is a passionate advocate for spreading easy to understand, reliable, and trustworthy nutrition information. She is currently a full time online entrepreneur with two nutrition focused websites.

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