Nutrition Assessment
Key points:
- Nutrition Assessment is the first step of the Nutrition Care Process.
- Data collected during Nutrition Assessment is used for all other steps in the Nutrition Care Process.
- Nutrition Assessment ultimately leads to the identification of a nutrition problem (also known as the Nutrition Diagnosis).
- New information or assessment data may provide reasons for reassessment, change in nutrition diagnosis or nutrition intervention.
Nutrition assessment data can come from a variety of sources, such as referral forms, interviews, medical records, family members or caregivers, community-based surveys and focus groups; statistical reports, administrative data, client-related outcomes or experience measures; and epidemiological studies.
When documenting the nutrition assessment, keep the following questions in mind:
- Is the assessment data concise and relevant to support the Nutrition Diagnosis?
- Is the assessment data comprehensive and aligned with the nutrition assessment domains, such as food/nutrition-related history or biochemical data, medical tests and procedures?
- Are the appropriate comparative standards used?
Nutrition assessment data is categorized into nine domains:
Food/Nutrition-Related History contains terms that capture data typically collected from an interview with the client where food and nutrition intake and related behaviors were discussed.
Anthropometric Measurements includes terminology that helps describe the physical measurements for the client such as height, weight, body mass, growth pattern indices/percentile ranks and weight history.
Biochemical Data, Medical Tests and Procedures includes terms for laboratory data and medical tests.
Physical Exam Findings includes terminology that describes findings from a physical exam, interview or the health record. Examples include subcutaneous fat, muscle, oral health, suck/swallow/breathe ability, and appetite.
Client History includes terminology that captures the client's personal history such as age, gender, ethnicity, and reported medical and social history. (Note: This domain is only used in the Nutrition Assessment step and is not used in Nutrition Monitoring and Evaluation. All other domains in the Nutrition Assessment step can be used for reporting client progress in the monitoring and evaluation steps.)
Assessment, Monitoring and Evaluation Tools capture tool ratings that assess health or disease status or risk.
Etiology Category includes terminology that is used to communicate the type of nutrition diagnosis etiology.
Comparative Standards contains terminology that describes what indicator data are compared against. An example includes energy needs and the method used to determine the estimation.
Progress Evaluation includes the terms used to describe progress toward a nutrition related goal(s) and resolution of a nutrition diagnosis(es).
Nutrition Assessment Critical Thinking
Use important and relevant data showing the nutrition diagnoses exist.
Examples: Use total energy intake as evidence for inadequate energy intake and percentage of food consumed for inadequate oral intake.
Obtain or order data or request additional data to support a nutrition diagnosis.
Examples: Request ferritin for improved evaluation of iron status. Await post-dialysis data.
Valid and reliable tools and guidelines that fit the client population are recommended.
Examples: Use a tool (eg, subjective global assessment, mini-nutritional assessment long form) to identify malnutrition and guidelines for a nutrition-focused physical exam.
Tools/procedures should not be altered; doing so can negatively affect the findings.
Example: Follow guidelines and instructions for measuring hand-grip strength.
For accurate interpretation of findings, compare them to standards and norms and determine if they make sense for the reference population.
Examples: Compare lab data to the established reference range. Use growth charts suitable for a child's age.
Visit the Academy's eNCPT for additional training and subscription information for using the terminology in Electronic Health Record (EHR) or Electronic Medical Record (EMR) systems.
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