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Nutrition Assessment

Nutrition Assessment
Pamela Charney, PhD, RD

MOMENTUM PRESS, LLC, NEW YORK

Nutrition Assessment
Copyright Momentum Press, LLC, 2016.
All rights reserved. No part of this publication may be reproduced,
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First published in 2016 by
Momentum Press, LLC
222 East 46th Street, New York, NY 10017
www.momentumpress.net
ISBN-13: 978-1-60650-751-3 (paperback)
ISBN-13: 978-1-60650-752-0 (e-book)
Momentum Press Nutrition and Dietetics Practice Collection
Cover and interior design by Exeter Premedia Services Private Ltd.,
Chennai, India
First edition: 2016
10 9 8 7 6 5 4 3 2 1
Printed in the United States of America.

Abstract
It has long been known that nutritional deficiencies are associated with
morbidity and mortality in hospitalized patients. Registered dietitians
(RDs) are responsible for the diagnosis and treatment of malnutrition in
all practice settings. Accurate diagnosis of malnutrition depends on the
skills of RDs in completing the nutrition assessment combined with critical thinking skills. There are five components of the nutrition assessment;
they are as follows:




Nutrition-focused physical exam


Client history
Food and nutrition history
Anthropometric measures
Biochemical measures, procedures, and tests

RDs must consider each component in order to accurately diagnose


nutrition problems.
Once the nutrition diagnosis has been made, RDs must develop and
implement interventions to treat malnutrition and other nutrition diagnoses. Nutrition interventions must be targeted and appropriate to the
nutrition diagnosis, the patient, and the situation.
Health care providers in todays complex health care environment are
often called upon to justify the need for their services. RDs must monitor
and evaluate the outcomes of nutrition interventions in order to demonstrate the impact of nutrition therapy on health outcomes.
The Nutrition Care Process (NCP) provides RDs with a solid framework that describes the critical thinking process that RDs use in all practice settings. The four steps of the NCP include nutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition monitoring/
evaluation. While the NCP applies to all practice settings, the dietetics
terminology gives RDs an agreed upon set of terms that describe the work
of the clinical RD.

vi ABSTRACT

Keywords
care process, critical thinking, dietetics, dietetics practice, nutrition assessment, nutrition diagnosis, nutrition intervention, nutrition monitoring/
evaluation, registered dietitian or nutritionist

Contents
Chapter 1 Relationship Between Nutrition and Health......................1
Chapter 2 Nutrition Care Process and Model.....................................5
Chapter 3 Nutrition Assessment.......................................................11
Chapter 4 Nutrition Diagnosis.........................................................29
Chapter 5 Nutrition Intervention.....................................................41
Chapter 6 Nutrition Monitoring and Evaluation..............................55
References67
Index77

CHAPTER 1

Relationship Between
Nutrition and Health
Introduction
History is replete with references to the strong connection between
nutrition and health (Cannon 2005). Hippocrates was among the first
to describe nutritional therapy as primary treatment for disease (Cross
2010). Multiple descriptions of the role of diet in maintaining health can
be found in manuscripts from the Middle Ages and Renaissance periods
(Cannon 2005). While most agree that this connection exists, modern
health systems often place insufficient emphasis on the identification and
treatment of nutrition problems.

Prevalence of Nutrition Problems in Different Health


Care Settings and Populations
Hospitalized Patients
It has long been known that hospitalized patients who have inadequate
intake, weight loss, and other signs that are often associated with malnutrition may have more complications and longer length of stay than normally nourished patients. During the Crimean War, Florence Nightingale
noted that wounded soldiers who had access to a healthy diet were more
likely to survive their injuries than soldiers who had a poor diet. In her
Notes on Nursing, she discussed the importance of nutrition to recovery
and carefully described aspects of meal service that might enhance food
intake (Nightingale 1860).
In the 1930s, Hiram Studley, a gastrointestinal surgeon, noticed that
patients who had lost weight prior to surgery for peptic ulcer had more
complications and higher mortality than those who had not lost weight

NUTRITION ASSESSMENT

(Studley 1936). The connection between weight loss and outcome was
clearthe mortality rate for those who lost less than 20 percent of their
usual weight before surgery was less than 5 percent, while more than 30
percent of those who lost more than 20 percent of their usual weight
before surgery died. Parekh and Steiger provided a description of the relevance of Studleys work in modern surgery (Parekh and Steiger 2004).
More recently, it was found that loss of more than 10 percent of
usual weight was associated with significantly higher risk for postoperative complications in adolescents undergoing spinal fusion surgery
(Tarrantetal.2015). Thus, the connection between weight loss and surgical outcome appears to remain strong in spite of advances in surgical
technique and postoperative care.
Further evidence supporting the importance of nutrition assessment
to dietetics practice was provided in the mid-1970s when a series of articles focused on the discovery that many hospitalized patients suffered
from malnutrition (Bistrian et al. 1974, 1976; Bistrian 1977; Weinsier
etal. 1979). The best known of these publications has been since cited by
thousands of other publications, thus, indicating the interest that health
care providers have in the role of nutrition status in health outcomes
(Butterworth 1974).
In the past 30 years, researchers have focused on determining the
precise nature of the relationship between nutritional status and health
outcomes. While most agree that there is a strong connection between
unintentional weight loss and health outcomes, there is less agreement
on the mechanism(s) involved. It does appear that insufficient nutrient
intake over time is related to loss of muscle mass and decreased functional status (Windsor and Hill 1988). Therefore, until recently, the focus
of nutrition interventions was to ensure adequate protein intake. More
recently, knowledge of the metabolic response to stress has resulted in
a broader focus that includes protein and other nutrients that support
recovery (Turner 2010).
Older Adults
At the beginning of the 20th century, life expectancy in the United States
was approximately 50 years. By the end of the 20th century, life expectancy

Relationship Between Nutrition and Health 3

had risen to more than 70 years. Along with increasing life expectancy,
there was also a shift from an agricultural to urban society, making it more
difficult for extended families to provide support for aging parents and
grandparents. Long-term care (LTC) facilities were expected to provide
care for older adults who could no longer care for themselves. High costs
and concerns regarding quality of care have driven a recent shift away
from LTC to aging in place, resulting in greater numbers of older adults
living in the community.
One benefit of LTC facilities was the ability to monitor health status
on a regular basis. Older adults living in the community must balance the
social benefits of remaining in familiar surroundings with the absence of
continual health monitoring. Changes in appetite associated with aging
may lead to gradual decrease in nutrient intake with subsequent weight
loss. Sporadic health visits mean that weight loss may go undetected until
there is a health crisis.
Weight loss is strongly associated with mortality in older adults.
Unintentional weight loss is a strong predictor of mortality in community-dwelling older adults (Landi, Onder, and Cesari 2004; Olin et al.
2005; Reynolds et al. 1999). Poor nutritional status is also associated with
poor psychological well-being in older adults with dementia (Muurinen
et al. 2015).
Chronic Conditions
Chronic health conditions are often associated with changes in appetite,
nutrient intake, or nutrient utilization, all of which may impact nutritional status. Health care providers must be able to identify the appropriate cause of nutritional deficitspoor appetite, poor intake caused by
overly restricted diets, or altered nutrient utilization. Nutritional deficits
related to poor appetite or overly restricted diets may respond to nutrition
interventions, while deficits related to alterations in nutrient utilization
most likely require coordinated efforts of all members of the health care
team.

Index
Academy of Nutrition and Dietetics
(AND), 29
Acute Physiology and Chronic Health
Evaluation (APACHE II), 27
American Occupational Therapy
Association (AOTA), 67
American Physical Therapy
Association, 7
AND. See Academy of Nutrition and
Dietetics
Anthropometric measurements,
2326, 6465
AOTA. See American Occupational
Therapy Association
Biochemical data, medical tests, and
procedures, 2628
Chronic health conditions, 3
Clinical nutrition interventions,
4648
Condition-specific growth charts, 26
Critical thinking skills, 3637
Dietary Reference Intakes (DRIs), 64
Differential diagnosis, 35
Documentation, 4142, 5254
Donabedian, Avedis, 6
DRIs. See Dietary Reference Intakes
Economic outcomes, 5859

Health care professionals, 22


Health outcomes
categories, 5760
defined, 58t
nutrition outcomes, 5657
vs. nutritional status and, 2
Health-related quality of life
(HR-QOL), 5960
Health screening, defined, 9
Hepatic transport proteins, 27
HOAC. See Hypothesis Oriented
Algorithm for Clinicians
HR-QOL. See Health-related quality
of life (HR-QOL)
Hyperphosphatemia, 47
Hypothesis Oriented Algorithm for
Clinicians (HOAC), 7
IDNT. See International Dietetics and
Nutrition Terminology
Informed intuition. See Differential
diagnosis
International Dietetics and Nutrition
Terminology (IDNT), 21,
38, 60
domains of, 4850
Involuntary weight loss, 36
King, Lester, 30
Long-term care (LTC) facilities, 3

Food and nutrient delivery class, 49


Food and nutrition intake, 1619, 64

Malnutrition, 38
Mortality rate, 12
weight loss and, 3

Glycosylated hemoglobin, 27
Goal setting, 41
Guide to Physical Therapist Practice, 7

Nightingale, Florence, 1
Nurses, 31
Nursing diagnosis, 3334

78 Index

Nutrition assessment
anthropometric measurements,
2326
biochemical data, medical tests, and
procedures, 2628
categories for, 1628
client history, 1921
data sources for, 1316
food and nutrition intake in, 1619
goal of, 2930
history of, 1113
nutrition-focused physical findings,
2123
overview, 11
Nutrition Care Process (NCP), 5
benefits of, 41, 5254
commonalities among, 7
external process, 8
inner ring of, 89
intervention phase of, 41
nursing and, 6
nutrition monitoring and
evaluation, 5566
occupational therapy, 67
patient-centered care, 9
physical therapy, 7
Nutrition counseling, 50
Nutrition diagnosis process
critical thinking skills to, 3637
differential diagnosis of, 35
documentation of, 4142, 5254
etiology of, 41
example for, 3234
health care professionals and, 3032
nurses, 31
nutrition problems, 36
overview of, 2930
PES, 3839
terms to describe, 3739
thought process of, 30
Nutrition diagnostic statement (PES),
3839
guidelines for, 39
nutrition interventions and, 42t
sample, 39
Nutrition education class, 4950
Nutrition interventions, 4154

clinical, 4648
definition of, 41
effectiveness of, 61
goal setting, 41
P-E-S statement and, 42
planning and implementation, 43t,
5152
public, 48
RD-directed and -implemented,
4248
scope of practice issues and, 4446
terminology classes, 4850
Nutrition intervention classes
coordination of nutrition care, 50
food and nutrient delivery class, 49
nutrition counseling, 50
nutrition education class, 4950
Nutrition problems, 13
in hospitalized patients, 12
in older adults, 23
Nutrition monitoring and evaluation,
5566
defined, 61
health vs. nutrition outcomes,
5657
importance of, 56
indicators for, 6263
overview, 5556
terminologies, 6365
Nutrition outcomes
categories of, 60
health outcomes vs., 5657
Nutrition prescription, 51
Nutrition screening, 910
Nutrition-focused physical findings,
2123
defined, 21
Nutrition-related QOL (NR-QOL),
60
Nutritional deficits, 3
Nutritional status, health outcomes
and, 2
Obesity epidemic, 48
Occupational therapists (OTs), 32
Occupational therapy, 67
OTs. See Occupational therapists

Index 79

Patient-centered care, 9
Phenylketonuria (PKU), 4647
Physical inactivity (NB-2.1), 63
Physical therapists (PTs), 3132
Physical therapy diagnosis, 33
PKU. See Phenylketonuria
PTs. See Physical therapists
Public health nutrition interventions,
48
Referral to community agencies/
programs (RC-1.4), 63
Registered dietitians (RDs), 29, 41
directed and implemented, 4248
Reliability, 63

Satisfaction outcomes, 59
Serum albumin, 26
Subjective global assessment (SGA),
23
U.S. Bureau of Labor Statistics, 31
Validity, 63
Vitamin D, 27
Visceral protein status, 26
Weight loss
involuntary, 36
mortality rate and, 3

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