Chapter 5 Nutrition Care Process

and other health care professionals. Nutrition assessment terminology groups assessment data into five different domains. (See Box 5.2.)

BOX 5.2 Five Domains of Nutrition Assessment (Step 1)

● Food/Nutrition-Related History ● Anthropometric Measurements

●

Biochemical Data, Medical Tests, and Procedures

● Nutrition-Focused Physical Findings ● Client History

Source: Academy of Nutrition and Dietetics. Nutrition assessment introduction. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Nutrition Assessment Snapshot. http://ncpt.webauthor.com/ pubs/idnt-en/page-022. Accessed January 25, 2016.

The nutrition assessment includes: ●

reviewing data collected to identify factors that affect nutritional and health status;

●

clustering data elements that support a nutrition diagnosis as described in the nutrition diagnosis reference sheets published in the Nutrition Care Process Terminology; and

●

identifying standards against which the assess- ment data will be compared.

The specific types of data collected in the assessment step vary depending on the practice settings, the present health status of the individual or group, how data relate to the outcomes to be measured, recom- mended practices (such as Evidence-Based Nutrition Practice Guidelines), and whether the assessment is an initial evaluation or a reassessment.

Nutrition assessment requires making comparisons between the data collected and reliable standards of care. It is an ongoing process that involves not only the initial data collection but also the continual reassess- ment and analysis of resident/client or group needs. The nutrition assessment provides the groundwork for determining the nutrition diagnosis in the second step of the NCP.

The nutrition and dietetics practitioner uses critical thinking skills during nutrition assessment to ensure that appropriate care is provided (see Box 5.3). Examples of critical thinking in nutrition assessment include the following: determining the appropriate data to collect, validating the data, and distinguishing rele- vant from irrelevant data in order to arrive at the most appropriate nutrition diagnosis.

53

Step 2: Nutrition Diagnosis Nutrition diagnosis is a critical step between nutrition assessment and nutrition intervention. Its purpose is to identify and describe a specific nutrition problem that can be resolved or improved through interventions by the RDN.

Nutrition diagnosis should not be confused with medical diagnosis. A medical diagnosis can be defined as a disease or pathology of specific organs or body systems that can be treated or prevented. A medical diagnosis does not change as long as the disease or con- dition exists. However, a nutrition diagnosis can change as the resident’s/client’s or group’s response changes. For example, a resident/client may have the medical diagnosis of type 1 diabetes, which will not change until a cure for the disease is found. However, the nutrition diagnosis for this individual could vary over time. At one point, a nutrition assessment may lead the RDN to diagnose, for example, “Inconsistent carbohydrate intake”; later, the nutrition diagnosis “Excessive carbo- hydrate intake” might be better supported by the assess- ment data.

After evaluating the assessment data and determin- ing the nutrition diagnosis(es), the RDN has an evidence base for developing interventions, setting realistic goals and measurable expected outcomes, and tracking the progress in meeting those expected outcomes. Nutrition assessment data should be clustered as signs and symp- toms that support the nutrition diagnoses documented by the RDN. Diagnoses should be prioritized based on criti- cal assessment of what problems are most important to resolve and within the RDN’s scope of practice to address. The standardized nutrition diagnosis terms are

BOX 5.3 Critical Thinking Steps During Nutrition Assessment

● Determining appropriate data to collect ●

Determining the need for additional information

● ●

Selecting assessment tools and procedures that match the situation

Applying assessment tools in valid and reliable ways

● Distinguishing relevant from irrelevant data ●

Distinguishing important from unimportant data

● Validating the data

Source: Academy of Nutrition and Dietetics. Nutrition assessment introduction. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. Nutrition Assessment Snapshot. http://ncpt.webauthor.com/ pubs/idnt-en/category-1. Accessed January 25, 2016.