Chapter 2 Nutrition Assessment


The Nutrition Care Process begins with nutrition assess- ment. Assessment data are available from the referral source, the client’s medical records, and the client. Prior to the first encounter, data can be compiled from the client’s medical records, forms the client completes, and informa- tion received from the referral source. It is essential to know the client’s medical condition(s) for which medical nutrition therapy (MNT) is requested, the medical therapy the cli- ent is receiving, and the goals of the therapy (see Boxes 2.1 through 2.13 and Tables 2.1 through 2.3, pages 20–35) as well as the medications prescribed for the medical condi- tions(s) (see Boxes 2.14 through 2.16 and Tables 2.8 through 2.10, pages 38–51). By collecting as much data as possible before the first encounter, the implementation of education and counseling can begin more efficiently. It is also helpful at the beginning of the MNT encounter


to determine why the client has scheduled the appointment and to answer his or her questions. A client’s reply to a question such as “What brought you here today?” can help determine his or her readiness to change. For example, the reply “My doctor told me to come” requires different edu- cation and counseling strategies than the reply “I asked my doctor for a referral.” A second question—“Do you have questions or goals for our session today?”—will help tailor the encounter so that the client’s concerns are addressed. (See the nutrition counseling section in Chapter 5.) This chapter does not cover all assessment data that


might be needed, but the various tables highlight import- ant assessment parameters related to lipid disorders (LDs),


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