A Comprehensive Guide to Nutrition Assessment

Nutrition assessment is an important part of the Nutritional Care Process (NCP) and is used to determine a person's nutritional status. It involves collecting objective and subjective data, such as anthropometric measurements, dietary intake, medical history, and physical exam. This data is then used to identify any existing or potential nutritional problems and create a plan to achieve desired health outcomes. In this article, we will discuss the basic steps of nutrition assessment and how professionals use the NCP QUEST auditing tool to evaluate dietitians' documentation notes. The first step of the NCP is screening.

This involves identifying individuals who are at risk for malnutrition or who may benefit from nutrition intervention. Screening can be done through a variety of methods, such as anthropometric measurements, dietary intake assessment, and medical history review. Once individuals are identified as being at risk for malnutrition or in need of nutrition intervention, they can move on to the second step of the NCP: nutritional assessment. The second step of the NCP links nutritional assessment with intervention. The Registered Dietitian (RD) identifies and labels a specific nutritional diagnosis that the RD is responsible for treating.

A standardized language for NCP has been developed to be used in identifying a nutritional diagnosis. Currently, a nutritional diagnosis may exist or the resident is at risk of its occurrence. It's important to note that a nutritional diagnosis is not a medical diagnosis. The nutritional diagnostic statement must be clear, concise, related to a problem, and based on reliable and accurate evaluation data. The third step includes planning and implementing a plan focusing on the nutrition problem identified in the nutritional diagnosis. This step includes discussing realistic goals with the resident and other members of the interdisciplinary team and creating a plan to achieve that goal. Often, in the long-term care setting, interventions may include referral to speech therapy, altering the texture or consistency of the diet, liberalizing the diet, and providing nutrient-rich supplements.

Nutritional evaluations are used to determine a person's nutritional status or growth patterns. Dieticians apply the data collected from the nutritional assessment to plan a nutritional intervention, which involves helping a person maintain or achieve the desired state of health.

Anthropometric Measurements

Anthropometric measurements are objective measures that help determine the amount of muscle and the percentage of body fat. These measures can be used to assess weight loss or gain in an individual or to compare two different people. They can also be used to compare growth rates in children.

Anthropometry may include height, weight, body mass index (BMI), measurements of skin folds, and size of body structure. During a nutritional evaluation, a dietitian takes anthropometric measurements and then compares them with standard values to make an informed assessment of growth or weight.

Dietary Intake Assessment

Your customer provides a detailed diet diary. This diary should have enough time to get a good idea of your eating habits and your food intake. It is usually three to five days. The customer records all the food and beverages he eats and the quantity.

With Nutrition Maker, you can do it directly on your computer. For example, a breakfast diary for the first day could include three eggs with a quarter ounce of ham, one ounce of cheddar cheese and eight ounces of whole milk.

Medical History Review

It is also important to determine if a person is taking vitamins, minerals, or herbal supplements that may affect nutritional status. The dietitian can simply ask the person what they ate in the 24 hours before the nutritional evaluation.

Nutrition Care Process

In 2002, the Academy of Nutrition and Dietetics (formerly the American Dietetics Association) created the Nutritional Care Process (NCP) as a way to improve the consistency and quality of individualized care for residents and the predictability of residents' outcomes. The NCP QUEST is an auditing tool used to evaluate dietitians' documentation notes through the nutritional care process. As a framework used for critical thinking and decision-making, Registered Dietitian Nutritionists (RDNs) can use the nutrition care process in all work settings, including clinical, administrative, food service, research, community health and education.

Nutrition Education

The Academy works with several accrediting organizations, such as DNV GL Healthcare Accreditation, Health Care Accreditation Commission (HCAC), and The Joint Commission (TJC), to use the nutrition care process to guide surveys, evaluate standards and performance elements of dietary services.

EnCpt Subscribers

EnCpt subscribers have access to the most up-to-date terminology used in nutrition care, as well as reference sheets that provide clear definitions and explanations of all terms including indicators, evaluation criteria, etiologies and signs and symptoms.

Conclusion

Nutrition assessment is an important part of providing quality care for individuals at risk for malnutrition or in need of nutrition intervention. By following these steps outlined in this article – screening individuals at risk for malnutrition; identifying specific nutritional diagnoses; planning interventions; collecting objective data; assessing dietary intake; reviewing medical history; using auditing tools; providing nutrition education; and utilizing EnCpt subscribers – professionals can ensure that they are providing quality care for their patients.