Nutrition Assessment: Examples in Two Case Studies
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1 Nutrition Care Process Model Tutorials Nutrition Care Process and Terminology Committee Academy of Nutrition and Dietetics Nutrition Care Process Terminology 2015 Edition Nutrition Assessment: Examples in Two Case Studies Objective The objective of this presentation is to review and feature the use of Nutrition Assessment terminology in case study material for two different patients. By the end of this module the participant will be able to understand use of nutrition assessment terminology in two case examples: A 67 year old Hispanic male with heart failure An 8 year old white male child with iron deficiency anemia and food allergies Case #1 Referral from Family Practice Clinic to RDN: 67 year old Hispanic male with Heart Failure Step 1: gather data from medical records Step 2: verify in patient interview Step 3: complete nutrition history questionnaire Step 4: Identify indicators and establish whether the data are within normal parameters using comparative standards 1
2 Case #1 Description of patient: 67 year old Hispanic male medical diagnosis of heart failure (diagnosed 2 months prior) retired engineer lives alone in apartment height: 5 6 ; weight: 135 lbs. weight loss of 20 lbs. from dyspnea inability to consume large meals unable to shop or cook 24-hour recall indicates he uses many frozen and processed foods; intake between kcal/day Case #1: Identify Terms Begin the process of identifying terms by asking the following questions: Which terms can be used to describe the data so that it can be extracted in the future? Which data are new vs. already existing in the medical record? What parameters or comparative standards can be used to evaluate the data? What additional data are needed to make a definitive nutrition diagnosis? Cardiology Key Nutrition Assessment Data Domain: Food/Nutrition Related History (FH) Class: Food and Nutrient Intake (1) Sub-Class: Energy Intake (1.1) Sub-sub Class: Energy Intake (1.1.1)» Record the Total energy intake (FH ): kcal/day Sub-Class: Food and Beverage Intake (1.2) Sub-sub Class: Food Intake (1.2.2)» Describe the Amount of food (FH ): unable to consume large meals» Describe the Types of food/meals (FH ): convenience frozen meals Sub-Class: Micronutrient Intake (1.6) Sub-sub Class: Mineral/element intake (1.6.2)» Describe the intake of Sodium (FH ): high These data are new and should be contributed to the medical record. 2
3 Cardiology Key Nutrition Assessment Data Domain: Food/Nutrition Related History (FH) Class: Behavior (5) Sub-Class: Social Network (5.5)» Record Ability to build and utilize social network (FH 5.5.1): should be encouraged due to patient s statement of not liking to eat alone. Class: Physical Activity and Function (7) Sub-Class: Nutrition-related ADLs and IADLs (7.2)» Record the Physical ability to complete tasks for meal preparation (FH 7.2.1) is limited due to patient s stated inability to shop for food and cook. Cardiology Key Nutrition Assessment Data Domain: Anthropometric Measurements (AD) Class: Body composition/growth/weight history (1.1)» Record: Height/length (AD 1.1.1): 5 6 Weight (AD 1.1.2): 135 lbs. Weight change (AD 1.1.4): decrease of 20 lbs. over 2 months Cardiology Key Nutrition Assessment Data Domain: Biochemical Data, Medical Tests and Procedures (BD) No information Domain: Nutrition-Focused Physical Findings (PD) No information 3
4 Cardiology Key Nutrition Assessment Data Domain: Client History (CH) Class: Personal History (1) Sub-Class: Personal Data (1.1)» Record Age (CH 1.1.1): 67 years old» Record Gender (CH 1.1.2): male» Record Ethnicity (CH 1.1.5): Hispanic» Record Language (CH 1.1.6): Spanish/English Class: Patient/Client/Family Medical/Health History (2) Sub-Class: Patient/client OR family nutrition-oriented medical/health history (2.1)» Record Cardiovascular (CH 2.1.2): patient has medical diagnosis of heart failure in last 2 months, dyspnea Class: Social History (3) Sub-Class: Social history (3.1)» Record Living/Housing situation (CH 3.1.2): patient living in apartment 4 blocks from Medical Center» Record Occupation (CH 3.1.6): retired engineer Cardiology Key Nutrition Assessment Data Domain: Comparative Standards (CS) Class: Energy Needs (1) Sub-Class: Estimated energy needs (1.1)» Record Total energy estimated needs (CS 1.1.1): 1600 kcal/day to maintain weight» Record Method for estimating needs (CS 1.1.2): Mifflin St. Jeor equation with sedentary activity levels Class: Micronutrient Needs (4) Sub-Class: Estimated mineral needs (4.2)» Record Sodium (CS 4.2.7): less than 2000 mg/day Class: Weight and Growth Recommendation (5) Sub-Class: Recommended body weight/body mass Index/growth (5.1)» Record Recommended body mass index (BMI) (CS 5.1.2): Case #2 Referral from Pediatric Clinic to RDN request for RDN consultation for assistance with meal planning 8 year old white male child with Fe deficiency anemia Step 1: gather data from medical records Step 2: verify in patient interview Step 3: complete nutrition history questionnaire Step 4: Identify indicators and establish whether the data are within normal parameters using comparative standards 4
5 Case #2 Description of patient: 8 year old white male child allergies to eggs and peanuts diagnosed with Fe deficiency anemia growth recently slowed with current BMI at the 30 th percentile (44 th percentile one year ago) food history questionnaire indicates an intake of kcal/day poor appetite food variety limited; intake of only 4 or 5 different foods. mother states he is more irritable and more fatigued than usual. Mother requests assistance for planning bag lunches and other meals that will help her child gain weight. Case #2: Identify Terms Begin the process of identifying terms by asking the following questions: Which terms can be used to describe the data so that it can be extracted in the future? Which data are new vs. already existing in the medical record? What parameters or comparative standards can be used to evaluate the data? What additional data are needed to make a definitive nutrition diagnosis? Pediatric Key Nutrition Assessment Data Domain: Food/Nutrition Related History (FH) Class: Food and Nutrient Intake (1) Sub-Class: Energy Intake (1.1) Sub-sub Class: Energy Intake (1.1.1)» Record the Total energy intake (FH ): kcal/day Sub-Class: Food and Beverage Intake (1.2) Sub-sub Class: Food Intake (1.2.2)» Describe the Types of food/meals (FH ): takes lunch to school» Describe the Food variety (FH ): limited to 4 or 5 different foods These data are new and should be contributed to the medical record. 5
6 Pediatric Key Nutrition Assessment Data Domain: Food/Nutrition Related History (FH) Class: Knowledge/Beliefs/Attitudes (4) Sub-Class: Food and nutrition knowledge/skill (4.1)» Record the Area and level of knowledge/skill (FH 4.1.1): Mother is asking for assistance in meal planning to achieve weight gain. Sub-Class: Beliefs and Attitudes (4.2)» Record the Readiness to change nutrition related behaviors (FH 4.2.7): Child is afraid to try new foods due to possible allergic reactions. Class: Behavior (5) Sub-Class: Mealtime Behavior (5.4)» Record Limited number of accepted foods (FH 5.4.9): Child will eat only 4 or 5 different foods. Pediatric Key Nutrition Assessment Data Domain: Anthropometric Measurements (AD) Class: Body composition/growth/weight history (1.1)» Record the following: Height/length (AD 1.1.1): 4 1, increase of 1 /one year (4 0 one year ago) Weight (AD 1.1.2): 51.5 lbs. Weight change (AD 1.1.4): increase of 1.5 lbs. over one year (50.0 lbs. on year ago) Growth pattern indices/percentile ranks (AD 1.1.6): BMI for age, 30 th percentile (44 th percentile one year ago) Pediatric Key Nutrition Assessment Data Domain: Biochemical Data, Medical Tests and Procedures (BD) No information Domain: Nutrition-Focused Physical Findings (PD) Class: Nutrition-focused physical findings (1.1) Sub-Class: Overall findings (PD 1.1.1)» Record Asthenia (PD ): lack of energy Sub-Class: Digestive system (PD 1.1.5)» Record Decrease in appetite (PD ): poor appetite 6
7 Pediatric Key Nutrition Assessment Data Domain: Client History (CH) Class: Personal History (1) Sub-Class: Personal Data (1.1)» Record Age (CH 1.1.1): 8years old» Record Gender (CH 1.1.2): Male» Record Race (CH 1.1.4): White» Record Language (CH 1.1.6): English Class: Patient/Client/Family Medical/Health History (2) Sub-Class: Patient/client OR family nutrition-oriented medical/health history (2.1)» Record Hematology/oncology (CH 2.1.7): patient has medical diagnosis of iron deficiency anemia Pediatric Key Nutrition Assessment Data Domain: Comparative Standards (CS) Class: Energy Needs (1) Sub-Class: Estimated energy needs (1.1)» Record Total energy estimated needs (CS 1.1.1): kcal/day» Record Method for estimating needs (CS 1.1.2): DRI for 8 year old with growth and low to very active Physical Activity Level (PAL) Class: Weight and Growth Recommendation (5) Sub-Class: Recommended body weight/body mass Index/growth (5.1)» Record Desired growth pattern (CS 5.1.3): Increase of 2 3 height and 5 10 lbs. per one year. Summary In this presentation we have reviewed the nutrition assessment data and terminology for two case studies: A 67 year old Hispanic male with heart failure An 8 year old white male child with iron deficiency anemia and food allergies 7
8 Summary This concludes the nutrition assessment tutorial. Please proceed to the Nutrition Diagnosis Tutorial for the presentation of the development of the Nutrition Diagnosis and PES statement for both case studies. 8
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