NAD509: Nutrition
Assessment
CLIENT
HISTORY
Dr. Syahrul Bariah Abdul Hamid
Centre of Nutrition & Dietetics,
Faculty of Health Sciences, UiTM
What is NCP?
– A systematic problem solving method that food and nutrition professionals use
to think critically and make decisions that address practice related problems.
– A standardized model intended to guide Registered Dietitians in providing high
quality nutrition care.
Purpose of NCP
– designed to improve the consistency and quality of nutrition care and the predictability
of the nutrition care outcomes. It is not intended to standardize nutrition care for
patients/clients, but to establish a standardized process for providing care.
– Provide structure and terminology for research studies and data collection.
– Provide a standardized language
There are four steps in the process:
– Nutrition Assessment
– Nutrition Diagnosis
– Nutrition Intervention
– Nutrition Monitoring and Evaluation
Nutrition Care Process: ADIM
1. Assessment: nutritional health status
2. Diagnosis: interpret data
3. Intervention: develop a plan of action
4. Monitor/Evaluate: monitor the effectiveness of the plan
Nutrition Assessment
– to obtain, verify, and interpret data needed to identify nutrition-
related problems, their causes, and significance.
– It is an ongoing, nonlinear and dynamic process that involves data
collection and continual analysis of the patient/client’s status
compared to specified criteria
How to obtain data?
– For individuals, data can come directly from the patient/client
through interview, observation and measurements, a medical
record, and the referring health care provider.
– For population groups, data from surveys, administrative data sets,
and epidemiological or research studies are used.
Use of nutrition assessment data
– Nutrition assessment data, or indicators, are compared to criteria,
or relevant norms and standards.
– These norms and standards may be national, institutional, or
regulatory.
– Nutrition assessment findings are then documented in nutrition
diagnosis statements and nutrition intervention goal setting.
What do we expect?
Critical thinking skills:
– 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
Domains in NA
– Client/patient history
– Anthropometric measurements
– Biochemical data, medical tests, procedures
– Food/Nutrition related history
– Nutrition-focused physical findings
Anthropometric
Measurements
• Height, weight, body mass index
(BMI), growth pattern
indices/percentile ranks, and weight
history
Client History Biochemical Data, Medical Tests, and Proce
• Personal history, medical/health/family history, dures
treatments and complementary/alternative • Lab data (e.g., electrolytes, glucose) and tests
medicine use, and social history (e.g., gastric emptying time, resting metabolic
rate
Nutrition-Focused Physical Findings Food/Nutrition-Related History
• Physical appearance, muscle and fat wasting, • Food and nutrient
swallow function, intake, food and nutrient administration, medication,
complementary/alternative medicine use,
appetite, and affect knowledge/beliefs, food and supplies
availability, physical activity, nutrition
quality of life
– When assessing a nutrition indicator, compare current data against a
• Nutrition prescription
• Reference standard or comparative standard
– National Standards for populations such as Malaysia RNI, MNT Guidelines for
specific disease conditions, e.g., A.S.P.E.N.,E.S.P.E.N., U.S. National Kidney
Foundation, Malaysian Dietitian’s Association (MDA)
Comparative standard
When choosing a Comparative Standard, 2. Population characteristics
there are three factors to consider: - Age
1. Practice setting - Gender
- Acute care
3. Disease state and severity
- Long term care community - Renal disease
- Ambulatory care - Diabetes, type and severity
- Public health community - - Critical illness
Client history
Personal History (1)
General patient/client information such as age, gender, sex, race, ethnicity, language,
education, and role in family
Patient/Client/Family Medical/Health History (2)
Patient/client or family disease states, conditions, and illnesses that may have
nutritional impact.
Social History (3)
Patient/client socioeconomic status, housing situation, medical support, and
involvement in social groups.
Patien Social
Perso t/clie Treat histor
nal da nt OR ments y (3.1)
ta (1.1 family
●age
●Gender
●Patient/client chief
/thera
●Medical ●Socioeconomic factors
Living/housing situation
●
●Race
nutrition complaint treatment/thera ●Domestic issues
) py (2.
●Cardiovascular
●Ethnicity ●Social and medical
py
●Language
nutri
●Literacy factors
●Endocrine/metabolis
m ●Surgical
support
●Geographic location of
●Education
tion-o
●Role in family
●Tobacco use
●Physical disability
●GI
●Gynecology
●Neurological
2)
treatment
●Palliative /end
home
●Occupation
●Religion
●History of recent crisis
of life care
riente
●Mobility ●Psychological ●Daily stress level
Case Study 1
Personal data
Patient/client OR family nutrition-
oriented medical/health history
Treatments/therapy
Social history
Case Study 2
– Mr. Grand is a 55 year old insured Caucasian male seen in a family practice clinic. His primary complaint
is pain, swelling, and redness in his right great toe. He says he woke up in the night with extremely
excruciating pain in his toe, by morning his toe was dark red and warm. He denies a history of recent
trauma or similar problems in other joints.
– He is an accountant for a large corporation. He travels frequently by train or airplane to various offices
around the country. He denies smoking, admits to drinking 3-4 beers per night, denies use of street
drugs.
– Generally, he is healthy and did not have previous hospitalizations or surgeries. He has hypertension and
hyperlipidemia for 3 years.
– He has been married once, for 25 years. He has two grown children in good health. Mother is alive and
well. Father died at age 68 from complications of diabetes and hypertension. He has a brother who also
has hypertension.
– Eats at least three meals per day, tries to eat low fat, low cholesterol foods. States he does not exercise
regularly, due to his busy schedule. Has blood drawn yearly for cholesterol and checking for diabetes.
Former primary care physician passed away about 6 months ago. He reports that he likes to eat. One of
his favorite foods is chicken livers which he reports to consume several times a week.
