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EBOOKS Nutrition Assessment

Pamela Charney
It has long been known that nutritional deficiencies are associated with
LIBRARY morbidity and mortality in hospitalized patients. Registered dietitians
Katie Ferraro, Editor
(RDs) are responsible for the diagnosis and treatment of malnutrition
Create your own in all practice settings. Accurate diagnosis of malnutrition depends
Customized Content on the skills of RDs in completing the nutrition assessment combined
Bundle the more with critical thinking skills. There are five components of the nutrition
assessment; they are as follows:
books you buy,
the higher your
Nutrition-focused physical exam
discount! Client history
Food and nutrition history

THE CONTENT Anthropometric measures

Biochemical measures, procedures, and tests
Nutrition and
Dietetics Practice

RDs must consider each component in order to accurately diagnose
Psychology nutrition problems.
Health, Wellness, The Nutrition Care Process (NCP) provides RDs with a solid

Nutrition Assessment
and Exercise framework that describes the critical thinking process that RDs use

Science in all practice settings. The four steps of the NCP include nutrition
Health Education assessment, nutrition diagnosis, nutrition intervention, and nutrition

monitoring/evaluation. While the NCP applies to all practice settings,
the dietetics terminology gives RDs an agreed upon set of terms that
THE TERMS describe the work of the clinical RD.
Perpetual access for
a one time fee Pamela Charney, PhD, RD is a registered dietitian with over 20 years
No subscriptions or experience. She has a great deal of experience in all care settings,
ranging from 30 bed critical access hospitals to 500 bed academic
access fees
centers. She received her baccalaureate degree from the
University of West Florida, completed a dietetic internship at W alter
concurrent usage
Reed Army Medical Center, and is a US Army veteran. She has masters
Downloadable PDFs degrees in nutritional sciences and clinical informatics and patient

Free MARC records centered technology from the University of Washington and a PhD in
health sciences from Rutgers University. Dr. Charney has a long record
of professional service and was a charter member of the Academy
For further information,
of Nutrition and Dietetics Nutrition Care Process and Dietetics
a free trial, or to order,
Terminology Committees. She is also a sought-after speaker at local,
national, and international levels and has written extensively on the
nutrition care process, critical thinking in dietetics practice, nutrition
assessment, and evaluation of quality of nutrition care. Pamela Charney
ISBN: 978-1-60650-751-3
Nutrition Assessment
Nutrition Assessment

Pamela Charney, PhD, RD


Nutrition Assessment

Copyright Momentum Press, LLC, 2016.

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First published in 2016 by

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ISBN-13: 978-1-60650-751-3 (paperback)

ISBN-13: 978-1-60650-752-0 (e-book)

Momentum Press Nutrition and Dietetics Practice Collection

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Printed in the United States of America.

It has long been known that nutritional deficiencies are associated with
morbidity and mortality in hospitalized patients. Registered dietitians
(RDs) are responsible for the diagnosis and treatment of malnutrition in
all practice settings. Accurate diagnosis of malnutrition depends on the
skills of RDs in completing the nutrition assessment combined with criti-
cal thinking skills. There are five components of the nutrition assessment;
they are as follows:

Nutrition-focused physical exam

Client history
Food and nutrition history
Anthropometric measures
Biochemical measures, procedures, and tests

RDs must consider each component in order to accurately diagnose

nutrition problems.
Once the nutrition diagnosis has been made, RDs must develop and
implement interventions to treat malnutrition and other nutrition diag-
noses. Nutrition interventions must be targeted and appropriate to the
nutrition diagnosis, the patient, and the situation.
Health care providers in todays complex health care environment are
often called upon to justify the need for their services. RDs must monitor
and evaluate the outcomes of nutrition interventions in order to demon-
strate the impact of nutrition therapy on health outcomes.
The Nutrition Care Process (NCP) provides RDs with a solid frame-
work that describes the critical thinking process that RDs use in all prac-
tice settings. The four steps of the NCP include nutrition assessment,
nutrition diagnosis, nutrition intervention, and nutrition monitoring/
evaluation. While the NCP applies to all practice settings, the dietetics
terminology gives RDs an agreed upon set of terms that describe the work
of the clinical RD.

care process, critical thinking, dietetics, dietetics practice, nutrition assess-
ment, nutrition diagnosis, nutrition intervention, nutrition monitoring/
evaluation, registered dietitian or nutritionist
Chapter 1 Relationship Between Nutrition and Health......................1
Chapter 2 Nutrition Care Process and Model.....................................5
Chapter 3 Nutrition Assessment.......................................................11
Chapter 4 Nutrition Diagnosis.........................................................29
Chapter 5 Nutrition Intervention.....................................................41
Chapter 6 Nutrition Monitoring and Evaluation..............................55


Relationship Between
Nutrition and Health
History is replete with references to the strong connection between
nutrition and health (Cannon 2005). Hippocrates was among the first
to describe nutritional therapy as primary treatment for disease (Cross
2010). Multiple descriptions of the role of diet in maintaining health can
be found in manuscripts from the Middle Ages and Renaissance periods
(Cannon 2005). While most agree that this connection exists, modern
health systems often place insufficient emphasis on the identification and
treatment of nutrition problems.

Prevalence of Nutrition Problems in Different Health

Care Settings and Populations
Hospitalized Patients

It has long been known that hospitalized patients who have inadequate
intake, weight loss, and other signs that are often associated with malnu-
trition may have more complications and longer length of stay than nor-
mally nourished patients. During the Crimean War, Florence Nightingale
noted that wounded soldiers who had access to a healthy diet were more
likely to survive their injuries than soldiers who had a poor diet. In her
Notes on Nursing, she discussed the importance of nutrition to recovery
and carefully described aspects of meal service that might enhance food
intake (Nightingale 1860).
In the 1930s, Hiram Studley, a gastrointestinal surgeon, noticed that
patients who had lost weight prior to surgery for peptic ulcer had more
complications and higher mortality than those who had not lost weight

(Studley 1936). The connection between weight loss and outcome was
clearthe mortality rate for those who lost less than 20 percent of their
usual weight before surgery was less than 5 percent, while more than 30
percent of those who lost more than 20 percent of their usual weight
before surgery died. Parekh and Steiger provided a description of the rel-
evance of Studleys work in modern surgery (Parekh and Steiger 2004).
More recently, it was found that loss of more than 10 percent of
usual weight was associated with significantly higher risk for postop-
erative complications in adolescents undergoing spinal fusion surgery
(Tarrantetal.2015). Thus, the connection between weight loss and sur-
gical outcome appears to remain strong in spite of advances in surgical
technique and postoperative care.
Further evidence supporting the importance of nutrition assessment
to dietetics practice was provided in the mid-1970s when a series of arti-
cles focused on the discovery that many hospitalized patients suffered
from malnutrition (Bistrian et al. 1974, 1976; Bistrian 1977; Weinsier
etal. 1979). The best known of these publications has been since cited by
thousands of other publications, thus, indicating the interest that health
care providers have in the role of nutrition status in health outcomes
(Butterworth 1974).
In the past 30 years, researchers have focused on determining the
precise nature of the relationship between nutritional status and health
outcomes. While most agree that there is a strong connection between
unintentional weight loss and health outcomes, there is less agreement
on the mechanism(s) involved. It does appear that insufficient nutrient
intake over time is related to loss of muscle mass and decreased func-
tional status (Windsor and Hill 1988). Therefore, until recently, the focus
of nutrition interventions was to ensure adequate protein intake. More
recently, knowledge of the metabolic response to stress has resulted in
a broader focus that includes protein and other nutrients that support
recovery (Turner 2010).

Older Adults

At the beginning of the 20th century, life expectancy in the United States
was approximately 50 years. By the end of the 20th century, life expectancy
Relationship Between Nutrition and Health 3

had risen to more than 70 years. Along with increasing life expectancy,
there was also a shift from an agricultural to urban society, making it more
difficult for extended families to provide support for aging parents and
grandparents. Long-term care (LTC) facilities were expected to provide
care for older adults who could no longer care for themselves. High costs
and concerns regarding quality of care have driven a recent shift away
from LTC to aging in place, resulting in greater numbers of older adults
living in the community.
One benefit of LTC facilities was the ability to monitor health status
on a regular basis. Older adults living in the community must balance the
social benefits of remaining in familiar surroundings with the absence of
continual health monitoring. Changes in appetite associated with aging
may lead to gradual decrease in nutrient intake with subsequent weight
loss. Sporadic health visits mean that weight loss may go undetected until
there is a health crisis.
Weight loss is strongly associated with mortality in older adults.
Unintentional weight loss is a strong predictor of mortality in commu-
nity-dwelling older adults (Landi, Onder, and Cesari 2004; Olin et al.
2005; Reynolds et al. 1999). Poor nutritional status is also associated with
poor psychological well-being in older adults with dementia (Muurinen
et al. 2015).

Chronic Conditions

Chronic health conditions are often associated with changes in appetite,

nutrient intake, or nutrient utilization, all of which may impact nutri-
tional status. Health care providers must be able to identify the appro-
priate cause of nutritional deficitspoor appetite, poor intake caused by
overly restricted diets, or altered nutrient utilization. Nutritional deficits
related to poor appetite or overly restricted diets may respond to nutrition
interventions, while deficits related to alterations in nutrient utilization
most likely require coordinated efforts of all members of the health care

Nutrition Care Process

In 2003, the Academy of Nutrition and Dietetics adopted the Nutrition
Care Process and Model (NCPM), which was described as a framework
for critical thinking and decision making specific to dietetics practice
(Lacey and Pritchett 2003). A planned five-year cycle was implemented
and the NCPM was revised in 2008 and 2013 (Writing Group of the
Nutrition Care Process/Standardized Language Committee 2008).

Historical Perspective
To begin to understand the Nutrition Care Process (NCP) and how to
use it in practice, it is important to step back and look at how and why
the NCP came about. In a nutshell, the NCP is the dietetic professions
answer to a larger question in health care: How can health outcomes be
improved? Improved health outcomes are defined by overall improve-
ment in the cost, quality, and efficiency of health care. For the dietetics
profession, demonstrating the impact of nutrition care as a component
of improved health outcomes provides an opportunity to prove the value
of what we do.
Health outcomes can be thought of as the product of the care pro-
vided along with how the care was provided. The vast majority of health
care providers want to give their patients the highest quality of care pos-
sible. In order to do so, care processes are needed to support high-quality
care. For example, if it is thought that high-quality care for patients who
have experienced a cardiac event includes echocardiography, then health
care systems that do not have access to echocardiography make it difficult,
if not impossible, to provide high-quality care. Deficiencies in care are
not related to the clinician who wants the patient to have the study;

instead, the care process (lack of access to the test) impedes p rovision of
high-quality care.
Avedis Donabedian is considered by many to be the father of health
care quality. Prior to the 1960s, many felt that it was impossible to measure
the process by which health care is provided. Donabedian noted that it
was entirely possible to measure the quality of health care by observing
its structure, its processes and its outcomes (Donabedian 1966). More
recently, the Institute of Medicines definitions of quality health care
incorporate an evaluation of the care process as an important addition in
the determination of how well care provided meets current professional
standards (Palmer 1997).

Care Processes Used by Other Professions

Use of a care process is not unique to dietetics practice, nor is dietetics
the first allied health profession to adopt a care process. Most of the allied
health professions utilize a care process to provide structure for provision
of care and to define what it is that separates each of the health profession
from each other. For example, the nursing care process defines what it
means to be a nurse and delineates what it is that only nurses can do.


The first modern discussions on nursing care processes were seen in the
mid-1950s (Wright 1992). There are now several models used to describe
the nursing care process. Interestingly, all are similar to the NCP in that
the patient or client is at the center of the process. Nursing care processes
also tend to have steps similar to the four steps of the NCPassessment,
diagnosis, intervention, and monitoring and evaluation.

Occupational Therapy

The American Occupational Therapy Association (AOTA) published a

two-stage professional care process in 1999 (Moyers 1999):

Stage OneThe referral process by which a patients func-

tional performance is evaluated.
Nutrition Care Process andModel 7

Stage TwoOccupational Therapy (OT) interventions and

follow-up plans.

In 2002, AOTA revised the framework for OT practice in order to

describe an additional section:

Stage OneEvaluation of functional performance

OT interventions
Outcomes of OT interventions

As with the Nursing and Nutrition Care Processes, the OT care pro-
cess included the relationship between the therapist and client as central
to the OT care process (AOTA Inc. 2002).

Physical Therapy

In 1986, the American Physical Therapy Association published the Hypoth-

esis Oriented Algorithm for Clinicians (HOAC) that served as a framework
for physical therapy (PT) practice (Rothstein and Echternach 1986). The
algorithm was further clarified in 1995 when the Guide to Physical Thera-
pist Practice was published (American Physical Therapy Association 1995).
After several revisions, specialty practice in PT was further defined with the
publication of a framework for practice in the specialty area of neurologic
PT practice (Schenkman, Deutsch, and Gill-Body 2006).

Commonalities Among Care Processes

It appears that there are more similarities than differences among allied
health professional care processes. Each stresses a focus on the relationship
between the therapist and the patient or client. All healthcare professional
care processes include a mechanism to describe how the allied health pro-
fessional identifies a need for intervention (assessment and diagnosis), to
determine the most appropriate course of action (the intervention), and
to determine if the intervention was successful (monitoring and evalua-
tion). Thus, it can be seen that dietetics practice is not unique in utilizing
a care process that provides a framework for critical thinking supported
by evidence.

Description of the NCP

The NCPM consists of the four steps of the NCP surrounded by two
rings: an inner ring and an outer rings. The inner ring describes charac-
teristics that are unique to the dietetics practitioner and the outer ring
describes characteristics of the health care system that impact dietetics
practice. The patient or client is at the center of the model, reflecting the
need for patient- or client-centered care.
Nutrition risk screening and health outcomes are both closely related
to nutrition care but are accomplished in collaboration with other health
professionals. Therefore, nutrition risk screening and assessment of health
outcomes are seen as contributors to the NCP.

The Outer RingExternal Factors

The United States has one of the most complex health care systems in the
world. Dietetics practice may be impacted by social and economic factors
that the dietetics professional has little control over. In spite of this lack
of control, the registered dietitians (RDs) must be aware of and acknowl-
edge these factors in order to plan nutrition interventions that are realistic
for the situation. For example, an RD working in a neonatal intensive
care unit follow-up clinic in an economically challenged area must take
financial resources into account when recommending discharge infant
formulas. In this situation, it would be important to consider which
formulas are supplied by the Women, Infants, and Children (WIC) pro-
gram. While the desired outcomes would be the same regardless of the
care setting, the RD considers external factors so that interventions can
be flexible and adjusted to meet patient or client needs.

The Inner Ring

Dietetics practitioners possess a set of knowledge and skills that influ-

ence practice. The inner ring of the NCPM attempts to describe these as

Dietetics knowledge
Critical thinking skills
Nutrition Care Process andModel 9

Ability to collaborate with others

Skills and competency in dietetics practice

Thus, the inner ring describes characteristics that are unique to the
RD. It is important to remember that while the RD has little to no con-
trol over the concepts in the outer ring, the individual RD has the ability
to influence and change concepts in the inner ring.
Of the four concepts, critical thinking is probably most difficult to
define. Health professionals have long struggled with defining critical
thinking (Riddell 2007). Research in nursing describes critical thinking
as an organized, purposeful way of thinking that is applied to a situation
or problem. A nurse who uses critical thinking skills is open to new pos-
sibilities and experiences (Wilkinson 2007). There is no reason to think
that these definitions would not apply to dietetics practice.

Patient-Centered Care

The past decade has seen a shift in health care from an expectation
that providers direct all aspects of care to an atmosphere that encour-
ages patients and their families to be active participants in their care.
Patient-centered care requires that all members of the health care team
change their focus so that patients have the information they need to be
primary decision-makers instead of relying on providers to make deci-
sions for them. Patient-centered care is thought to be associated with
improvements in quality of care (Aboumatar et al. 2015).
As members of the health care team, RDs must be familiar with
the tenets of patient-centered care. The shift to focus on patient needs
requires strong communication skills and an ability to move from pro-
viding simple diet instructions to working as partners with patients to
develop workable lifestyle changes.

Nutrition Screening

Health screening is defined as the process utilized to identify risk for a

health condition in a population of individuals who do not have out-
ward signs of the health condition in question. When a screening test

is positive, further testing can be done. For example, health fairs often
include capillary cholesterol measurement. Elevated cholesterol acts as a
screening test for lipid abnormalities.
Nutrition risk screens are used to identify risk for nutrition diagnoses
in individuals who do not appear to have a nutrition problem. Regula-
tory agencies such as the Joint Commission require that nutrition risk
screening be completed shortly after patients are admitted to a health care
facility. When nutrition risk screening is done as part of the admission
assessment, it is not possible for dietetics practitioners to complete every
nutrition screen. Therefore, most facilities utilize nursing staff to com-
plete nutrition risk screening.
Nutrition screening identifies risk for nutrition problems, while
nutrition assessment identifies the problem and determines the severity
of the problem. While most nutrition screens focus on identifying risk for
malnutrition, it is important to have mechanisms in place to identify risk
for other nutrition diagnoses.

The Four Steps

The NCP consists of the following four interrelated steps:

Nutrition assessment
Nutrition diagnosis
Nutrition intervention
Nutrition evaluation/monitoring

Each step will be described in detail in Chapters 3 to 6.


Nutrition Assessment
As described earlier, nutrition assessment is the process by which dietetics
professionals collect and analyze data about an individual, group, or pop-
ulation in order to determine if a nutrition diagnosis is present. Data
collected during the assessment typically fall into one of the following five
categories identified by the Nutrition Care Process (NCP):

Anthropometric measurements
Biochemical data, medical tests, and procedures
Food- and nutrition-related history
Client history
Nutrition-focused physical examination findings

Standard 1 of the Academys Standards of Practice for Registered

Dietitians states that Registered dietitians (RD) use accurate and rele-
vant data and information to identify nutrition-related problems (The
American Dietetic Association 2008). The rationale for the standard
states that assessment provides the foundation for nutrition diagnosis. In
point of fact, nutrition assessment also provides the foundation for other
NCP steps such as intervention and monitoring or evaluation in addition
to nutrition diagnosis. In other words, accurate nutrition assessment is
the key to providing high-quality care. Incorrect interpretation or miss-
ing nutrition assessment data might lead to missing the correct nutrition
diagnosis, which, in turn, has an adverse impact on each subsequent step
of the NCP and it ultimately affects a patients well-being.

History of Nutrition Assessment

It may seem difficult to believe that registered dietitians (RDs) have had
such difficulty in agreeing on the best methods for conducting something

as vital, to dietetics practice, as nutrition assessment. Understanding a

bit of the history of nutrition assessment might help to clarify why such
situation exists. Nutrition assessment has not always had a primary role
in dietetics practice. Prior to the recognition of dietetics as a health care
profession, nurses were responsible for nutrition services, which typically
involved ensuring that foods served met the requirements determined by
physician diet orders. As patient care became more complex, nurses were
no longer able to manage all aspects of patient care. Allied health pro-
fessions including dietetics, occupational therapy, and physical therapy
took on patient care responsibilities that busy nurses no longer had time
to complete. RDs assumed responsibility for food and nutrition services,
which continued to focus on provision of special diets ordered for medi-
cal and surgical conditions.
Evidence supporting the importance of nutrition assessment to
dietetics practice was provided in the mid-1970s when a series of articles
focused on the discovery that many hospitalized patients suffered from
malnutrition (Bistrian et al. 1974, 1976; Bistrian 1977; Weinsier and
Heimburger 1997). The best known of these publications has been since
cited by thousands of other publications, which is an indication of the
interest that health care providers have in the role of nutrition status in
health outcomes (Butterworth 1974). (An interesting side note is that
while each of these papers discussed the importance of nutrition assess-
ment in acute care and provided suggested methods to assess nutrition
status, RDs were not included as coauthors.)
When these early descriptions of malnutrition in hospitalized patients
were published, the role of the RD in acute care still focused on the devel-
opment of modified diets and patient education (Chima 2007). How-
ever, faced with the startling evidence regarding nutrition problems in
hospitalized patients, RDs recognized that they were uniquely positioned
to intervene and, thus, stepped up to this challenge. Clinical dietetics
became much more visible as clinical RDs took the responsibility of
assessing nutrition status of hospitalized patients. The recorded role of
the RD in nutrition assessment of hospitalized patients is first seen in
diet manuals and guidelines published in the late 1970s and early 1980s
(Bonnell 1974; Chima 2007; Ohlson 1976). Nutrition assessment grad-
ually moved more fully into the mainstream of dietetics practice but the
Nutrition Assessment 13

methodologies for doing assessment have been as varied as the skills and
the knowledge of the individual RD until the development of the nutri-
tion assessment portion of the NCP.

Data Sources for Assessment

Data sources used to gather assessment information include medical
records, community profiles, financial records, interviews, research, and
survey data. Table 3.1 provides some information about each of these cat-
egories as they apply to the assessment of nutrition status of individuals
and groups. Table 3.2 identifies data sources for information needed to
complete the nutrition assessment. It should be remembered that RDs
working in education, management, research, or food service also assess
problems and situations in order to determine if a problem exists. How-
ever, at this time, there is no standardized terminology to describe man-
agement, research, or food service dietetics practice. Therefore, this book

Table 3.1 Nutrition assessment categories at the individual and group

or community level
Category Individual level Group or community level
Anthropometric data Height Mean height
Weight Mean weight
Percent body fat Range of height and weight in a
Percent lean body mass population
Body mass index (BMI) Mean BMI
Food and nutrition 24-hour recall Market survey data
history Food frequency Plate waste data
Food records Population level data from surveys
Nutrition-focused phys- General appearance Endemic goiter
ical examination Muscle wasting Stunting in children
Oral health Community level data on the prev-
Excessive fat stores alence of obesity or malnutrition
Biochemical data, tests, Glucose Hyperfluorosis
and procedures Glycated hemoglobin Population based screening
Lipid panel
Client history Overall health history Socioeconomic data
Medication history Education level in the community
Occupation Disease prevalence

Table 3.2 Data sources for nutrition assessment

Care Type of Source of Examples for specific care
setting data data settings
Ambulatory care
Food- and Patient interview Food records
nutrition- Old records 24-hour recall
related history Other providers Medication lists
Physical activity records
Anthro- RD measurement Height
pometric Clinic records Weight
measurements Patient report Weight change
Growth percentiles
Skinfold tests
Bioelectric impedance analysis
Biochemical Lab reports Blood glucose
data, medical Patient report Lipid panel
tests, and Referral Glycosylated hemoglobin
procedures Gastric emptying
Biopsy results
Nutrition- RD-conducted Hand grip strength
focused physical Edema
physical examination General appearance
findings Oral screening
Client history Patient report Special diets
Report from Changes in intake
family or care Chronic conditions
provider Access to food and services
Barriers to physical activity
Acute care
Food- and Nursing flow 24-hour recall
nutrition- sheets Intake prior to admission
related history Patient interview
Anthro- RD measurement Height
pometric History and phys- Weight
measurements ical examination BMI
Nursing flow
Biochemical Lab section of Glucose
data, medical medical record Electrolytes
tests, and Surgical reports Phosphorus
procedures Physician notes Surgery and procedure results
and complications
Nutrition Assessment 15

Nutrition- RD-conducted Edema

focused physi- physical exam- General appearance
cal findings ination Muscle and fat wasting
Oral screening
Bowel sounds
Client history RD interview
Admission notes
Records from
past admissions
Food- and Participation in Women, infants, and children
nutrition- food programs program participation
related history Farmers markets Supplemental nutrition assis-
Facilities for tance program
physical activity Community center
Economic data Food bank
Anthro- School health Obesity prevalence
pometric records Underweight prevalence
measurements Community
Biochemical Survey data Mean glycosylated hemoglobin
data, medical Mean lipid levels
tests, and
Nutrition- Survey data Reported signs and symptoms of
focused physi- Interviews vitamin and mineral deficiency
cal findings
Client history Survey data Chronic disease (e.g.,obesity,
Interviews type 2 diabetes, cancer)
Long-term care
Food- and Admission Percent meals eaten
nutrition- database Self-feeding ability
related history Nursing flow
Intake records
Anthro- Weekly or Weight
pometric monthly weights Knee height
measurements or both BMI
Biochemical Medical record Glycosylated hemoglobin
data, medical Lipid panels
tests, and


Table 3.2 Data sources for nutrition assessment (Continued)

Care Type of Source of Examples for specific care
setting data data settings
Nutrition- RD-conducted Blood pressure
focused physi- physical exam Skin integrity
cal findings Fluid status
Client history Resident Chronic diseases
interview Past surgeries
Family or care-
giver interview

will focus on application of the assessment step of the NCP in clinical


Five Categories for Nutrition Assessment Data

Complete and comprehensive nutrition assessment requires gathering
data from each of the following five categories: (1) food and nutrition
intake, (2) client history, (3) nutrition-focused physical findings, (4)
anthropometric measurements, and (5) biochemical data, medical tests,
and procedures.

Food and Nutrition Intake

Dietetics professionals are responsible for assessing food and nutrition

intake in all care settings. Table 3.3 describes the most commonly used
methods to gather nutrient intake information.
Critical evaluation of intake information is vital. Both objec-
tive and subjective information should be evaluated in order to verify
accuracy. It is known that certain groups under- or overreport intake;
therefore, the information gathered should never be accepted at face
value (Abbot et al. 2008). It is important to remember that once the
information is obtained, the RD must evaluate the information in order
to determine if accurate information has been collected. In acute care
settings, calorie counts are sometimes ordered. The typical calorie count
includes the recording of all foods and beverages consumed by the patient
Nutrition Assessment 17

Table 3.3 Methods to gather nutrient intake information

Method Setting Description Comments
24-hour recall Acute care Interview focused on May not represent
Ambulatory foods and amounts typical intake in
care consumed in last 24 acutely ill patients
hours Interviewer must
Trained interviewer probe for condiments,
Little to no training added fats, and sugars
for person being Accuracy improved
interviewed by combining with
another method
Food frequency Community Questionnaire Can be very lengthy;
Research focused on frequency shorter versions may
and amounts of miss foods or food groups
foods or food groups
Diet records Ambulatory Three to seven days Person doing the record-
care records needed; ing must have extensive
Research should include a training
weekend day
Newer methods
using photographic
Calorie count Acute care Staff assigned to doc- Known to be
Long-term care ument all foods and inaccurate; data are
beverages consumed frequently missing or
Should not be used
without a careful
evaluation of data

in some time frame, usually 24 to 72 hours. Calorie counts are fraught

with error and are only rarely accurate. Busy staff may forget to record
intake or not have not been sufficiently trained, thus causing errors in
estimation of portion sizes. Foods and beverages brought from home are
often not recorded. For these reasons, most facilities no longer conduct
calorie counts. A diet history obtained by an expert RD would most
likely provide more reliable information than a calorie count recorded by
untrained, busy staff.
There has been some research investigating the use of digital photog-
raphy to measure food and nutrient intake. While the estimations of food
and nutrient intake may be more accurate when digital photography is

used, it is not known whether this method would be useful in acute care
settings (Martin et al. 2014).

Consider the Following Scenario

An RD who specializes in weight management receives a request to see
a client who was having problems losing weight despite following a
calorie-restricted diet along with increased physical activity for several
weeks. The RD obtains a food and nutrition-related history from the
client. It appears that the client is consuming far less than estimated
requirements for weight loss. The client is concerned that she has a
metabolic problem and asks if she should seek bariatric surgery.
The RD recalled that over- and underreporting might lead to sig-
nificant error in determining nutrient intake. Further questioning
revealed that physical activity was overreported and energy intake
was underreported; therefore, further work on diet and exercise was
An RD who has less-developed critical thinking skills and lacks
experience that would prompt further probing might accept the
patient report at face value and refer the patient for surgery.

The scenario here demonstrates the need for strong critical think-
ing skills when evaluating nutrition history information. Inaccura-
cies in reporting food and nutrient intake occur for many reasons
(Fisheretal.2008; Lissner et al. 2007). For instance, the patient or client
might have distorted views of portion sizes or might want to please the
interviewer by reporting intake that is much different from actual intake
in order to better meet perceived normal or good diets (Heitmann, Lissner,
and Osler 2000). Therefore, whenever possible, more than one method
should be used to gather and compare data that allow for cross-check-
ing and verification. Information should be evaluated in context of other
data gathered. For example, reports suggesting very low intake might be
questioned if the patient or client is significantly overweight and has not
lost weight. Conversely, reports suggesting excessive intake might need
re-evaluation if the information does not match other assessment infor-
mation indicating a weight loss.
Nutrition Assessment 19

Once the validity of the information obtained has been ascertained,

RDs must then select appropriate reference standards for evaluating the
adequacy of food and nutrient intake. Because reference standards do
not exist for individuals with health conditions, RDs often refer to the
Dietary Reference Intakes (DRIs) as a starting point in evaluation of
intake (Murphy and Poos 2002; Yates 2006). When combined with other
information gathered during the nutrition assessment, the DRIs can be
used (with caution) to approximate adequacy of intake in different care
settings and populations (The American Dietetic Association 2011).

Client History

Client history encompasses a wide range of information about a patient,

client, group, or community. At the personal level, the history includes
past illnesses, chronic conditions, socioeconomic status, medication
history, social supports, and living conditions. The client history also
includes the family history of these indicators. Many of these findings are
also appropriate to use in assessing groups or communities.
There is an art to obtaining a complete patient history. The RD
should develop rapport with the patient or client in order to gain the trust
needed for honest description of health and socioeconomic information.
Some patients or clients may not feel comfortable discussing sensitive
financial or social information that have a direct impact on nutritional
status. RDs with strong history taking skills are able to subtly direct the
conversation in order to obtain necessary information.
The medical history is part of the client history. Medical training
includes a strong emphasis regarding skills needed to elucidate needed
information from the patient and caregivers (Gillis 2006). Physicians
begin a medical history with the patients chief complaint. The chief com-
plaint, or cc is the reason the patient sought care. The chief complaint is
typically written in the patients own words. It can be vague, for example,
I have a headache, or more specific, for example, If I eat more than 40
grams of fat at a meal within 30 minutes I have sharp abdominal pain.
The chief complaint is the starting point for much of the assessment. RDs
should note the patients chief complaint. Quite often, the medical chief
complaint is not specific enough for nutrition assessment. In those cases,
the RD should seek to elucidate the nutrition chief complaint.

After the chief complaint is determined, a complete medical history

is obtained. This begins with an assessment of current health status.
Inorder to obtain the current health status, the RD might ask the follow-
ing questions:

How would you describe your current health? Would you say
you feel well on most days? Are you able to do the things you
want or need to do every day?
Have you been feeling ill lately? If so, how often and for how
long? Describe what you feel like.
Do you have any problems chewing or swallowing? If so, have
these problems made you change the type and amount of
food that you eat?
Do you have any chronic health conditions that impact your
ability to eat the foods you want to eat?
Is there anything else about your health status that you want
me to know?

Information about the patients surgical history is also obtained as

part of the client history. Many surgical procedures, particularly gastro-
intestinal (GI) surgery, can have a lasting impact on the patients ability
to consume, digest, absorb, or metabolize food and nutrients. Table 3.4
describes some of the nutritional consequences of surgical procedures.
Fooddrug interactions have been defined as the consequence of
a physical, chemical, or physiologic relationship between a drug and a
product consumed as food or a nutrient present in a botanically-derived
food or dietary supplement (Won, Oberlies, and Paine 2012). Compo-
nents of prescription and over-the-counter medications can interact with
each other and with components of foods. Some medications must be
taken with foods in order to minimize GI side effects or to enhance drug
absorption. Other medications must be taken at a certain time before or
after eating. Unexpected changes in diet or timing of meals can have a
significant impact on response to medications. A patient who has been
taking a given medication for some time with no side effects or problems
with medication action may experience an adverse drug event caused by
a minor change in diet.
Nutrition Assessment 21

Table 3.4 Nutritional consequences of surgical procedures

Type of surgical procedure Nutritional consequence
Neurosurgery Possible changes in ability to sense
hunger or satiety
Loss of motor control needed for
GI surgery Changes in ability to chew or swallow
Short gut syndrome causing malabsorp-
tion of nutrients
Early satiety following gastric surgery
Dumping syndrome
Decreased gastric capacity
Dehydration and electrolyte imbalance
Major orthopedic surgery Weight loss
Inability to self-feed
Muscle wasting due to inactivity

The final component of the patient history is the social history. When
obtaining a social history, the RD must focus on issues surrounding
educational level, housing situation, economic concerns, family or social
support, spiritual concerns, and beliefs and attitudes surrounding food.

Nutrition-Focused Physical Findings

The domain nutrition-focused physical findings of the IDNT (Inter-

national Dietetics and Nutrition Terminology) is defined as Find-
ings from an evaluation of body systems, muscle and subcutaneous fat
wasting, oral health, suck/swallow/breathe ability, appetite, and affect
(TheAmericanDietetic Association 2011).
Although physical assessment skills are a required entry-level skill,
RDs often rely on others for physical assessment findings. Even though
the RD might not conduct the examination, it is important for the RD
to understand the focus of each component of the physical examina-
tion. For example, the presence or absence of bowel sounds is integral
to postoperative assessment of GI function. While many RDs are able
to listen for and assess bowel sounds, RDs who lack this skill must know

how to interpret results obtained by others. The complete assessment of

bowel sounds can take up to 10 minutes, and quite often clinicians do
not have the time to listen for that long. Therefore, RDs must use critical
thinking skills to evaluate reports of missing bowel sounds, particularly
in postoperative patients who have a nontender, nondistended abdomen
(Madsenetal.2005). However, RDs should conduct a nutrition-focused
physical assessment in order to ensure accuracy and validity of the data
Clinicians should use a head-to-toe approach and should develop
consistent skills so that nothing is missed (Fauci et al. 2008). Physician
documentation of initial history and physical examination information
follows a very consistent format. The note begins typically with a descrip-
tion of the chief complaint or the reason due to which the patient sought
assistance from a health care provider. Following this are the history of
current illness and past medical and surgical histories. The physical exam-
ination is done only after a complete history is obtained. Each compo-
nent is systematically listed so that other providers know exactly where to
look for information.
Health care professionals who participate in history-taking and
physical examination are taught to utilize a systematic approach (Fauci
et al. 2008). Physical examination begins with an assessment of overall
appearance. Documentation of initial history and physical examination
information should follow a very consistent format so that nothing is
It can be noted here that the subjective global assessment (SGA)
is a validated method for assessment of nutrition status (and does not
require biochemical information). Developed in 1982 as a method to
teach nutrition-focused physical examination skills to physicians in
training, the SGA relies entirely on clinician interpretation of findings
from the history and physical examination (Baker et al. 1982). There
is no gain in accuracy when hepatic transport protein levels are added
to SGA results (Covinskyet al. 2002). Therefore, there should be very
little reason to require the evaluation of hepatic transport proteins in
the initial assessment process (Baker et al. 1982; Detsky et al. 1984,
Nutrition Assessment 23

Table 3.5 Comparison of subjective global assessment and nutrition

assessment domains

International dietetics and Subjective global assessment

nutrition terminology
Anthropometric measurements Weight change
Food- and nutrition-related history Recent intake and changes in intake
Nutrition-focused physical findings Physical examination: muscle wasting, edema,
fat loss, ascites
Client history GI symptoms
Functional capacity
Medical and surgical history
Biochemical data, medical tests, and None

1987a, 1987b). Table 3.5 shows the comparison of the assessment

categories of the SGA with the nutrition assessment domains included
in the IDNT.

Anthropometric Measurements

Anthropometric measures of nutrition status, including height, weight,

BMI, waist circumference, BIA, weight history, and indicators of growth
provide information regarding body composition. Most care settings
have the ability to measure height and weight. Once accurate height
and weight measurements are available, BMI can be calculated, or in
pediatric settings, growth parameters can be determined by plotting on
an appropriate growth chart. Other anthropometric indicators, appro-
priate care settings, and derived calculations can be seen in Tables 3.7
and 3.8.
While simple and inexpensive measures such as height and weight
may seem easy to obtain, but in practice this is not always the case.
In acute care, stated or estimated height and weight might be used if
scales and measurement devices are not conveniently located or if the
patient cannot stand long enough for the measurement to be obtained. In
these cases, height and weight provided by the patient or estimated by the

clinician are often recorded. There are known inaccuracies when height
and weight are estimated in an acute care setting (Beghetto etal.2006;
Determann et al. 2007). However, stated height and weight provided
by healthy adults less than 60 years of age was found to be sufficiently
accurate for use in research and community settings (Kuczmarski,
Kuczmarski, and Najjar 2001). When admission height and weight are
estimated rather than actually measured, a notation should be included
in the documentation. This can serve as a reminder to obtain actual
measurements as soon aspossible.
Even when actual measurements are obtained, there is still no guaran-
tee that they will be accurate. Infants and toddlers can be very difficult to
weigh and measure, and skilled personnel might not always be available
to complete the measurements. Patients might have a significant degree
of edema or may not be able to completely follow instructions for height
measurements. For these reasons, even measured height and weight should
be evaluated in conjunction with other information. For example, loss of
height or major deviations from an established growth curve in infants
and children should be a red flag that there might have been an inaccurate
measurement at some point. A large change in weight over a short time
period is another warning of problems. Finally, even when meticulous
attention is given to measurement techniques, errors in documenting
results can occur. For example, the medical record might include a weight
measurement of 150 kg for a patient who actually weighs150lbs. For
these reasons, the RD should compare the documented height and weight
to a visual inspection of the patient to further verify the data.
Reference standards for the comparison of anthropometric informa-
tion exist for some populations. RDs must be able to determine which
standard to use for evaluation in the clinical setting. Various height and
weight tables exist for adults, along with the BMI. In pediatric prac-
tice, growth charts are used to determine adequacy of growth. Accurate
plotting of height and weight in pediatric practice has been noted to be
problematic; one study in a tertiary pediatric acute care facility found
that less than 25 percent of admissions had height measurements that
were correctly plotted on growth charts (Lipman et al. 2009). There
are also many condition-specific growth charts that can be used to plot
Nutrition Assessment 25

Table 3.6 Anthropometric measures*

Measure Care settings Comments
Height Ambulatory Length in infants
Acute care Knee-height or arm-span measure-
Long-term care ments provide accurate estimates
Community of height
Research Accurate measurement more likely
when using stadiometer
Weight Ambulatory Evaluate for excessive fluid gain or
Acute care loss which can impact accuracy
Long-term care Evaluate rate of weight gain in
Community infants and children
Research Compare to usual weight or some
ideal or desirable weight
Use of stated weight should be
Use of Z-scores in pediatrics
Waist circumference Ambulatory Estimate of abdominal fat content
Research Combined with BMI provides esti-
Community mate of risk for chronic disease
Accuracy depends on meticulous
attention to point at which to
BIA Ambulatory Determines total body water
Research (TBW)
Use TBW to estimate fat-free mass
Dual energy X-ray Ambulatory Measures lean tissue, adipose tissue,
absorptiometry Research and bone density
Cumbersome equipment
Skinfold thickness Ambulatory Measures thickness of skinfolds at
Research various locations
Community Triceps skinfold most commonly
Equipment must be calibrated
Better accuracy when average of
three measures at same anatomic
spot is calculated
*Each requires careful attention to technique; reliable resources should be consulted for the
correct measurement technique.

growth parameters in infants and children who have health conditions.

Each of these must be carefully evaluated as many were developed using
small samples, lacked consistent methods for obtaining measurements,

Table 3.7 Body composition measures derived from measurements

Measure Care setting Derived from
BMI Ambulatory Height
Community Weight
Long-term care
Growth percentiles and Pediatric acute care Length or height
Z-scores Pediatric ambulatory Weight
Head circumference
Arm muscle area Ambulatory Triceps skinfold
Community Arm circumference
Fat-free mass Ambulatory BIA
Research Air displacement pleth-
ysmography (Bod Pod,
Pea Pod)
Percent usual weight Acute care 
Current and usual body
Ambulatory weight
Long-term care

or have not been fully validated. RDs in pediatric practice must know
which chart to use as well as how to plot height and weight correctly.

Biochemical Data, Medical Tests, and Procedures

The domain covers a number of biochemical indices that are often used to
evaluate nutrition status in all care settings. While some of these tests may
be useful, each laboratory test carries a risk to the patient or client (from
the needle stick, psychological impact related to worrying about results)
and adds to the cost of care provided. Also, many of these tests have not
been adequately validated as markers of nutrition status and should be
used with caution. For example, levels of the serum hepatic transport
proteins, particularly serum albumin and prealbumin (transthyretin) are
often used as measures of visceral protein status in acute care. This concept
is not supported when critically evaluated (Friedman and Fadem 2010;
Fuhrman, Charney, and Mueller 2004).
Nutrition Assessment 27

Use of hepatic transport proteins, particularly serum albumin as mea-

sures of nutrition status, most likely began following the publication of
reports describing a condition seen in children living in underdeveloped
areas of the world (Williams 1935). In the 1970s, additional publications
purported a connection between levels of serum albumin and nutrition
(Bistrian et al. 1974, 1976; Bistrian 1977). In the 1980s, serum prealbu-
min became popular among clinicians because it had a shorter half-life and
smaller total body pool than albumin and, thus, was thought to be a more
specific measure of nutrition status (Baron 1986; Bernsteinetal.1989;
Bernstein and Pleban 1996). Clinicians jumped on the visceral protein
bandwagon without first critically evaluating what was being measured.
As discussed earlier, the use of expensive, unnecessary lab testing does not
add to the diagnostic accuracy of the SGA.
Hepatic transport proteins are negative acute phase reactants, mean-
ing that following injury or illness, levels decrease as part of the normal
response to stress, regardless of nutrient intake (Fuhrman, Charney, and
Mueller 2004; Gabay and Kushner 1999). It is often claimed that the
inflammatory response can be accurately assessed through the measure-
ment of C-reactive protein (CRP). CRP is a nonspecific marker of an
inflammatory state and lacks sufficient sensitivity to describe the severity
of illness (Black, Kushner, and Samols 2004). However, other validated
illness severity scoring tools such as Acute Physiology and Chronic Health
Evaluation (APACHE II) can be utilized to determine illness severity
(Chen et al. 1999).
Other biochemical tests have proved useful in assessing nutrition sta-
tus depending on the care setting. Glycosylated hemoglobin (Hgb A1c)
provides an estimate of glucose control over the past 60 to 90 days and is
useful in ambulatory or long-term care. Recent changes in recommenda-
tions for vitamin D intake in infants and children were based on the eval-
uation of serum levels of vitamin D (Misra et al. 2008). There are some
condition-specific recommendations for biochemical testing. Nutrition
assessment of patients with chronic kidney disease should include the
evaluation of serum blood urea nitrogen (BUN), creatinine, phosphorus,
and potassium, along with the calculation of glomerular filtration rate.

Depending on the situation and patient or client needs, other biochemi-

cal tests that RDs must be able to evaluate include serum lipid panels, liver
function tests, screening tests for celiac disease, and serum electrolytes.
When conducting a nutrition assessment on individuals, RDs should
also review results from other medical tests and procedures. For example,
intestinal biopsy results provide information regarding GI function that
would be used to evaluate information from the food- and nutrition-
related history. Echocardiogram and other tests of cardiac physiology
might suggest cardiac problems that impact nutrient needs and intake
due to fluid accumulation.

Nutrition Diagnosis
The most controversial component of the Nutrition Care Process (NCP)
is the second step, that is, nutrition diagnosis. Why is it so controversial?
Traditionally, registered dietitians (RDs) have not considered themselves
to be members of a diagnosing profession. Many dietetics professionals were
trained to focus first and foremost on the nutrition assessment and then
the intervention. But the act of diagnosingthe process of discerning or
distinguishing the nature of a disease or problemhas always been a part
of the process, but it was never codified until the development of the NCP.
The Academy of Nutrition and Dietetics (AND) defines nutrition
diagnosis as the identification and labeling of the specific nutrition prob-
lem that dietetics practitioners are responsible for treating independently
(Lacey and Pritchett 2003). While RDs are trained to assess nutrition
status, to develop plans to do something for the patient, client, or group
(intervention), and to monitor the results of the intervention, most have
no formal training in the diagnostic process. It is incorrect to think that
only physicians can diagnose. Each of the health professions is responsible
for diagnosing health conditions that are within the scope of practice for
the profession. Therefore, RDs must take responsibility for diagnosing
nutrition problems. Taking responsibility for the diagnosis and treatment
of nutrition problems ensures that dietetics gains respect of a health care
system that values the diagnostic thought process.
Historically, the goal of nutrition assessment was to find a problem.
Once the problem was identified, RDs took action to solve the problem,
but never used the word diagnosis. There was clearly a diagnosis involved,
but it was usually never specified or codified as such. Why does this mat-
ter? Well, if the process moves right from assessing to intervention with-
out calling and naming the intermediate process the nutrition diagnosis,
we lose the chance to demonstrate the full scope and breadth of dietetics
practice. Omitting to pointing out the diagnostic phase implies that we

can define how we assess nutrition status and what we do for patients and
clients, but we cannot describe why we do those things. More importantly
perhaps, we cannot really demonstrate the impact of RD-directed inter-
ventions if we do not diagnose or clearly indicate that we have diagnosed
the nutrition problem that led to the intervention. And, if we focus on
or use diagnoses from the domain of another health profession, that is,
cancer, type 2 diabetes mellitus, or failure to thrive, as the driving force
behind the work of dietetics and not the diagnoses developed from the
domain of the dietetics profession, then we lose important information
that answers the question Why is it vital that the RD provide nutrition
care? What was the nutrition problem that necessitated the RDs presence
in the care of this patient?

Diagnostic Thought Process

RDs are responsible for gathering sufficient information during the
assessment process to allow accurate diagnosis of nutrition problems.
Diagnosing is much more complex than simply picking a diagnosis from
a list. Skilled diagnosticians utilize a highly structured thought process to
organize and evaluate information gathered during the assessment. This
process allows the diagnostician to keep information that is pertinent to
the current situation and discard information that is redundant, incor-
rect, or does not pertain to the current situation.
When faced with a diagnostic dilemma, the expert RD first asks, Did
I miss something? This triggers a review of data gathered during the
assessment. If there are gaps, additional information must be sought. This
process continues until the RD has a reasonable certainty that the correct
nutrition problem has been diagnosed.

What Is a Diagnosing Profession?

Traditionally, health care practice reserved the practice of diagnosing for
physicians only. However, it might not be entirely correct to state that only
physicians can diagnose health problems. In a paper published in 1967,
Lester King, MD, wrote Although diagnosis ordinarily has medical con-
notations, this is not essential, for the term involves activities by no means
unique to medicine (King 1967). Further clarification comes from the
Nutrition Diagnosis 31

U.S. Bureau of Labor Statistics that classifies several health care profes-
sions as diagnosing professions (Bureau of Labor Statistics 2008). While
no one but the licensed physician can make a medical diagnosis, each
diagnosing professional is responsible for making diagnoses within his or
her own professional scope of practice. A brief description of some of the
diagnosing health professions is included in the following.


Physicians diagnose medical problems by gathering information and clin-

ical data from the patient, ordering diagnostic tests and procedures, and
comparing the information gathered to known descriptions of disease or
pathophysiology. They complete these tasks by first obtaining the medical
history followed by a physical examination. Information gathered from
the history and physical examination help the physician determine if addi-
tional diagnostic testing is needed to confirm a suspected diagnosis. Once
the diagnosis is determined, physicians then prescribe and administer
treatment that might include counseling patients on diet, hygiene, and
preventative health care (Bureau of Labor Statistics 2008).


The nursing care process includes the diagnosis of health problems or

potential health problems as a function of nursing care. Experts in nurs-
ing practice describe nursing diagnosis as different from medical diagno-
sis in that while the medical diagnosis focuses on illness associated with
one or more organ systems, the nursing diagnosis focuses on preventing,
alleviating, or minimizing health issues (Wilkinson 2012). Accordingly,
nurses might gather a history of the current illness and symptoms, assist
with performing and analyzing diagnostic tests, provide advice and emo-
tional support, and teach patients and their families how to Manage
their illness or injury, explaining diet, nutrition and exercise programs
(Bureau of Labor Statistics 2008).

Physical Therapists

Physical therapists (PTs) focus on preventing injury and impairments in

physical functioning and on maximizing physical function. In the 1980s,

PTs began to recognize the importance of diagnosing by addressing the

concept of clinical classification by which patients could be classified based
on the identification of clusters of data (Delitto and Snyder-Mackler
1995). In 1995, the Guide to Physical Therapy Process described diagnosis
as a cluster of signs and symptoms, syndromes, and categories that guide
the PT in determining the best intervention (American Physical Therapy
Association 1995). The PT diagnostic process includes the following:

Obtaining the relevant history

Performing systems review
Selecting and administering specific tests and measures
Interpreting all data
Organizing the data (American Physical Therapy Association

Occupational Therapists

As with other allied health professions, occupational therapists (OTs)

have a long history of identification and treatment of problems associated
with the performance of activities of daily living or occupation. There has
been some controversy within the field of OT practice regarding how the
OT determines the problems that patients are having with occupational
performance. However, the Bureau of Labor Statistics includes occu-
pational therapy as a diagnosing profession (Bureau of Labor Statistics
2008). Inthe early 1990s, Rogers stated that assessment is broader and
more descriptive than diagnosis because diagnosis focused on finding a
problem while the assessment included the patients assets as well as deficits
(Rogers and Holm 1991). More recently, however, research delineating
the connections between OT diagnoses, interventions, and patient out-
comes in home care has emerged, lending support to future development
of OT diagnosis.

An Example: One Patient, Many Providers,

Each of the aforementioned health care professions approaches d
problems within its area of practice from a different perspective. One
Nutrition Diagnosis 33

way to see this is by looking at a clinical situation from the viewpoint of

these different providers and adding RDs to the mix. Let us look at the
following example, which has been greatly simplified to focus on the var-
ious diagnoses and how each health care professional diagnoses problems
within his or her scope of practice.
Medical diagnosis: Mary S is a 67-year-old woman who was admitted
to the hospital following a fall at a local mall. Immediately after falling,
she complained of severe pain in her hip and was not able to move. EMTs
were called. She was transported to the emergency department (ED) due
to her complaint of severe hip pain. In the ED, she complained of severe
pain with any movement. Given the history of her fall and description of
pain, an X-ray was ordered. Based on the history of a fall and the results
of the X-ray, the ED physician diagnosed an intertrochanteric fracture of
the left hip (ICD-9-CM 820.21, Fracture of intertrochanteric section of
femur, closed). Following surgical intervention and uneventful recovery,
Mary was returned to the surgical unit.
Nursing diagnosis: Mary slept for the first few hours after being trans-
ferred to the surgical unit. When she woke, one of the first things she said
to her nurse was that her hip hurt a lot. Therefore, the NANDA nursing
diagnosis of alteration in comfort: pain was used. While other nursing
diagnoses will also be determined about the patient, at this point in time,
the nurses focus in caring for Mary is to assess the impact of pain on
postoperative recovery and to take steps to help Mary manage her pain.
Physical therapy diagnosis: Physical therapy was consulted as part of
the hip fracture care plan. Part of the PTs evaluation revealed that Mary
was not participating in changing body positioning due to the fear of
increasing pain. The immediate focus was placed on facilitating her ability
to shift her position in bed prior to beginning rehabilitation. Using the
International Classification of Functioning, Disability and Health (ICF),
physical therapy interventions were aimed at allowing Mary to change
basic body position, unspecified (d4109).
Nutrition diagnosis: On the second postoperative day, Marys nurse
sent a consult to the RD because Mary had refused all three meals. The
nurse on the orthopedic ward told the RD that typically patients with
similar hip surgeries are eating well by this time. It is of concern that
Mary is not eating at all because on admission, Mary had a BMI of
17.4. Following nutrition assessment, the RD gathered and evaluated

sufficient information to allow the diagnosis of inadequate oral food/

beverage intake.

How Health Care Professionals Diagnose

Diagnosing is much more complex than simply picking a diagnosis from
a list. In many ways, the diagnostic thought process can be compared to
detective work (Rapezzi, Ferrari, and Branzi 2005). Think of Sherlock
Holmes and other fictional detectives like Columbo or Charlie Chan.
Each used a particular set of skills to diagnose the solution to a crime.
Likewise, diagnosticians do not simply guess the correct diagnosis, instead
they use a structured thought process to organize and evaluate informa-
tion and then to keep or discard clues.
When faced with a diagnostic dilemma, the clinician first gathers clues
through obtaining a thorough patient history. History taking has long
been an important part of medical practice. Prior to the advent of the
modern diagnostic tests such as X-ray, MRI, and CT scans, the medical
history was a major component of medical decision making, and many
medical textbooks contained detailed descriptions of methods to obtain a
complete history from patients (Gillis 2006). Typically, the history begins
with asking the patient to describe his or her current state of health and
any symptoms experienced. Following this, questioning focuses on recent
exposure to illness, past personal experience with illness, and family his-
tory of illness. As the history progresses, questions become more focused,
depending on how preceding questions were answered.
Following the initial medical history and questioning, clinicians for-
mulate the differential diagnosis or list of diagnoses that might cause the
current signs and symptoms. For example, a client might be referred to
an RD in the outpatient clinic for education on a low-sodium diet. After
gathering information from the medical record and an initial interview of
the patient, the differential diagnosis might include the following:

Excessive sodium intake

Limited adherence to food- and nutrition-related recommen-
Food- and nutrition-related knowledge deficit
Excessive fluid intake
Nutrition Diagnosis 35

The RD would then need to gather more information to determine

which nutrition diagnoses can be taken off the list and which are more
likely to exist. Let us say that the client has never been educated on a
low-sodium diet in the past. That would eliminate limited adherence to
food- and nutrition-related recommendations from the differential diagnosis
list because there is no reason to expect someone to adhere to recommen-
dations they never received. However, that would indicate that food- and
nutrition-related knowledge deficit might be a correct nutrition diagnosis.
Nardone refers to development of the differential diagnosis as
informed intuition (Nardone 1990). The speed with which the clini-
cian formulates the differential diagnosis list depends on the experience
of the clinician as well as familiarity with a given set of signs and symp-
toms that a patient might experience. As we can see here, the differential
diagnosis drives the decision to order tests and procedures or to gather
more information that will help to rule in or rule out each possible diag-
nosis (Harbison 2006; Soltani and Moayyeri 2007). Diagnosing nutrition
problems should not involve a blanket ordering of tests in the hope that
something interesting will turn up.
Let us see how the RD might utilize the NCP to help evaluate a
patients history. A nutrition history might begin with the patient or c lient
referred for weight loss following chemotherapy for lung cancer. An RD
with extensive experience in caring for patients experiencing weight loss
following chemotherapy would use his or her skill and experience with
similar situations: The nutrition-focused history might begin by asking if
the patient or client had been trying to lose weight. If the answer is yes,
further questions might focus on the reasons for which the weight loss
was desired; this would be followed by providing an understanding of
the importance of good nutrition during cancer therapy, and remaining
cancer treatments as well as any future cancer treatment that might make
further weight loss ill-advised. If the answer is no, then questions would
take a different approach, perhaps delving into timing of weight loss, the
connection between weight loss and side effects of chemotherapy, and
changes in functional capacity. Each response would be evaluated and
clustered with similar responses that point toward one or more nutrition
diagnoses and away from other nutrition diagnoses. The RD uses critical
thinking skills to carefully evaluate each piece of information in order to

get closer to the correct diagnosis without unnecessary labs or lab tests
that might not provide additional information.
Now, how would the RD without extensive experience diagnose
this patients nutrition problems? He or she might request lab testing
to evaluate protein stores, forgetting that changes in functional capacity
might be a good indicator of muscle function since protein stores are not
the problem, it is how protein functions in the body. Or, the RD with less
experience might even skip the detailed weight history and simply jump
into an intervention for involuntary weight loss without bothering to verify
that there actually was involuntary weight loss. Thus, at the next visit, there
might be no change in weight because the nutrition intervention that was
implemented did not focus on the correct diagnosis.

Using Critical Thinking Skills to Diagnose

The NCP model highlights the need for well-developed critical thinking
skills in order to accurately diagnose nutrition problems. The problem
is that no one seems to agree on what exactly is meant by critical think-
ing skills. Much has been published regarding critical thinking skills in
nursing practice (Allen, Rubenfeld, and Scheffer 2004; Duchscher 2003;
Facione and Facione 1996; Gambrill 2005; Ignatavicius 2001; Riddell
2007; Scheffer and Rubenfeld 2000; Wilkinson 2007). Much less has
been published regarding critical thinking in dietetics practice. A search of
the MedLine database using PubMed revealed only two publications that
focused on promotion of critical thinking skill development in dietetics
education (Dalton 1999; Lohse, Nitzke, and Ney 2003). While the 2008
accreditation standards for dietetics education programs specify that
opportunities be given for development of critical thinking skills, there
is no mention of what those skills are or how they could be measured
(Commission on Accreditation for Dietetics Education 2008; S kipper,
Young, and Mitchell 2008).
Fortunately, we probably can assume that the critical thinking skills
needed for dietetics practice would mimic those needed for other allied
health professions. Scheffer and Rubenfeld used a Delphi technique to
achieve consensus among a group of nurse experts on the following defi-
nition of critical thinking:
Nutrition Diagnosis 37

Critical thinking in nursing is an essential component of profes-

sional accountability and quality nursing care. Critical thinkers
in nursing exhibit these habits of the mind: confidence contex-
tual perspective, creativity, flexibility, inquisitiveness, intellectual
integrity, intuition, open-mindedness, perseverance, and reflec-
tion. Critical thinkers in nursing practice the cognitive skills of
analyzing, applying standards, discriminating, information seek-
ing, logical reasoning, predicting, and transforming knowledge.
(Scheffer and Rubenfeld 2000)

Scheffer and Rubenfelds research further defined 10 habits of the

mind and seven skills associated with critical thinking in nursing practice
(Scheffer and Rubenfeld 2000).

Using Nutrition Diagnostic Terms to Describe

Nutrition Diagnoses
Following nutrition assessment, nutrition diagnosis is the second step of
the NCP. RDs gather and analyze information about a patient or client in
order to assess nutrition status. Critical thinking skills are used to develop
a short list or differential diagnosis, which is an essential tool in the diag-
nostic process for all health professions.
Since diagnosing nutrition problems is a relatively new skill for most
RDs, let us spend some time looking at how the nutrition diagnosis
step of the NCP was developed. In 2003, Lacey and Pritchett recom-
mended documenting nutrition diagnoses using the PES statement that
includes the problem or nutrition diagnosis, the etiology or cause of the
problem, and the signs or symptoms associated with the nutrition problem
(Lacey and Pritchett 2003). Unfortunately, Lacey and Pritchett do not
include the rationale for this recommendation. However, it appears that
the use of diagnostic statements originated with the NANDA terminology
used by nurses to describe nursing diagnoses (North American Nursing
Diagnosis Association 2015).
As we have discussed earlier, the critical thinking skills associated with
diagnostic skills are not traditionally taught in dietetics education. The
concept of nutrition diagnosis is still relatively new to many as the NCP

was first published less than 10 years ago (Lacey and Pritchett 2003).
Therefore, many educators may not be prepared to teach diagnostic skills
since they have had no exposure to diagnostic thought processes them-
selves. Preceptors in supervised practice sites may not have strong diag-
nostic skills. There is also the perception held by some that RDs do not
need diagnostic skills to pick a nutrition diagnosis. Some RDs are reluc-
tant to diagnose nutrition problems because they are not confident in
their diagnostic skills. Additionally, there is sometimes a misperception
by some outside dietetics that RDs cannot diagnose at all!
On the other hand, many RDs who have developed the necessary
skill set needed to diagnose nutrition problems are wondering what they
ever did before developing these skills. These pioneer nutrition diagnosti-
cians typically are those who work closely with colleagues from the other
health diagnosing professions. Those working in facilities that train other
health professionals have been able to witness those students being taught
diagnostic skills and have successfully applied those skills to their own

The Nutrition Diagnostic Statement (PES)

The AND recommends that RDs document nutrition diagnoses using

a PES statement (The American Dietetic Association 2011). The PES
statement begins with the nutrition problem or diagnosis, followed by
a description of the etiology or cause of the diagnosis, and the signs and
symptoms that are descriptive of the diagnosis.
The nutrition diagnoses class contains 60 nutrition diagnoses, clus-
tered into three domains: intake, clinical, and knowledge/behavior. Using
a standardized terminology such as that provided by the International
Dietetics and Nutrition Terminology (IDNT) to document nutrition
diagnoses means that the terms will have the same meaning, regardless
of setting or clinician. For example, lacking a standardized terminology,
the term malnutrition might be interpreted in many ways depending on
the RDs experience and practice setting. When the IDNT is utilized, the
term malnutrition has a given meaning, regardless of extraneous issues.
After diagnosing the nutrition problem, the next step in constructing
the PES statement is to describe the etiology or cause of the problem.
Nutrition Diagnosis 39

The etiology of the nutrition diagnosis is linked to the diagnosis by the

phrase related to and should be a succinct description of the cause of
the diagnosis. The etiology must be something that the RD can resolve
or lessen the severity of through the nutrition intervention. Finally, the
signs and symptoms are described and linked to the etiology through the
phrase as evidenced by. The signs and symptoms should be specific and
measurable, as changes in the signs and symptoms will be used to moni-
tor progress toward curing or ameliorating the nutrition diagnosis. Some
general guidelines for the PES statement are as follows:

The PES statement must be clear and concise.

The PES statement must be meaningful to other health care
providers and should make sense.
The etiology must be a factor that the RD can treat inde-
pendently; avoid using medical diagnoses or treatments
whenever possible.
Every sign and symptom that the patient/client/group
exhibits need not be listed; the one that directly relates to
the diagnosis should be used. For example, if the diagnosis is
involuntary weight loss, then the sign and symptom should be
a measure of weight, such as loss of 5 lbs without trying.
For optimal clarity, each statement contains one diagnosis,
one etiology, and one sign and symptom.

Sample Nutrition Diagnostic (PES) Statements

Inadequate oral food/beverage intake related to chemotherapy-

induced nausea as evidenced by five-day average intake less
than 25 percent of meals.
Excessive energy intake related to unchanged intake while
immobile following surgery as evidenced by intake 140 per-
cent of estimated requirements.
Food/nutrition related knowledge deficit related to patient
report of no previous nutrition education as evidenced by the
inability to complete nutrition knowledge quiz.

Nutrition Intervention
As defined by the Nutrition Care Process (NCP), dietetics profession-
als are responsible for independent treatment of health problems related
to nutrition. Nutrition intervention is defined as purposefully planned
actions intended to positively change a nutrition-related behavior, envi-
ronmental condition, or aspect of health status for an individual (and his/
her family or caregivers), target group, or the community at large (The
American Dietetic Association 2007). The intervention phase of the NCP
includes two componentsplanning the intervention and implementing
the intervention. During the planning phase, the registered dietitian (RD)
identifies the nutrition intervention that has the best chance of success-
fully treating the nutrition problem. Goal setting is also done during the
planning phase of nutrition intervention. Goals should be realistic and
achievable. The implementation phase is where the action takes place. In
some cases, the RD might be responsible for carrying out the intervention
independently. In other situations, the RD will collaborate with others to
ensure that the intervention is carried out.
Nutrition interventions must be focused on the nutrition diagnosis.
For example, if a knowledge deficit is diagnosed, then the proper inter-
vention would be related to education or counseling. If the RD diagno-
ses a knowledge deficit and then changes the diet order, no education is
provided and there is no demonstrable link between the diet order and
the patient or clients knowledge deficit. This is the equivalent to a physi-
cian prescribing an antibiotic (intervention) to resolve a wound infection
Another way of thinking focuses on documentation of the nutrition
diagnosis to help identify the correct intervention. Using this approach,
it can be seen that an appropriate nutrition intervention will eliminate or
reduce the severity of the etiology of the nutrition diagnosis. Going back
to the example from medicine, the antibiotic will eliminate the source of

Table 5.1 Relationship between nutrition intervention and the P-E-S

Problem Food- and nutrition-related knowledge deficit
Etiology No previous instruction on high potassium foods
Signs and symptoms Patient report
Nutrition intervention Education, brief
Intervention focus Provide missing information on high potassium foods

the infection (harmful bacteria). If it is not possible to impact the etiology,

then the intervention should lessen or change the signs and symptoms.
Table 5.1 breaks down a P-E-S statement to show how the intervention
is linked to the etiology.
The nutrition intervention step of the NCP is further broken down
to provide more details about how RDs do something for their patients or
clients. When RDs decide that there is a need for a nutrition interven-
tion, intervention planning is done in order to determine the appropriate
intervention, the level of intensity, how to intervene, and the timing of
the intervention. Table 5.2 shows these steps. The nutrition prescription
is usually developed during the planning phase of the nutrition inter-
vention. Once planning is complete, the RD must then implement the
intervention. Implementation of a nutrition intervention includes the
action phase, where the intervention is carried out, and a set of actions
following the action phase that includes documentation. Each compo-
nent of the nutrition intervention will be described in detail later in this

RD-Directed and RD-Implemented Nutrition

Good nutrition is essential to good health. There is a body of litera-
ture demonstrating the importance of nutrition in maintaining health
as well as in recovering from illness (Karlsson and Nordstrom 2001;
Priceetal.2005; Ravasco et al. 2005; See and Murray 2006). Historically,
research focusing on nutrition interventions hasnt always specified that
the nutrition interventions studied were RD directed or implemented by
the RD. Using the NCP allows demonstration of the impact of actual
Nutrition Intervention 43

Table 5.2 Planning nutrition interventions

Intervention planning Comments
Determine which nutrition inter- Might be indicated by the diagnosis; that is, a
vention should be implemented knowledge deficit diagnosis could be treated
by implementing an education nutrition
Intervention should change or improve the
etiology; if thats not possible, goal of inter-
vention should be to ameliorate the signs or
Evaluate evidence, guidelines, and rec-
ommendations that support the nutrition
intervention considered
Level of intensity Consider time available
Consider the setting
Consider patient or client readiness
How to intervene Evaluate patient or client barriers such as
visual impairment that require adjustment of
intervention strategies
Determine if the RD has the skills and expe-
rience needed to successfully implement the
Timing of the intervention Availability of time dedicated to completing
the nutrition intervention
Evaluate the need for more than one session
to achieve the intended results
Goal setting Collaborate with patient or client and others
to develop goals that are specific, measurable,
and attainable
Determine expected outcomes

RD-directed nutrition interventions through the interlinkage between

nutrition assessment, nutrition diagnosis, and nutrition intervention.
And the interconnected monitoring and evaluation step of the NCP pro-
motes development and analysis of databases that are needed to demon-
strate the health and economic benefits of nutrition interventions.
Lets briefly look at some areas for more research focused on RD-
directed or RD-implemented nutrition interventions. Well start with
a discussion on the scope of practice and what it means, followed by
examples of the different ways that RDs can be responsible for nutrition

Scope of Practice Issues and Nutrition Interventions

The profession of dietetics encompasses a wide range of individual profes-

sional skill level and autonomy in different practice settings. RDs work-
ing in many health care facilities are bound by institutional policy as well
as regulatory and licensure requirements. Navigating the maze of levels of
practice and practice roles in the workplace can be a very difficult task. For
example, RDs employed by one health care facility might have authority
to implement certain nutrition interventions using clinical privileges that
have been defined and approved by their employer. Other RDs with sim-
ilar education, skill, and knowledge working in another facility across the
street must seek another provider to implement the intervention due to
the lack of clinical privileges. A care process that will fit the needs of both
the scenarios must meet the needs of both types of practice.
Institutions begin the process of credentialing or verifying the qualifi-
cations, experience, and education of a clinician by examining the scope
of practice for that profession. Professional scopes of practice are legislated
at the state level and can differ from state to state (Dower, C hristian, and
ONeil 2007). Evaluation of the scope of practice regulation for health
professionals provides the RD seeking enhanced responsibility informa-
tion regarding the types of skills and education needed for safe practice
by health professions practicing within that state. Once this initial eval-
uation is done, the RD needs to compare those regulations to his or her
own personal scope of practice.
RDs employed in states that have achieved licensure for dietetics prac-
tice may have a scope of practice defined in the licensure provisions for
their state that is accessible for all to review. The Academy of Nutrition
and Dietetics or AND also has several tools that RDs can use to deter-
mine the personal scope of practice and the current level of practice and
develop a plan for moving to a higher level of practice if desired. The
Scope of Dietetics Practice Framework can facilitate the development of
a personal scope of practice by the RD (American Dietetic Association
2011; OSullivan-Maillet, Skates, and Pritchett 2005).
There has been some confusion regarding the scope of practice and
how to interpret it for a given health profession, particularly if tasks over-
lap. Dietetics professionals seeking increased autonomy in implementing
Nutrition Intervention 45

nutrition interventions should familiarize themselves with any state

licensure and scope of practice regulations. Some RDs have assumed
that tasks included in the scope of practice of one profession cannot be
included in another. According to the National Council of State Boards
of Nursing, no one profession owns a skill or activity in and of itself,
meaning that a skill or activity residing within one professions scope of
practice document can be included in the scope of practice of another
profession as long as training, experience, and competence have been
demonstrated (National Council of State Boards of Nursing 2007).
Therefore, its imperative that all state licensure laws and practice acts for
RDs be carefully reviewed, as these documents differ from state to state.
The Standards of Professional Performance and Standards of Practice
for Registered Dietitians provide guidelines to determine the minimum
requirements for RDs practicing at three levels: generalist, specialty, and
advanced (The American Dietetic Association 2008).
The NCP can be used as a framework for practice, regardless of RD
level of practice and professional responsibility. The inner ring of the
NCP model illustrates the attributes intrinsic to the RD that facilitate
self-evaluation, including the following:

Dietetics knowledge
Skills and competency
Critical thinking
Collaborative ability and network
Communication skills
Use of evidence-based practice
Application of American Dietetic Associations Code of Ethics

Each of these attributes distinguishes the RD from other health pro-

fessions (Writing Group of the Nutrition Care Process/Standardized Lan-
guage Committee 2008) in addition to providing a framework for the
RD to evaluate appropriate level of practice.
RDs who have some degree of professional autonomy and responsi-
bility can direct the implementation of a nutrition intervention by others
or can implement the nutrition intervention themselves. Quite often, this
level of practice requires clinical privileging through a facilitys medical

staff committee. Those without similar levels of professional autonomy

can still collaborate with other health care professionals who can directly
implement a nutrition intervention.

RD-Directed and RD-Implemented Nutrition InterventionsDo

They Matter?

Regardless of the level of professional autonomy, the use of a care process

such as the NCP encourages the collection of data needed to demonstrate
what most dietetics professionals already know: Nutrition interventions
make a difference. The profession of dietetics has come a long way from
the 1920s, when nutrition interventions mainly consisted of preparation
of special meals (Gilson 1947; Titus 1927). In 1974, Bonnell stated that
As a member of the health team, the dietitian must have the ability and
knowledge to be a consultant and to participate with the physician in
decisions regarding nutrition (Bonnell 1974). By using a standardized
terminology to describe nutrition interventions, the RD moves beyond
mere participation in nutrition decision-making to independent deci-
sion-making and intervention. This process, accompanied by a body
of research demonstrating that nutrition interventions implemented or
directed by the RD save money and lives, is critical to moving the dietet-
ics profession forward.
While more research is needed in all areas of dietetics practice, fol-
lowing are some examples where RDs have been able to demonstrate the
beneficial impact of nutrition interventions.

Nutrition Interventions that Matter

Clinical nutrition interventions: Phenylketonuria (PKU) is one of a com-

plex group of inherited metabolic disorders. Nutrition therapy is integral
to management of PKU and is ideally initiated in the first weeks of life
and continues throughout the lifespan. The diet for PKU is very complex
and is designed to carefully manage dietary sources of the amino acid
phenylalanine. In addition to knowledge of dietary sources of phenyl-
alanine, those treating individuals with PKU must also understand how
requirements for phenylalanine change throughout the lifecycle and how
Nutrition Intervention 47

to adjust diet guidelines accordingly. Traditional education methods have

had varying long-term impact on phenylalanine control, and because
of this Durham-Shearer studied a patient-focused educational system
(Durham-Shearer et al. 2008). Results indicated that collaborating to
include patients and their families in the development of educational
materials could lead to increased knowledge and thus diet adherence.
These results show improvement in nutrition management of metabolic
disorders when unique, RD-implemented nutrition interventions such
as collaboration with others are utilized as opposed to the usual interven-
tion of written materials provided at health care provider appointments
(Durham-Shearer et al. 2008).
Hyperphosphatemia is a common complication of chronic kidney
disease. Nutrition intervention is thought to be a mainstay of treatment
for hyperphosphatemia due to the relative difficulty in filtering the large
phosphate molecule during dialytic therapy. Patients receiving dialytic
therapy are often counseled to increase protein intake. Unfortunately,
foods high in protein also tend to be high in phosphorus, making dietary
phosphate management difficult. Morey, Walker, and Davenport found
that increasing the number of RD-implemented educational sessions pro-
vided for patients receiving dialytic therapy led to improvement in phos-
phate control (Morey, Walker, and Davenport 2008).
A case study describing dietetic services provided for a burn patient
also provides insight into the importance of both RD-directed and
RD-implemented nutrition interventions (Windle 2008). All RD activi-
ties focused on patient care were recorded and evaluated. RD attendance
at bedside rounds was shown to result in some positive changes in nutri-
tion care. Additional nutrition interventions provided included collabo-
ration with nursing and medical professionals, requesting and monitoring
weights, and providing oral supplements. While it is difficult to make any
assumptions regarding the impact of the RDs interventions in this case
study, what we can see is that RD interventions are a central component
of burn care.
So, what do these studies tell us about the importance of RD-directed
or RD-implemented nutrition interventions? While the previous exam-
ples are encouraging, the studies were small and limited by sample size.
There were additional limitations resulting from the lack of long-term

maintenance of some of the changes seen. However, each gives a glimpse

into some of the ways in which RD-implemented nutrition interventions
might improve health outcomes.
Public health nutrition interventions: The health and economic toll of
the obesity epidemic is enormous, with estimates that medical expenses
alone for overweight or obese individuals were greater than $78 billion
in 1998 (U.S. Department of Health and Human Services 2010). While
solid support for nutrition intervention in clinical settings is still a work
in progress, interesting data in public health nutrition is emerging that
demonstrates the benefits associated with nutrition interventions. Dalziel
and Segal investigated the cost-effectiveness of nutrition interventions in
10 studies. Two studies that included intensive nutrition intervention by
the RD showed the highest level of certainty in the estimation of benefit
as well as a high cost-effectiveness measured as cost per quality adjusted
life year (Dalziel and Segal 2007). Dalziel and Segal concluded by stating,

Nutrition interventions can constitute a highly effective compo-

nent of a strategy to reduce the growing disease burden linked
to over/poor nutrition. There is an urgent need for high-quality
trial data from which economic performance of nutrition inter-
ventions can be modeled. (Dalziel and Segal 2007)

RDs working in community and public health settings can utilize the
NCP and nutrition intervention terminology to gather the type of data
needed to demonstrate the impact of nutrition interventions.

Intervention Domain of IDNT

The International Dietetics and Nutrition Terminology (IDNT) includes
terms that describe a set of nutrition interventions that are applicable to
all work settings (The American Dietetic Association 2009). Using stan-
dardized terminology to describe nutrition interventions helps ensure
that other RDs and health care providers understand what the RD did to
improve the nutrition problem.
Looking at the nutrition intervention worksheet, the RD can see
details that might be used to describe the nutrition intervention in more
Nutrition Intervention 49

detail. In this example, the intervention medical food supplements

might be accomplished by recommending a change in the current supple-
ment order along with the reason for the change. Nutrition Intervention
worksheets also provide a selection of nutrition diagnoses that might be
associated with the intervention along with some sample signs/symptoms
that could be improved through successful intervention. Remember that
the nutrition diagnoses and signs/symptoms provided are not intended to
be exhaustive. Clinical judgment and experience must be used to deter-
mine if a given nutrition intervention will improve or treat the nutrition
problem that has been diagnosed.

Food and Nutrient Delivery Class

When the desired intervention focuses on the timing, amount, and type
of foods/nutrients provider, as well as the environment in which foods/
nutrients are provided, the nutrition intervention most likely falls into
the Food and Nutrient Delivery Class. This class includes the following:

Meals and snacks

EN and PN
Supplements including medical food supplements, vitamin or
mineral supplements, and bioactive substance supplements
Feeding assistance
Feeding environment
Nutrition-related medication management

Nutrition Education

The nutrition education class is typically the focus when a nutrition

diagnosis associated with the need for enhanced knowledge and skill is
The nutrition education class includes the following:

Initial/brief nutrition education

Comprehensive nutrition education (The American Dietetic
Association 2009)

An initial/brief education intervention is differentiated from a com-

prehensive education intervention by the amount of time involved as well
as the focus of the education intervention. A brief session might be used
to impart survival skills or to focus on one aspect of a nutrition behavior
(Sacerdote et al. 2006). Comprehensive education interventions have a
more in-depth focus that requires additional time for the reinforcement
of skill acquisition or training.

Nutrition Counseling

Nutrition counseling is most often implemented in an outpatient or

community setting that is more conducive to development of the client
counselor relationship needed for successful counseling. RDs who utilize
nutrition counseling techniques must be skilled in each of the following
components of a nutrition counseling intervention:

Theoretical basis/approach
Strategies (The American Dietetic Association 2009)

Both the components, theoretical basis and strategies, should be

documented for each patientclient encounter.

Coordination of Nutrition Care

Health care is provided in a number of different settings by a number of

clinicians with varying training, credentialing, and experience. Patients/
clients may have multiple care needs that require input from more than
one health care professional. RDs can implement nutrition interventions
focused on coordinating care both within an institution as well as follow-
ing discharge. These interventions can be described as follows:

Coordination of other care during nutrition care

Discharge and transfer of nutrition care to new setting or
provider (The American Dietetic Association 2009).
Nutrition Intervention 51

Nutrition Intervention
As mentioned earlier, nutrition interventions have two components:
planning and implementation. While planning and implementation are
distinct actions included in a nutrition intervention, they are interrelated
and often flow together. For example, the RD might be in the implemen-
tation phase of a discharge planning nutrition intervention when new
information becomes available that requires revisiting the planning phase
of this intervention and, thus, a quick adjustment of the implementation.
Nutrition prescriptions must be formulated and communicated to the
patient or client and other members of the health care team as part of goal
setting and documentation of the nutrition intervention. Once plans for
the intervention are complete and the nutrition prescription is in place,
RDs implement the nutrition intervention.

The Nutrition Prescription

A nutrition prescription is simply a statement of the patient or clients

unique nutritional requirements as determined by the RD using reference
standards or dietary guidelines while keeping in mind the patient or clients
health condition, requirements, and abilities. The nutrition prescription
drives the goal-setting phase of nutrition intervention planning as well as
the selection of the nutrition intervention to be implemented. The nutrition
prescription can include a general statement regarding the desired diet goal
(low fat, low glycemic index diet) or can include more specific information
about desired nutrient intake (800 mg of phosphorus diet, <10 percent total
calories as saturated fat). The nutrition prescription can also include the
route of feeding (oral, enteral, or parenteral) or can focus on specific foods
or food groups (no more than one 12 oz can regular soda per day).


Once a nutrition problem is diagnosed, the RD and patient or client

collaborate to determine a goal and identify the most appropriate nutri-
tion intervention that will facilitate meeting that goal. The goals set

should be realistic and achievable; while its ideal that the patient or client
be involved in the goal setting, in some care settings, patient or client
involvement is not feasible. Goal setting is integral to the monitoring and
evaluation step of the NCP as its not possible to determine the success of
the intervention if there was no initial goal set!


After the nutrition prescription has been developed, goals set, and an
intervention(s) selected, the nutrition intervention is implemented. The
terminology used to describe the intervention may depend on the type
of prescriptive authority held by the RD. Those RDs with the ability to
implement a nutrition intervention might order a change in meal timing
directed toward those responsible for meal delivery, while those who do
not have the ability to implement a nutrition intervention might recom-
mend a change in meal timing.

Making the Connection Between Nutrition Assessment,

Nutrition Diagnosis, and NutritionIntervention
One of the benefits of the NCP is the ability to demonstrate a clear
connection between each step through use of the IDNT. Regardless of
the documentation style used, others can plainly see what the RD diag-
nosed, how that diagnosis was made, why a given intervention was imple-
mented, and what indicators will be monitored to evaluate the outcomes
of the intervention. Lets consider a short bowel syndrome patient who
is admitted for dehydration. In this patient, the medical diagnoses might
be short bowel syndrome and dehydration, while the nutrition diagnoses
documented using P-E-S statements could be as follows:

Inadequate fluid intake related to impaired thirst as evi-

denced by patient report of less than 900 mL fluids consumed
compared to estimated 1,200 mL requirements.
Involuntary weight loss related to inadequate fluid intake as
evidenced by 2 lb weight loss over past 6 days.
Nutrition Intervention 53

Food/nutrition-related knowledge deficit related to need for

additional fluid consumption while traveling as evidenced by
patient report.

After all the assessment information is gathered and evaluated, it

becomes apparent that the problem with fluid intake is due to a few days
with multiple family requirements that precluded adherence to a planned
schedule for fluid consumption. Therefore, three nutrition interventions
are implemented: a short-term increase in IV fluids for rehydration,
weight checks to be sure that fluid weight is regained, and a brief nutri-
tion education session to ensure that alternate strategies for meeting fluid
intake requirements when traveling are available.
Using diagnostic skills to identify nutrition problems can lead to a
positive impact on RD workflow and efficiency. In the past, without
the expected participation of the RD in diagnosing nutrition problems,
nutrition interventions were implemented based on a diagnosis made by
another healthcare professional. For example, in some facilities policy
stipulated that RDs must visit all patients with diabetes mellitus. How-
ever, assigning RD time based on medical diagnosis can be time con-
suming and not necessarily an effective use of the RDs time. So in some
instances, it is appropriate for nutrition intervention to be based on med-
ical diagnosis, for example, patients with short bowel syndrome admitted
for fluid and electrolyte losses. More often, though, the medical diagnosis
does not signify the presence or absence of a nutrition diagnosis. Lets
look at the following example.
A childrens hospital has a large hematology/oncology service and
often admits children for inpatient management of induction chemother-
apy. Prior to this admission, it was customary for the child and parent or
caregiver to be referred to the outpatient nutrition service for an initial
nutrition assessment and comprehensive education if there was a knowl-
edge deficit related to the impact of chemotherapy on appetite and intake.
However, review of facility data indicated that 97 percent of these admis-
sions did not develop side effects of their chemotherapy regimen until at
least one week after induction. Most had not lost weight and had normal
appetite and food intake during the three- to four-day stay. Therefore, it

was determined that the RD would be consulted only for those patients
who had lost weight or had documented poor intake for three to four
days prior to admission. Changing policy from consult based on medical
diagnosis to consult based on nutrition diagnosis resulted in a significant
savings in time and effort by the RD and allowed the staff to concentrate
on enhancing services provided to the outpatient oncology clinic.

Nutrition intervention is the third step of the NCP. Using a care pro-
cess like the NCP along with a standardized terminology like the IDNT
to describe nutrition interventions done by RDs has a positive impact
on nutritional on health and well-being in all care settings. Nutrition
interventions that have been defined by the IDNT include four distinct
categories: meal/nutrient intake, nutrition education, nutrition counsel-
ing, and coordination of nutrition care. Each of these categories includes
descriptors providing further detail regarding the intervention. Utilizing
the intervention terminology along with the NCP allows RDs to clearly
describe what was done for a patient or client or group, why the inter-
vention was done, and what the expected goal of the intervention is.
Data gathered from use of the intervention terminology in multiple sites
can then be used to convince all stakeholders of the need for enhanced
nutrition services in all care settings.

Nutrition Monitoring
Monitoring and evaluation (M/E) is the fourth step of the Nutrition Care
Process (NCP) (Lacey and Pritchett 2003). If the nutrition diagnosis was
correct, the correct intervention implemented, and appropriate indica-
tors of progress toward goals selected, then M/E should demonstrate that
goals set during nutrition intervention have been met. Errors in any of the
preceding steps of the NCP might result in M/E data that are confusing
or lacking connection to the nutrition diagnosis or intervention. Before
beginning the M/E step, registered dietitians (RDs) should ensure that
goals set during nutrition intervention are appropriate and meaningful
and that indicators of progress toward goals are monitored in a reason-
able time frame so that outcomes of care can be correctly interpreted and
reported. Therefore, the M/E step of the NCP really involves monitoring
of indicators and evaluation of outcomes. Given the importance of the
M/E step, it is important to completely define M/E as well as the impor-
tance of selecting the best indicators of progress toward outcome goals.
Then it can be seen how M/E relates to all areas of dietetics practice.
Monitoring and evaluating the results of nutrition interventions pro-
vides the link that allows RDs to demonstrate the value of nutrition care.
A successful M/E system would identify and measure outcomes that are
meaningful to all stakeholders, including patients, referring providers,
administrators, and policy makers. Therefore, it is imperative that out-
comes that will be monitored are carefully selected.
Outcomes selected might vary depending on the situation or care
setting. Administrators might be interested in differences in length of
hospital stay or patient satisfaction with RD services. The patient or cli-
ent wants to know if the intervention will resolve the nutrition problem
and how long that will take. Decisions regarding the best outcomes to

evaluate should take into account the care setting, time available for mon-
itoring, organizational or patient goals and objectives, and the ability to
gather the needed data.
The importance of M/E outcomes is not limited to the NCP. Let us
think about the importance of M/E in other aspects of our daily life. Any
time we try something new or different, we monitor results and evalu-
ate the usefulness of the change. For example, let us say that a colleague
suggests a different route to drive to school or work. Your goal is to save
five or more minutes over your current route. The new route saves five
minutes driving time, but has a number of turns and might be difficult
to navigate in the dark. When trying the new route, the driving time
and difficulty of navigation is monitored. Following several attempts at
the new route, evaluation shows that the attention needed to navigate is
simply not worth the potential for saving five minutes.

Health Outcomes versus Nutrition Outcomes

An outcome is simply what happens after some action is taken.
Outcomes of interest differ depending on the situation. For example,
health care providers would be interested in differences in length of stay,
infection rates, need for readmission for the same diagnosis, or patient
satisfaction following hospital stay for acute illness. Facility adminis-
trators often compete for business with other facilities and, therefore,
might monitor and evaluate outcomes such as cost of care and physician
satisfaction. Decisions regarding the best outcomes to evaluate should
take into account the care setting, time available for monitoring, orga-
nizational goals and objectives, and the ability to gather data needed
Global health care outcome management can be accomplished by all
health care providers and, therefore, is not considered to be a part of the
NCP. Nutrition outcomes impact many health outcomes. Consider the
role of MNT in the management of outcomes in management of hyper-
lipidemia, for example. Therefore, RDs do contribute to managing overall
health outcomes by ensuring that nutrition intervention outcome goals
are met. If this seems a bit confusing, think of nutrition outcomes as a
subset of overall health outcomes. Nutrition outcomes are those that the
Nutrition Monitoring andEvaluation 57

RD is responsible for achieving as part of the NCP and can be directly

traced back to a nutrition intervention.
Thus, it can be seen that nutrition outcomes are an important contrib-
utor to health outcomes. To illustrate this, let us look at a multidisciplinary
group including a nurse, exercise physiologist, and RD that initiated a
weight loss program that included nutrition counseling provided by an
RD. Overall outcome goals for the program included improved qual-
ity of life (QOL) and improved glucose tolerance following weight loss.
Nutrition diagnoses most often identified in program participants might
have been obesity and nutrition-related knowledge deficit. Nutrition
interventions for these diagnoses might have included ongoing counsel-
ing aimed at enhancing the participants ability to maintain steady weight
loss and education about the calorie content of foods eaten. The RD
then monitored and evaluated changes in weight and calories consumed
throughout the program. Evaluation of program results showed a con-
nection between the amount of weight lost and improvements in QOL
and glucose tolerance. Thus, the nutrition outcome (weight loss) can be
seen as a component of the overall health outcomes (QOL and improved
glucose tolerance).

Health Outcome Categories

It would be incorrect to assume that health status was the only outcome of
interest to the patient and health care system. While recovery from illness
or injury is the ultimate goal, at times cure is not possible. In those cases,
the health care team might evaluate outcomes associated with QOL, cost
of care, or patient satisfaction with administrative aspects such as access
to providers. There are broad health outcome categories that are of inter-
est to all health care providers, including RDs. These broad categories
include health, satisfaction, and patient-specific and economic outcomes,
as described in Table 6.1.
Health outcomes: Health outcomes are those that describe a change in
a person, group, or communitys health status as a result of an interven-
tion by a health care provider. While the cure of disease is the ideal health
outcome, when cure is not possible, improved symptom management
would be a health outcome of interest. Reduction of risk for acquiring a

Table 6.1 Health outcome categories defined

Outcome category Definition Examples

Health Measures of change in current Successful weight loss
or future health status of Fewer complications of
individuals or communities chronic disease
that can be attributed to an
Economic Measures of the cost-effec- Decreased laboratory costs
tiveness of a given health Decreased length of stay
intervention compared to Lower medication cost
usual or standard care**
Satisfaction Patient, provider, or customer Physician satisfaction with
reports that expectations consult response time
related to quality of service Patient satisfaction with
are met administrative require-
Patient-specific Patient/client reported Change in QOL
changes in disease symptom Improvement in disease
management or QOL as a symptoms
result of an intervention
*From World Health Organization.
**Donaldson, Mugford, and Vale (2002).

condition is also a health outcome, particularly when interventions are

focused on groups that have a higher risk for developing a disease or con-
dition. For example, increasing physical activity to 150 minutes or more
per week was demonstrated to reduce risk for developing chronic disease
(Blair and Morris 2009). While health outcomes are the focus of much
research, economic, satisfaction, and QOL outcomes are also important
determinants of effectiveness of care provided.
Economic outcomes: The United States has one of the most expen-
sive health care systems in the world (Sarpel et al. 2008; Sessions and
Lee 2008). Much interest has been generated regarding studying of the
cost of care in order to ensure that high-quality, cost-effective care is
provided. Studying the economic impact of health care is complex and
requires methodology that might be difficult to implement in tradi-
tional clinical trials. Additionally, studies of the economic benefits of
health interventions are often difficult to interpret (Marshall and Hux
2009). One systematic review of home tele-health care found a poten-
tial for home tele-health to reduce health care costs with full evaluation
Nutrition Monitoring andEvaluation 59

limited by study methodology (Polisena et al. 2009). In spite of the

complexities, there is emerging information regarding cost-effectiveness
in healthcare.
Satisfaction outcomes: Increasing attention is being given to outcomes
related to patient satisfaction as well as provider satisfaction. Patient sat-
isfaction can be described as satisfaction with an interaction with the
health care system or a given health care provider. Provider satisfaction
describes the providers feelings regarding some aspect of the workplace,
be it administrative support, communication channels, or technology
Measures of patient satisfaction are an important component of health
outcomes as suboptimal health outcomes might be explained by the eval-
uation of satisfaction with the care provided. It can be difficult to mea-
sure patient satisfaction because satisfaction can have different meanings
depending on the person and the situation (Chow et al. 2009). Patient
satisfaction with health care services is often measured using surveys.
There are several standardized surveys used to determine satisfaction with
not only the care provided but also with ancillary services such as clean-
liness of rooms, time to respond to calls for assistance, food service, and
education provided prior to discharge. Many facilities utilize external
consultants to evaluate patient satisfaction; Press Ganey is one patient
satisfaction survey tool used in acute care (Press Ganey 2009).
In addition to patient satisfaction, it is important to evaluate how
well other providers, including physicians and nurses, are satisfied with
services provided by RDs. Implementing nutrition interventions often
requires communication and collaboration with other members of the
health care team. It is a good idea to periodically check how well others
are satisfied with the professionalism, timeliness, and quality of care pro-
vided by the RD. Remember that provider dissatisfaction can not only
impact job satisfaction (Chang et al. 2009) but might also lead to subop-
timal patient care (Hickson and Entman 2008).
Patient specific: Health-related quality of life (HR-QOL) is a term
used to describe a persons satisfaction with their overall health status and
how health conditions impact daily living. There are many tools that can
be used to evaluate HR-QOL in a number of situations (Sajid, Tonsi,
and Baig 2008). Many of the HR-QOL tools are specific to a given

condition or disease, making it important to select the correct HR-QOL

tool depending on the situation (Azoulay, Kentish-Barnes, and Pochard
2008; Davies 2009).

Nutrition Outcome Categories

In order to demonstrate the potential benefits associated with the NCP,
RDs can monitor and evaluate the impact of nutrition interventions in
each of the health outcome categories. The nutrition components of
health-related outcomes include weight changes, changes in laboratory
values, or changes in food and nutrient intake that facilitate achievement
of some broader, global health-related outcome goal. Economic outcomes
associated with nutrition interventions might include decreased food
waste, lower formulary cost, or decreased labor cost.
Many RDs are familiar with measurements of patient satisfaction
with nutrition services. As discussed earlier, Press Ganeys inpatient
satisfaction survey is often used in acute care. The Press Ganey inpatient
survey includes a measure of satisfaction with meals served that includes
food quality, food temperature, and the courtesy of the person who deliv-
ers the meal tray (Press Ganey Associates 2008). Analysis of Press Ganey
survey results can facilitate action plans aimed at improving nutrition
services provided (Tranter et al. 2009).
In the past few years, RDs have begun to focus on nutrition-related
QOL (NR-QOL) and the development of tools to measure NR-QOL
(Barr and Schumacher 2003). The International Dietetics and Nutrition
Terminology (IDNT) includes the nutrition diagnosis Poor nutrition
quality of life (NB-2.5), which has been defined as Diminished patient/
client perception of quality of life in response to nutrition problems and
recommendations (The American Dietetic Association 2011). There
is currently no validated tool that can be used to measure NR-QOL.
Therefore, it is recommended that scores on other validated tools be used
along with other signs and symptoms such as Frustration or dissatis-
faction with MNT recommendations or Inability to change food- or
activity-related behavior to evaluate NR-QOL (The American Dietetic
Association 2011).
Nutrition Monitoring andEvaluation 61

Monitoring and Evaluation Defined

The NCP defines M/E as a method for determining if the patient/client
is achieving the nutrition intervention goals or desired outcomes (The
American Dietetic Association 2011; Writing Group of the Nutrition
Care Process/Standardized Language Committee 2008). M/E has two
components: monitoring, which can be thought of as collecting infor-
mation, and evaluation, the process used to analyze the information col-
lected in order to determine if progress is being made toward a goal. RDs
monitor nutrition-focused indicators and evaluate progress toward goals
set during the nutrition intervention.
Decisions regarding the effectiveness of a nutrition intervention
depend on the selection of goals or outcomes expected following imple-
mentation of the nutrition intervention. Critical thinking during goal
selection ensures that effective criteria for the measurement of progress
are identified and monitored during M/E. Goals selected should focus
on the aspects of health care that are directly related to the action of the
RD in order to provide evidence of the effectiveness of nutrition inter-
ventions. While it is important to document global health outcomes such
as decreased risk for surgical complications, the M/E step of the NCP
allows RDs to demonstrate the important role of nutrition interventions
in optimizing global health outcomes.

Connection of M/E to Preceding Steps of the NCP

As the final step of the NCP, M/E provides the opportunity to demon-
strate that each step of the NCP was correctly implemented. When an
RD conducts a nutrition assessment, information is gathered and evalu-
ated. The RD then uses critical thinking skills to determine if the infor-
mation gathered is associated with a particular nutrition diagnosis. When
the information is consistent with the signs and symptoms of a nutrition
problem, a nutrition diagnosis is made. Next, a nutrition intervention
focused on improving the nutrition diagnosis is selected. As part of the
nutrition intervention, the RD and patient/client set goals for the inter-
vention. Indicators are the parameters that are measured to determine if
progress is being made. When the nutrition intervention goals have been

met, indicators selected for M/E demonstrate resolution of the nutrition


What Should Be Monitored? Selecting Indicators

Indicators are simply the parameters that RDs use to demonstrate the
effectiveness of a nutrition intervention. Therefore, it is important to care-
fully select nutrition indicators that will be monitored during the M/E
step of the NCP. Ideally, indicators that are monitored during this step
change in direct response to a nutrition intervention. Indicators selected
must also demonstrate an acceptable level of reliability and validity when
used to measure a nutrition outcome. Therefore, it is important to review
the categories of indicators included in the M/E domain of the IDNT
and the terms that can be used as indicators to demonstrate the effective-
ness of nutrition care.

Which Indicators

Indicators selected for monitoring differ depending on the situation.

Timing is also an important consideration when determining which
indicators to monitor. For example, RDs working in acute care might
not want to monitor amount of weight lost following a brief nutrition
education for obese inpatients admitted to a facility where the average
length of stay is only four days. In this setting, it might be more valuable
to evaluate the patients knowledge about the importance of healthy
eating for weight loss before and after the brief nutrition education.
On the other hand, monitoring weight loss is an important component
of outcomes resulting from multiple visits to the outpatient or com-
munity RD. Indicators selected would ideally change as a direct result
of a nutrition intervention. This connection can be difficult to make
for some indicators. For example, a patient who has hyperlipidemia
might have improvement in serum lipid levels as a result of nutrition
intervention along with lipid lowering medications. The RD must be
able to describe this interaction when documenting outcomes in these
Nutrition Monitoring andEvaluation 63

Reliability and Validity

When evaluating potential indicators for use in the M/E step of the NCP,
the need to select indicators that are valid and reliable cannot be over-
stated (Higgins and Straub 2006). Reliability refers to the reproducibility
of data, while validity describes the truthfulness of data. Indicators that
are both reliable and valid are referred to as precise (Fitzner 2007). It is
important to remember that an indicator that is reliable but not valid pro-
duces consistent results when repeated, but these results do not measure
the true value of the measure. The validity of an indicator is more com-
plex, but basically is an attempt to determine if the indicator in question
is actually measuring the concept that it is intended to measure (Roberts
and Priest 2006).

Monitoring and Evaluation Terminology

In most cases, indicators used in the nutrition assessment step of the NCP
will be the same indicators that could be followed during the M/E step.
Let us say that a patient or client provides an activity log that lists two
20-minute walking sessions over the past month (Frequency of physical
activity, FH-6.3.3). Based partly on this information, the RD diagnosed
Physical inactivity (NB-2.1) and implemented the nutrition interven-
tion Referral to community agencies/programs (RC-1.4) to provide the
patient or client with options for group walking programs with the goal
to increase the activity to at least one session per week. At the next visit,
M/E will evaluate the frequency of physical activity again to determine
if the goal is met. For this reason, the IDNT combines terms describing
nutrition assessment and monitoring/evaluation in one section of the ter-
minology so that this connection between assessment and M/E can be

When Should Monitoring Be Done?

M/E really involves three components: monitoring, measuring, and eval-

uation. Decisions must be made regarding the timing of the monitor-
ing. It is important to get the timing right. If monitoring is done too

infrequently, important changes in the indicator might be missed. On

the other hand, too frequent monitoring might lead to changes in an
intervention based on an insignificant change in an indicator or increased
costs associated with nutrition care due to unnecessary costs associated
with frequent monitoring. Factors such as the care setting, financial
constraints, patient or client wishes, and system capabilities often limit
choices regarding frequency of monitoring.

Intake Terms

Food and nutrient intake of healthy individuals can be compared to stan-

dards such as Dietary Reference Intakes (DRIs) tables to determine ade-
quacy (Murphy and Poos 2002). Monitoring and evaluating food and
nutrient intake becomes more complex when patients or clients have
health conditions that impact nutrient needs. In these cases, available
guidelines for adequate intake may differ significantly from recommended
intake by healthy individuals. In addition to determining criteria for eval-
uating food and nutrient intake, RDs must consider the accuracy of data
provided. Direct observation of meals and feedings by the RD is typically
neither feasible nor appropriate; therefore, secondary data sources such as
input on flow sheets or diet records must often be utilized. Information
regarding food and nutrient intake should always be considered in con-
junction with other indicators in order to verify accuracy.

Anthropometric Terms

While, on the surface, measurement of height and weight appear to be

simple to achieve, in practice, accurate measures of height and weight
are often difficult to obtain. There are several reasons for this: Other
clinicians might not understand the importance of accurate measures,
measurement tools may be inaccurate or not available, or those taking
the measurements might not have appropriate training in the techniques
for obtaining height and weight. Therefore, clinician estimates or patient
or client self-report are often substituted. There are known issues with
estimations of height and weight (Beghetto et al. 2006; Bloomfield etal.
2006; Chumlea and Guo 1992; Cline et al. 1989; Determann et al.
Nutrition Monitoring andEvaluation 65

2007). RDs must use critical thinking skills to determine how accurate
estimates of height and weight are as well as use methods to ensure that
actual height and weight are measured when needed.

Biochemical Data, Medical Tests, and Procedures

There is no known biochemical indicator of nutrition status that has

acceptable reliability and validity in determining nutrition status. How-
ever, there are some biochemical markers that can be utilized by RDs
who have the knowledge, skill, and experience to separate the impact
of nutrition interventions on specific biochemical markers. For exam-
ple, RDs who are working at an advanced level in diabetes management
might have the ability to determine if a change in blood glucose levels and
hemoglobin A1c (Hgb A1c) were due to a specific nutrition intervention
(Kulkarni, Boucher, and Daly 2005).

Nutrition-Focused Physical Findings

Evaluation of abnormal findings from a nutrition-focused physical exam-

ination often requires additional knowledge and skills beyond that of the
entry level RD. The supervised practice component of dietetics education
provides sufficient training for the new RD to determine if findings are
within normal limits. However, the time allotted for clinical experience
does not provide enough experience with different levels of abnormal
findings to allow evaluation of subtle changes. RDs who have knowledge,
skills, and experience in conducting nutrition-focused physical examina-
tions are able to monitor and evaluate changes in physical findings, par-
ticularly when done as part of an interdisciplinary health care team. For
example, there are specific skin changes associated with essential fatty acid
deficiency. During an intravenous lipid shortage, a patient who relies on
parenteral nutrition for all nutrient needs developed a skin rash. The RD
collaborated with a dermatologist to evaluate the rash and other findings.
It was determined that the rash was due to an essential fatty acid defi-
ciency. When intravenous lipids became available again, the rash disap-
peared following one week of feedings that included appropriate amounts
of essential fatty acids.

M/E is the fourth step of the NCP. It can be argued that M/E is the most
important step of the NCP. While each of the other steps is integral to
the NCP, patients, other health care providers, and administrators rely on
results of M/E in order to determine the worth of nutrition services. RDs
are responsible for gathering data needed to demonstrate the effective-
ness of nutrition interventions in the treatment of nutrition diagnoses.
Thus, it is vital that M/E be done appropriately. M/E involves monitor-
ing, measuring, and evaluating indicators that change as a direct result of
a nutrition intervention.
Although not specifically addressed in descriptions of M/E, RDs must
also have the ability to clearly and effectively communicate the results of
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Academy of Nutrition and Dietetics Health care professionals, 22
(AND), 29 Health outcomes
Acute Physiology and Chronic Health categories, 5760
Evaluation (APACHE II), 27 defined, 58t
American Occupational Therapy nutrition outcomes, 5657
Association (AOTA), 67 vs. nutritional status and, 2
American Physical Therapy Health-related quality of life
Association, 7 (HR-QOL), 5960
AND. See Academy of Nutrition and Health screening, defined, 9
Dietetics Hepatic transport proteins, 27
Anthropometric measurements, HOAC. See Hypothesis Oriented
2326, 6465 Algorithm for Clinicians
AOTA. See American Occupational HR-QOL. See Health-related quality
Therapy Association of life (HR-QOL)
Hyperphosphatemia, 47
Biochemical data, medical tests, and Hypothesis Oriented Algorithm for
procedures, 2628 Clinicians (HOAC), 7

Chronic health conditions, 3 IDNT. See International Dietetics and

Clinical nutrition interventions, Nutrition Terminology
4648 Informed intuition. See Differential
Condition-specific growth charts, 26 diagnosis
Critical thinking skills, 3637 International Dietetics and Nutrition
Terminology (IDNT), 21,
38, 60
Dietary Reference Intakes (DRIs), 64 domains of, 4850
Differential diagnosis, 35 Involuntary weight loss, 36
Documentation, 4142, 5254
Donabedian, Avedis, 6
King, Lester, 30
DRIs. See Dietary Reference Intakes
Long-term care (LTC) facilities, 3
Economic outcomes, 5859
Malnutrition, 38
Food and nutrient delivery class, 49 Mortality rate, 12
Food and nutrition intake, 1619, 64 weight loss and, 3

Glycosylated hemoglobin, 27 Nightingale, Florence, 1

Goal setting, 41 Nurses, 31
Guide to Physical Therapist Practice, 7 Nursing diagnosis, 3334
78 Index

Nutrition assessment clinical, 4648

anthropometric measurements, definition of, 41
2326 effectiveness of, 61
biochemical data, medical tests, and goal setting, 41
procedures, 2628 P-E-S statement and, 42
categories for, 1628 planning and implementation, 43t,
client history, 1921 5152
data sources for, 1316 public, 48
food and nutrition intake in, 1619 RD-directed and -implemented,
goal of, 2930 4248
history of, 1113 scope of practice issues and, 4446
nutrition-focused physical findings, terminology classes, 4850
2123 Nutrition intervention classes
overview, 11 coordination of nutrition care, 50
Nutrition Care Process (NCP), 5 food and nutrient delivery class, 49
benefits of, 41, 5254 nutrition counseling, 50
commonalities among, 7 nutrition education class, 4950
external process, 8 Nutrition problems, 13
inner ring of, 89 in hospitalized patients, 12
intervention phase of, 41 in older adults, 23
nursing and, 6 Nutrition monitoring and evaluation,
nutrition monitoring and 5566
evaluation, 5566 defined, 61
occupational therapy, 67 health vs. nutrition outcomes,
patient-centered care, 9 5657
physical therapy, 7 importance of, 56
Nutrition counseling, 50 indicators for, 6263
Nutrition diagnosis process overview, 5556
critical thinking skills to, 3637 terminologies, 6365
differential diagnosis of, 35 Nutrition outcomes
documentation of, 4142, 5254 categories of, 60
etiology of, 41 health outcomes vs., 5657
example for, 3234 Nutrition prescription, 51
health care professionals and, 3032 Nutrition screening, 910
nurses, 31 Nutrition-focused physical findings,
nutrition problems, 36 2123
overview of, 2930 defined, 21
PES, 3839 Nutrition-related QOL (NR-QOL),
terms to describe, 3739 60
thought process of, 30 Nutritional deficits, 3
Nutrition diagnostic statement (PES), Nutritional status, health outcomes
3839 and, 2
guidelines for, 39
nutrition interventions and, 42t Obesity epidemic, 48
sample, 39 Occupational therapists (OTs), 32
Nutrition education class, 4950 Occupational therapy, 67
Nutrition interventions, 4154 OTs. See Occupational therapists
Index 79

Patient-centered care, 9 Satisfaction outcomes, 59

Phenylketonuria (PKU), 4647 Serum albumin, 26
Physical inactivity (NB-2.1), 63 Subjective global assessment (SGA),
Physical therapists (PTs), 3132 23
Physical therapy diagnosis, 33
PKU. See Phenylketonuria U.S. Bureau of Labor Statistics, 31
PTs. See Physical therapists
Public health nutrition interventions,
48 Validity, 63
Vitamin D, 27
Referral to community agencies/ Visceral protein status, 26
programs (RC-1.4), 63
Registered dietitians (RDs), 29, 41 Weight loss
directed and implemented, 4248 involuntary, 36
Reliability, 63 mortality rate and, 3
Katie Ferraro, University of San Francisco School of Nursing, Editor

Diet and Disease: Nutrition for Gastrointestinal, Musculoskeletal,

Hepatobiliary, Pancreatic, and Kidney Diseases
by Katie Ferraro

Weight Management and Obesity

by Courtney Winston Paolicelli

Dietary Supplements
by B. Bryan Haycock and Amy A. Sunderman

Introduction to Dietetic Practice

by Katie Ferraro

Sports Nutrition
by Kary Woodruff

Nutrition Throughout the Lifecycle

by Elizabeth Eilender

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