Nutrition Assessment

Key points:

• Nutrition Assessment is the first step of the Nutrition Care Process.
• Data collected during Nutrition Assessment is used for all other steps in the Nutrition Care Process.
• Nutrition Assessment ultimately leads to the identification of a nutrition problem (also known as the Nutrition Diagnosis).
• New information or assessment data may provide reason for reassessment, change in nutrition diagnosis or nutrition intervention.

During nutrition assessment, the RDN collects, classifies and synthesizes important and relevant data needed to identify nutrition-related problems and their causes. Nutrition Reassessment is to identify whether previously collected information has changed or remained the same, this then allows the RDN to determine if previous nutrition problems have been resolved or changed, or if new nutrition problems exist.  

Nutrition assessment data can come from a variety of sources, such as referral forms, interviews, medical records, family members or caregivers, community-based surveys and focus groups; statistical reports, administrative data, client-related outcomes or experience measures; and epidemiological studies.

Nutrition assessment data is categorized into six domains:

• Food/Nutrition-Related History contains terms that capture data typically collected from an interview with the client where food and nutrition intake and related behaviors were discussed. 
• Anthropometric Measurements includes terminology that helps describe the physical measurements for the client such as height, weight, body mass index, growth pattern indices/percentile ranks and weight history.
• Biochemical Data, Medical Tests, and Procedures includes terms for laboratory data and medical tests. 
• Nutrition-Focused Physical Findings includes terminology that describes nutrition-related physical signs or symptoms derived from a nutrition-focused physical exam, interview, or health record. Examples include subcutaneous fat, muscle, oral health, suck/swallow/breathe ability, and appetite.
• Client History includes terminology that captures the client’s personal history such as age, gender, ethnicity, and reported medical and social history. (Note: This domain is only used in the Nutrition Assessment step and is not used in Nutrition Monitoring and Evaluation. All other domains in the Nutrition Assessment step can be used for reporting client progress in the monitoring and evaluation steps.)
• Assessment, Monitoring, and Evaluation Tools capture tool ratings that assess health or disease status or risk.

In addition, the Nutrition Care Process has a comparative standards category. Comparative standards are what nutrition assessment data is measured against. The RDN considers various reference standards and recommendations, client disease states and multiple other factors to identify the appropriate comparative standard.

When documenting the nutrition assessment, keep the following questions in mind:
Is the assessment data concise and relevant to support the Nutrition Diagnosis?
Is the assessment data comprehensive and aligned with the nutrition assessment domains, such as food/nutrition-related history or biochemical data, medical tests and procedures?
Are the appropriate comparative standards used?

Visit the Academy’s eNCPT for additional tutorials and to subscribe for more Nutrition Care Process resources, explanation and narratives, terminology sheets, reference sheets and more.