FN 255: Introduction to MNT
 Amber Yui, RD, LD, MPH, CHES
Health Professions Division
Lane Community College
Eugene, Oregon
Unit 2 Preparations, Chapter 2
Nutrition Assessment

Unit 2 Study Questions DUE before midnight (11:55 pm) SUNDAY
Refer to pages 17-33 of your packet for a hard copy of the information below.
You do NOT need to print this document, if you have the packet for FN 255.

ACTIVITIES AT A GLANCE. Check them off as you complete them.
ck
 By midnight (11:55 pm) SUNDAY complete Unit 2 Study Questions for 10 points (be certain you've FIRST done ALL of the Unit Preparation Questions below). (If you have any questions, post them in our "Forum Week 2" in Moodle.)
ck
 Sometime BEFORE SUNDAY participate in our Forum Week 2" by making at least two postings throughout the week with at least one of the postings BEFORE Friday evening. So the total MINIMUM is 2 postings on TWO different days. (A posting can be either posting a question you have or replying to a classmate's question or comment. You don't have to respond to all of the threads if you don't feel you have anything to add. You can also choose to respond more often.)


OBJECTIVES

After reading the assigned reading, filling out the Unit Preparations below, participating in the "Forum Week 2", and completing the Unit 2 Study Questions, you will be able to:
 RESOURCES

WEEKLY FORUMS:
Each week, there will be a FORUM that will allow you to post any questions you have about the lecture or materials covered as well as allow the instructor to post any changes or corrections that need to be communicated.

A SQ will ask if you participated at least twice in this week's forum. (Refer the syllabus for additional details.)

FORUM WEEK 2: (Go to our Moodle classroom and click on "Forum Week 2" to participate.)
  1. "Student Questions": Do you have any questions about the Unit 2 Preparations? Please post your questions/concerns in the forum for others to be able to respond.

  2. "The Healthcare Team": Are there any members of the healthcare team that you did not see listed in the Unit Preparations this week that you think should be included? If so, what are their "nutritional responsibilities", "educational background", and "professional website"?

  3. "Nutrition Screening versus Nutrition Assessment": Based on the information covered in the Unit Preparations this week, how are nutrition screening and nutrition assessments similar and different?

  4. "Indirect Calorimetry": Read the article A Guide to Indirect Calorimetry By Ashley Doyle-Lucas and Brenda M. Davy, PhD, RD, FACSM, Today’s Dietitian, Vol. 11 No. 4 P. 50 (April 2009) and share anything you found to be interesting or surprising based on what you read.

  5. "Nutrition Interview": This week you will be interviewing a family member, friend classmate, or co-worker to complete a nutrition screening and 24-hour food recall. After completing the Unit Preparations for the nutrition screening and 24-hour food recall, please share your experience and what you learned from obtaining this information.

  6. "Reviewing the Correct Answers": To review your grades and the correct answers for the assignments submitted in Moodle, click on the title of the SQ under the corresponding week in Moodle. This week I want you to review your scores from Unit 1 and post any questions you may have about the material. You will see a lot of these questions again on the first exam, which is during Week 5 of the term. Please send the instructor an INDIVIDUAL message in Moodle if you feel there was an error with the grading. (Note: Considering the number of changes with Moodle 2.0, the details of how to review your correct answers need to be re-established. Keep in mind the correct answers will not be posted until AFTER the instructor has completed grading the assignment.)

  7. CORRECTIONS / CLARIFICATIONS: (Please check our weekly forum for additional corrections and clarifications.)
Unit 2 Preparations, Chapter 2
Nutrition Assessment
The Unit 2 Study Questions will be based on the answers you obtain from filling in ALL of the blanks and checking out the links for the Unit 2 Preparations below. Filling out the unit preparations is the best way to prepare for the SQ, and considering all quizzes are timed, you will not have ample time to complete the quiz if the Unit Preparations are not completed first.

The following topics will be covered this week:
I.  The Healthcare Team

II. Nutrition Screening and Nutrition Assessment

III. Overview of Regulatory Agencies and Documentation

IV. Chapter 2: Nutrition Assessment


I. The Healthcare Team

In order to provide high-quality care, there must be ongoing communication among members of the healthcare team. This assures that the team effectively evaluates the needs of each patient and develops cohesive, comprehensive, workable plans for care.

Providing medical care is a complex task and requires many different types of expertise. Professionals in many healthcare disciplines contribute this expertise. The healthcare team is a group of professionals, each with unique training and expertise, who contribute to the overall care of a client.

The nutrition professional providing MNT is usually part of a healthcare team. The following members typically comprise the health care team:
 Which member of the healthcare team are you most surprised to see included in the list? Why?


Let's take a look at some typical roles and responsibilities for members of the healthcare team below as they relate to high-quality nutrition care (This list is a based on the information available in Nutrition & MNT for Dietary Managers by Sue Grossbauer):
Healthcare Team Member
 "Nutritional" Responsibilities
 Educational Background
 Professional Website
RD
  • Assumes primary responsibility and accountability for nutrition screening and assessment and resident nutrition care planning
  • Selects and sets up nutrition screening/assessment system (in cooperation with the nursing service and facility administration); trains facility staff as needed
  • Monitors the screening system
  • Performs nutritional assessments
  • Develops nutrition care plans
  • Records assessment findings, recommendations, and follow-up plans in medical record
  • Alerts other team members to any part of the nutritional care plan needing their cooperation
  • Defines the role of a dietary manager and provides training
  • Provides nutrition counseling
  • Monitors the accuracy of diet service
  • Participates in quality management

http://www.eatright.org/
CDM
  • Interviews clients for diet history
  • Conducts routine nutrition screening/collects data for assessment
  • Calculates nutrient intake
  • Implements diet plans
  • Documents nutrition information on client's medical records
  • Counsels clients on basic diet restrictions; specifies standards and procedures for food preparation to comply with diet restrictions
  • Evaluates effectiveness of nutrition care plans
  • Assists in nutrition care process according to established policies and procedures

http://www.anfponline.org/
RN
  • Assesses client needs; develops, implements, and monitors care plan
  • Delivers direct nursing care
  • Ensures that resident consumes food; organizes the resident feeding responsibilities, distributes the workload, determines need for adaptive eating devices with input from OT
  • Assists with mealtimes and feeding
  • Records accurate and meaningful information about client's food and fluid intake
  • Provides education to clients

http://www.nursingworld.org/
Administrator
  • Ensures that a nutritional screening/assessment system exists
  • Ensures adequacy of staffing to implement and maintain the system
  • Supports all staff members in performing their duties
N/A (often RN background)
MD
  • Evaluates medical conditions and develops diagnoses
  • Plans, oversees, and monitors treatment
  • Bears major responsibility for the nutritional status of the resident (in conformance to acceptable standards of practice)
  • Writes diet orders and/or approves protocol for standard orders
  • Orders other treatments which affect nutritional status
  • Utilizes information provided by other members of the healthcare team

http://www.ama-assn.org/
SW
  • Evaluates social and support needs
  • Assists patients and families with decision-making
  • Helps clients and families plan care upon discharge from a healthcare institution
  • Assists with applying for other healthcare services, such as home-delivered meals or home care
  • Identifies resources
  • Provides counseling

http://www.socialworkers.org/
SLP
  • Evaluates chewing and swallowing function of residents
  • Recommends appropriate therapy for dysphagia (difficulty swallowing)
  • Provides evaluation and therapy for speech-related needs

http://www.asha.org/
OT
  • Evaluates needs related to fine motor skills
  • Often recommends assistive eating devices and other techniques to help patients feed themselves
  • Provides therapy to develop fine motor skills

http://www.aota.org/

Based on the table above, answer the following questions:
 Using the professional website links provided in the table above, fill in the column regarding "educational background" for the RD (registered dietitian) and one other health care professional included in the table.  Feel free to include credentialing requirements, and be prepared to answer a SQ or two based on your findings.

II.  Nutrition Screening and Nutrition Assessment

Nutrition assessment is usually preceded by nutrition screening to identify clients or groups who are at risk for nutritional disequilibrium and who may require nutrition intervention.

Which process comes first, a nutrition screening or nutrition assessment?

Nutrition Screen: Screening involves comparing specific client characteristics to cut-off points or factors, also known as indicators or "triggers", associated with nutritional risk. Indicators are pieces of information that might suggest a concern or risk. Many are numbers or measurements, whereas others might be based on diagnosis, usual food intake, or laboratory data.

The screening protocol depends on the group under study, the environment, the available resources, and the purpose of identifying those clients at risk. The methods used should be sensitive enough to identify clients at nutritional risk. The person who conducts nutrition screening may be a dietary manager, dietary technician, or other caregiver as dictated by institutional policy.

An effective nutrition screening process includes the following:
 Click on the following link to review a nutrition screening done at Corvallis Manor Nursing & Rehab and then answer the questions that follow:
Corvallis Manor Nutrition Screen

Who is responsible for completing the first part of the nutrition screening on page 1 of the document?
Is the patient determined to be at low, moderate, or high nutritional risk?
Which indicators do you think contributed to this level of nutritional risk?


For a score of 10 or greater who is the patient referred to next?

Print the Nestle Mini Nutritional Assessment and interview a family member, friend, classmate, or coworker to answer letters A-F. Complete ONLY the screening section letters A-F, NOT the assessment sections letter G-R.

Who did you interview? (include their name, age, and sex)
What was the screening score? (subtotal max. 14 points)
Based on the score obtained, is the person you interviewed at risk for malnutrition?    Yes or No
(12 points or greater Normal – not at risk – no need to complete assessment; 11 points or below Possible malnutrition – continue assessment)

Note: This week's Unit Preparations for Chapter 2 will also require you to interview a family member, friend, classmate, or coworker to complete a 24-hour recall. You are welcome to interview the same individual for both assignments. Therefore, you may want to read Chapter 2 and review Figure 2-4 on page 64 prior to completing the Nestle Mini Nutritional Assessment.


Review the ADA Nutrition Risk Assessment and answer the following questions:
True or False. In the ADA Nutrition Risk Assessment, more points (or a higher score) equates to a lower nutrition risk?
True or False. A patient with a recent fracture and surgery is at moderate nutritional risk?

Even a nutrition risk scoring system may incorporate certain overrides or automatic flags. Overrides or automatic flags can be helpful to be certain that individuals who might benefit from the MNT receive appropriate assessment. For example, a patient who has been NPO (nothing by mouth) or received only clear liquids for more than 5 days will automatically be considered to be at high nutritional risk at many facilities.

Many sources and standards exist for nutrition screening. Tools vary from one institution to another. If you join the staff of a healthcare institution, you will most likely find that there is a tool in place. Refer to the MNT prioritization from Sacred Heart River Bend in Eugene, OR and answer the following questions:
   
    Sacred Heart River Bend Initial Nutrition Prioritization Guidelines
    (If the link above is not working, refer to the pdf file of this link posted under Week 2 in Moodle.)

What is the timeframe for evaluating a patient who is considered to be at high nutritional risk versus low nutritional risk?


Determine which level of nutritional risk each patient would be based on their primary diagnosis:
 Note: Most likely you will not recognize most of the diagnostic terms used in the Prioritization Guidelines above, but knowing basic medical terminology is a must for anyone who screens and/or assesses patients in a healthcare facility. Throughout this term we will discuss many of the terms and diagnoses for you to begin building a stronger base in medical terminology, or build on your current base if some of the terms are already familiar to you.

Patients whose nutrition screening suggests concerns then need a nutrition assessment.

Nutrition Assessment: This is an in-depth evaluation of a client's nutritional well-being. Ordinarily, the person who performs a nutrition assessment is a registered dietitian (RD).

The nutritional assessment is the basis for the nutrition care plan and formulation of goals. These goals should be made with the client or family members whenever possible, should be realistic and measurable, and should have specific action plans. The patient's nutritional status must be evaluated before intervention is initiated, and should be revisited throughout the course of care.

Components of a complete nutrition assessment include the following:
 Another way to remember the different components of a nutrition assessments is to learn the ABCD's.


ABCThe Four Components of a Nutrition Assessment:

No single component or assessment tool is sensitive and specific enough to be used as the sole indicator of nutritional status. Therefore, a variety of components are used in conjunction to provide a more comprehensive and accurate nutrition assessment of the individual.

Based on the above definitions, how are nutrition screening and nutrition assessments similar and different?







Note: We will build on the definitions of nutrition assessment and nutrition screening above as we cover Chapter 2 of our text and apply the information covered in our two Comprehensive Case Studies this term. Therefore, if this is still a bit murky you will have additional opportunities to clarify the similarities and differences between the two processes.

III. Overview of Regulatory Agencies and Documentation

The problem of malnutrition in hospitalized patients was revealed in a 1974 article, “The Skeleton in the Hospital Closet,” by Charles Butterworth, Jr, MD, and published in Nutrition Today. Today, malnutrition in hospitals remains a serious issue. It occurs worldwide and affects patients of all ages—from infants in the neonatal intensive care unit (NICU) to geriatric (elderly) patients. Malnutrition has been associated with an increased length of hospital stay, increased morbidity and mortality, impaired respiratory and cardiac function, decreased immune function, and poor growth in infants and children (Fessler TA. Malnutrition: a serious concern for hospitalized patients. Today's Dietitian. 2008;10(7):44).

Nutrition screening and assessment processes are generally dictated by relevant healthcare regulations, both federal and state. In the mid-1990s, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that hospitals establish nutrition screening and assessment guidelines. Standards may require that nutrition screening be conducted within a given timeframe after admission, and again at prescribed intervals. Based on regulations, the roles of nutrition professionals in screening and assessing may vary from one institution to another. Likewise, the method of documenting screening and assessing activities may also vary.

At most healthcare facilities, nutrition screening should occur within the first 24 hours of admission. Nutrition screening helps a nutrition professional identify healthcare clients in need of nutrition intervention. It is also required in compliance with regulations and standards. Screening criteria usually include weight and height, recent weight change, oral intake, and sometimes diagnosis and/or other comorbidities.

The nutritional education and training of many physicians is limited. In 1985, the National Academy of Sciences found that U.S. medical schools required an average of only 21 hours of nutrition instruction and only 27% of the schools surveyed had a specific required nutrition course. Therefore, it is imperative that nutrition experts are part of the healthcare team and contribute to providing excellent care.

However, in a healthcare environment, it is not enough to provide excellent care. It is also critical to document all medical care, including nutrition-related care. The following list is adapted from Nutrition & MNT for Dietary Managers by Sue Grossbauer, which describes a handful of purposes documentation serves:
 Healthcare facilities participating in the Medicare and Medicaid programs must follow federal regulations developed by the Centers for Medicare & Medicaid Services (CMS), which include documentation requirements. Refer to the following link to answer the questions below:

    CMS Revised Guidance for Long-term Care

On page 12 of the document, what does the individual care plan address?


When is the care plan updated?


What was the most interesting or surprising thing you learned on page 26-27 of the document regarding "Care Plan" and "Care Plan Revision"?


Click on the links below to answer the following questions:
05-008 Pinnacle Nutrition Care Plan (handwritten)
AHT Nutrition Care Plan (computerized)

According to the Pinnacle NCP, what would be an appropriate goal(s) and approach(es) for a patient who complains of hunger?



According to the first page of the AHT Nutrition Care Plan, which approaches were selected for reaching the goal for average po (by mouth) intake to be greater than 50%?



In April 2003, a new security regulation called HIPAA took effect. HIPAA stands for Health Insurance Portability and Accountability Act, a federal law intended to protect the privacy of healthcare clients, which also standardized the exchange of healthcare information. If you work in a healthcare facility, the manner in which you handle medical records and related documents will be guided, in part, by HIPAA. HIPAA regulations dictate that patient information and health-related data will be kept secure. This affects confidentiality practices, how healthcare providers handle any medical documentation, and how computer systems that contain patient information are managed.


IV. Chapter 2: Nutrition Assessment

Read chapter 2 in your text and answer the following questions:

According to the beginning of Chapter 2, __________________________ is the process used to evaluate nutrition status, identify disorders of nutrition, and determine which individuals need nutrition instruction and/or nutrition support.

Define malnutrition:



Protein-energy malnutrition or protein-calorie malnutrition can result from which of the following:
 Which of the following characteristics refer to marasmus:
 Which of the following are considered to be visceral proteins:
 According to the first paragraph on page 42, kwashiorkor CAN occur in developed countries among children and adults with inadequate ______________ or _______________ diet patterns.

PEM occurs not only in developing countries but also among ill individuals in ______ nations when their intakes are inadequate to meet their needs for energy and tissue synthesis.

According to the middle of page 42, ______________ and __________ can alter serum protein levels so that they are ______ reliable indicators of PEM.

What are the three steps that describe the progressive manner of vitamin and mineral deficiencies (List in order of what occurs first to last.)?




What is the most common vitamin or mineral deficiency?

True or False: Suboptimal intakes of vitamins and minerals may result in adverse outcomes even if overt deficiency is not present.


True or False: It is common for multiple vitamin and mineral deficiencies to be present or for these deficits to occur in conjunction with PEM.


Which health risks are increased in an individual with an excess of body fat. (Note: Someone can be a "normal" weight but have excess body fat, and someone else can be considered "overweight" but be very lean and have minimal body fat. The key is to focus on metabolic fitness, a concept discussed in Ch 10 of FN 225.)





True or False: Overnutrition refers to an excessive intake of only calories (carbohydrates, fats and proteins). Refer to page 44 for details.


What are the four components of a nutrition assessment?





With regard to anthropometric measurements, because of variations in body build and other factors, the values determined by these equations may not be very accurate for a particular ___________.

BMI does not involve measurement of ____________________________, and thus is not an accurate method for assessing the percentage of LBM or fat.


Why are height, weight, BMI and IBW usually the most commonly used anthropometric measurements in most settings where MNT is practiced? (Refer to Box 2-2 Pg 47-51)



What is one of disadvantages of simply using ht, wt, BMI and IBW rather than additional anthropometric measurements? (Refer to Box 2-2 pg 47).



Growth charts through the CDC (Centers for Disease Control) are used to evaluate the anthropometric measurements of children. If a child was of normal height for age, but low weight for age (below the 5th percentile), what has likely occurred?

Page 46 of the text discusses body composition: The relative _____________ of body fat and LBM and the ____________ of body fat is much more relevant to health and fitness than the simple determination of the appropriateness of wt for height or BMI.

Which type of fat is especially closely related to health risk?

Good _____________________________ must be used in selecting laboratory analyses to be performed and interpreting test results.

A through ______________________ and ____________________ can be as effective in identifying many cases of malnutrition as a battery of _____________________.

Which one of the laboratory values of protein status discussed on Table 2-1 has the shortest half-life? What does this mean?



Circulating proteins provide the simplest index of protein nutrition, but their serum or plasma concentrations rise and fall in sick or injured individuals for many reasons that have ________ to do with nutrition.

Which of the conditions discussed on pages 52 and 54 can suppress circulating levels of the circulating proteins?



According to Table 2-1 on page 53, when determining someone’s nitrogen balance, protein is multiplied by 0.16 because protein is approximately 16% _________.

Serum protein measurements do correlate well with the patient’s ___________  and thus help identify patients at ____________ for nutritional problems.

What is one of the most sensitive visceral proteins for assessment of nutritional status?

For many vitamins and minerals, ________________ mechanisms maintain normal or near-normal circulating concentrations of the nutrient even though intake is ______________ and tissue stores are _____________.

Nutritional anemias can result from deficiencies of which vitamins and minerals?





Which factors could contribute to a vitamin B12 deficiency?




According to Table 2-2, which vitamins or minerals would be affected by a low Hct and Hgb?




According to Figure 2-3, if you had determined someone was either folate or B12 deficient, which ONE test may assist in the differentiation between a folate versus vitamin B12 deficiency?

Which nutrient can “mask” a vitamin B12 deficiency?

Using Table 2-3 on pages 60-63, which signs may be related to a possible protein deficiency?





Using Table 2-3 on pages 60-63, which signs may be related to a possible excess of Vitamin A?





In addition to the clinical and physical assessment of the individual, the individual’s _____________ can provide some information needed for a thorough clinical assessment.

List two or more of the pros and cons of each diet or nutritional history tool discussed on pages 59, 64-66:
TOOLS
 PROS
 CONS
1. 24-hour recall




2. Food frequency questionnaire




3. Food record




4. Diet history






Using Figure 2-4 on page 64, interview a family member, friend, classmate, or coworker.
*Print the 24hour recall form to fill out as you go through questions 1-7 in Figure 2-4.

What was the most interesting or surprising thing you learned from collecting the 24hr recall information? (Be specific and include the name, age, and sex of the individual in your answer for full credit.)




Which diet or nutritional history method would provide the MOST information?


Why is this method (the answer to the question above) NOT utilized as often as a 24-hour recall?



According to page 70 of the text, if an individual has an intake that meets the RDA or AI for a nutrient, the likelihood of a dietary deficiency is _______.

What are some of the limitations of using nutrient databases?





Health care providers rarely have the _______ to perform a complete nutrition assessment on every patient.

It is most important that individuals who are nutritionally at risk or those who are malnourished be identified ___________; thorough ____________ can then be performed on these individuals, and intervention can be planned as ______________.

____________________ of individuals consists of gathering some readily available subjective and objective information.

How are a nutrition assessment (defined on page 41 and 44) and nutrition screening (defined on page 70) similar and different?






Which of the findings below are not likely to indicate the presence of malnutrition or nutritional risk?
 What are the three components of energy expenditure?




BEE is determined largely by the amount of _____ body mass.

What is considered to be the “gold standard” to measure BEE. (Note: Formulas are often used instead as the equipment and time to use this method are often not available.)

Read the article A Guide to Indirect Calorimetry By Ashley Doyle-Lucas and Brenda M. Davy, PhD, RD, FACSM, Today’s Dietitian, Vol. 11 No. 4 P. 50 (April 2009) and answer the question below.




What ONE word can be used for all three of the blanks below?
 Once the BEE is determined, the estimate is multiplied by an _____________________ to obtain an estimate of the _____________________________.

Who has a higher LBM than a “normal” weight, young individual, an individual who is obese or elderly? Why?



What are elderly people encouraged to do rather than drastically limit their energy intake to maintain a desirable body weight?

What are the two advantages of regular exercise with regard to energy expenditure?



What variables can alter one’s protein needs?



For healthy adults or those undergoing elective surgery how many grams of protein per kilogram of body weight is usually adequate?

An individual with which of the following condition(s) may need more protein:
 Fluid overload is a hazardous state that may compromise cardiorespiratory function and is usually reflected in a rapid weight gain of how many pounds per day over a period of several days?

Of the three types of dehydration, which one is the most common form?

Using Table 2-7, what happens to the HR (heart rate) of an individual as they become more severely dehydrated?


Who is the professional prepared to address complex nutrition needs and education?

What is the purpose of the NCP (Nutrition Care Process)?


How is the nursing process similar to the nutrition care process?





Which one of the nursing diagnosis examples likely to be associated with nutritional health and problems was most interesting or surprising to you? Why?



Using the references and selected bibliography from pages 78-79 of Chapter 2, choose and read one resource and answer the following questions. (One way to find one of the resources is to use LCC's online research database: http://www.lanecc.edu/library/find/article.htm):





End of Week 2 Unit Preparations

After filling in ALL of the blanks to the questions above go to the
 "Unit 2 Study Questions" under Week 2 in Moodle to submit your answers.
(Note: If you take the quiz after the due date, please send me a message. It will probably not be graded
until you do that as I may not realize it was done. I can do this ONE time.)