Nutrition Assessment Use Case
October 30, 2014
The purpose of this use case is to describe the process of completing a nutrition assessment
and documenting a nutrition diagnosis/problem for a patient with acute malnutrition of
unknown origin. (Excerpt from HL7 V3 Diet Order DAM)
Use Case Sequence of Steps
1.
Dietitian receives the Dietitian Consultation order to do a nutritional assessment of a
50 year old female newly admitted to an acute care setting. The patient presents
with recent weight loss, decreased appetite, and fatigue.
2.
Dietitian collects assessment data to include the following:
a)
Anthropometric data are collected from the EHR system and include, but are
not limited to, the patient’s height, weight (current, usual and history of
weight change), weight change while in hospital (loss or gain), and body mass
index (BMI). [objective]
b)
Biochemical data are collected from the EHR system. [objective]
c)
Client history is collected from the EHR system to include, but not be limited
to the history and physical, pending or actual medical diagnoses and
medications. [subjective/objective]
i. For purposes of this use case the patient is admitted with multiple
symptoms but no clear diagnosis.
ii. At the time of the nutrition assessment the medical history and physical
reveal symptoms of abdominal bloating, decreased appetite, weakness
and fatigue. The provisional diagnosis is pancreatic cancer. The
differential diagnosis is to rule out an additional tumors, particularly in
the bowel.
d)
Diet/ intake history is gathered by direct interviews with patient, family, and
staff as well as data within the EHR system and Food and Nutrition
Management System (FNMS). These data include, but are not limited to, the
diet order, usual eating pattern and food related behaviors, changes in
appetite, amounts of food/fluids typically consumed, and amounts of
foods/fluids consumed since being admitted. [subjective/objective]
e)
Nutrition-focused physical findings (observations) are collected from patient
observation, staff interviews, and/or the EHR system. This included physical
signs such as the presence of mouth sores and muscle wasting, significant
weight loss over a specific period of time. [objective] The Malnutrition
Screening Tool (MST) was used to identify the factors most prevalent in
malnutrition.
f)
Comparative standards such as energy and protein calculations to determine
nutritional needs may be calculated by the dietitian. The Harris-Benedict
equation was used to calculate caloric needs. (objective)
3.
A nutrition diagnosis/problem was determined by the dietitian and documented in
the EHR system based on the assessment data collected. The nutrition
diagnosis/problem statement includes three components: the (nutrition) problem,
the etiology of the problem, and the signs and symptoms of the problem utilizing
standard terminology.
This process would be followed by recommendations/interventions, a care plan, other
procedures, and/or a referral.
The outcome of this clinical synthesis leads to the following types of clinical assessment
statements:
• Inadequate energy intake related to decreased appetite as evidenced by energy
consumption less than assessed needs and weight loss of 5 pounds in one week.
• Starvation-related malnutrition related to suboptimal protein and energy intake as
evidenced by decreased muscle mass and diminished hand-grip strength.
Following treatment with a high calorie, high protein diet the patient’s nutritional status is
reassessed.
Presenting complaints:
A 50 yo Caucasian female patient presents to her consultant Registered Dietitian Nutritionist (RDN) with
complaints of abdominal bloating, decreased appetite, weakness, and fatigue for approximately 1-2
weeks.
Medical and family history:
After listening to the patient’s presenting complaints, the RDN then proceeds to take a full medical and
family history from the patient.
Medical history to discern:
• Any recent or past injury or infection:
o This patient has a history of Diabetes and Ulcerative Colitis and has been told by her PCP
she needs to lose weight.
• Age at onset and how long symptoms have been present and whether there has been any
pattern to them:
o This patient started to experience the symptoms at late 49 years of age and over the past
week past has experienced :
▪ Loss of appetite
▪ Unintentional Weight loss
▪ Weakness
▪ Fatigue
• How symptoms have affected patient’s daily activities of living, driving, and working
o The abdominal bloating, decreased appetite, weakness, and fatigue have prevented her
from exercising, attending social events, and have no desire to prepare meals or eat solid
food.
o Smoking history:
▪ This patient smokes occasionally at social events.
Family history includes:
• Whether any genetic relatives were/are affected by the condition
o This patient’ maternal grandmother (age at onset 45) and genetic mother (at onset age 50)
were both diagnosed with Diabetes.
o This patient’s genetic mother was diagnosed (at onset age 40) with Chron’s Disease and
Mild Colitis.
Diet History inlcudes:
• This patient typically follows a regular diet despite history of diabetes, Chron’s Disease and
Coliits.
•
She eats three meals and 1 -2 snacks per day.
•
Avoids high sugary foods.
•
The patient has had diabetic diet education and has learned what foods trigger her Chron’s
Disease and Colitis symptoms.
•
Over the past week has noticed changes in her diet
o
consuming one meal per day or drinking an oral supplement if tolerated
o
Has no desire for solid food
The medical history, family history, and diet history details are also recorded in the patient’s
medical record.
Physical Examination:
Anthropometric data
• Height: 165 cm
• Weight: 79 kg
• BMI: 29 (overweight)
Symptoms
• Abdominal Bloating (Inflammation): Before and after consuming a meal. Bloating may last
all day.
• Decreased Appetite (Compromised intake): Over the past week
• Weight loss: About 5 pounds over the past week
• Fatigue (Decreased functional status): Over the past week
• Weakness (loss of muscle and fat mass): Especially the upper and lower extremities
Signs
•
•
•
•
•
Abdominal Inflammation (Bloating): Bloating around the abdominal area and pushes up to
the esophagus, constant sense of discomfort.
Decreased (Compromised) intake: Feels no sense of appetite due to abdominal bloating
and discomfort. No desire to eat solid food.
Weakness: Loss of muscle strength and mass on both lower and upper extremities. Lack of
energy. Decreased hand-grip strength.
Fatigue (Decreased functional status): Bodily weariness, not able to function, sense of
excursion after excessive amount of work (exercise, performing day to day activities).
Diminish hand grip strength.
Weight loss: approximately 2.5Kg with in the last week. Possible muscle and fat wasting.
Activity of daily living functionality
Adversely affected by abdominal bloating, decreased intake of food, general
weakness, and fatigue
Skin
•
•
•
Mild Swelling
Mild dryness
Pale in color
The RDN records the physical examination findings in patient’s medical record.
Clinical Assessment:
The RDN evaluates and applies clinical reasoning on patient data including presenting complaints,
medical history, family history and physical examination results.
After applying the clinical reasoning, the RDN documents the following (clinical impression):
Provision/working nutrition diagnosis:
•
Inadequate energy intake related to decreased appetite as evidenced by energy
consumption less than assessed needs and weight loss of 5 pounds in one week.
Differential nutrition diagnosis:
•
Starvation-related malnutrition related to suboptimal protein and energy intake as
evidenced by decreased muscle mass and diminished hand-grip strength.
Nutritional needs assessment:
•
•
•
Caloric needs: 2,370 kcals/day (30kcal/kg/day)
Protein needs: 102 gm/kg/day (1.2 gm/kg/day)
Fluid needs: 2,370 ml/day (1ml/kg/day)
Management Plan:
Based on this initial clinical assessment result and after discussion with the patient, the RDN
also decides on the following management plan:
Evaluate and or request Laboratory test results :
•
•
FBE/CBC , urine x protein and microscopy ( indicators of inflammation)
o Hb
1
o WBC
o Platelets
o Hematocrit
o RBC
CMP
•
Albumin
•
Alkaline phosphatase:
•
ALT (alanine aminotransferase):
•
AST (aspartate aminotransferase):
•
BUN (blood urea nitrogen):
•
Calcium:
•
Chloride:
•
CO2 (carbon dioxide):
•
Creatinine:
•
Glucose test:
•
Potassium test:
•
Sodium:
•
Total bilirubin:
•
Total protein:
Treatments
• High Calorie, High Protein Diet
• High Calorie, High Protein oral supplement PRN
• Weight maintenance and monitoring
• Provide diet education on High Calorie, High Protein Diet
The treatment plan details are documented in patient’s medical record
Follow-up
The RDN recommends the patient to make a follow-up appointment with the clinical
registration desk to return for reassessment when the test results become available
Follow-up nutrition assessment – 3 days later
The patient was assessed by RDN according to her nutrition risk. (3 days for high risk, 5 days for
moderate risk and 7 days for low risk)
 High Risk assigned
Review of dietary intake
 Type of diet consumed: High calorie, high protein diet

Amount of daily intake: Day 1 – 40%, Day 2- 55%, Day 3- 55%
Review of diagnostic test results
The RDN reviews the patient’s diagnostic tests (lab/blood and imaging) results (and note the abnormal
findings) prior to seeing the patient at the follow-up appointment
Laboratory test results:


FBE/CBC
o Hb
o WBC
o Platelets
o Haematocrit
o RBC
CMP
 Albumin
 Alkaline phosphatase:
 ALT (alanine aminotransferase):
 AST (aspartate aminotransferase):
 BUN (blood urea nitrogen):
 Calcium:
 Chloride:
 CO2 (carbon dioxide):
 Creatinine:
 Glucose test:
 Potassium test:
 Sodium:
 Total bilirubin:
 Total protein:
100 g/L
6.2 x109/L
307 x109/L
0.33
3.70 x1012/L
(reference range 115-160)
(reference range 4.0-110)
(reference range 140-400)
(reference range 0.33-0.47)
(reference range 3.80-5.20)
2.8
50
20
15
14
7.2
97
22
0.9
107
3.9
138
1.0
5.0
(3.9 to 5.0 g/dL)
(44 to 147 IU/L)
(8 to 37 IU/L)
(10 to 34 IU/L)
(7 to 20 mg/dL)
(8.5 to 10.9 mg/dL)
(96 - 106 mmol/L)
(20 to 29 mmol/L)
(0.8 to 1.4 mg/dL)
(70 to 100 mg/dL)
(3.7 to 5.2 mEq/L)
(136 to 144 mEq/L)
(0.2 to 1.9 mg/dL)
(6.3 to 7.9 g/dL)
Review of physical examination findings
Symptoms:
 Stiffness: None
 Pain: score of 0-1/10
 Malaise and fatigue: slight improvement with better rest and relaxation
 General weakness:
 Appetite: only finished around half of the meal tray.
 Mood: DSS21 stress scale = moderate, relaxation and rest
 Sleep: slight improvement associated with midnight weakening
Signs:
 Normal
Nutrition focused physical Assessment
The RDN evaluates and applies clinical reasoning on new patient data including new nutrition focused
physical examination results.
Oral assessment:
Cranial nerve assessment:
Heart and lung assessment:
Abdominal assessment:
Skin:
Hair:
Nails:
Normal
Normal
Normal
Little distended
Pale in color, dry and scaly
Dull in color
Brittle
Clinical Assessment
The RDN evaluates and applies clinical reasoning on new patient data including diagnostic test results
and new physical examination results.
The clinical evaluation and reasoning lead to the RDN establishing:
Final nutrition diagnosis:
Starvation-related malnutrition related to suboptimal protein and energy intake as evidenced by laboratory
findings, decreased muscle mass and diminished hand-grip strength.
The RDN documents the clinical findings and final diagnosis in the patient’s medical record
Treatment Plan:
Not included in this script