Please use this as a guide when you are writing a nutrition assessment in ADIME format.Each section of the nutrition care process shows what needs to be included and will be graded.

Anthropometric Measurements

Height, weight, weight history, BMI, growth pattern indices/percentile, hand-grip strength, mid-upper arm circumference, Subjective Global Assessment

Biochemical Data, Medical Tests and Procedures

Examples include laboratory data, fluid balance tests, gastric residual volume, resting metabolic rateNutrition-Focused Physical Findings

Muscle and subcutaneous fat wasting, oral health, cognition, bowels, pressure injury, vital signs, nutrition impact symptoms

Client History

Personal (age, language, literacy), medical, family and social history (housing, economic considerations), recentcrisis, supports

Comparative Standards

Estimated needs and method for estimating (Schofield), weight/growth recommendations. Must contain all evidence for etiologyand signs and symptoms

Nutrition Assessment, Monitoring and Evaluation Tools

Tools used for health or disease status or risk assessment, reassessment, and monitoring and evaluation such as subjective global assessment tool ratings,nutrition assessment tool ratings, household food security tool ratings, food variety tool ratings

DiagnosisProblemUse nutrition diagnoses terminology

Etiology"Root cause," can use free text

Signs and SymptomsQuantifiable data, basis for monitoring and evaluation outcomes, free text. If no Nutrition Diagnosis: "No nutrition diagnosis exists"

Synthesize all assessment data1.Inadequate oral intake as related to cancer treatment and associated nausea, vomiting and inability to prepare meals as evidenced by BMI: 15 kg/m² and 20% loss of body weight in 3/12 and consuming only 2 small meals/day

2.Inadequate protein-energy intake as related to poor appetite and elevated requirements as evidenced by patient consuming ~50% of requirements 1 000 kcal (4 000 kJ) and 40 g protein/day

InterventionNutrition Prescription/Goal Nutrition Intervention

Food and/or Nutrient Delivery

Meal and snacks

Enteral and parenteral nutrition

Oral or vitamin/mineral supplement (type frequency)

Feeding assistance (opening packages) and environment

Nutrition-related medication management, such as. anti-emetic

Nutrition Education

What was provided? What resources given?

Nutrition Counseling

Theoretical basis, such as cognitive behavioral therapy

Strategies, such as counseling, goal setting, rewards

Coordination of Nutrition Care

Coordination of care with others, such as food charts, weight

Discharge and transfer of nutrition carePrescriptionPatient's individualized recommended dietary intake of energy/selected food or nutrients based on reference standards or dietary guidelines

ExampleIncrease intake by 1 000 kcal (4 000 kJ) and

40 g protein/day to provide 2 000 kcal (8 000 kJ)

90 g protein (1.5 g/kg)

GoalHigh-energy, high-protein diet for weight maintenance during admission

Plan

Commence oral nutrition supplements providing1 000 kcal

(4 000 kJ) and 45 g protein

Educate patient and family on importance of nutrition weight maintenance and optimal treatment outcomes. Education resources providedMonitoring and EvaluationFollow-up Time

What will you assess at review?Food/Nutrition-related History

Anthropometric measurements

Biochemical data, medical tests, procedures

Nutrition-focused physical findings

Nutrition assessment, monitoring, and evaluation tools

Includes

Information to be assessed at next review to determine if goal/prescription and interventions have been implemented and are effective

Signs and symptoms from PES Statements

Data for monitoring progress (patient understanding or compliance with intervention), measurement and evaluation of outcomes (data to compare to nutrition goals). Prescription to determine further action

CASE STUDY:

DFN 348 Spring 2021 Malnutrition Case Study

63-year-old woman with significant PHMx of generalized anxiety disorder and IBS admitted for observation.Patient complaining of abdominal pain, malaise and loss of appetite x 10 days.Patient with no po intake x 3 days.Meds:Xanax (not taking).Diet Rx:Regular with Ensure TID. Social hx:married, 2 children.Significant home stressors with children making poor life choices and financial stressor within the family.NFPF:2+ pitting edema; temporal & clavicle wasting; reduced grip strength.Skin:dry with pinch test positive for low turgor.Ht:5'3"CBW:100#UBW: 110# (4 months ago).Labs:Na+ 150 mEq/L (135-145), K+ 4.8 mEq/L (3.5-5.5), Cl- 110 mEq/L (96-106), BUN 30 mg/dL (7-20), Creatinine 1.2 mg/dL (0.5-1.0), glu 102 mg/dL (70-99); urine analysis - urine specific gravity 1.040 (1.002-1.030); color - deep amber.Usual dietary intake:am 1 cup coffee, 1 piece of toast with butter, lunch cup soup, 6 crackers, water, 1 cup coffee, dinner chicken cutlet, 1 small baked potato and 3 pieces of broccoli.