Nutrition assessment is the first step in the nutrition care process. During this step, the dietitian gathers a variety of information about a specific individual. The purpose of the nutrition assessment is to gain pertinent information in order to adequately manage and prevent nutrition related health conditions. It is important to note that while the nutrition assessment is the first step for all individuals, it does not mean that individuals are receiving standardized care. In fact, individuality is a critical component to nutrition assessments.
The information gathered during the nutrition assessment varies for each person. Things to consider include:
- health history
- admission diagnosis and/or the reason for their stay at the long-term care facility
- anthropometric measures such as height/weight and their weight history
- food and fluid intake and their ability to chew and swallow
- biochemical and laboratory data
- medication regimen
Each of these can greatly impact the nutrition care of individual and the nutrition interventions that could follow.
After gathering information to draw conclusions about this person’s nutrition care, it is time to calculate their estimated nutritional needs. This process can use a variety of equations that include varying factors such as activity, stress or even burn injury. Regardless of the equation used, it is of the utmost importance to ensure that the resident is receiving adequate energy needs through their diet. This step becomes the most individualized, because energy requirements are not one-size fits all. This is where interaction with the individual can be beneficial.
Another important aspect of nutrition care in the long-term care setting is allowing the individual as much control as possible in their nutrition care. A good process includes gathering all the pertinent information to complete the nutrition assessment to be well informed of the resident and then speaking with the individual before completing the progress note. After general introductions, this conversation involves questions such as “How do you feel your appetite has been lately?” and “Have you noticed any changes in your weight recently or the way your clothes are fitting?”. The purpose of this conversation is to get a picture of the individual’s weight history and eating regimen before arriving to the long-term care facility. This is also a prime opportunity to involve this person in their plan of care by discussing nutrition related goals and if necessary, discussing different nutrition interventions that may be appropriate and seeing which they would like to try.
The final step of the nutritional assessment is creating a plan of when you are going to follow-up with this resident. For some, it may be more frequently due to high risk situations such as artificial nutrition through tube, skin integrity issues, or a health condition that requires frequent monitoring such as end stage renal disease. However, for others, their nutritional risk may be minimal. Therefore, monitoring on a quarterly or annual basis while monitoring their monthly weight may be sufficient. Either way, establishing and maintaining a good line of communication with the nursing, dietary and administrative staff is a sure-fire way to ensure each resident is receiving optimal care.
D., & C. (2008, August 1). Revisions to Appendix PP – “Interpretive Guidelines for Long-Term Care Facilities,” Tags F325 and F371. Retrieved December 31, 2018, from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R36SOMA