The following table illustrates Nutrition Assessment data.
Explanatory additions to the NCP Mind Map are in blue italics. NCP terms and codes are in black font.(1)
Codes are provided for the domains and the primary and secondary headings beneath each domain.
Select the Nutrition Assessment domain below to go directly to that section.
- Food/Nutrition-Related History (FH)
- Anthropometric Measurements (AD)
- Biochemical Data, Medical Tests and Procedure (BD)
- Nutrition-Focused Physical Findings (PD)
- Client History (CH)
- Assessment, Monitoring and Evaluation Tools (AT)
- Etiology Category (EY)
- Comparative standards (CS)
- Progress Evaluation (EV)
| FOOD/NUTRITION-RELATED HISTORY (FH) |
| FOOD AND NUTRIENT INTAKE (FH-1) Composition and adequacy of food and nutrient intake, meal and snack patterns, current and previous diets and/or food modifications, and eating environment. Collect food intake records, 24-hour recall, food diary or food frequency questionnaire to estimate or assess: Energy intake determination (FH-1.1) Total energy intake from all sources including food, beverages, breastmilk/formula, supplements, and via enteral and parenteral routes. · Energy intake - Total energy estimated intake in 24 hours Food and beverage intake determination (FH-1.2) Type, amount, and pattern of intake of foods and food groups, indices of diet quality, intake of fluids, breastmilk and infant formula. · Fluid intake - Estimated fluid intake - Total fluid estimated intake in 24 hours, assess for high-energy beverages such as milk-based drinks, fruit juice, sports drinks, soda (soft drink) - Liquid meal replacement estimated oral intake in 24 hours · Food intake, current dietary guidelines, high-energy diet - Amount of food - Types of food, assess fo high-energy foods - Meal/snack pattern - Assess for morning tea, afternoon tea, supper - Missed meals, largest meal, grazing - Frequency and timing of meals - Diet quality index - Food variety · Breastmilk/infant formula intake - Breastmilk intake - Assess for breast milk fortification - Assess for formula supplementation after breastmilk feeds - Infant formula intake - Assess formula concentration Bioactive constituent intake determination (FH-1.4) Alcohol, plant stanol and sterol esters, soy protein, psyllium and ß-glucan, and caffeine intake from all sources, e.g., food, beverages, supplements, and via enteral and parenteral routes. · Alcohol intake - Alcohol intake in one week - Alcohol intake in 24 hours - Days per week alcoholic drinks consumed - Alcohol intake pattern on drinking days - Drink size/volume - Frequency Macronutrient intake determination (FH-1.5) Fat and cholesterol, protein, carbohydrate, and fiber intake from all sources including food, beverages, supplements, and via enteral and parenteral routes. · Acceptable macronutrient distribution range · Fat intake - Estimated fat intake - Total fat estimated intake in 24 hours, consider food preparation methods - Saturated fat estimated intake in 24 hours - Trans fatty acid estimated intake in 24 hours - Polyunsaturated fat estimated intake in 24 hours - Monounsaturated fat estimated intake in 24 hours - Omega-3 fatty acid estimated intake in 24 hours - Essential fatty acid estimated intake in 24 hours - Medium chain triglyceride estimated intake in 24 hours · Protein intake - Estimated protein intake - Total protein estimated intake in 24 hours - High biological value protein estimated intake in 24 hours · Carbohydrate intake - Estimated carbohydrate intake - Total carbohydrate estimated intake in 24 hours - Complex carbohydrate estimated intake in 24 hours - Simple sugar carbohydrate estimated intake in 24 hours - Estimated total daily glycemic index value, if CFRD - Estimated total daily glycemic load, if CFRD - Total carbohydrate from diet, if CFRD - Insulin to carbohydrate ratio, if CFRD · Fiber intake - Estimated fiber intake - Total fiber estimated intake in 24 hours, constipation - Soluble fiber estimated intake in 24 hours - Insoluble fiber estimated intake in 24 hours Micronutrient intake determination (FH-1.6) Vitamin and mineral intake from all sources including food, beverages, supplements, and via enteral and parenteral routes. · Vitamin intake, fat-soluble vitamins - Estimated vitamin intake - Vitamin A estimated intake in 24 hours - Vitamin D estimated intake in 24 hours - Vitamin E estimated intake in 24 hours - Vitamin K estimated intake in 24 hours - Multivitamin estimated intake in 24 hours · Mineral/element intake - Estimated mineral intake - Calcium estimated intake in 24 hours - Assessment of calcium in the diet assessed at least annually(3) - Iron estimated intake in 24 hours - Magnesium estimated intake in 24 hours - Sodium estimated intake in 24 hours - Quantity of salt in the diet - Use of salt for cooking and at table - Use of sodium replacement therapy, such as salt tablets, oral rehydration solution - Restaurant and take out meals - Consider food preparation methods FOOD AND NUTRIENT ADMINISTRATION (FH-2) Current and previous diets and/or food modifications, eating environment, and enteral and parenteral nutrition administration. Diet history (FH-2.1) Description of food and drink regularly provided or consumed, past diets followed or prescribed and counseling received, and the eating environment. · Diet order - General, healthful diet order - Modified diet order · Diet experience - Previously prescribed diets - Adequacy - Compliance - Challenges - Need for further nutrition education - Previous diet/nutrition education/counseling - Self selected diet/s followed - Food allergies - Food intolerance · Eating environment - Location - Atmosphere - Caregiver/companion - Appropriate breastfeeding accommodations/facility - Eats alone - Impact of social isolation and feeling alone MEDICATION AND COMPLEMENTARY/ALTERNATIVE MEDICINE USE (FH-3) Prescription and over-the-counter medications, including herbal preparations and complementary/alternative medicine products used. Medications (FH-3.1) · Prescription medication use, with nutrition-related side-effects Antibiotics (Inhaled, oral, parenteral) - Oral antibiotics, such as amoxicillin, clavulanic, acyclovir, azithromycin, vancomycin - Inhaled antibiotics, such as tobramycin, gentamycin Respiratory Care - Inhaled corticosteroids - Inhaled beta 2-agonists for airway clearance, such as Albuterol (accuneb, proair) - Inhaled nasal spray for inflammation, such as Flonase - Inhaled mucolytic agents to thin and clear mucus, such as Dornase alfa (pulmozyme) - Sodium chloride inhalation solution to mobilize mucus and improve airway clearance - Transmembrane conductance regulator (CFTR) potentiators such as Ivacaftor (kalydeco) Antidiabetics - Insulin for CFRD, such as Lantus, Novolog - Glucagon 1mg subq/IM injection one time only PRN for severe hypoglycemia - Glucose chewable tab 4 g PO one time only PRN for severe hypoglycemia Pancreatic Enzymes - Pancreatic enzyme replacement therapy (PERT) such as Creon delayed-release capsule, Pancreaze, Ultresa, Zenpep - Children and adults dosing is 500-2 500 units of lipase per kg body weight per meal; or <10 000 units lipase per kg body weight per day; or <4 000 units lipase per gram dietary fat. Maximum recommended dose is 10 000 IU/kg/day(4) - Example Creon 2400: 24 000 USP units of lipase, 76 000 USP units of protease, 120 000 USP units of amylase - Consider route of delivery, mixed with juice or swallowed, preferably taken before meals and snacks GERD Relief - Proton-pump inhibitors to assist the action of enzymes and prevent reflux such as protonix Laxative - Example polyethylene glycol · Over-the-counter (OTC) medication use · Misuse of medication, recreational drugs Complementary/alternative medicine (FH-3.2) · Nutrition related complementary/alternative medicine use · CF-specific multivitamin that improves the absorption of fat-soluble vitamins, such as Aquadeks - Fat-soluble vitamins (A, D, E, K) KNOWLEDGE BELIEF ATTITUDE DETERMINATION (FH-4) Understanding of nutrition-related concepts and conviction of the truth and feelings/emotions toward some nutrition-related statement or phenomenon, along with readiness to change nutrition-related behaviors. Food and nutrition knowledge (FH-4.1) · Nutrition knowledge of supportive individuals · Nutrition knowledge of individual client - Area(s) and level of knowledge/skill - Energy balance concepts, energy-dense foods, nutrient-dense foods, energy use in physical activity - Connection between nutrition status and dietary intake · Diagnosis specific or global nutrition-related knowledge score Food and nutrition skill (FH-4.2) · Nutrition skill of supportive individuals · Nutrition skill of individual client Belief and attitude determination (FH-4.3) · Nutrition priority of individual client (present/absent), values supporting change · Nutrition priority of client's supportive individuals (present/absent), values supporting change · Nutrition priority of client's supportive structures (present/absent), values supporting change · Conflict with individual client's value system (present/absent) - Importance and integration of food-related activities · Conflict with client's supportive individuals' value system (present/absent) - Consider the importance of food-related activities · Behavioral beliefs (motivation, control, norms, readiness) - Perceived susceptibility to nutrition related health problems score - Self-rated, 1 = very low to 7 = very high perceived susceptibility - Perceived severity of risk to health score - Self-rated, 1 = very low to 7 = very high perceived severity of risk - Perceived benefit of nutrition-related change score - Self-rated, 1 = very low to 7 = very high perceived benefit - Likelihood of performing nutrition-related behavior score - Self-rated, 1 = unlikely to perform behavior to 7 = very likely to perform behavior - Perceived control over nutrition related behavior score - Self-rated, 1=very low to 7=very high perceived control - Nutrition self-efficacy score (self-belief regarding achieving success) - Self-rated, 1=very low confidence to 7 = very high confidence in ability - Perceived barrier to nutrition related behavior score (importance ratings and barriers to change) - Self-rated, 1=very low to 7=very high perceived barriers - Readiness to change nutrition related behavior stage (readiness to change) - Precontemplation stage (present/absent) - Contemplation stage (present/absent) - Preparation stage (present/absent) - Action stage (present/absent) - Maintenance stage (present/absent) - Relapse stage (present/absent) - Readiness to change nutrition related behavior score - Self-rated on scale of 1 to 10; 1 = not ready to 10 = fully ready to change - Negative emotions about food and nutrition (present/absent) - Triggers to poor appetite, reduced intake - Consider the impact of change - Positive emotions about food and nutrition (present/absent) - Unrealistic nutrition related goals (present/absent), weight gain expectations - Unscientific nutrition beliefs/attitudes (present/absent) - Body image disturbance (present/absent) - Preoccupation with food (present/absent) - Preoccupation with weight (present/absent) - Preoccupation with body shape (present/absent) - Negative nutrition self talk (present/absent), words used to describe lapses to self - Positive nutrition self talk (present/absent) - Preferences for food (yes/no) - Energy-dense foods - Preferences for sweet or salty foods - Familiarity with healthy choices - Preferences for beverages (yes/no) BEHAVIOR DETERMINATION (FH-5) Adherence behavior (FH-5.1) · Self reported nutrition adherence score · Nutrition encounter ratio - Nutrition visit attendance · Ability to recall nutrition goals · Nutrition self monitoring at agreed upon rate - Diet history · Nutrition self management as agreed upon - Weight monitoring - Dietary intake - Physical activity logs - Blood sugar levels of CFRD Avoidance behavior (FH-5.2) · Avoidance · Restrictive eating · Cause of avoidance behavior Eating behavior (FH-5.4) · Meal duration · Percent of meal time spent eating · Patient/client/caregiver fatigue during feeding process resulting in inadequate intake · Willingness to try new foods - Including alternatives to energy-dense favorites - Seasoning foods with to salt, cooking fresh foods - Changes in eating patterns, attitudes, motivation, influence of psycho-social issues - Need for further nutrition counseling · Limited number of accepted foods · Rigid sensory preferences Social network behavior (FH-5.5) · Ability to build and utilize social network FACTORS AFFECTING ACCESS TO FOOD AND FOOD/NUTRITION-RELATED SUPPLIES (FH-6) Factors that affect intake and availability of a sufficient quantity of safe, healthful food as well as food/nutrition-related supplies. Food and nutrition program participation (FH-6.1) · Eligibility for government programs · Participation in government programs · Eligibility for community programs · Participation in community programs Safe food availability (FH-6.2) · Availability of shopping facilities · Procurement of safe food · Appropriate meal preparation facilities · Availability of safe food storage · Appropriate storage technique · Identification of safe food Food and nutrition related supplies availability (FH-6.4) · Access to food and nutrition-related supplies PHYSICAL ACTIVITY AND FUNCTION (FH-7) Physical activity, cognitive and physical ability to engage in specific tasks, e.g., breastfeeding and self-feeding. Breastfeeding assessment (FH-7.1) · Initiation of breastfeeding · Breastfeeding approach - Exclusive breastfeeding · Breastfeeding problems Nutrition-related ADLs and IADLs (FH-7.2) · Nutrition-related activities of daily living (ADL) score · Nutrition-related instrumental activities of daily living (IADL) score Physical activity (FH-7.3) · Physical activity history - Preferences - Recent changes - Limitations · Consistency · Frequency · Duration · Intensity · Type of physical activity · Strength · Other sedentary activity time · Involuntary physical movement · Non exercise activity thermogenesis Factors affecting access to physical activity (FH-7.4) · Neighborhood safety · Walkability of neighborhood · Proximity to parks/green space · Access to physical activity facilities/programs NUTRITION RELATED CLIENT CENTRED MEASURES (FH-8) Patient/client’s perception of his or her nutrition intervention and its impact on life. Food and/or nutrition quality of life (FH-8.1) · Food and/or nutrition quality of life responses |
| ANTHROPOMETRIC MEASUREMENTS (AD) |
| Body composition/growth/weight history (AD-1.1) · Height - Measured height (in/cm) - Measured length (in/cm) - Birth length (in/cm) - Estimated height (in/cm) - Stated height (in/cm) - Measured peak adult height (in/cm) - Knee height (in/cm) - Height measurement device · Weight - Measured weight (lb, oz, kg, g) - Stated weight (lb, oz, kg, g) - Stated peak weight (lb, kg) - Measured peak weight (lb, kg) - Usual stated body weight (UBW) (lb, oz, kg, g) - Usual body weight (UBW) percentage (%) - You may consider age of onset at this point - Birth weight (lb, oz, kg, g) - Stated pre-pregnancy weight (lb, oz, kg, g) - Dosing weight (lb, oz, kg, g) · Frame - Frame size (small/medium/large) - Wrist circumference (in/cm) · Weight change - Weight gain (lb, kg, oz, g) - Weight loss (lb, kg, oz, g) - Weight change percentage (%) - Measured gestational weight gain (lb, oz, kg, g) - Measured gestational weight loss (lb, oz, kg, g) - Weight change intent (intentional/unintentional) - Specify time frame - Lowest weight/time - Highest weight/time - Most weight lost on diet program - Patterns of weight loss and gain · Body mass - Body mass index (BMI) (kg/m2) - In routine clinical practice BMI is now accepted as the most appropriate measure of nutritional status in people with CF over the age of two years (4,5) - Adult females should aim for 22 kg/m2 and adult males 23 kg/m2 - Body mass index prime ratio (BMI prime) (actual BMI to the upper limit BMI of 25) · Growth pattern indices - BMI for age percentile (percentile) - BMI for age z score - Head circumference (in/cm) - Birth head circumference (in/cm) - Head circumference for age percentile (percentile) - Head circumference for age z score (z score) - Length for age percentile (percentile) - Length for age z score (z score) - Stature for age percentile (percentile) - Stature for age z score (z score) - Weight for length percentile (percentile) - Weight for length z score (z score) - Weight for age percentile (percentile) - Weight for age z score (z score) - Weight for stature percentile (percentile) - Weight for stature z score (z score) - Mid parental height comparator (in/cm) · Body compartment estimates, not used often - Body fat percentage (%) - Body fat percentage technique - Body surface area (m2) - Calculated body surface area (m2) - Bone age (years) - Bone mineral density t score (t score) - Bone mineral density z score (z score) - Bone mineral density technique - Mid arm muscle circumference (in/cm) - Mid arm muscle circumference percentile (percentile) - Triceps skinfold thickness (in/cm) - Triceps skinfold percentile (percentile) - Triceps skinfold z score (z score) - Waist circumference (in/cm) - Waist circumference narrowest point (in/cm) - Waist circumference iliac crest (in/cm) - Hip circumference (in/cm) - Waist to hip ratio (ratio) - Mid upper arm circumference (in/cm) - Mid upper arm circumference left arm (in/cm) - Mid upper arm circumference z score (z score) |
| BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD) |
| Acid base balance (BD-1.1) · Arterial pH · Arterial bicarbonate · Partial pressure of carbon dioxide in arterial blood (PaCO2) · Partial pressure of oxygen in arterial blood (PaO2) · Venous pH · Venous bicarbonate Electrolyte and renal profile (BD-1.2), electrolytes assessed annually · BUN · Creatinine · BUN:creatinine ratio · Glomerular filtration rate · Sodium (Na) · Chloride (Cl) · Potassium (K) · Magnesium (Mg) · Calcium, serum (Ca) · Calcium, ionized (Ca) · Phosphorus (P) · Serum osmolality · Parathyroid hormone Essential fatty acid profile (BD-1.3) · Triene:Tetraene ratio Gastrointestinal profile (BD-1.4) · Alkaline phosphatase · Alanine aminotransferase (ALT) · Aspartate aminotransferase (AST) · Gamma glutamyl transferase (GGT) · Gastric residual volume · Bilirubin, total · Ammonia, serum · Toxicology report, including alcohol · Prothrombin time (PT) · Partial thromboplastin time (PTT) · INR ratio · Amylase · Lipase · Fecal fat, 24 hour · Fecal fat, 72 hour · Fecal fat, qualitative · Fecal calprotectin · Fecal lactoferrin · Fecal elastase (as indicated to determine pancreatic sufficiency) · Pancreatic elastase · 5'nucleotidase · D-xylose · Lactulose hydrogen breath test · Lactose hydrogen breath test · Fructose hydrogen breath test · Glucose hydrogen breath test · Urea hydrogen breath test · Intestinal biopsy · Stool culture · Gastric emptying time · Small bowel transit time · Abdominal X-ray · Abdominal CT (computed tomography) · Abdominal ultrasound · Endoscopic ultrasound · Pelvic CT (computed tomography) · Modified barium swallow · Barium swallow · Esophagogastroduodenoscopy · Endoscopic retrograde cholangiopancreatography (ERCP) · Capsule endoscopy · Esophageal manometry · Esophageal pH test · Gastroesophageal reflux monitoring · Gastrointestinal sphincter monitoring · Urate · Liver enzymes Glucose/endocrine profile (BD-1.5) Serial monitoring of fasting and two-hour post-prandial blood glucose measures (practice varies) Home glucose monitoring for established CFRD · Glucose, fasting · Glucose, casual · Hemoglobin A1c (HgbA1c), if confirmed with diabetes · Preprandial capillary plasma glucose · Peak postprandial capillary plasma glucose · Glucose tolerance test (OGTT) · Cortisol level · Growth hormone · Luteinizing hormone Inflammatory profile (BD-1.6) · C-reactive protein (CRP) Lipid profile (BD-1.7) · For those needing cardiovascular risk assessment · Cholesterol, serum · Cholesterol, HDL · Cholesterol, LDL · Cholesterol, non HDL · Total cholesterol:HDL cholesterol ratio · LDL:HDL ratio · Triglycerides, serum Metabolic rate profile (BD-1.8) · Resting metabolic rate, measured (RMR) · Respiratory quotient, measured (RQ) Mineral profile (BD-1.9) · Copper, serum or plasma (Cu) · Iodine, urinary excretion (I) · Zinc, serum or plasma (Zn) · Boron, serum or plasma (B) · Chromium, serum or urinary (Cr) · Fluoride, plasma (F-) · Manganese, urinary, blood, plasma (Mn) · Molybdenum, serum (Mo) · Selenium, serum or urinary (S) Nutritional anemia profile (BD-1.10) · If iron-deficiency anemia suspected · Hemoglobin · Hematocrit · Mean corpuscular volume · Red blood cell folate · Red cell distribution width · B12, serum · Methylmalonic acid, serum · Folate, serum · Homocysteine, serum · Ferritin, serum, interpret in conjunction with C-reactive protein level · Iron, serum · Total iron-binding capacity · Transferrin saturation Protein profile (BD-1.11) · Albumin, interpret with caution · Prealbumin · Transferrin · Creatine kinase · B type natriuretic peptide · Succinylacetone · Total serum immunoglobulin A · Carbohydrate deficient transferrin Urine profile (BD-1.12) · Urine color · Urine osmolality · Urine specific gravity · Urine volume · Urine calcium, 24 hour · Urine d-xylose · Urine glucose · Urine ketones, urine test · Urine sodium · Urine microalbumin · Urine protein, random · Urine protein, 24 hour · Urine uric acid, random · Urine uric acid, 24 hour · Urine organic acid panel · Urine glutarate · Urine methylmalonate · Urine acylglycines/creatinine · Urine argininosuccinate · Urine succinylacetone/creatinine · Urine orotate · Urine orotate/creatinine · Urine 2-hydroxyisovalerate · Urine 2-oxoisovalerate · Urine galactitol · Urine reducing substances · Urine porphyrins Vitamin profile (BD-1.13) · Vitamin A, serum or plasma retinol · Vitamin C, plasma or serum · Vitamin D, 25-hydroxy · Vitamin E, plasma alpha-tocopherol · Thiamin, activity coefficient for erythrocyte transketolase activity · Riboflavin, activity coefficient for erythrocyte glutathione reductase activity · Niacin, urinary N’methyl-nicotinamide concentration · Vitamin B6, plasma or serum pyridoxal 5’phosphate concentration · Pantothenic acid, urinary pantothenate excretion, plasma · Biotin, urinary 3-hydroxyisovaleric acid excretion · Biotin, lymphocyte propionyl-CoA carboxylase in pregnancy, serum · Biotinidase · Protein induced by vitamin K absence or antagonist II Carbohydrate metabolism profile (BD-1.14) · Galactose-1-phosphate in red blood cell · Galactose-1-phosphate uridyl transferase · Fructose · Lactate · Pyruvate · Lactate:pyruvate Fatty acid profile (BD-1.15) · Acylcarnitine panel · Acylcarnitine, plasma · Free carnitine · Total carnitine · Free carnitine:total carnitine · Fatty acid panel mitochondrial C8 to C18 · Fatty acid panel essential C12 to C22 · Fatty acid panel peroxisomal C22 to C26 · MCAD enzyme assay in fibroblasts or other tissues · Fatty acid ß-oxidation in fibroblasts |
| PHYSICAL EXAM FINDINGS (PD) (REFS!!) |
| Nutrition focused physical findings (PD-1.1) · Overall findings - Lethargic - Underweight - Short stature for age · Adipose finding - Atrophy of orbital fat - Loss of subcutaneous fat - Loss of subcutaneous triceps fat - Loss of subcutaneous biceps fat - Loss of subcutaneous fat overlying the ribs · Bone finding - Acromion abnormal prominence - Bone widening at ends - Clavicle abnormal prominence - Increased anteroposterior diameter of chest - Rib abnormal prominence - Scapula abnormal prominence - Spine abnormal prominence - Iliac crest abnormal prominence - Patella abnormal prominence · Cardiovascular-pulmonary system finding - Bradycardia - Bradypnea - Cyanosis - Decreased breath sounds - Dyspnea, on exertion - Kyphosis - Increased breath sounds - Nasal polyps - Pneumothorax - Respiratory crackles - Scoliosis - Sleep apnea - Tachypnea - Wheeze · Digestive system - Bowel function, including flatus, specify, such as type, frequency, volume - Abdominal bloating - Abdominal cramping - Abdominal distension - Abdominal pain - Anorexia - Ascites - Bulky stool - Constipation - Decrease in appetite - Diarrhea - Early satiety - Epigastric pain - Excessive belching - Excessive flatus - Fatty stool, Steatorrhea - Gastroesophageal reflux - Heartburn - Hyperactive bowel sounds - Hypoactive bowel sounds - Intestinal obstruction - Liquid stool - Loose stool - Nausea - Vomiting - Pancreatic drainage volume - Pancreatic inflammation - Chylous drainage volume - Gastroparesis, intestinal enteropathy · Extremity finding - Drowsiness, fatigue, joint pain · Eye finding - Abnormal vision, glasses, contact lenses - Retinopathy - Angular blepharitis - Biotot’s spots - Circles under eyes - Corneal arcus - Conjunctival discoloration - Conjunctival hemorrhage - Conjunctival keratinization - Excessive tear production · Genitourinary system finding - Amenorrhea - Anuria - Delay in sexual development and/or puberty - Menorrhagia - Obstructive azoospermia - Polyuria, atypical/in infants - Undescended testicles · Hair finding - Abnormal keratinization of hair follicle - Alopecia - Brittle hair - Corkscrew hairs - Dry hair - Fine hair - Follicular hyperkeratosis - Hair changes due to malnutrition - Hair lacks luster - Hypertrichosis - Increased loss of hair - Nutritional hair color change - White hair - Easily pluckable hair - Lanugo hair formation - Loss, thinning · Hand and nail finding - Aquagenic wrinkling of the palm (AWP) - Clubbing of nails - Flaking of nails - Koilonychia - Leukonychia - Longitudinal grooving of nails - Nail changes - Ridged nails - Splits in nails - Thin nails - Splinter hemorrhage under nails - White flecks in nails - Blue nail beds - Pale nail beds - Spooning · Mouth finding - Ageusia - Angular stomatitis - Aphthous ulcer of mouth - Aptyalism - Blue lips - Blue line on gingiva - Candidiasis of the mouth - Cheilosis - Excessive thirst (polydipsia) - Gingival hypertrophy - Gingivitis - Halitosis - Hemorrhagic gingivitis - Hypogeusia - Ketotic breath - Oral candidiasis - Oral lesion - Parotid swelling - Stomatitis - Uremic breath - Pale gums · Muscle finding - Muscle atrophy - Muscle cramp - Muscle pain - Muscle weakness - Quadriceps muscle atrophy - Deltoid muscle atrophy - Gastrocnemius muscle atrophy - Gluteal muscle atrophy - Interosseous hand muscle atrophy - Pectoral muscle atrophy - Temporalis muscle atrophy - Trapezius muscle atrophy - Latissimus dorsi muscle atrophy - Hand-grip strength- use to document a decline in physical function - Weakness · Nerves, cognition, and feeling finding - Depressed mood - Dizziness - Feels cold - Flat affect - Peripheral nerve disease, neuropathy · Skin finding - Decreased skin turgor - Dry skin - Impaired skin integrity - Jaundice - Pale complexion - Peeling skin - Impaired wound healing - Scaling skin · Teeth finding - Dental caries - Dental fluorosis - Dental plaque - Edentulous - Erosion of teeth - Impaired dentition - Ill fitting denture - Mottling of enamel - Partially edentulous mandible - Partially edentulous maxilla - Rampant dental caries · Throat and swallowing finding - Choking during swallowing - Cough - Dysphagia - Esophageal lesion - Food sticks on swallowing - Gagging - Hoarse voice - Hypoactive gag reflex - Odynophagia - Swallow impairment · Tongue finding - Atrophy of tongue papillae - Beefy red tongue - Difficulty moving tongue - Dry tongue - Glossitis - Glossodynia - Hypertrophy of tongue papillae - Lesion of the tongue - Strawberry tongue - Macroglossia - Short frenulum of tongue - Split frenulum of tongue - Blue tongue - Cracked tongue - Magenta tongue - Pale tongue · Vital signs - Blood pressure, systolic (mmHg) - Blood pressure, diastolic (mmHg) - Heart rate - Jugular venous pressure - Mean arterial pressure - Pulse rate - Respiratory rate - Temperature |
| CLIENT HISTORY (CH) |
| PERSONAL HISTORY (CH-1) General patient/client information such as age, gender, sex, race, ethnicity, language, education, and role in family Personal history (CH-1.1) · Age - Age in days (neonates) - Age in months (up to 36 months) - Age in years · Gender, personal identification - Female - Male · Sex, biological - Female - Male · Race, if relevant to care - American Indian or Alaska Native - Asian - Black or African American - Native Hawaiian or Other Pacific Islander - White · Ethnicity - Hispanic or Latino - Not Hispanic or Latino · Language - English - Spanish · Literacy factors - Language barrier - Low literacy · Occupation · Income · Education - Years of education (Year of education) · Role in family - Specify (patient/client's reported role, e.g., mother, cousin, in the description of his/her family) · Tobacco (and drug) use - Yes - Average number cigarettes smoked per day (number/day) - Total number of other tobacco products used/day (number/day) - Number years tobacco products used on a regular basis (years) - No · Physical disability - Eyesight impaired - Hearing impaired · Mobility - House bound - Bed or chair bound - Tremors (Parkinson’s) CLIENT AND/OR FAMILY HEALTH HISTORY (CH-2) Patient/client or family disease states, conditions, and illnesses that may have nutritional impact. Individual client and/or family nutrition oriented health history (CH-2.1) Specify issues(s) and whether it is patient/client history (P) or family history (F) · Patient/client chief nutrition complaint (specify) P or F · Cardiovascular disease history (specify) P or F - Cardiovascular disease - Congestive heart failure - Hyperlipidemia - Hypertension - Stroke · Endocrine/metabolism disease history (specify) P or F - Cystic fibrosis - Diabetes, mellitus - Diabetes, gestational - Inborn errors - Malnutrition/failure to thrive - Metabolic syndrome - Obesity - Overweight (specify duration) - Thyroid dysfunction · Excretory disease history (specify) P or F - Dehydration - Renal failure, acute - Renal failure, chronic · Gastrointestinal disease history (specify) P or F - Crohn's disease - Diverticulitis/osis - Dyspepsia - Inflammatory bowel disease - Lactase deficiency - Liver disease - Pancreatic disease (specify) · Gynecological disease history (specify) P or F - Amenorrhea - Lactating - Mastitis - Perimenopausal/postmenopausal - Pregnant - Gestational age (weeks) - Single fetuses - Multiple fetuses (specify) · Hematology/oncology disease history (specify) P or F - Anemia (specify) - Cancer (specify) · Immune disease history (e.g., food allergies) (specify) P or F - AIDS/HIV - Food allergies - Sepsis/severe infection · Integumentary disease history (specify) P or F - Burns · Musculoskeletal disease history (specify) P or F - Multiple trauma/fractures - Osteoporosis - Osteoarthritis · Neurological disease history (specify) P or F - Developmental delay · Psychological disease history (specify) P or F - Alcoholism - Cognitive impairment - Dementia/Alzheimer’s - Depression - Eating disorder (specify) - Psychosis - Mood swings and irritability · Respiratory disease history (specify) P or F - Chronic obstructive pulmonary disease · Other (specify) P or F Treatments/therapy (CH-2.2) Documented medical or surgical treatments that may impact nutritional status of the patient · Medical treatment/therapy (specify) - Chemotherapy - Dialysis - Mechanical ventilation/oxygen therapy - Ostomy (specify) - Radiation therapy - Medical history · Surgical treatment (specify) - Coronary artery bypass (CABG) - Gastric bypass (specify type) - Intestinal resection - Joint/orthopedic surgery/replacement - Limb amputation - Organ transplant (specify) - Total gastrectomy - Surgical history · Palliative/end-of-life care (specify) · Complementary/alternative medicine SOCIAL CONTEXT (CH-3) Patient/client socioeconomic status, housing situation, medical support, and involvement in social groups. Social History (CH-3.1) · Socioeconomic factors (specify) - Economic constraints (major/minor) - Access to medical care (full/limited/none) - Diverts food money to other needs - Limits on medical coverage - Food budget limits - Ability to purchase items recommended by dietitian · Living/housing situation (specify) - Lives alone - Lives with family member/caregiver - Homeless - Other household members eating same food - The person who does shopping and cooking · Domestic issues (specify) · Social and medical support (specify) - Family members, roles - Caregivers - Community group/senior center/church - Support group attendance (e.g., weight control, substance abuse, etc.) - Support from friends - Limits on medical coverage - Physician/nurse involvement - Social isolation · Geographic location of home (specify) - Urban - Rural - Limited exposure to sunlight (vitamin D) - Travel time to consultations · Occupation (specify) - Stay-at-home mother - Student - Retired - Impact on physical activity · Religion (specify) - Catholic - Jewish - Protestant - Islam - Impact on intake, such as Ramadan · History of recent crisis (specify) - Job loss - Family member death - Trauma, surgery · Daily stress level (specify) (high, moderate, low bodily or mental tension) |
| ASSESSMENT, MONITORING AND EVALUATION TOOLS (AT) |
| NUTRITION ASSESSMENT, MONITORING AND EVALUATION TOOL RATINGS (AT-1) Subjective global assessment (SGA) rating (AT-1.1) The scored patient generated subjective global assessment (PG-SGA) rating (AT-1.3) · pt-global.org The scored patient generated subjective global assessment (PG-SGA) score (AT-1.4) Mini nutritional assessment long form (MNA-LF) rating (AT-1.5) |
| ETIOLOGY CATEGORY (EY) |
|
NUTRITION DIAGNOSIS ETIOLOGY CATEGORY IDENTIFICATION (EY-1) Beliefs attitudes etiology (EY-1.1) Cultural etiology (EY-1.2) Knowledge etiology (EY-1.3) Physical function etiology (EY-1.4) Physiologic metabolic etiology (EY-1.5) Psychological etiology (EY-1.6) Social personal etiology (EY-1.7) Treatment etiology (EY-1.8) Access etiology (EY-1.9) Behavior etiology (EY-1.10) |
| COMPARATIVE STANDARD (CS) |
| Sample related to cystic fibrosis |
| ENERGY NEEDS (CS-1) Estimated energy needs (CS-1.1) · Total energy estimated needs in 24 hours · Method for estimating total energy needs - Simple ratio method - Measured resting metabolic rate (RMR) - Physical activity factor (PAF) · Total energy estimated needs per kg body weight MACRONUTIENT NEEDS (CS-2) Estimated fat needs (CS-2.1) · Total fat estimated needs in 24 hours · Method for estimating total fat needs · Proportion of energy needs from fat in 24 hours Estimated protein needs (CS-2.2) · Total protein estimated needs in 24 hours · Total protein estimated needs per kg body weight - 1.8 to 2.4 g of protein per kg per day (based on DRI/age x 1.8 to 2.0) · Type of protein required · Method for estimating total protein needs · Proportion of energy needs from protein in 24 hours Estimated carbohydrate needs (CS-2.3) · Total carbohydrate estimated needs in 24 hours · Total carbohydrate estimated needs per kg body weight · Type of carbohydrate required · Method for estimating total carbohydrate needs Estimated fiber needs (CS-2.4) · Total fiber estimated needs in 24 hours · Type of fiber required · Method for estimating needs FLUID NEEDS (CS-3) Estimated fluid needs (CS-3.1) · Total fluid estimated needs · Method for estimating needs - 35-45 mL/kg/day MICRONUTRIENT NEEDS (CS-4) Estimated vitamin needs (CS-4.1) · Estimated vitamin A needs in 24 hours · Estimated vitamin C needs in 24 hours · Estimated vitamin D needs in 24 hours · Estimated vitamin E needs in 24 hours · Estimated vitamin K needs in 24 hours · Estimated Thiamin needs in 24 hours · Estimated Riboflavin needs in 24 hours · Estimated Niacin needs in 24 hours · Estimated Folate needs in 24 hours · Estimated vitamin B6 needs in 24 hours · Estimated vitamin B12 needs in 24 hours · Estimated Pantothenic acid needs in 24 hours · Estimated Biotin needs in 24 hours · Method for estimating 24 hour vitamin needs Estimated mineral needs (CS-4.2) · Estimated Calcium needs in 24 hours · Estimated Chloride needs in 24 hours · Estimated Iron needs in 24 hours · Estimated Magnesium needs in 24 hours · Estimated Potassium needs in 24 hours · Estimated Phosphorus needs in 24 hours · Estimated Sodium needs in 24 hours · Estimated Zinc needs in 24 hours · Estimated Sulfate needs in 24 hours · Estimated Fluoride needs in 24 hours · Estimated Copper needs in 24 hours · Estimated Iodine needs in 24 hours · Estimated Selenium needs in 24 hours · Estimated Manganese needs in 24 hours · Estimated Chromium needs in 24 hours · Estimated Molybdenum needs in 24 hours · Estimated Boron needs in 24 hours · Estimated Cobalt needs in 24 hours · Estimated Method for estimating needs needs in 24 hours WEIGHT AND GROWTH RECOMMENDATIONS (CS-5) Recommended body weight/body mass index/growth (CS-5.1) · Ideal/reference body weight (IBW) · Recommended body mass index (BMI) · Goal weight · Goal weight gain/day · Goal weight for length z score · Goal mid upper arm circumference z score · Goal BMI for age z score · Percent median BMI |
| PROGRESS EVALUATION (EV) |
|
INTERVENTION GOAL STATUS (EV-1) New goal identified (EV-1.1) Goal achieved (EV-1.2) Goal discontinued (EV-1.3) Goal not achieved (EV-1.4) Some progress toward goal (EV-1.5) Some digression away from goal (EV-1.6)
New nutrition diagnosis (EV-2.1) Active nutrition diagnosis (EV-2.2) Resolved nutrition diagnosis (EV-2.3) Discontinued nutrition diagnosis (EV-2.4) |
References
1. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. 2023. Accessed 18 April 2024. Available from: https://www.ncpro.org/.
2. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. NCP Step 1: Nutrition Assessment. 2020; Accessed 11 May 2021. Available from: https://www.ncpro.org/pubs/2020-encpt-en/page-015.
3. PEN Cystic Fibrosis Evidence Summary. Accessed 29 November 2017. Available from: http://www.pennutrition.com/KnowledgePathway.aspx?kpid=5523&trcatid=42&trid=6578
4. Hollander FM, De Roos NM, De Vries JHM, Van Berkhout FT. Assessment of nutritional status in adult patients with cystic fibrosis: Whole-body bioimpedance vs body mass index, skinfolds, and leg-to-leg bioimpedance. J Am Diet Assoc. 2005;105(4):549–555.
5. Stallings VA, Stark LJ, Robinson KA, Feranchak AP, Quinton H. Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc. 2008;108(5):832–839.
Updated April 23, 2024