Nutrition Assessment Use CaseOctober 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 yoCaucasianfemale 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:

oThis 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:

oThis 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

oThe 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.

oSmoking history:

▪This patient smokes occasionally at social events.

Family history includes:

•Whether any genetic relatives were/are affected by the condition

oThis patient’ maternal grandmother (age at onset 45) and genetic mother (at onset age 50) were both diagnosed with Diabetes.

oThis 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

oconsuming one meal per day or drinking an oral supplement if tolerated

oHas 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 recordsthe 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 documentsthe 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)

oHb 1

oWBC

oPlatelets

oHematocrit

oRBC

•CMP

•Albumin

•Alkaline phosphatase:

•ALT(alanineaminotransferase):

•AST(aspartate aminotransferase):

•BUN(bloodureanitrogen):

•Calcium:

•Chloride:

•CO2(carbondioxide):

•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
  • Hb 100 g/L (reference range 115-160)
  • WBC 6.2 x109/L (reference range 4.0-110)
  • Platelets 307 x109/L (reference range 140-400)
  • Haematocrit 0.33 (reference range 0.33-0.47)
  • RBC 3.70 x1012/L (reference range 3.80-5.20)
  • CMP
  • Albumin 2.8(3.9 to 5.0 g/dL)
  • Alkaline phosphatase: 50(44 to 147 IU/L)
  • ALT(alanine aminotransferase): 20(8 to 37 IU/L)
  • AST(aspartate aminotransferase): 15(10 to 34 IU/L)
  • BUN(blood urea nitrogen): 14(7 to 20 mg/dL)
  • Calcium: 7.2(8.5 to 10.9 mg/dL)
  • Chloride: 97(96 - 106 mmol/L)
  • CO2(carbon dioxide): 22(20 to 29 mmol/L)
  • Creatinine: 0.9(0.8 to 1.4 mg/dL)
  • Glucose test: 107(70 to 100 mg/dL)
  • Potassium test: 3.9(3.7 to 5.2 mEq/L)
  • Sodium: 138(136 to 144 mEq/L)
  • Total bilirubin: 1.0(0.2 to 1.9 mg/dL)
  • Total protein: 5.0(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: Normal

Cranial nerve assessment: Normal

Heart and lung assessment: Normal

Abdominal assessment:Little distended

Skin:Pale in color, dry and scaly

Hair:Dull in color

Nails:Brittle

Clinical Assessment

The RDN evaluates and applies clinical reasoning on new patient data including diagnostic test resultsand 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 documentsthe clinical findings and final diagnosis in the patient’s medical record

Treatment Plan:

Not included in this script