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Nutrition Assessment-Part 2
Mira Mutiyani
4 February 2019

11/08/2019 NCP Terminology/ADA/2015

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Course Objectives

By the end of this course, the students will:

 Understand a working definition and purpose of nutrition assessment

 Understand the components of nutrition assessment, including

 Activities of the nutrition and dietetics professional during nutrition
assessment
 Critical thinking skills that are useful during nutrition assessment
 Sources of data needed for decision making during nutrition assessment

 Understand the organization of domains, classes and sub-classes of the

nutrition assessment terms

 Understand documenting data

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Nutrition Care Process Model

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+ Biochemical Data, Medical Test and Procedure (BD)
Domain, classes, sub-classes

 Laboratory data, (e.g., electrolytes, glucose, and lipid panel) and tests (e.g.,
gastric emptying time, resting metabolic rate).
 Acid-base balance (1.1)
 Electrolyte and renal profile (1.2)
 Essential fatty acid profile (1.3)
 Gastrointestinal profile (1.4)
1.1 – 1.6
 Glucose/endocrine profile (1.5)
 Inflammatory profile (1.6)
 Lipid profile (1.7)
 Metabolic rate profile (1.8) Showed
 Mineral profile (1.9) sub-classes
 Nutritional anemia profile (1.10)
 Protein profile (1.11)
 Urine profile (1.12)
 Vitamin profile (1.13)

NCP Terminology/ADA/2015 11/08/2019

+ Nutrition-Focused Physical Findings (PD)
Domain, classes, sub-classes

 Findings from an evaluation of body systems, muscle and subcutaneous fat

wasting, oral health, suck/swallow/breathe ability, appetite, and affect.
 Nutrition-focused physical findings (1.1)
 Overall appearance PD-1.1.1 1.1
 Body language PD-1.1.2
 Cardiovascular-pulmonary PD-1.1.3
 Extremities, muscles and bones PD-1.1.4 Showed
sub-classes
 Digestive system (mouth to rectum) PD-1.1.5
 Head and eyes PD-1.1.6
PD-.1.1.1
 Nerves and cognition PD-1.1.7
 Skin PD-1.1.8
 Vital signs PD-1.1.9 Showed
terms
NCP Terminology/ADA/2015 11/08/2019
+ Client History (CH)
Domain, classes, sub-classes

Current and past information related to personal, medical, family, and social
history.

 Personal History (1): General patient/client information such as age, 1 – 3 (classes)

gender, race/ethnicity, language, education, and role in family.
 Personal data (1.1)

 Patient/Client/Family Medical/Health History (2): Patient/client or 1.1; 2.1 – 2.2; 3.1

family disease states, conditions, and illnesses that may have nutritional (sub-classes)
impact.
 Patient/client OR family nutrition-oriented medical/health history (2.1):
Specify issue(s) and whether it is patient/client history (P) or family history (F)
 Treatments/therapy (2.2): Documented medical or surgical treatments that may
impact nutritional status of the patient

 Social History (3): Patient/client socioeconomic status, housing situation,

medical care support and involvement in social groups.
 Social history (3.1)

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Re-Assessment

Re-Assessment

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Re-Assessment
During the re-assessment, one should:

 Determine whether the monitoring and evaluation parameters previously identified

have changed

 Identify the status of the previous nutrition diagnosis using the following language:
 no improvement
 Improvement
 diagnosis no longer appropriate
 resolved

 Ask if there is a new Nutrition Diagnosis (problem)?

 Determine whether additional data of any kind is needed

If goals were met and no further care is needed, patient can be

discharged from care

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Re-Assessment

Jika pada suatu kondisi

Ahli gizi perlu
tidak ditemukan data
melakukan assessment
yang abnormal pada
ulang
proses assessment

Apabila tidak ditemukan

permasalahan maka
ahgi gizi dapat Untuk mendapatkan
menyatakan “tidak ada data-data kembali
diagnosa gizi pada saat
ini”

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Important

Dapat dikatakan bahwa Nutrition assessment adalah

suatu pondasi dalam kegiatan asuhan gizi

Apabila asesment gizi tidak tepat maka akan

menyebabkan proses selanjutnya tidak tepat pula

Asesmen gizi yang tepat akan menghasilkan

diagnosis gizi yang tepat sehingga rencana
intervensi, monitoring dan evaluasi dapat tepat pula

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Results of Nutrition Assessment

Leads to appropriate initial

determination that a nutrition
diagnosis/problem exists

If a nutrition diagnosis can be made,

the RDN labels the problem and
creates a PES* statement in Step 2 of
the Nutrition Care Process *PES:
Problem, Etiology, Signs/Symptoms

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Results of Nutrition Assessment

If a nutrition problem is not identified,

further information or testing may be
necessary to make a determination

If the assessment indicates that no

nutrition problem currently exists that
warrants a nutrition intervention, the
term “No nutrition diagnosis at this
time (NO-1.1)” may be documented

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Results of Nutrition
Assessment/Reassessment

The RDN will determine

• If a nutrition diagnosis/problem exists
• The plan for continuation of care,
specifically:
• Progression through the NCP
• Need for additional information/testing
• Discharge from nutrition care

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Nutrition Care Indicators

Nutrition Care Indicators are markers

that can be observed and measured
• Food/Nutrition Related History
• Anthropometric measurements
• Biochemical data, Medical tests and Procedures
• Nutrition-Focused Physical Findings
• Client history

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Nutrition Care Indicators

When assessing a nutrition indicator, compare current data against a

 Nutrition prescription

 Reference standard or comparative standard

 National Standards for populations such as DRIs, US Dietary Guidelines
 Guidelines for specific disease conditions, e.g., A.S.P.E.N., E.S.P.E.N., U.S.
National Kidney Foundation
 Institutional Standards, e.g., established guidelines specifying weight
change in geriatric clients
 Regulatory standards that are legal boundaries for specific populations,
such as those developed by Joint Commission

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Comparative standard (CS) Definition

Comparative Standards are

the terms used by the RD,
RDN, DTR for comparison
of the collected data to
determine a nutrition
diagnosis (problem)

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Nutrition Assessment Components
Process

• Dietary intake Compare to

• Nutrition related relevant standards
consequences of health
and disease condition
• Psycho-social, functional,
and behavioral factors
• Knowledge, readiness,
interpreting data
and potential for change

Gather data, Identify possible

considering: problem areas

verifying
Obtaining

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Comparative standard (CS)

When choosing a Comparative Standard, there are three factors to

consider:
1. Practice setting
 Acute care
 Long term care community
 Ambulatory care
 Public health community
2. Population characteristics
 Age
 Gender
3. Disease state and severity
 Renal disease
 Diabetes, type and severity
 Critical illness

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Comparative standard (CS)

There are a few issues and limitations when using

Reference or Comparative Standards during Assessment:
• Accurate measurement for dietary intake is often difficult due to the
subjective nature of the assessment tools
• The U.S. Institute of Medicine advises combining dietary intake data
with clinical, biochemical, and other supporting information to lend
validity to the nutritional assessment.
• The Reference or Comparative Standards are population based and do
not represent any one individual.
• It is important to understand the population for whom the standard is
developed, e.g., the DRIs are developed for healthy individuals
• The individual or population you are assessing may or may not be
healthy

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Comparative Standard (CS)

 Energy Needs (1)

 Estimated energy needs (1.1)

 Macronutrient Needs (2)

 Estimated fat needs (2.1)
 Estimated protein needs (2.2)

 Estimated carbohydrate needs (2.3)

 Estimated fiber needs (2.4)

 Fluid Needs (3)

 Estimated fluid needs (3.1)

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Comparative Standard (CS) cont..

 Micronutrient Needs (4)

 Estimated vitamin needs (4.1)
 Estimated mineral needs (4.2)

 Weight and Growth Recommendation (5)

 Recommended body weight/body mass Index/growth (5.1)

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Important to Remember

An assessment of inadequate intake does

not always lead to nutrient deficiency
• Inadequate intake should be considered in
combination with other factors (such as clinical,
biochemical, anthropometric information, medical
diagnosis, clinical status)
• Bioactive substances do not have established DRIs
because they are not considered essential nutrients
• Criteria for evaluation of intake must be the
patient/client goal or nutrition prescription
• Practitioners from countries that do not use the DRIs
should refer to their own established dietary
reference standards

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Tools for Assessment

Nutrition Diagnosis Reference

Matrices
Sheets
• Signs • Nutrition Assessment
• Symptoms • Identifies potential
• Potential etiologies Nutrition Diagnoses by
looking at a list of signs
and symptoms
• Nutrition Diagnosis Etiology
• Provides options for
etiologies in each nutrition
diagnosis

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Summary

 Nutrition assessment and re-assessment is a process of obtaining, verifying,

and interpreting data

 Accurate interpretation of data depends on selection of appropriate

comparative standard

 Tools are available for clustering data for meaningful decisions

 Accurate use of the assessment terminology is important for accuracy

throughout the Nutrition Care Process

 Domains of nutrition assessment data are:

 Food/Nutrition Related History
 Anthropometric measurements
 Biochemical data, Medical tests and Procedures
 Nutrition-Focused Physical Findings
 Client history
NCP Terminology/ADA/2015 11/08/2019
+ Case study
documenting assessment data
Tn. Y, usia 40 tahun, beragama Islam, adalah seorang PNS. Tn. Y telah menderita hipertensi
selama 3 tahun terakhir, dan sering mengeluh pusing. Kedua orang tua Tn. Y juga
menderita hipertensi, dan ayah Tn. Y pernah dirawat 1 tahun yang lalu karena hipertensi
dan stroke. Tn. Y sudah dua hari di rawat di RS (MRS tanggal 12 Maret 2018) dengan keluhan
pusing, mual, dan tidak bisa bangun dari tempat tidur. Hasil diagnosa dokter adalah
Hipertensi grade I. Obat yang diberikan dokter antara lain Angioten dan Ezetrol. Selain itu,
Tn. Y juga mendaptkan Infus RL 24 x/mnt.
Hasil pengukuran antropometri menunjukkan TB 176 cm, BB 85 kg. Berdasarkan hasil
pemeriksaan di peroleh data sebagai berikut: Kolesterol total 257 mg/dL, kolesterol LDL
185 mg/dL, HDL 32 mg/dL. Tanda-tanda vital menunjukkan: TD 150/95 mmHg, suhu tubuh
380C, nadi 110 x/mnt, RR 30 x/mnt. Tn. Y mempunyai kebiasaan makan 2-3 kali/hari.
Makanan pokok yang biasa dikonsumsi adalah nasi dan roti. Tn. Y jarang mengkonsumsi
sayur, dan hanya sesekali mengkonsumsi buah. Setiap dari Tn. Y minum minuman kemasan
dan soft drink (2-3 botol/hari), air putih 750 ml/hari dan suka mengkonsumsi kue-kue
manis dan gorengan sebagai makanan camilan.
Sampai saat ini Tn. Y masih mengeluh mual dan pusing, nafsu makan menurun. Dokter tidak
memperbolehkan Tn. Y turun dari tempat tidur, sehingga mobilisasi hanya terbatas di atas
tempat tidur. Hasil recall tanggal 12 Maret 2018 diperoleh hasil energi 650 kkal, protein 25
g, lemak 10 g dan karbohidrat 147 g.
Tn. Y tinggal bersama istri dan dua orang anaknya. Istri Tn. Y sehari-hari juga bekerja
sebagai seorang guru di sebuat SD Negeri. Tn. Y mempunyai kebiasaan merokok sejak SMA
sampai dengan sekarang.

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Dokumentasi Asesmen Gizi
Asesmen Gizi Comparative standards Interpretasi
(CS)
1. Domain: Riwayat Klien
“client histrory” (CH)
2. Domain: Riwayat
Terkait Gizi dan
Makanan “food
history” (FH)
3. Domain:
Antropometri (AD)
4. Domain: Data
Biokimia, Tes Medis,
dan Prosedur
5. Domain: Nutrition-
focus physical findings
(PD)

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Asesmen Gizi Comparative standards (CS) Interpretasi
Domain: Riwayat Klien “client
histrory” (CH)
Class: Personal History (1)
Sub-Class: Personal Data (1.1)
• Umur: 40 tahun Kriteria usai menurut WHO, 2017: Usia dewasa
• 0-17 tahun: anak-anak dibawah umur (pemuda) : masa
• 18-65 tahun: pemuda produktif
• 66-79: setengah baya
• 80-99: orang tua
• 100 tahun ke atas: orang tua berusia
panjang
• Jenis kelamin: laki-laki
• Agama: Islam
• Pekerjaan: PNS
• Kebiasaan merokok: sejak
SMS sd sekarang
• Peran dalam keluarga: kepala
keluarga, tinggal bersama
istri dan kedua anak
NCP Terminology/ADA/2015 11/08/2019
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Dokumentasi Asesmen Gizi

Asesmen Gizi Comparative standards Interpretasi

(CS)
Domain: Riwayat Terkait
Gizi dan Makanan “food
history” (FH)

Lengkapi

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Dokumentasi Asesmen Gizi
Asesmen Gizi Comparative standards Interpretasi
(CS)
Domain: Anthropometry
(AD)
Class: Body
composition/growth/weig
ht history (1.1)
• TB : 176 cm
• BB : 85 kg
• IMT : 27.44 kg/m2 Klasifikasi BMI/IMT: Obese grade I
Underweight: <18.5
Normal: 18.5 – 22.9
Overweight: ≥ 23
At risk: 23.0-24.9
Obese I: 25.0-29.9
Obese II: ≥ 30
(Asia Pacific BMI cut off
NCP Terminology/ADA/2015 points, 2014) 11/08/2019
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Dokumentasi Asesmen Gizi

Asesmen Gizi Comparative Interpretasi

standards (CS)
Domain: Data Biokimia,
Tes Medis, dan Prosedur
(BD)

Lengkapi

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Dokumentasi Asesmen Gizi

Asesmen Gizi Comparative Interpretasi

standards (CS)
Domain: Nutrition-focus
physical findings (PD)

Lengkapi

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Assignment

 Selesaikan case study dengan menggunakan tabel dokumentasi

Asesment Gizi

 Tugas di kerjakan per individu dan di ketik

 Deadline: Senin, 11 Februari 2019

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