Nutrition Diagnosis

Nutrition Diagnosis

Instructions:

To meet this competency, please choose one of the cases listed on this page, and work up a PES statement. You can also use this same client to fill out your sample chart note for competency 10. To demonstrate the competency, be prepared to share your chart note during your Competency Check #1 meeting.

  1. A 57-year-old Caucasian male; reports high levels of stress at work. Hates vegetables, is a "meat and potato guy". Consumes a 6 pack of beer per night to "wind-down". Does not see a therapist; reports they did not talk about mental health growing up. Labs show low serum B12, low serum folate, and high MCV.

  2. A 62-year-old Hispanic male. reports frequent urination, excessive thirst, and weight loss. Skips breakfast, usually has a sandwich for lunch, and animal protein, starch, and one veggie for dinner. Drinks multiple cups of coffee during the day, and has to nap around 3 pm every day. Unable to exercise due to arthritis pain in knees.

Common Nutrition “Problems”

Intake:

  • Inadequate energy intake

  • Excessive energy intake

  • Inadequate fluid intake

  • Excessive fluid intake

  • Excessive alcohol intake

  • Increased nutrient needs:

  • Decreased nutrient needs:

  • Inadequate fat intake

  • Excessive fat intake

  • Inappropriate intake of fats

  • Inadequate protein intake

  • Excessive protein intake

  • Inadequate carb. intake

  • Excessive carb. intake

  • Inappropriate intake of carb.

  • Inadequate fiber intake

  • Excessive fiber intake

  • Inadequate vitamin/mineral intake:

  • Excessive vitamin/mineral intake:

Clinical:

  • Swallowing difficulty

  • Chewing difficulty

  • Altered GI function

  • Impaired nutrient utilization:

  • Food/medication interaction:

  • Underweight

  • Involuntary weight loss

  • Overweight

  • Involuntary weight gain

  • Inadequate milk production

  • Breastfeeding difficulty

Behavioral:

  • Food/nutrition knowledge deficit:

  • Harmful beliefs/attitudes re: food:

  • Not ready for diet/lifestyle change:

  • Disordered eating pattern

  • Undesirable food choices

  • Physical inactivity

  • Excessive exercise

  • Inability to prepare foods

  • Lack of access to food

  • Inability or lack of desire to manage self-care

Common Nutrition “Etiology”

  • Antecedent- Genetic SNPs

  • Antecedent- Family history of XYZ

  • Antecedent- Childhood exposure to environmental/cultural/social/medical/nutrition component 

  • Antecedent - Placed on diet in childhood

  • Antecedent - ACES 

  • Antecedent - Experienced family members discussing dieting/preoccupation with body image in childhood

  • Antecedent - Experienced family members with chronic illness in childhood

  • Trigger- Having had experienced Injury

  • Trigger- Having had experienced Food poisoning

  • Trigger- First diet at age XYZ

  • Trigger/Mediator- Exposure to Trauma

  • Trigger/Mediator- Exposure to Family/social dynamics

  • Trigger/Mediator- Exposure to Stress- health, family, work…

  • Mediator- Experiencing Knowledge deficit regarding nutrition, physical activity and/or health condition

  • Mediator- Experiencing Accessibility Barrier to food/medical services/exercise 

  • Mediator- Experiencing Diagnoses (depending on “P,” diagnoses may be in “S”)

  • Mediator- Exposure to Medications- nutrient depletions, interactions, side effects

  • Mediator- Desire for thinness/focus on body ideal


Common Nutrition “Signs & Symptoms”

Symptoms:

  • Constipation 

  • Diarrhea

  • Acid Reflux

  • Gas

  • Bloating

  • Bowel urgency

  • Straining with Bowel Movement

  • Brain fog

  • Fatigue

  • Difficulty concentrating

  • Anxiety

  • Low mood

  • Painful periods

  • Bloating during/before menstrual cycle

  • And so many more… 

NFPE Findings:

  • Dry scalp/skin

  • Brittle nails, white spots on nails…

  • Easy bruising

  • Hyperkeratosis pilaris

  • Rashes

  • Stomatitis

Food Record Findings

Diagnoses (depending on “P”, diagnoses may also be in “E”)

Lab Findings

  • Elevated or low lab work- list specifically (ie. HbA1c 7.4-H, LDL 289-H, 25-OH-D 7-L…)

  • Test findings that are not WNL- list specifically (ie. elevated Methanobrevibacter smithii, polyps found during colonoscopy…)

  • Blood Pressure (H or L)