Nutrition Assessment: Client History Flashcards
3 chief components of client hx?
personal history, medical history, social history
what is included in med hx?
health hx (pt and family), treatments and therapies, meds
basic methods to obtain info p.t. individual client history
client or proxy report, med records, referring health care provider, referring agency
basic methods obtain info p.t. populations client hx
surveys, administrative data sets
examples of personal data?
age, gender, sex, race/ethnicity, language (SLP, notepads), literacy, education, role in family (ie. primary caregiver?), tobacco use, physical disability, mobility
medical history takes a ____ approach
body systems (cardiovascular, endocrine/metabolic, excretory/urogenital, GI, hematology/oncology, immune, integumentary, musculoskeletal, neuro, psych , resp
examples of med treatments and therapies :
chemo, dialysis, mech ventilation/O2 therapy, ostomy, radiation therapy, therapies from other providers (i.e. allied health providers)
examples of surgical treatments and therapies:
CABG, gastric bypass, intestinal resection, joint/orthopedic surgery/replacement, limb amputation, organ transplant, gastrectomy
examples of palliation/end of life care
individuals with life threatening conditions, care of individuals with terminal illness
why important document pt med hx?
interact with nutrients, relevant side effects (eg. wt loss/gain), impact on biochem parameters, impact nutrient status, provide insight into med conditions if full med hx not documented
ex of social hx:
socioeconomic factors, living/housing situation (running water), domestic issues, social/medical support, geographic location of home (urban vs rural, sunlight), occupation, religion, major recent life events, activity level, daily stress level, are dietitian services covered
how to counsel when people are passionate about diets not healthy?
risks vs benefits, “how does this make you feel”
