The dietitian and nurse are important team members who assess, promote, and provide nutritional and health instruction. When the dietitian, takes a thorough Nutrition Health Assessment, the goal is to make every visit a positive and informative experience where the client always leaves with one important new piece of information. Beverly Price, RD, MA, RYT, explains how to maximize the experience with her feature “PUTTING IT ALL TOGETHER–THE NUTRITION AND HEALTH ASSESSMENT”
The dietitian and nurse are important team members who assess, promote, and provide nutritional and health instruction. When you, the dietitian, takes a thorough Nutrition Health Assessment, the goal is to make every visit a positive and informative experience where the client always leaves with one important new piece of information. Clients need to play an active role in their treatment decisions in order to heal. Great emphasis needs to be placed on the teaching role of the nutrition specialist to ensure that the client leaves feeling good about himself, enjoys food without guilt, and is able to talk about and confront his health issues. Your role is to equip your client to make permanent behavioral changes.
The nutritional counseling process is an approach to problem solving that allows the dietitian to gather data from the client, analyze it, and organize it in such a way that the clients can resolve their nutritional problems. While working as a team, the dietitian, nurse and client will develop an individualized nutritional plan along with supportive therapy. The information gathered through the assessment will serve as the foundation for critical thinking and problem solving.
As a health professional, you may have learned in school and in theory that the four steps to educating are: assessing, planning, implementing, and documenting. With each visit comes assessment and evaluation of where the client is at that time, and you must begin the process of planning, implementing and documenting again and again. This is all well and good, but let’s go beyond this standard routine and break the mold. Begin to understand and “know” the client so that she feels as if she has truly has made a connection with you and feels as if she has derived value and benefit from what you are offering.
INTRODUCTION TO THE CLIENT
When you shake hands, your session begins. Who is the person that walks into your office? When a client has been recently diagnosed with an illness, he or she may have many troubling feelings about their health. If a client has been through many nutrition and health programs and has been unsuccessful with change, he or she is very skeptical of meeting you. Therefore, there may be confusion, anger, defensiveness, and your client will appear overwhelmed. It is up to the health expert to turn the session into a purposeful, beneficial, and effective meeting while being attuned to what the patient is feeling as he or she walks into your office. Do try to help the client to relax. The client may be worried about what you may say or they may feel ashamed to talk about themselves. You want to invite honesty and openness. So greet this person, shake hands, and be compassionate and most of all, show competency. You are building a rapport with this person or family. You serve a valuable role in the care of their health.
Don’t sit behind your desk. Your visits are client centered. If possible, pull up a chair beside or near the client. Begin to look at the whole person in terms of body, mind, and spirit. It is your personal responsibility to lead the client into self-care and wellness. The beginning of the session is a good opportunity to begin your thought process. Take a moment to view the beauty within the person sitting beside you. You are about to gain an understanding and appreciation of the whole person and not a client who has a disease. Yes, shed light on the problem, which is the first reason the client has come to you. Try to also look at the big picture—jump out of the envelope. The assessment time is that discovery time. Here you will get a wealth of practical information.
You want interaction. You are building a relationship at this time. You want to ask the proper questions and listen and learn what the client is trying to tell you. There will always be feelings attached, along with explanations, in the consultation. Make the client feel you can be trusted and this session is confidential. Reassure the person who sits with you about your role in their treatment plan. The better you understand your client, the better you can help them make important decisions on their own.
REASON FOR SEEING THE DIETITIAN
Your direct questions regarding the reason for seeing you clears the air, defines what the first meeting is all about and a sets the purpose for the client coming to see you. Repeat it back, after you organize it in your mind, to verify what was told to you. Hopefully, the client’s responses are what is clearly in their mind and is what they want to accomplish in the first conference. Remember, patients today want to play an active role in their health care and you are the educator they are paying. You must deliver their healthcare in a manner that they seek out or they won’t return. Listen to what is being said. Give the client what they want versus what you think they need.
PERSONAL MEDICAL HISTORY
You are assessing for all nutrition and health related problems. You must go through a checklist of health-associated complications, as many will not voluntarily give you this information unless you ask. You are trying to obtain a clear picture of what is being said. Start with the head, work through the digestive system and end with elimination. You will truly see a different picture. If you don’t inquire, it will be tossed in along the way, when you least expect it, as you are counseling.
Take a good look at the person in front of you; his general state of health, physical appearance, his energy level. Keep this in mind and define the client physically, emotionally and spiritually to yourself.
FAMILY MEDICAL HISTORY
Keep in mind the word, “prevention.” It gives another important piece of information about where your client is going. Preventative nutrition and health is an area that clients may come in to see a dietitian or nurse to discuss as a primary issue. Or, this might be an area to discuss at later scheduled appointments. Genetically, a client may be predisposed to develop a malady that is similar to another family member. Many problems that run within families are nutritionally related so your plan can include preventative measures to avoid further complications.
RELATIONSHIPS: FAMILY AND SOCIAL HISTORY
It is important for your client to have a family support network. Start to understand the workings of your client’s household. If you don’t allow for this in the assessment, your client may be unable to perform set tasks you ask of him or her. Ask questions about the family structure, as a support system is critical to success. You are looking for criteria to determine healthy families and their abilities to provide for physical, emotional, social and spiritual needs of your clients. When planning for nutritional needs, recognize marital status along with members and their role in the household. If your client is a child, who is the child’s support group and what are the responsibilities of each person?
Listen, listen, and listen for behaviors, emotions, and habits. You need to be aware and pay close attention. Each individual has an eating style that is unique to him or her. Does your client shop for food, prepare food, and is this person able to handle these tasks on his or her own? If your client’s lifestyle involves eating out most of the time, be flexible enough to coach in that very direction. This section will be the area that demands empowerment of the patient although life circumstances need to be considered. Does the person in front of you have limited resources with what you are asking them to do?
Show the client a food list and ask them:
* What do you eat from this list?
* What do you like or dislike?
* Do you binge on any foods?
* Are any “unsafe” foods? (foods that they fear)
You may be dealing with a potential eating disordered client—a vast majority of individuals that walk through your door may have some type of food issue. If this is not your specialty, please… refer them to a nutritionist and therapist team that is trained in working with eating disorders. If you attempt to work with this client without formal training in this area, you can do tremendous damage to the client and can be liable.
The client’s thoughts about food form the basis of your education. It is at this point in the assessment when nutritional understanding and the client’s medical diagnosis will be coming together. Do not let your food beliefs or preferences influence your care plan.
Question your client on how you can best serve him or her. Your goal is to be the last stop shopping. Inquire what would make them stay on your meal plan and what problems they fear in following your lead. This is an area in counseling that you need to become skilled at. Listen very carefully. Sum up your client’s personality and learning style or ask how they gain knowledge best. Many individuals come with inflexible attitudes and resist change. This is a key to successful counseling. Remember, you are coming up with a way of life that will encompass all dimensions of living. Assume the client will need dietary common sense.
Conduct a one- day diet recall. Find out what your client drinks, whether or not they use “diet foods,” if and where they eat out, what they order in restaurants, what they prepare at home, what foods they carry in, and who cooks? Much knowledge comes out about your client regarding routine, behaviors, thinking patterns and lifestyle.
Practices that distinguish a social drinker from a heavy drinker and an alcoholic will add to your insight of the client. Does this client smoke or does he live with second hand smoke? Both practices have nutrition and health consequences. This is an area that can be addressed in your care plan. Those with addictions may need to be referred to a therapist. Addictions come out in food behaviors also.
MEDICATIONS, VITAMINS, MINERALS, AND HEALTH SUPPLEMENTS
Ask for a listing of all medications that your client is taking. Later, you might have to do some homework to find out if there are any contraindications or precautions with foods. Sometimes, just changing how a client administers medications may erase some side effects. Many medications have nutritional side effects that will have to be attended to at follow up meetings.
Clients must be questioned on supplement use. They are often hesitant and unwilling to let the doctor know what they are taking. It is a comfortable environment with a dietitian or nurse, and the client may be more willing to bring them and discuss them with you. When putting their plan together for future visits, research these supplements and talk to your client about adverse or positive side effects.
Nutraceuticals are being used by many clients to treat various health conditions and also for enhancing the body musculature. This is a very new and vital area to access, as it will open more avenues to follow up visits. This is especially true if the client wants you to evaluate what they are administering to themselves. They may ask for your suggestions as to what to take. Become informed. The overload of information given to the public is hard to interpret.
EXERCISE AND MIND-BODY MEDICINE
Is your client sedentary, or does he or she have a regular exercise program, or is he or she very active? Is the client involved in a fitness program and if so, what does it entail? What is the client’s exercise history over the years? Do they have good intentions to start an exercise program but in the past have failed to keep it up? Ask about the environment at home and does it provide easy convenience to doing exercise. If your client exercises, he or she will be more open to creating other healthy habits. You might want to include their time schedules in your assessment and question the practicality of purchasing home equipment. You want to motivate them to begin a fitness program. Most clients already know the benefits of exercise. They need you to coach them into how to make it a reality.
Each person is quite different and many already have a wonderful knowledge of what is available and how it works. Your office should be full of literature about mind/body healing. Test the client’s knowledge and ask what they have done before in the spirituality department. You can speak about this in follow up sessions. Introduce yoga, meditation and other forms of stress management that will help your patient get in touch with his or her inner self.
STRESS MANAGEMENT AND RELAXATION
Lifestyle is a very important piece of the puzzle when assessing a client. Tension, stress and lack of sleep can leave the body with physiological symptoms. Stress management and how to create time out for it, can be a learned behavior. Your client may need to be referred to a qualified therapist if his or her stress level is far from the norm. Pay attention to the client’s reaction because this continual fight/ flight response may come out in your sessions. The very fact that the client is beginning a program designed to change their food behaviors triggers negative responses, and old anger may surface. This will make future counseling sessions challenging. You might have to work very hard at keeping the client coming back.
At the close of the assessment, which can last from one hour to one and a half hours, explain what your client can expect with the follow up sessions. Ask what outcomes or goals your client wants to accomplish. This becomes quite different from the initial ones the client had in mind before your initial meeting. Tell your client what you hope to achieve if they follow through with each appointment. Stress the fact that your interaction is a partnership together with your client. Your job is to allow your client to achieve their own goals with your “tweeking” in order to achieve what they need for improved outcome.
The western world has created goal setting as a way of measuring, documenting, and focusing on what is necessary for the client to know. It is attached to an expected outcome. It makes the dietitian accountable and forces standardization. An example would be a patient with diabetes must understand the timing of meals, amounts of carbohydrates in food, ways to lower lipids, and stay in normal ranges for blood sugar. The client must have this also as a goal so he or she will change his or her eating behaviors and have better glycemic control. This is measurable. This gives the client a road to travel and gives him or her time frames from visit to visit. This will include skills and behavior changes. However, we all know that some things are beyond everyone’s control.
It is important to consider what the client is willing to do or you and the client will be set up for failure. At the end of the session there should be some understanding of what will be the next step. Set general goals with your client so they have an idea of the big picture but specific enough that they will start thinking about the first step. Make sure that there are only one or two goals set as too many will be come too overwhelming for the client. Don’t be surprised by the client who appears not to be listening too well, but comes back at the first follow-up having achieved his goals.
Keep these mantras in mind when working with your client. You can even transpose and copy these for your client:
· Not to worry, there are no failures. Any small new behavior change in the right direction is of great importance.
· Compare progress only with oneself.
· Increase level of awareness through self-discovery.
· With each client comes a sense of differences and each has traditions that they want to preserve, know yourself.
· Listen to the needs of one’s own body and be true to self.
· Stop attributing eating behaviors to personality weakness.
· Eliminate guilt.
· Add more nourishing foods because of love for self and love of one’s own body.
· Redefine what is one’s own unique diet for optimum physical, mental and spiritual health.
· Eat consciously.
· Grant time for changing one’s old routines and set up priorities.
Excerpted from Counseling School, What Your Professors Never Taught You in Your Dietetics or Nursing Curriculum—
A Continuing Education Manual and CD by
Jump Start Consulting, LLC, www.gettingthatjumpstart.com