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Memorandum
Date: June 20, 2005
To: UAWA
From: Phyllis Crowley
State Nutrition Coordinator
Subj.: VENA Module Part I
All CPAs and RDs in the Utah WIC Program must complete the VENA Module,
Part I, including Progress Check, Practical Assignment and Case Study.
In this VENA Module, Part I, each CPA and RD must complete the following
items, staple together and send to me at the State WIC Office by October 1,
2005.
Progress Check
Practical Assignment
Case Study
Please remember with the full implementation of Nutrition Risk Revisions 7 & 8
and VENA, all of the History Forms and the Food Guide Pyramid Tool can be
eliminated; thus, essentially replacing this paper method of data collection with
the VENA Nutrition Assessment Interview Process which involves the use of the
Utah VENA Templates and the Springboard Questions/Statements located in the
VENA Module.
Thank you for your commitment to quality nutrition services in the Utah WIC
Program.
VENA Module
Part I
Utah WIC Program
June 2005
Introduction
Value Enhanced Nutrition Assessment (VENA)
The Bridge Linking Nutrition Assessment to Nutrition Education
What is VENA?
Value Enhanced Nutrition Assessment (VENA) is a new initiative from the United
States Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) to
improve nutrition services in the WIC Program. It is part of a larger process
known as Revitalizing Quality Nutrition Services (RQNS). RQNS cultivates
projects and initiatives that revitalize and improve WIC nutrition services on a
continuous and ongoing basis. VENA provides WIC nutrition assessment
guidance to enhance and ensure the collection and interpretation of accurate and
relevant nutrition/health information - the first step in providing targeted and
relevant nutrition services to WIC participants.
Why is VENA Important?
VENA’s mission is to focus the purpose and scope of a multi-faceted WIC
nutrition assessment, not only for program eligibility determination, but more
importantly for the delivery of targeted and relevant WIC nutrition services –
nutrition education, referrals and food package tailoring. The WIC nutrition
assessment process has been viewed primarily as a means to identify nutrition
risk for the purpose of determining WIC Program eligibility.
VENA is the stepping stone towards connecting the assessment process to
compliment innovative, participant centered nutrition education practices.
Because many State and local WIC Programs have been incorporating adult
learning principles and alternative methods to deliver WIC nutrition education
more effectively, an evaluation of the processes used for WIC nutrition
assessment was also necessary.
1.
Development of VENA –
The Bridge Linking WIC Nutrition Assessment to Nutrition Education
The development of VENA was accomplished by a workgroup consisting of FNS
Headquarters and Regional Office staff and representatives from the National
WIC Association (NWA). FNS convened the joint workgroup in September of
2003. The charge to the VENA workgroup was to develop guidance that would
define for all State and local WIC agencies the components of a quality WIC
nutrition assessment process (to include anthropometric, biochemical, nutrition-
related medical conditions, predisposing risks and dietary assessment) across all
WIC Programs. The VENA workgroup was also charged with highlighting the
importance of assessment as it relates to nutrition education.
To complete its charge, VENA utilized this guiding principle: Strengthen and
redirect WIC nutrition assessment from eligibility determination to individualizing
nutrition education in order to maximize the impact of WIC nutrition services.
The implementation of VENA guidance will provide WIC staff with solid data and
information on which to base nutrition education, food package selection and
referrals.
VENA is the bridge that connects WIC nutrition assessment to effective and
appropriate nutrition intervention that best meets each participant’s needs.
Utilization of the techniques and resources offered through VENA will help to
ensure that WIC continues to address traditional and emerging health issues and
immediate concerns as well as potential threats to the nutritional health of its
participants long after they are no longer categorically eligible to receive WIC
benefits.
VENA templates are tables of pertinent data collection questions for each
category of WIC participant (P, B, N, I, C: 12 -23 mo; and C: 2-4 years). These
templates, located in the Appendix, have been incorporated into the computer
system as guidance tools to be used in conjunction with the Health Outcome
Based Models (pp 14 -37) when conducting a quality nutrition assessment.
2.
The Role of the Institute of Medicine
USDA has looked to the Institute of Medicine (IOM) to provide science based
information to guide them in making program policy decisions. Two reports
generated by the IOM (commissioned by USDA) were an important impetus
behind the development of VENA.
1) 1996 Institute of Medicine (IOM) Report1:
Nutrition and health assessments in the WIC Program are crucial to the
determination of an individual’s eligibility for WIC and for subsequent preventive
guidance. WIC nutrition risk criteria were initially developed to target WIC’s
limited resources to low-income individuals with poor health outcomes or at
greatest risk of developing poor health outcomes. The 1996 IOM report, entitled
WIC Nutrition Risk Criteria: A Scientific Assessment concluded that nutrition risk
criteria used in the WIC Program should serve both as indicators of nutrition and
health risk as well as indicators of nutrition and health benefit.
Indicators of nutrition and health risk should select those who have the greatest
need for the services provided by the WIC Program because of poorer health or
nutritional status at the time of assessment or because they are at future risk of ill
health that can be related to nutritional status.
Indicators of nutrition and health benefit, on the other hand, are those that select
applicants who are most likely to benefit from participating in the program over
those whose conditions are less likely to benefit from the WIC Program and all it
has to offer.
The 1996 IOM report provided the WIC community with a starting point to further
strengthen the WIC Program. The National WIC Association (NWA) and FNS
established a collaborative partnership, the Risk Identification and Selection
Collaborative (RISC), to address the issues and recommendations by the IOM, to
develop an action plan to standardize State Agency risk criteria, and to apply
emergent science in the development of risk criteria. In April of 1999, all State
agencies adopted the uniform nutrition risk criteria, as outlined in FNS Policy
Memorandum 98-9. RISC continues to work to revise and update the nutrition
risk criteria as new evidence based information becomes available.
1
Institute of Medicine; Committee on Scientific Evaluation of WIC Nutrition Risk Criteria. WIC nutrition
risk criteria: A scientific assessment. Washington, DC: National Academy Press; 1996.
3.
While the report included recommendations for use/non use of specific criteria
and criteria cut-offs, the 1996 IOM Committee did not find sufficient scientific
basis for developing standardized cut-offs for two dietary risk criteria: failure to
meet Dietary Guidelines (risk #401) and inadequate diet (risk #422). The
committee recommended that research be undertaken to develop and validate
dietary assessment tools for use in the WIC Program. As a result, FNS policy
related to these dietary risk criteria, allowed State agencies to define, as they
deemed appropriate, these two criteria, until such time as more information was
available to uniformly define dietary risk in the WIC Program
2) 2002 Institute of Medicine Report2:
To address the unresolved issues related to dietary risk in the WIC Program,
USDA, with recommendations from RISC, commissioned the IOM to complete
another study. The IOM was tasked with convening an expert committee to
propose a framework to assess dietary risk for program eligibility of WIC
applicants based on the Dietary Guidelines. The committee was also charged
with recommending specific cut-offs for the definition of the risk criterion, Failure
to Meet the Dietary Guidelines. In 2002 the IOM published the report, Dietary
Risk Assessment in the WIC Program.
The expected outcome of the IOM report on dietary risk was a science-based
definition of Failure to Meet the Dietary Guidelines that could be used across all
WIC Programs nationally. However, the committee’s study resulted in five study
findings and a single recommendation.
Finding 1. A dietary risk criterion that uses the WIC applicant’s usual intake of
the five basic Pyramid food groups as the indicator and the recommended
numbers of servings based on energy needs as the cut-off points is consistent
with failure to meet Dietary Guidelines.
Finding 2. Nearly all U.S. women and children usually consume fewer than the
recommended number of servings specified by the Food Guide Pyramid and,
therefore, would be at dietary risk based on the criterion failure to meet Dietary
Guidelines.
Finding 3. Even research-quality dietary assessment methods are not
sufficiently accurate or precise to distinguish an individual’s eligibility status using
criteria based on the Food Guide Pyramid or on nutrient intake.
2
Institute of Medicine; Committee on Dietary Risk Assessment in the WIC Program. Dietary risk
assessment in the WIC program. Washington, DC: National Academy Press; 2002.
4.
Finding 4. Physical activity assessment methods are not sufficiently accurate or
reliable to distinguish individuals who are ineligible from those that are eligible for
WIC services based on the physical activity component of the Dietary Guidelines.
Finding 5. Behavioral indicators have weak relationships with dietary or
physical activity outcomes of interest. As a result, they hold no promise of
distinguishing individuals who are ineligible for WIC from those who are eligible in
the category of dietary risk.
Based on these findings the IOM committee made the following
recommendation:
Presume that all women and children ages 2 to 5 years who meet the
eligibility requirements of income, category and residency status
also meet the requirement of nutrition risk through the category of
dietary risk based on failure to meet Dietary Guidelines, defined as
consuming fewer than the recommended number of servings from
one or more of the five basic food groups (grains, fruits, vegetables,
milk products and meats or beans) based on an individual’s
estimated energy needs.
The IOM made clear in its recommendation that the intent was not to affect the
current use of other nutrition risk criteria for eligibility determination. That is,
information should continue to be collected for the identification of potentially
serious nutrition risk factors, such as growth issues, iron deficiency, or
predisposing medical conditions related to nutrition. The assessment of non-
dietary risk criteria is required for the priority placement of participants, to provide
the necessary referrals and individualized nutrition services, and to ensure the
integrity of the WIC Program as a premier public health nutrition program.
Scope of VENA
VENA provides information and guidance to enable WIC staff to perform a quality
WIC nutrition assessment that screens for nutrition risk criteria (anthropometric,
biochemical, and dietary) as well as other health indicators
(clinical/health/medical and predisposing risks). The collection of
comprehensive, relevant nutrition assessment information is necessary to deliver
meaningful nutrition services to WIC participants.
5.
Art and Science of Nutrition Assessment
Process of a Quality Nutrition Assessment
Nutrition assessment is the first step in the nutrition care plan process. The
intent of VENA is to provide guidance on how to conduct WIC nutrition
assessments accurately, thoroughly, yet efficiently in a day and age when time
and staffing resources are limited.
A quality WIC nutrition assessment is a blending of art and science. It requires
staff well-trained in communication, critical thinking skills, and fundamentals of
assessment using a systematic approach to collect accurate and essential
nutrition assessment information.
The process of a quality WIC nutrition assessment includes:
1. Collecting accurate and essential information
2. Applying communication skills to foster openness and rapport with the
participant
3. Organizing, synthesizing and evaluating the collected information
4. Drawing appropriate conclusions and relationships from the information
collected
5. Identifying solutions, prioritizing the issues discovered, developing a plan
of care
6. Documenting the information and conclusions concisely and accurately
7. Referring to other needed resources
8. Closing the loop – providing follow-up as necessary
This section describes the processes, as well as the staff competencies,
necessary for a quality WIC nutrition assessment, to ensure that a complete
assessment is performed for every WIC participant. This guidance is provided to
assist WIC staff in using the assessment information they gather to gain insight
into the participants’ needs in order to help them learn to make better choices to
live healthier lives.
6.
To further understand the critical components of the assessment process, one
should understand the definition of assessment in generic terms. According to
the Cambridge Advanced Learner’s Dictionary, to assess means “to judge or
decide the amount, value, quality or importance of something.” The American
Heritage Dictionary defines it as such: “to determine the value, significance, or
extent of; appraise; to estimate.” By the very nature of determination, it is easy to
see that assessment is not an exact science, and that there are factors that will
impact the quality and accuracy of an assessment of any situation.
What is it that defines a successful assessment? Ideally, assessment would
consist of the WIC staff person identifying each and every risk pertinent to the
client through careful, yet systematic data collection and questioning. The
ultimate goal is a complete care plan that identifies the participant’s needs in a
prioritized manner and maintains continuity of care throughout subsequent visits.
The process of a quality WIC nutrition assessment includes:
1. Using a Systematic Approach to Collect Essential Information
Using a systematic approach to collect essential information helps to ensure that
relevant information is gathered efficiently, and data is not missed.
The American Dietetic Association describes a “process approach” to nutrition
care as the systematic identification and management of activities and the
interaction between activities.i A process approach in nutrition risk assessment
emphasizes the importance of the following:
Understanding and meeting requirements
Determining if the process adds value
Determining process performance and effectiveness
Using objective measurement for continual improvement of the process
For a successful assessment to be done, it is necessary to develop a systematic
approach to ensure that all these aspects are addressed and covered in an
efficient manner, while allowing for critical thinking.
7.
A complete assessment is much more than collecting data and information and
entering it into a computer system or filling out the appropriate form. Collecting
high quality information requires excellent communication skills, the ability to
make a person feel at ease, and the ability to ask the right questions at the right
time in the right format. Good assessment practice considers all sources of
potential information - from lab data, anthropometric measurements, medical
history, interview and psychosocial and environmental issues that might have an
impact on eating/feeding/nutritional status.
When developing a system to collect information it is important to consider
personal style as well as agency policy. Using a system to collect information
helps to ensure that all pertinent information is gathered, and lessens the risk of
forgetting a step. A systematic approach can be quickly captured in a flow chart
or check-list format that lists individual steps in a sequential order. This
approach includes such actions as:
Preparatory work: Take the time to review what was done or
recorded at the previous visit.
Learn the data collection system well: Know how to maneuver
through a computer system smoothly.
Assemble VENA templates & springboard questions: Make
sure these resources are readily available.
Know what questions to ask: Some information must be
gathered through asking questions. Asking the right questions can
often streamline the process of collecting information, and improve
efficiency, a true advantage when time is of essence.
Follow a sequence of events: Know the order of all necessary
steps, and stay true to the order each and every time.
Gathering information in a systematic manner is important because it determines
the results of the nutrition assessment and the WIC benefits (nutrition education,
food package tailoring, and referrals) that are provided. Information needs to be
accurate, complete, and appropriate to effectively and efficiently tailor the service
or product in order to meet the participant’s needs and expectations.
2. Communication: Building Rapport and Partnering
Information collection involves communication, because the information must
move from one source to another. The communication can be verbal, where the
information moves from one person to another through dialog.
8.
The information can be physical, where body language can convey a
participant’s emotions, feelings or receptiveness. The information can also be
written, whether in a medical record, lab report, WIC file, or other written
communication. We know communication is important, but is there a specific
skill or technique for how to maximize the quality of the information collected?
Building rapport and trust will foster a communication style that will most benefit
the exchange of information between staff and participant.
Building rapport is a necessary skill for opening the lines of honest
communication with a participant to identify her needs and to create a safe
environment that will invite the sharing of information. Rapport is defined by the
Merriam-Webster dictionary as “relation marked by harmony. Rapport is part of
verbal and non-verbal communication that is non-threatening. For example, by
building rapport, you might learn of a recent behavior, such as putting infant
cereal in the baby’s bottle. Methods used to help develop rapport include:
Concentrate on what is being said by the participant
Don’t interrupt, correct erroneous comments or make a point while
gathering information
Use a non-threatening method of asking questions
Paraphrase to confirm what you think you heard (“So you have two
concerns about your baby . . . ?”
Focus on behaviors rather than generalizations of motives or attitudes
(Ask “Does your child eat at least five fruits and vegetables a day?” rather
than “Does your child like vegetables?”
Avoid judgmental comments, facial expressions and body language
Use positive body language: face the participant, uncross arms, sit up
with good posture, etc.
Observe the nonverbal behavior of the participant or caretaker
Collect all the information before moving to the nutrition education
segment because the highest nutritional risk could be the last one
mentioned by the participant.
9.
3. Organizing, synthesizing and evaluating the collected information using
critical thinking
Critical thinking is the ability to synthesize the collected information and evaluate
it appropriately. In nutrition assessment, it enables a person to identify what
information is pertinent, what is extraneous, what is accurate, what is not, and
how it is all related and connected to the technical information that forms the
basis of the nutrition professional’s knowledge about the individual’s risk
conditions. It is a process of integrating facts, informed opinions, active
listening, observations, and autonomous thinking to arrive at conclusions and
develop relevant plans of care.
Critical thinking is the use of cognitive skills or strategies that increase the
probability of a desirable outcome. It is used to describe thinking that is
purposeful, reasoned and goal directed – the kind of thinking involved in solving
problems, formulating inferences, calculating likelihoods, and making decisions
when the thinker is using skills that are thoughtful and effective for the particular
context and type of thinking task. Critical thinking also involves evaluating the
thinking process – the reasoning that went into the conclusion we’ve arrived at
and the kinds of factors considered in making a decision. Critical thinking is
sometimes called directed thinking because it focuses on a desired outcome. ii
The purpose of critical thinking is, therefore, to achieve understanding, evaluate
viewpoints, and solve problems. Since all three areas involve the asking of
questions, we can say that critical thinking is the questioning or inquiry we
engage in when we seek to understand, evaluate or resolve. iii Critical thinking is
deciding rationally what to or what not to believe. iv
Critical thinking is “the art of thinking about your thinking while you are thinking in
order to make your thinking better: clearer, more accurate, or more defensible.”v
4. Drawing the appropriate conclusions and relationships from the
information collected
Those who display higher levels of critical thinking skills care about whether their
beliefs and conclusions are true, and that their decisions are justified. In order to
accomplish this, they seek out all alternatives, explanations, and possibilities to
insure that they are not missing something, and try to keep as open a mind as
possible. Needless to say, they must be well informed and confident in their
knowledge base in order to accomplish this goal. They also tend to care about
the precision with which a position is presented, and are open and willing to listen
to others’ views and reasons.
10.
How does one recognize if critical thinking skills are being successfully
employed? Answering a question with another question is a good start. Asking
questions to generate more questions starts the process of weaving the web that
identifies and ultimately defines the relationships and inferences that can be
made from the collected information.
It is possible to assess one’s own thinking by evaluating thoughts against such
intellectual standards as:
Clarity – Could you elaborate further on that point? Could you express
that point in another way? Could you give me an example?
Precision – Could you give more details? Could you be more specific?
Accuracy – Is that really true? How could we check that? How could we
find out if that is true?
Relevance – How is that connected to the question? How does that bear
on the issue?
Fairness – Has all information been given equal consideration?
Logic – Does this really make sense? Does that follow from what you
said? How does that follow? When we think, we bring a variety of
thoughts together into some order. When a combination of thoughts
support each other and make sense in combination, the thinking is
“logical.”
Depth – How does your answer address the complexities in the question?
How are you taking into account the problems in the question? Is that
dealing with the most significant factors?
Breadth – Do we need to consider another point of view? Is there
another way to look at this question? What would this look like from the
point of view of the . . . . (participant, physician, etc.)?
Evidentiary support – Do you have facts or figures to back up your
conclusions?
Individuals who make decisions are often held accountable for their decisions.
This is true for staff in WIC who are conducting assessments and enrolling
participants. An inability to weave the web to find appropriate relationships and
draw accurate conclusions impacts the quality of services a WIC participant
would ultimately receive. The types of questions that these intellectual standards
generate should and can become a part of the inner voice that guides one to
better reasoning.
Reference: Universal Intellectual Standards; Linda Elder and Richard Paul; Foundation
for Critical Thinking website; www.criticalthinking.org
11.
5. Identifying solutions and prioritizing the issues discovered
Within the context of a WIC assessment, identification of solutions and prioritizing
issues is the bridge that spans the gap between risk assignment and the content
of the educational contact. When a WIC assessment results in the complete
identification of problems or risks, the next step for the WIC professional is to
prioritize the problems, develop a plan of action for future contacts to deal with
the identified issues, provide some initial counseling, and prescribe an
appropriate food package.
6. Documenting the information and conclusions concisely and accurately
Documentation of information in participant charts serves several purposes. It
can serve to provide evidence of the effectiveness of the care plan developed for
a WIC participant. In instances of litigation, documentation in a participant’s file
may be considered a legal document of what was done and what was not done.
Documentation is reviewed during management evaluations or program
monitoring in order to assure the quality of WIC services provided. A review of
documentation can reveal problem areas that might require training.
Adequate documentation is necessary for all the reasons previously mentioned,
but documentation should ultimately be done with the purpose of communicating
internally with other staff, and to help streamline workflow. Good quality
documentation should minimize the need for re-evaluating where to start
discussions with a participant when they walk in the door.
Documentation is critical to the WIC staff for internal communications. The right
type and quantity of information should provide such things as identified risks or
problems, referrals made and acted upon, topics discussed, problems
encountered, and goals set with the participant.
7. Referring to other resources
Referrals represent an integral component of the WIC Program. According to
Federal Regulations, the following types of referrals must be provided:
a. Local agencies shall maintain and make available for distribution to all
pregnant, postpartum, and breastfeeding women and to parents or
caretakers of infants and children applying for and participating in the
Program a list of local resources for drug and other harmful substance
abuse counseling and treatment.
b. State and local agencies shall provide WIC Program applicants and
participants or their designated proxies with information on other
health-related and public assistance programs, and when appropriate,
shall refer applicants and participants to such programs.
12.
c. The local agency shall, in turn, provide to adult individuals applying for
or reapplying for the WIC Program for themselves or on behalf of
others, written information about the Medicaid Program.
d. At least during the initial certification visit, each participant, parent, or
caretaker shall receive an explanation of how the local food delivery
system operates and shall be advised of the types of health services
available, where they are located, how they may be obtained and why
they may be useful.
8. Follow-up: Closing the loop
In the WIC setting, critical thinking is the process of being able to detect nutrition
and nutrition related risks. It involves asking open ended questions that are
probing in nature when more information is needed, and looking at that
information to identify what pertinent nutrition risks and issues affect the nutrition
health of the WIC participant. This process is not simple, nor is it fast. It requires
time to process and analyze the information collected, prioritize the issues
according to health risks, and re-evaluate the information for items that might
need to be addressed at future contacts.
Once an initial WIC nutrition assessment is completed, the conclusions drawn
from the process are used to guide and create an individualized WIC care plan,
including nutrition education goals and referrals to social and health services.
But the process doesn’t end there! Every time a participant returns, the WIC staff
should start the assessment process by following-up on progress made by the
participant from the previous visit. Look into his or her record – Did the
participant reach a goal that had been set at the previous appointment? What
barriers were experienced, if any? These types of follow-up questions close the
loop and help identify a starting point for discussions.
Following-up on goals is particularly valuable in facilitating behavior change. If a
participant learns to anticipate that the WIC staff will be asking specifically about
progress with a goal, it holds them more accountable each and every time they
return to the WIC clinic. In addition, participants appreciate the continuity of care
that is provided when WIC staff recognize and remember aspects of a previous
encounter.
Conducting quality nutrition assessments results in delivering quality nutrition
services at every WIC appointment. Quality services include re-assessment or
evaluation at each nutrition contact and certification to monitor progress towards
health-related goals. Without adequate follow-up, opportunities will be limited for
refining and realigning goals that ultimately contribute to positive healthy
outcomes for all participants.
13.
i
Lacey, K, Pritchett, E. Nutrition Care Process and Model: ADA adopts road map to quality care and
outcomes management. JADA, Vol. 103, No. 8, August 2003.
ii
Halpern, Diane F, Thought and knowledge: An Introduction to Critical Thinking, 1996
iii
Mariorana, Victor P, Critical Thinking Across the Curriculum: Building the Analytical
Classroom, 1992.
iv
Norris, Stephen P, Synthesis of Research on Critical Thinking, Educational
Leadership; 42:8; May 1985, pp. 40-45.
v
Paul, Binker, Adamson, and Martin (1989)
Health Outcome-based WIC Nutrition Assessment
The WIC Program has always been considered an adjunct to good health care in
order “to prevent the occurrence of health problems…and improve the health
status” of program participants. Because the goal for all WIC participants is good
health, nutrition assessment procedures must explore and address the various
factors that contribute to good health. Using health outcomes to define
comprehensive nutrition assessment is consistent with two national initiatives to
improve the health and well-being of Americans:
Healthy People 2010 Health Objectives
Bright Futures Guidelines for Health Supervision of Infants, Children, and
Adolescents
Healthy People 2010 serves as a broad agenda for health promotion and disease
prevention for all Americans. Bright Futures is a set of health supervision
guidelines designed to promote health and reduce the risk of disease in infants,
children, and adolescents.
The health outcome-based approach to WIC nutrition assessment is adapted
from the framework for Healthy People 2010 (HP 2010). The HP 2010
framework consists of goals, objectives, health determinants, and health status.
For WIC, the goal represents a desirable health outcome. The achievement of
the desirable health outcome is dependent upon “health determinants,” a set of
factors influenced by individual behaviors, past and current health conditions,
and family and environmental circumstances.
14.
Health Outcome-based Assessment
Using health outcomes in nutrition assessment results in a process that is goal
driven, positive, and structured, yet is flexible for regional, state, and local use
and adaptation.
The assessment becomes a joint exploration between WIC staff and the
participant or caregiver of an infant or child participant in which each health
determinant is examined and areas that are consistent are identified. The
participant or caregiver acknowledges her role in goal attainment and decides
how (or whether) to alter current behaviors.
Throughout the assessment process, current behaviors consistent with goal
attainment are recognized and supported. Behaviors that are not consistent with
goal attainment are further probed to identify causes, such as a lack of
knowledge or skill, attitudes and beliefs, cultural practices, family/support system,
and/or a lack of resources or access to a safe, nutritious food supply or to health
care services within the community. Education, including anticipatory guidance,
encouragement, and referrals are provided to support the participant in reaching
his or her goal.
“Springboard” questions and statements can be used to initiate dialogue for each
area, explore the health determinant, and to transition from one health
determinant to another. For example, the assessment of a pregnant woman
might begin as follows. “There are important steps you can take to help your
baby grow and be healthy. Can we explore these steps together?”
Health outcomes (goals) and a set of health determinants have been developed
for each WIC participant category. See following pages.
15.
Pregnant Woman Assessment
GOAL: Delivers a healthy, full-term infant while maintaining optimal health status.
HEALTH DETERMINANTS:
Makes an informed decision to breastfeed her infant.
Assesses her knowledge and attitudes about breastfeeding.
Identifies support to ensure a positive breastfeeding experience.
Receives ongoing preventive health care including prenatal care.
Achieves a recommended maternal weight gain.
Remains free from nutrition or food-related illness, complications, or injury.
Avoids alcohol, tobacco, and other drugs.
Consumes a variety of foods to meet energy and nutrient requirements.
SPRINGBOARD QUESTIONS AND STATEMENTS:
FIRST TRIMESTER:
How is your pregnancy going? Can you tell me about the prenatal care
that you are receiving?
Tell me about the changes you have noticed in your breasts.
What do you think about breastfeeding?
What does your family and spouse/partner say about breastfeeding?
SECOND TRIMESTER:
How is your pregnancy progressing? Can you tell me about the prenatal
care that you are receiving?
What does your family and spouse/partner say about breastfeeding?
What are your concerns about breastfeeding?
How are you preparing for your new baby and breastfeeding?
What concerns do you have about your breasts?
THIRD TRIMESTER:
How are you preparing for labor, delivery and your stay in the hospital?
What does your family and spouse/partner say about breastfeeding?
Tell me what you know about when to breastfeed your baby after delivery?
What do you know about how to position and latch your baby for
breastfeeding?
16.
How do you feel about rooming in with your baby?
What have you told your doctor about your plans for feeding your baby?
What concerns do you have about support at home after you and your
baby leave the hospital?
GENERAL AT ANYTIME DURING PREGNANCY:
Weight gain is a normal part of pregnancy. What are some of the weight
changes that you have noticed?
Your growing baby counts on you to stay healthy. How would you describe
your overall health?
What do you know about alcohol, tobacco, and drugs and what they can do
to your baby?
Many women say they change the way they eat when they find out they’re
pregnant. What changes have you made in your eating habits?
Essential Nutrition Assessment Data to Collect/Analyze for a Pregnant Woman:
Anthropometric:
1. Pregravid weight status and maternal weight gain pattern
a. 101 – underweight women
b. 111 – overweight women
c. 131 – low maternal weight gain
d. 132 – weight loss during pregnancy
e. 133 – high maternal weight gain
2. Physical Activity
Laboratory:
1. Low Hematocrit/Hemoglobin
a. 201
2. Elevated Lead level
a. 211
17.
Clinical/Health/Medical Viewed in the Table Below in Yellow Highlights:
Dietary/Nutrition Practices Viewed in the Table Below in Pink Highlights:
Predisposing Risks Viewed in the Table Below in Green Highlights:
Utah Nutrition Risk Factor Reference Sheet
High NR Description Priority Auto No
F#
Risk P B N I C Assign Regression
BMI < 18 101 Underweight Women 1 1 6 X X
<5th 103 Underweight or At Risk 1 3 X
111 Overweight Women 1 1 6 X X
113 Overweight (Children Age 2-5) 3 X
114 At Risk of Overweight 1 3 partial
121 Length/Height < 10th 1 3 X
X 131 Low Maternal Weight Gain 1 X
X 132 Wt Loss During Pregnancy 1 P partial X
P 133 High Maternal Weight Gain 1 1 6 B & N only X
X 134 Failure to Thrive 1 3
X 135 Inadequate Growth 1 3
X 141 Low Birth Weight 1 3 partial X
I 142 Prematurity 1 3 partial X
I 151 Small for Gestational Age 1 3 X
X 152 Head Circumference < 5th 1 X
153 Large for Gestational Age 1 X
3% below 201 Low Hematocrit 1 1 4 1 3 X
211 Elevated Blood Lead Level 1 1 6 1 3 X
X 301 Hyperemesis Gravidarum 1 X
X 302 Gestational Diabetes 1 X
303 Hx Gestational Diabetes 1 1 6
311 Hx of Preterm Delivery 1 1 6
312 Hx of Low Birthweight 1 1 6
321 Hx of Fetal/Neonatal Loss 1 1 6
P & < 16 331 Pregnancy < 18 yr. at 1 1 6 X
conception
332 Close Spaced Pregnancies 1 1 6 X
P 333 High Parity and Young Age 1 1 6
rd
3 Trimester 334 Lack of Prenatal Care 1 X
P, B 335 Multifetal Gestation 1 1 6 B & N only X
X 336 Fetal Growth Restriction 1
337 Hx of Birth of LGA Infant 1 1 6
338 Pregnant and Currently BF 1 X
X 341 Nutrient Deficit Disease 1 1 4 1 3
X 342 GI Disorders 1 1 4 1 3
X 343 Diabetes Mellitus 1 1 4 1 3
344 Thyroid Disorders 1 1 6 1 3
345 Hypertension 1 1 6 1 3
X 346 Renal Disease 1 1 4 1 3
X 347 Cancer 1 1 4 1 3
348 CNS Disorder 1 1 6 1 3
349 Congenital Disorders 1 1 6 1 3
350 Pyloric Stenosis 1
X 351 Metabolic Inborn Errors 1 1 4 1 3
Continued on next page
High NRF Description Priority Auto No
#
Risk P B N I C Assign Regression
352 Infectious Diseases 1 1 6 1 3
353 Food Allergies 1 1 6 1 3
354 Celiac Disease 1 1 6 1 3
355 Lactose Intolerance 1 1 6 1 3
356 Hypoglycemia 1 1 6 1 3
357 Drug Nutrient Interaction 1 1 6 1 3
P, B 358 Eating Disorders 1 1 6
359 Surgery, Trauma, Burns 1 1 6 1 3
360 Other Medical Conditions 1 1 6 1 3
361 Depression 1 1 6 3
362 Developmental Delays 1 1 6 1 3
371 Maternal Smoking 1 1 X
P 372a Alcohol Use 1 1 6 X
P 372b Illegal Drug Use 1 1 6
381 Dental Problems 1 1 6 1 3 gingivitis of Preg.
X 382 Fetal Alcohol Syndrome 1 3
401 Failure to Meet Diet Guidelines 4 4 6 5
411 Inappropriate Nutrition (I) 4
425 Inappropriate Nutrition (C) 5
427 Inappropriate Nutrition (P,B,N) 4 4 6
428 Diet Risk/Feeding 4 5
501 Possibility of Regression 7 7 7 7 X
502 Transfer of Certification 1 1 6 1 3 X
601a BF Mom of Infant-Prior 1 1 X
601b BF Mom of Infant-Prior 2 2 X
601c BF Mom of Infant-Prior 4 4 X
X 602 BF Complications - Women 1
X 603 BF Complications - Infant 1
701 Mom on WIC/Not on WIC 2 X
702a BF Infant of Mom-Prior 1 1 X
702b BF Infant of Mom-Prior 2 2 X
702c BF Infant of Mom-Prior 4 4 X
703 Mom w/Ment Prob/Sub Use-I 1
801 Homelessness 4 4 6 4 5 X
802 Migrancy 4 4 6 4 5 X
901 Environmental Risk 4 4 6 4 5
902 Guardian-Lmt'd Fdg Skills 4 4 6 4 5
903 Foster Care 4 4 6 4 5
Breastfeeding Woman Assessment
GOAL: Achieves optimal health during the childbearing years and reduces the
risk of chronic diseases.
HEALTH DETERMINANTS:
Receives ongoing preventive health care including early postpartum care.
Achieves a desirable weight or BMI.
Remains free from nutrition or food-related illness, complications or injury.
Avoids alcohol, tobacco, and other drugs.
Consumes a variety of foods to meet energy and nutrient requirements.
Breastfeeds her infant(s) successfully.
SPRINGBOARD QUESTIONS AND STATEMENTS:
How is breastfeeding going for you?
What are your concerns about breastfeeding?
What does your family, spouse/partner say about breastfeeding?
What has your doctor told you about breastfeeding?
How is your weight?
What questions do you have about health care, supplements and/or
medications?
Because you are breastfeeding your baby, it’s best to avoid tobacco,
alcohol and other drugs. What do you think about this?
What you eat and drink makes a big difference in your health, your energy
level and how you feel about yourself. Let’s talk about how you’re eating
now that you’re home with a new baby.
20.
Essential Nutrition Assessment Data to Collect/Analyze for a Breastfeeding
Woman:
Anthropometric:
1. Pregravid weight status and maternal weight gain pattern
a. 101 – underweight women
b. 111 – overweight women
c. 133 – high maternal weight gain
2. Physical Activity
Laboratory:
1. Low Hematocrit/Hemoglobin
a. 201
2. Elevated Lead level
a. 211
Clinical/Health/Medical Viewed in the Table Below in Yellow Highlights:
Dietary/Nutrition Practices Viewed in the Table Below in Pink Highlights:
Predisposing Risks Viewed in the Table Below in Green Highlights:
Utah Nutrition Risk Factor Reference Sheet
High NRF Description Priority Auto No
#
Risk P B N I C Assign Regression
BMI < 18 101 Underweight Women 1 1 6 X X
<5th 103 Underweight or At Risk 1 3 X
111 Overweight Women 1 1 6 X X
113 Overweight (Children Age 2-5) 3 X
114 At Risk of Overweight 1 3 partial
121 Length/Height < 10th 1 3 X
X 131 Low Maternal Weight Gain 1 X
X 132 Wt Loss During Pregnancy 1 P partial X
P 133 High Maternal Weight Gain 1 1 6 B & N only X
X 134 Failure to Thrive 1 3
X 135 Inadequate Growth 1 3
X 141 Low Birth Weight 1 3 partial X
I 142 Prematurity 1 3 partial X
I 151 Small for Gestational Age 1 3 X
X 152 Head Circumference < 5th 1 X
153 Large for Gestational Age 1 X
3% below 201 Low Hematocrit 1 1 4 1 3 X
211 Elevated Blood Lead Level 1 1 6 1 3 X
X 301 Hyperemesis Gravidarum 1 X
X 302 Gestational Diabetes 1 X
303 Hx Gestational Diabetes 1 1 6
311 Hx of Preterm Delivery 1 1 6
312 Hx of Low Birthweight 1 1 6
321 Hx of Fetal/Neonatal Loss 1 1 6
P & < 16 331 Pregnancy < 18 yr. at conception 1 1 6 X
332 Close Spaced Pregnancies 1 1 6 X
P 333 High Parity and Young Age 1 1 6
rd
3 Trimester 334 Lack of Prenatal Care 1 X
P, B 335 Multifetal Gestation 1 1 6 B & N only X
High NRF Description P B N I C Auto No
# Assign Regression
X 336 Fetal Growth Restriction 1
338 Pregnant and Currently BF 1 X
X 341 Nutrient Deficit Disease 1 1 4 1 3
X 342 GI Disorders 1 1 4 1 3
X 343 Diabetes Mellitus 1 1 4 1 3
344 Thyroid Disorders 1 1 6 1 3
345 Hypertension 1 1 6 1 3
X 346 Renal Disease 1 1 4 1 3
X 347 Cancer 1 1 4 1 3
348 CNS Disorder 1 1 6 1 3
349 Congenital Disorders 1 1 6 1 3
350 Pyloric Stenosis 1
X 351 Metabolic Inborn Errors 1 1 4 1 3
352 Infectious Diseases 1 1 6 1 3
353 Food Allergies 1 1 6 1 3
354 Celiac Disease 1 1 6 1 3
355 Lactose Intolerance 1 1 6 1 3
356 Hypoglycemia 1 1 6 1 3
357 Drug Nutrient Interaction 1 1 6 1 3
P, B 358 Eating Disorders 1 1 6
359 Surgery, Trauma, Burns 1 1 6 1 3
360 Other Medical Conditions 1 1 6 1 3
361 Depression 1 1 6 3
362 Developmental Delays 1 1 6 1 3
371 Maternal Smoking 1 1 X
P 372a Alcohol Use 1 1 6 X
P 372b Illegal Drug Use 1 1 6
381 Dental Problems 1 1 6 1 3 gingivitis of Preg.
X 382 Fetal Alcohol Syndrome 1 3
401 Failure to Meet Diet Guidelines 4 4 6 5
411 Inappropriate Nutrition (I) 4
425 Inappropriate Nutrition (C) 5
427 Inappropriate Nutrition (P,B,N) 4 4 6
428 Diet Risk/Feeding 4 5
501 Possibility of Regression 7 7 7 7 X
502 Transfer of Certification 1 1 6 1 3 X
601a BF Mom of Infant-Prior 1 1 X
601b BF Mom of Infant-Prior 2 2 X
601c BF Mom of Infant-Prior 4 4 X
X 602 BF Complications - Women 1
X 603 BF Complications - Infant 1
701 Mom on WIC/Not on WIC 2 X
702a BF Infant of Mom-Prior 1 1 X
702b BF Infant of Mom-Prior 2 2 X
702c BF Infant of Mom-Prior 4 4 X
703 Mom w/Ment Prob/Sub Use-I 1
801 Homelessness 4 4 6 4 5 X
802 Migrancy 4 4 6 4 5 X
901 Environmental Risk 4 4 6 4 5
902 Guardian-Lmt'd Fdg Skills 4 4 6 4 5
903 Foster Care 4 4 6 4 5
Assessment of a Non-Breastfeeding Postpartum Woman
GOAL: Achieves optimal health during the childbearing years and reduces the
risk of chronic diseases.
HEALTH DETERMINANTS:
Receives ongoing preventive health care including early postpartum care.
Achieves a desirable weight or BMI.
Remains free from nutrition or food-related illness, complications or injury.
Avoids tobacco, alcohol and other drugs.
Consumes a variety of foods to meet energy and nutrient requirements.
SPRINGBOARD QUESTIONS AND STATEMENTS:
Keeping yourself healthy is important so you can take care of your baby [and
other children]. Have you had your postpartum checkup yet (or when is it
scheduled)?
Most women are anxious to return to their pre-pregnancy weight or a desirable
postpartum weight. Let’s see what you weigh today.
Some women have medical conditions or problems during their pregnancies that
continue to affect their nutrition and dietary needs after the pregnancy ends.
Has your doctor told you that you have any medical conditions or health
problems now? Medications and supplements can also affect your nutrition and
health.
Using tobacco, alcohol and other drugs can affect your health and the health of
your family. Can we talk about this a little more?
What you eat and drink makes a big difference in your health, your energy level
and how you feel about yourself. Let’s talk about how you’re eating now that
you’re home with a new baby.
23.
Essential Nutrition Assessment Data to Collect/Analyze for a Non-Breastfeeding
Postpartum Woman:
Anthropometric:
1. Pregravid weight status and maternal weight gain pattern
a. 101 – underweight women
b. 111 – overweight women
c. 133 – high maternal weight gain
2. Physical Activity
Laboratory:
1. Low Hematocrit/Hemoglobin
a. 201
2. Elevated Lead level
a. 211
Clinical/Health/Medical Viewed in the Table Below in Yellow Highlights:
Dietary/Nutrition Practices Viewed in the Table Below in Pink Highlights:
Predisposing Risks Viewed in the Table Below in Green Highlights:
Utah Nutrition Risk Factor Reference Sheet
High NRF # Description Priority Auto No
Risk P B N I C Assign Regression
BMI < 18 101 Underweight Women 1 1 6 X X
<5th 103 Underweight or At Risk 1 3 X
111 Overweight Women 1 1 6 X X
113 Overweight (Children Age 2-5) 3 X
114 At Risk of Overweight 1 3 partial
121 Length/Height < 10th 1 3 X
X 131 Low Maternal Weight Gain 1 X
X 132 Wt Loss During Pregnancy 1 P partial X
P 133 High Maternal Weight Gain 1 1 6 B & N only X
X 134 Failure to Thrive 1 3
X 135 Inadequate Growth 1 3
X 141 Low Birth Weight 1 3 partial X
I 142 Prematurity 1 3 partial X
I 151 Small for Gestational Age 1 3 X
X 152 Head Circumference < 5th 1 X
153 Large for Gestational Age 1 X
3% below 201 Low Hematocrit 1 1 4 1 3 X
211 Elevated Blood Lead Level 1 1 6 1 3 X
X 301 Hyperemesis Gravidarum 1 X
X 302 Gestational Diabetes 1 X
303 Hx Gestational Diabetes 1 1 6
311 Hx of Preterm Delivery 1 1 6
312 Hx of Low Birthweight 1 1 6
321 Hx of Fetal/Neonatal Loss 1 1 6
P & < 16 331 Pregnancy < 18 yr. at 1 1 6 X
conception
332 Close Spaced Pregnancies 1 1 6 X
P 333 High Parity and Young Age 1 1 6
rd
3 334 Lack of Prenatal Care 1 X
Trimester
High NRF # Description Auto No
Risk P B N I C Assign Regression
X 336 Fetal Growth Restriction 1
337 Hx of Birth of LGA Infant 1 1 6
338 Pregnant and Currently BF 1 X
X 341 Nutrient Deficit Disease 1 1 4 1 3
X 342 GI Disorders 1 1 4 1 3
X 343 Diabetes Mellitus 1 1 4 1 3
344 Thyroid Disorders 1 1 6 1 3
345 Hypertension 1 1 6 1 3
X 346 Renal Disease 1 1 4 1 3
X 347 Cancer 1 1 4 1 3
348 CNS Disorder 1 1 6 1 3
349 Congenital Disorders 1 1 6 1 3
350 Pyloric Stenosis 1
X 351 Metabolic Inborn Errors 1 1 4 1 3
352 Infectious Diseases 1 1 6 1 3
353 Food Allergies 1 1 6 1 3
354 Celiac Disease 1 1 6 1 3
355 Lactose Intolerance 1 1 6 1 3
356 Hypoglycemia 1 1 6 1 3
357 Drug Nutrient Interaction 1 1 6 1 3
P, B 358 Eating Disorders 1 1 6
359 Surgery, Trauma, Burns 1 1 6 1 3
360 Other Medical Conditions 1 1 6 1 3
361 Depression 1 1 6 3
362 Developmental Delays 1 1 6 1 3
371 Maternal Smoking 1 1 X
P 372a Alcohol Use 1 1 6 X
P 372b Illegal Drug Use 1 1 6
381 Dental Problems 1 1 6 1 3 gingivitis of Preg.
X 382 Fetal Alcohol Syndrome 1 3
401 Failure to Meet Diet Guidelines 4 4 6 5
411 Inappropriate Nutrition (I) 4
425 Inappropriate Nutrition (C) 5
427 Inappropriate Nutrition (P,B,N) 4 4 6
428 Diet Risk/Feeding 4 5
501 Possibility of Regression 7 7 7 7 X
502 Transfer of Certification 1 1 6 1 3 X
601a BF Mom of Infant-Prior 1 1 X
601b BF Mom of Infant-Prior 2 2 X
601c BF Mom of Infant-Prior 4 4 X
X 602 BF Complications - Women 1
X 603 BF Complications - Infant 1
701 Mom on WIC/Not on WIC 2 X
702a BF Infant of Mom-Prior 1 1 X
702b BF Infant of Mom-Prior 2 2 X
702c BF Infant of Mom-Prior 4 4 X
703 Mom w/Ment Prob/Sub Use-I 1
801 Homelessness 4 4 6 4 5 X
802 Migrancy 4 4 6 4 5 X
901 Environmental Risk 4 4 6 4 5
902 Guardian-Lmt'd Fdg Skills 4 4 6 4 5
903 Foster Care 4 4 6 4 5
Assessment of an Infant
GOAL: Achieves optimal growth and development in a nurturing environment and
develops a foundation for healthy eating practices.
HEALTH DETERMINANTS:
Consumes breast milk or iron-fortified infant formula AND other foods as
developmentally appropriate to meet energy and nutrient requirements.
Receives ongoing preventive health care, including screenings and
immunizations.
Achieves a normal growth pattern.
Remains free from nutrition or food-related illness, complications, or injury.
Establishes a trusting relationship with parent(s) that contributes to positive
feeding experiences.
SPRINGBOARD QUESTIONS AND STATEMENTS:
If breastfed, continue with this question: I’m so glad you decided to breastfeed
your baby – it’s the best for your baby and it’s the best choice for you, too!
Sometimes, especially in the early weeks of breastfeeding, things happen that
make breastfeeding challenging. Tell me how breastfeeding has been going for
you.
During the first year, babies grow and change so much! It’s helpful to know that
everything is okay – that’s one of the reasons regular checkups are so important
for babies. When was the last time your baby went to the doctor?
Sometimes babies have medical conditions or other health issues that affect their
nutrition and dietary needs. Has a doctor ever told you that your baby has any
medical conditions or illnesses? Medications and supplements can also affect
your baby’s nutrition and health.
Weighing and measuring babies is one way to see whether babies are growing
and healthy. What do you think about your baby’s weight?
Your baby’s diet will change several times during the first year as s/he moves
from breastfeeding/bottle -feeding to semisolid foods and eventually to table
foods. Let’s talk about what your baby is eating now.
Feeding your baby is such a wonderful opportunity for both of you to get to know
each other. Tell me how you know when your baby is hungry? And, when you
know your baby is full?
26.
Essential Nutrition Assessment Data to Collect/Analyze for an Infant
Anthropometric:
1. Underweight or At Risk
a. 103
2. Length/Height< 10th
a. 121
3. At risk of Overweight
a. 114
4. Inadequate Growth
a. 135
5. Low birth weight
a. 141
6. Physical Activity
Laboratory:
1. Low Hematocrit/Hemoglobin
a. 201
2. Elevated Lead level
a. 211
The remaining risk criteria for the infant category is continued on the next 2 pages.
27.
Clinical/Health/Medical Viewed in the Table Below in Yellow Highlights:
Dietary/Nutrition Practices Viewed in the Table Below in Pink Highlights:
Predisposing Risks Viewed in the Table Below in Green Highlights:
Utah Nutrition Risk Factor Reference Sheet
High NRF Description Priority Auto No
#
Risk P B N I C Assign Regression
BMI < 18 101 Underweight Women 1 1 6 X X
<5th 103 Underweight or At Risk 1 3 X
111 Overweight Women 1 1 6 X X
113 Overweight (Children Age 2-5) 3 X
114 At Risk of Overweight 1 3 partial
121 Length/Height < 10th 1 3 X
X 131 Low Maternal Weight Gain 1 X
X 132 Wt Loss During Pregnancy 1 P partial X
P 133 High Maternal Weight Gain 1 1 6 B & N only X
X 134 Failure to Thrive 1 3
X 135 Inadequate Growth 1 3
X 141 Low Birth Weight 1 3 partial X
I 142 Prematurity 1 3 partial X
I 151 Small for Gestational Age 1 3 X
X 152 Head Circumference < 5th 1 X
153 Large for Gestational Age 1 X
3% below 201 Low Hematocrit 1 1 4 1 3 X
211 Elevated Blood Lead Level 1 1 6 1 3 X
X 301 Hyperemesis Gravidarum 1 X
X 302 Gestational Diabetes 1 X
303 Hx Gestational Diabetes 1 1 6
311 Hx of Preterm Delivery 1 1 6
312 Hx of Low Birthweight 1 1 6
321 Hx of Fetal/Neonatal Loss 1 1 6
P & < 16 331 Pregnancy < 18 yr. at 1 1 6 X
conception
332 Close Spaced Pregnancies 1 1 6 X
P 333 High Parity and Young Age 1 1 6
rd
3 Trimester 334 Lack of Prenatal Care 1 X
P, B 335 Multifetal Gestation 1 1 6 B & N only X
X 336 Fetal Growth Restriction 1
337 Hx of Birth of LGA Infant 1 1 6
338 Pregnant and Currently BF 1 X
X 341 Nutrient Deficit Disease 1 1 4 1 3
X 342 GI Disorders 1 1 4 1 3
X 343 Diabetes Mellitus 1 1 4 1 3
344 Thyroid Disorders 1 1 6 1 3
345 Hypertension 1 1 6 1 3
X 346 Renal Disease 1 1 4 1 3
X 347 Cancer 1 1 4 1 3
348 CNS Disorder 1 1 6 1 3
349 Congenital Disorders 1 1 6 1 3
350 Pyloric Stenosis 1
X 351 Metabolic Inborn Errors 1 1 4 1 3
352 Infectious Diseases 1 1 6 1 3
353 Food Allergies 1 1 6 1 3
354 Celiac Disease 1 1 6 1 3
355 Lactose Intolerance 1 1 6 1 3
356 Hypoglycemia 1 1 6 1 3
357 Drug Nutrient Interaction 1 1 6 1 3
P, B 358 Eating Disorders 1 1 6
359 Surgery, Trauma, Burns 1 1 6 1 3
360 Other Medical Conditions 1 1 6 1 3
361 Depression 1 1 6 3
362 Developmental Delays 1 1 6 1 3
371 Maternal Smoking 1 1 X
P 372a Alcohol Use 1 1 6 X
P 372b Illegal Drug Use 1 1 6
381 Dental Problems 1 1 6 1 3 gingivitis of Preg.
X 382 Fetal Alcohol Syndrome 1 3
401 Failure to Meet Diet Guidelines 4 4 6 5
411 Inappropriate Nutrition (I) 4
425 Inappropriate Nutrition (C) 5
427 Inappropriate Nutrition (P,B,N) 4 4 6
428 Diet Risk/Feeding 4 5
501 Possibility of Regression 7 7 7 7 X
502 Transfer of Certification 1 1 6 1 3 X
601a BF Mom of Infant-Prior 1 1 X
601b BF Mom of Infant-Prior 2 2 X
601c BF Mom of Infant-Prior 4 4 X
X 602 BF Complications - Women 1
X 603 BF Complications - Infant 1
701 Mom on WIC/Not on WIC 2 X
702a BF Infant of Mom-Prior 1 1 X
702b BF Infant of Mom-Prior 2 2 X
702c BF Infant of Mom-Prior 4 4 X
703 Mom w/Ment Prob/Sub Use-I 1
801 Homelessness 4 4 6 4 5 X
802 Migrancy 4 4 6 4 5 X
901 Environmental Risk 4 4 6 4 5
902 Guardian-Lmt'd Fdg Skills 4 4 6 4 5
903 Foster Care 4 4 6 4 5
Assessment of a Child 12 through 23 Months of Age
GOAL: Achieves optimal growth and development in a nurturing environment and
develops a foundation for healthy eating practices.
HEALTH DETERMINANTS:
Receives lactation management and support for breastfeeding
Receives ongoing preventive health care, including screenings and
immunizations.
Achieves a normal growth pattern.
Remains free from nutrition or food-related illness, complications, or injury.
Consumes a variety of foods to meet energy and nutrient requirements.
Achieves developmental milestones, including self-feeding.
SPRINGBOARD QUESTIONS AND STATEMENTS:
If breastfed, continue with this question: I’m so glad you are still
breastfeeding your baby – it’s the best for your baby and it’s the best
choice for you, too! Sometimes, things happen that make breastfeeding
challenging. Tell me how breastfeeding has been going for you.
Children are healthier when they see the doctor for checkups. Has (name)
had his/her (one year/15 month/18 month/2 year) check up?
How do you feel about the way (name) is growing?
Children need to feel good in order to grow and learn. If they don’t feel well,
they may not grow or learn as well. How is (name’s) health, overall?
Safety is always an issue with children. Parents worry that their children
will get hurt. What concerns do you have about safety?
Children need the right foods to grow strong. This is a great time to help
them learn good eating habits. How are you helping (name) develop good
habits?
Just like adults, children need to feel a sense of accomplishment. They
want to learn how to feed themselves and do a good job with it. How do
you feel about the way (name) is progressing with eating?
30.
Essential Nutrition Assessment Data to Collect/Analyze for a Child 12 through 23
Months of Age
Anthropometric:
1. Underweight or At Risk
a. 103
2. Length/Height< 10th
a. 121
3. At risk of Overweight
a. 114
4. Inadequate Growth
a. 135
5. Low birth weight
a. 141
6. Physical Activity
Laboratory:
1. Low Hematocrit/Hemoglobin
a. 201
2. Elevated Lead level
a. 211
The remaining risk criteria for the child (12 – 23 months of age) category is continued on
the next 2 pages.
31.
Clinical/Health/Medical Viewed in the Table Below in Yellow Highlights:
Dietary/Nutrition Practices Viewed in the Table Below in Pink Highlights:
Predisposing Risks Viewed in the Table Below in Green Highlights:
Utah Nutrition Risk Factor Reference Sheet
High NRF Description Priority Auto No
#
Risk P B N I C Assign Regression
BMI < 18 101 Underweight Women 1 1 6 X X
<5th 103 Underweight or At Risk 1 3 X
111 Overweight Women 1 1 6 X X
113 Overweight (Children Age 2-5) 3 X
114 At Risk of Overweight 1 3 partial
121 Length/Height < 10th 1 3 X
X 131 Low Maternal Weight Gain 1 X
X 132 Wt Loss During Pregnancy 1 P partial X
P 133 High Maternal Weight Gain 1 1 6 B & N only X
X 134 Failure to Thrive 1 3
X 135 Inadequate Growth 1 3
X 141 Low Birth Weight 1 3 partial X
I 142 Prematurity 1 3 partial X
I 151 Small for Gestational Age 1 3 X
X 152 Head Circumference < 5th 1 X
153 Large for Gestational Age 1 X
3% below 201 Low Hematocrit 1 1 4 1 3 X
211 Elevated Blood Lead Level 1 1 6 1 3 X
X 301 Hyperemesis Gravidarum 1 X
X 302 Gestational Diabetes 1 X
303 Hx Gestational Diabetes 1 1 6
311 Hx of Preterm Delivery 1 1 6
312 Hx of Low Birthweight 1 1 6
321 Hx of Fetal/Neonatal Loss 1 1 6
P & < 16 331 Pregnancy < 18 yr. at 1 1 6 X
conception
332 Close Spaced Pregnancies 1 1 6 X
P 333 High Parity and Young Age 1 1 6
rd
3 Trimester 334 Lack of Prenatal Care 1 X
P, B 335 Multifetal Gestation 1 1 6 B & N only X
X 336 Fetal Growth Restriction 1
337 Hx of Birth of LGA Infant 1 1 6
338 Pregnant and Currently BF 1 X
X 341 Nutrient Deficit Disease 1 1 4 1 3
X 342 GI Disorders 1 1 4 1 3
X 343 Diabetes Mellitus 1 1 4 1 3
344 Thyroid Disorders 1 1 6 1 3
345 Hypertension 1 1 6 1 3
X 346 Renal Disease 1 1 4 1 3
X 347 Cancer 1 1 4 1 3
348 CNS Disorder 1 1 6 1 3
349 Congenital Disorders 1 1 6 1 3
350 Pyloric Stenosis 1
X 351 Metabolic Inborn Errors 1 1 4 1 3
352 Infectious Diseases 1 1 6 1 3
353 Food Allergies 1 1 6 1 3
354 Celiac Disease 1 1 6 1 3
355 Lactose Intolerance 1 1 6 1 3
356 Hypoglycemia 1 1 6 1 3
357 Drug Nutrient Interaction 1 1 6 1 3
P, B 358 Eating Disorders 1 1 6
359 Surgery, Trauma, Burns 1 1 6 1 3
360 Other Medical Conditions 1 1 6 1 3
361 Depression 1 1 6 3
362 Developmental Delays 1 1 6 1 3
371 Maternal Smoking 1 1 X
P 372a Alcohol Use 1 1 6 X
P 372b Illegal Drug Use 1 1 6
381 Dental Problems 1 1 6 1 3 gingivitis of Preg.
X 382 Fetal Alcohol Syndrome 1 3
401 Failure to Meet Diet Guidelines 4 4 6 5
411 Inappropriate Nutrition (I) 4
425 Inappropriate Nutrition (C) 5
427 Inappropriate Nutrition (P,B,N) 4 4 6
428 Diet Risk/Feeding 4 5
501 Possibility of Regression 7 7 7 7 X
502 Transfer of Certification 1 1 6 1 3 X
601a BF Mom of Infant-Prior 1 1 X
601b BF Mom of Infant-Prior 2 2 X
601c BF Mom of Infant-Prior 4 4 X
X 602 BF Complications - Women 1
X 603 BF Complications - Infant 1
701 Mom on WIC/Not on WIC 2 X
702a BF Infant of Mom-Prior 1 1 X
702b BF Infant of Mom-Prior 2 2 X
702c BF Infant of Mom-Prior 4 4 X
703 Mom w/Ment Prob/Sub Use-I 1
801 Homelessness 4 4 6 4 5 X
802 Migrancy 4 4 6 4 5 X
901 Environmental Risk 4 4 6 4 5
902 Guardian-Lmt'd Fdg Skills 4 4 6 4 5
903 Foster Care 4 4 6 4 5
Assessment of a Child 2 through 4 Years of Age
GOAL: Achieves optimal growth and development in a nurturing environment and
begins to acquire dietary and lifestyle habits associated with a lifetime of good
health.
HEALTH DETERMINANTS:
Receives ongoing preventive healthcare, including screenings and
immunizations.
Achieves a normal growth pattern.
Remains free from nutrition or food-related illness, complications, or injury.
Achieves developmental milestones, including self-feeding.
Consumes a variety of foods to meet energy and nutrient requirements.
SPRINGBOARD QUESTIONS AND STATEMENTS:
Children grow and change so fast. That’s why checkups continue to be
important. When did (name) have his/her last checkup?
How do you feel about the way (name) is growing?
How has (name’s) health been lately?
Children this age love to explore. That’s how they learn. Parents must
balance the need for safety with the importance of letting their child have
many opportunities to learn. What safety issues do you have concerns
about?
Children are very proud of themselves as they work on their eating skills.
How is (name) progressing?
Children count on their parents to help them learn to eat right. But, they
sometimes act like they don’t want to learn. How do you feel about the
foods (name) is eating?
34.
Essential Nutrition Assessment Data to Collect/Analyze for a Child 2 through 4
Years of Age
Anthropometric:
1. Underweight or At Risk
a. 103
2. Length/Height< 10th
a. 121
3. At risk of Overweight
a. 114
4. Overweight (Age 2 through 4 years)
a. 113
5. Inadequate Growth
a. 135
6. Low birth weight
a. 141
7. Physical Activity
Laboratory:
1. Low Hematocrit/Hemoglobin
a. 201
2. Elevated Lead level
a. 211
The remaining risk criteria for the child (2 through 4 years of age) category is continued
on the next 2 pages.
35.
Clinical/Health/Medical Viewed in the Table Below in Yellow Highlights:
Dietary/Nutrition Practices Viewed in the Table Below in Pink Highlights:
Predisposing Risks Viewed in the Table Below in Green Highlights:
Utah Nutrition Risk Factor Reference Sheet
High NRF Description Priority Auto No
#
Risk P B N I C Assign Regression
BMI < 18 101 Underweight Women 1 1 6 X X
<5th 103 Underweight or At Risk 1 3 X
111 Overweight Women 1 1 6 X X
113 Overweight (Children Age 2-5) 3 X
114 At Risk of Overweight 1 3 partial
121 Length/Height < 10th 1 3 X
X 131 Low Maternal Weight Gain 1 X
X 132 Wt Loss During Pregnancy 1 P partial X
P 133 High Maternal Weight Gain 1 1 6 B & N only X
X 134 Failure to Thrive 1 3
X 135 Inadequate Growth 1 3
X 141 Low Birth Weight 1 3 partial X
I 142 Prematurity 1 3 partial X
I 151 Small for Gestational Age 1 3 X
X 152 Head Circumference < 5th 1 X
153 Large for Gestational Age 1 X
3% below 201 Low Hematocrit 1 1 4 1 3 X
211 Elevated Blood Lead Level 1 1 6 1 3 X
X 301 Hyperemesis Gravidarum 1 X
X 302 Gestational Diabetes 1 X
303 Hx Gestational Diabetes 1 1 6
311 Hx of Preterm Delivery 1 1 6
312 Hx of Low Birthweight 1 1 6
321 Hx of Fetal/Neonatal Loss 1 1 6
P & < 16 331 Pregnancy < 18 yr. at 1 1 6 X
conception
332 Close Spaced Pregnancies 1 1 6 X
P 333 High Parity and Young Age 1 1 6
rd
3 Trimester 334 Lack of Prenatal Care 1 X
P, B 335 Multifetal Gestation 1 1 6 B & N only X
X 336 Fetal Growth Restriction 1
337 Hx of Birth of LGA Infant 1 1 6
338 Pregnant and Currently BF 1 X
X 341 Nutrient Deficit Disease 1 1 4 1 3
X 342 GI Disorders 1 1 4 1 3
X 343 Diabetes Mellitus 1 1 4 1 3
344 Thyroid Disorders 1 1 6 1 3
345 Hypertension 1 1 6 1 3
X 346 Renal Disease 1 1 4 1 3
X 347 Cancer 1 1 4 1 3
348 CNS Disorder 1 1 6 1 3
349 Congenital Disorders 1 1 6 1 3
350 Pyloric Stenosis 1
X 351 Metabolic Inborn Errors 1 1 4 1 3
352 Infectious Diseases 1 1 6 1 3
353 Food Allergies 1 1 6 1 3
354 Celiac Disease 1 1 6 1 3
355 Lactose Intolerance 1 1 6 1 3
356 Hypoglycemia 1 1 6 1 3
357 Drug Nutrient Interaction 1 1 6 1 3
P, B 358 Eating Disorders 1 1 6
359 Surgery, Trauma, Burns 1 1 6 1 3
360 Other Medical Conditions 1 1 6 1 3
361 Depression 1 1 6 3
362 Developmental Delays 1 1 6 1 3
371 Maternal Smoking 1 1 X
P 372a Alcohol Use 1 1 6 X
P 372b Illegal Drug Use 1 1 6
381 Dental Problems 1 1 6 1 3 gingivitis of Preg.
X 382 Fetal Alcohol Syndrome 1 3
401 Failure to Meet Diet Guidelines 4 4 6 5
411 Inappropriate Nutrition (I) 4
425 Inappropriate Nutrition (C) 5
427 Inappropriate Nutrition (P,B,N) 4 4 6
428 Diet Risk/Feeding 4 5
501 Possibility of Regression 7 7 7 7 X
502 Transfer of Certification 1 1 6 1 3 X
601a BF Mom of Infant-Prior 1 1 X
601b BF Mom of Infant-Prior 2 2 X
601c BF Mom of Infant-Prior 4 4 X
X 602 BF Complications - Women 1
X 603 BF Complications - Infant 1
701 Mom on WIC/Not on WIC 2 X
702a BF Infant of Mom-Prior 1 1 X
702b BF Infant of Mom-Prior 2 2 X
702c BF Infant of Mom-Prior 4 4 X
703 Mom w/Ment Prob/Sub Use-I 1
801 Homelessness 4 4 6 4 5 X
802 Migrancy 4 4 6 4 5 X
901 Environmental Risk 4 4 6 4 5
902 Guardian-Lmt'd Fdg Skills 4 4 6 4 5
903 Foster Care 4 4 6 4 5
Name______________________________
Clinic______________________________
Date________
Progress Check
Circle the best answer(s)
1. Circle the general risk criteria categories below that can be reviewed,
assessed and entered into the computer system prior to calling back or walking
into the consult room to conduct a certification interview with a participant and/or
family.
a, predisposing risks
b. clinical/health/medical
c. diet/nutrition practices
d. biochemical/laboratory
e. anthropometric
2. The first step in the nutrition care plan process is
a. interviewing the participant
b. data entry
c. writing a care plan
d. nutrition assessment
3. A systematic approach to data collection includes
a. preparatory work
b. learning the data collection system well
c. assembling VENA templates and springboard questions
d. knowing what questions to ask
e. following a sequence of events
f. all of the above
4. ________________is a necessary skill for opening lines of honest
communication with a participant.
a. humor
b. clear speech
c. observation
d. building rapport
5. The purpose of critical thinking is to
a. achieve understanding
b. evaluate viewpoints
c. solve problems
d. all of the above
e. none of the above
38.
Practical Assignment:
Characteristics of Critical & Creative Thinkers
(taken from www.kafkaz.net/kfitch/critical.htm )
As you read the following lists of traits, think about the 3 which most typically
describe you as a thinker and how that affects your nutrition assessment process
in the WIC clinic. Please write a brief summary.
1. Dwelling comfortably in the land of “no single correct answer.” Those
with highly honed critical and creative thinking skills learn to dwell comfortably in
this land of conditions and possibilities, gradually becoming ever more adept at
solving problems and making sound decisions based on the best available
evidence at the time. Highly evolved critical and creative thinkers are always
open to the possibility that what counts as the "best" answer is subject to change
as conditions warrant. Uncertainty, of course, is never wholly easy to deal with,
but developing our thinking skills can go a long way toward making it easier to
cope with a world in which there is no teacher's manual with answers to life's
problems helpfully listed in the back.
2. Understanding that “no single correct answer” doesn’t mean that some
answers aren’t better than others in the instance at hand. We can identify
worthwhile answers and solutions even when there's more than one choice.
How? Good answers are those that encompass the greatest amount of the
available evidence, that are consistent with the information we've gathered, that
do the best job of providing satisfactory solutions under the current
circumstances, and so on.
3. Formulating questions: Many have observed that there are no such things
as a stupid questions--with the exception of those that go unasked. Questions, in
other words, are inherently good things because they prompt our thinking. Strong
thinkers know how to generate interesting questions that lead them down new
paths, and they recognize that even questions that might seem sort of silly, at
first, can actually prove quite valuable.
39.
4. Switching critical lenses with growing ease, and recognizing that one’s
critical lens determines what one sees: You may have heard the saying,
"When your only tool is a hammer, everything looks like a nail." That saying is an
excellent illustration of the importance of critical lenses. "Critical lens," is
shorthand for "perspective" or "point of view." In college, the general education
courses you take are designed to familiarize you with a variety of critical
perspectives, so that you learn to think like a biologist, an economist, a
psychologist, a sociologist, a chemist, a writer, and so on. One goal of college is
to help us become "well-rounded," which means that we should be familiar with a
variety of ways of looking at the world, and we should be able to discern the
connections and contradictions afforded by those varying perspectives. Even
seemingly simple observations grow richer and more complex when we have a
variety of perspectives to bring to bear on them.
5. Honing the perceptual skills that feed the pool of “intellectual raw data”
that makes complex conceptions possible: To think, in short, we must take
the time to notice our worlds, collecting data about them through our senses, our
experiences, and our reading and research. Makes sense, doesn't it? Keen
perceivers make strong thinkers.
6. Knowing how to move from both the general to the specific and the
specific to the general: Strong thinkers can both apply general principles to
individual cases and extract general principles from a collection of individual
cases.
7. Understanding and appreciating both fixed and organic forms: For
instance, a strong writer should be able to write in a variety of circumstances. He
or she should know when and how to write very formal things such as resumes,
letters of application, and business letters, but should also be aware of when and
how to create more fluid forms. Similarly, a strong thinker should know when and
how to apply specific formulas, and when and how to get along without them.
8. Developing a willingness to be an explorer, not an expert: Thinking is a
journey whose destination is often uncertain. Critical and creative thinkers learn
to enjoy the journey despite or because of its uncertainty.
9. Making cross-disciplinary, cross-media connections: Unlikely
connections can lead to valuable insights. Think, for instance, of the design of a
spiral staircase, which is said to have inspired understanding of the double-helix
structure of a DNA Molecule.
40.
10. Willingly setting aside the widely accepted “correct” answer to explore
other options: For years, the idea that ulcers are caused by diet and stress was
accepted as gospel in the medical community. Indeed, when the idea that
bacteria may play an important role in the formation of ulcers was first
introduced, it was considered so controversial that it was dismissed out of hand
by many experienced doctors. Years later, even as the debate rages on in
medical journals, antibiotic treatment of ulcers is routine, bringing relief to
thousands of people each year.
11. Considering the moral and ethical domain: No human is an island.
Because our ideas, our actions, and our decisions effect others, many of the
most Valuable Intellectual Traits of critical and creative thinkers fall into the
realm of morals and ethics.
Brief Summary:
41.
There are many tools that one can use to assist in the development of the critical
thinking process. One of these tools is referred to as concept mapping.
Name: Concept Map
Description: A concept map is a special form of a web diagram for exploring
knowledge and gathering and sharing information. Concept mapping is the
strategy employed to develop a concept map. A concept map consists of nodes
or cells that contain a concept, item or question and links. The links are labeled
and denote direction with an arrow symbol. The labeled links explain the
relationship between the nodes. Arrows describe the direction of the relationship
and reads like a sentence( www.graphic.org/concept.html).
The following steps allow you to build a concept map; remember that you can
create many different maps from the same list, depending on how you interpret
the relationships between ideas.
1. Transfer the concepts and examples to small pieces of paper or post-it notes
(you may want to use different colors for concepts and examples).
2. Arrange the pieces of paper on a large sheet of paper or poster board, with the
broadest or most abstract ideas at the top and the most specific ideas at the
bottom. Do not include the examples yet.
3. If possible, arrange the concepts so that ideas go directly under ideas that they
are related to (often this is not possible because ideas relate to several other
concepts). At this point, you may wish to add concepts that help explain, connect,
or expand the ideas that you have.
4. Draw lines from upper concepts to lower concepts that they're related to; do
the same for any related concepts that are on the same level. You may decide to
rearrange the pieces of paper during this stage.
5. This is the most important and most difficult step: on the connecting lines, write
words or phrases that explain the relationship of the concepts. For example, you
could connect the concept "extracurricular activities" to the concept "resume‚"
with the phrase "should not be included on" (in other words, a resume should not
contain a list of extracurricular activities. You may continue to rearrange the
pieces of paper to make the relationships easier to visualize.
6. Put the examples under the concepts they belong with, and connect the
concept to the example with a phrase like for example.
(www.gpc.edu/~shale/humanities/composition/handouts/concept.html)
42.
Example of a Concept Map
www.gpc.edu/~shale/humanities/composition/handouts/concept.html
Case Study
Draw a Concept Map of nutrition assessment data that needs to be collected for:
Ms. Smith’s chart which consists of only the R&R, a prenatal grid, two growth
charts (one for a 6 month old infant girl and one for a 2 year old boy) and a new
formula prescription for Enfacare (medical diagnosis: FTT; length of time: until 1
year of age, signed & dated by MD)
44.
Appendix
See attachments of VENA Templates
