Module III

1. Observe the development and evaluation of nutrition care plans with clients
and the RDs approach to counseling.
Observed as the Lead WIC Nutritionist delivered nutrition education and
provided nutrition interventions to patients. The RD first determined if they
could speak English. If her client speaks little, to no English, she has a list of
questions written in Spanish that she asks them. If she is unable to
determine an answer, her WIC assistant, who is fluent in Spanish can come in
to translate.
For initial appointments, the RD asks a series of questions provided by the
Crossroads database. She spends more time getting to know the client and
determining their level of nutrition knowledge. She uses the answers from
this initial interview to determine the most important nutrition focused topic
to address. There are typical handouts that are provided at this meeting
including: a pregnancy folder full of information on breastfeeding, vitamin
and mineral needs during pregnancy, how to position a baby in the crib to
sleep, and a pamphlet on other community services that may benefit the
mother and her family. Food vouchers are printed and instructions on their
use are provided. A follow-up appointment is made for the mother.
Depending on where she is in her pregnancy, the follow-up may be on
pregnancy nutrition, postpartum nutrition, or on infant or child nutrition.
During this visit the nutrition care plan is initially developed.
Most appointments are follow-ups and the RD is familiar with the client and
their history. She asks a few questions in order to enter information into the
medical record and probes with open-ended questions to see if the client has
any nutrition concerns they would like to discuss. She follows up on goals set
at previous appointments to see how the client is advancing and helps the
client set new nutrition focused goals. Based on the conversation the RD
provides educational handouts tailored to the clients concerns and offers
suggestions and ideas for improved nutritional behaviors.
The RD will often make several passes at the same topic to see if any
additional information can be gleaned that was omitted or forgotten the first
time. During this appointment, as well as any initial appointments, the RD is
subtly looking for nutrition focused physical findings such as the condition of
the clients skin, hair, nails, and teeth. She is looking for signs of fatigue,
sleep deprivation, physical abuse and drug or alcohol abuse. If the infant or
child is present she notes how active they are or if they seem lethargic. She
looks for signs of under-nutrition and poor nutrition.
2. Familiarize yourself with the medical record and forms used in the
development of nutrition care plans. Practice plotting growth charts.

RD provided all forms to me on the first day to review in hard copy. This WIC
office no longer uses paper copies, instead records everything in crossroads
as they interview the client.
There are several different forms based on the client for nutrition
assessments and care plans. These include ones for pregnant women,
postpartum women, infants, and children age two and over. The forms all
initially collect information such as age, insurance provider, birth date, race,
ethnicity, sex, address, primary language and household composition.
Categories of questions are broken into 4 categories including:
Eco-social: Does client smoke or live with smokers, get food stamps,
have adequate and safe water, food secure, have places to store/cook
food. Does the client have limited abilities, homeless, or migrant.
If they are a child/infant: are they in foster care, or childcare? Who is
their primary care giver and what are their abilities? Are they drug or
alcohol dependent?
Anthro- and Biochemical- Pre-pregnancy weight, BMI, height, Hct, Hgb.
Birth weight, length, gestational age etc.
Clinical- History of pregnancy and outcomes, medical conditions,
medications, tobacco, drugs, alcohol and infant feeding plan. How
many stools, wet diapers, immunization status?
Diet and Physical Activity- Eating patterns, type of milk consumed,
type of formula used. Physical activity level, fruit and vegetable
consumption, water intake, how many meals are eaten out of house,
how much TV is viewed.
After this initial assessment is performed, nutrition risk criteria is selected by
the RD. Examples include: Low maternal weight gain, history of low birth
weight, dental problems, homelessness, recipient of abuse, hypertension,
hyperglycemia, cancer, depression..
The nutrition care plan is then determined. Education topics are selected,
referrals are made, the food package is selected and a follow-up appointment
is made. The client is also asked do chose a nutrition goal that they will work
on for the next visit.
Plotted growth for 10-year-old on the CDC growth charts. Used the staturefor-age, weight-for-age, and BMI-for-age. Used the WHO growth charts for
children under three. Used the weight-for-length value to determine if the
child was gaining weight at an acceptable rate. Any decline in a growth
curve elicited immediate review and a plan of action was developed to ensure
it did not continue. Reviewed the prenatal weight gain charts for normal,
overweight and obese women. These charts provided a highlighted area
which demonstrated desirable weight gain. Recommendations for weight
gain according to trimester are provided as are recommendations for total
weight gain.

3. Develop care plan for low risk woman and a low risk infant/child.
Hillsborough WICPatient D. StoXXX
Pre-natal visit. Took height, weight and hemoglobin. Asked about
immunization history. Inquired about tobacco and alcohol use. Obtained diet
history. Pt is eating fruit once per day. Normally she does not like fruit, but
she is eating it now because she knows it is healthy. Patient eats several
vegetables daily. Eats grilled chicken. Avoids greasy food and fast food.
Drinks one glass of whole milk in the morning and with dinner. Drinks one
caffeinated beverage daily. Water daily. Juice a few times a week. Eats whole
grains several times a day.
Pt is experiencing nausea related to the smell of toothpaste and coffee. Pt
says she is brushing daily and flossing several times a week. Pt has a 14month-old she is still breastfeeding twice in 24-hour period. Once in the
morning and once before bed. Plans to breastfeed her new baby as well.
Nutrition care plan: Patient was provided education on healthy beverage
choices, the importance of eating fruit and vegetables, and healthy gums and
teeth. Patient will try a different flavor of toothpaste to see if aversion to
toothpaste improves. Patient receiving adequate folic acid from prenatal
vitamin and diet.
Patient goals: Continue varied diet and continue taking prenatal vitamins.
Food certificates were issued.
Patient M. XXXX
Nutrition education- Pt is a 3 year old with concerns over 90%tile weight for
height. Pt was weighed and measured today and has lost 10 ounces since last
visit. Pt is now 87%tile weight for height. Mother attributes this to fact it is
nicer outside and the child is spending less time watching TV.
Mother says that diet has not changed with 3 meals and regular snacks
throughout the day. Child enjoys crackers and pretzels. MOP reports 1 fruit
and 1 vegetable, and 2 cups of milk daily. Pt now takes juice less often. Does
not drink soda, sometimes Gatorade.
Patient nutrition education provided on ensuring less than 2 hours of TV is
viewed per day and outside active play is encouraged as much as possible.
MOP instructed to continue varied diet and to try to incorporate more fruits
and vegetables and less processed chips, pretzels and crackers if possible.
MOP wanted to know if fruit snacks counted as fruit, and was told no.
Goals: Less TV time, more outdoor play
Increase amounts of fruits and vegetables in diet

Follow-up appointment was scheduled for recertification for child.

Food certificates were issued. One gallon of milk was substituted with 1
pound of cheese.
4. Document the assessment in the medical record.
Documented encounters above and several others at Hillsborough WIC. Used
the crossroads software to ask all pertinent questions, record nutrition
assessment, provide recommended education, review notes of previous
encounters, develop goals and schedule follow-up appointments.